Clinical Examples: Delayed Amputation for Vascular Insufficiency

Ischemic gangrene of the hand and fingers is usually an unwanted addition to an already complicated medical condition, presenting both psychological and physical issues. The goal is to achieve amputation healing with the fewest complications along the way. A major problem is that adjacent to the areas of clear gangrene is a zone if indeterminate viability. If undisturbed, this zone may have enough perfusion to heal, but if stressed by infection or surgery, it may die. When to amputate? Where to plan incisions which will heal uneventfully?
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Case 1. This demonstrates the risk of  amputation before the zone of adequate perfusion had been allowed to declare itself. One month after surgery, the wound margins are themselves ischemic.
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Case 2. This patient developed ischemia of the radial aspect of her left hand during a carotid endarterectomy. These pictures were taken four weeks postop.
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Imaging demonstrated nonreconstructible vascular disease.
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The wounds were kept clean and dry until demarcation was complete. two months after the initial event, the thumb tip has autoamputated  and the first dorsal interosseous muscle has developed ischemic contracture, resulting in a fixed flexion and radial deviation of the index metacarpophalangeal joint.
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At this point, the index amputation was shortened and the first dorsal interosseous muscle  was released by distal tenotomy. Here, one month postop, three months after the initial event, with full range of motion and wound healing.
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With this approach, greater thumb length  was preserved than would have been possible with early amputation.
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Case 3. This patient with nonreconstrutible vascular disease of both hands presented with multiple ischemic fingertips was managed with local care until demarcation was complete, allowing uncomplicated amputations with uneventful healing.
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Final result, three months after presentation.
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