Ring Avulsion produces both a crush and an avulsive injury to the digital soft tissue envelope. Tissue, which appears viable, can quickly become compromised by a second insult, such as post-replantation swelling which inevitably is associated with crush amputations. This can lead to progressive necrosis resulting in compromise of the underlying vessels and replant failure. The traditional approach to this problem is aggressive debridement and resurfacing with split thickness skin graft over reconstructed vessels. Often this technique cannot be employed because of the inappropriate wound bed such as exposed bone or tendon. This approach is also complicated by the development of a hematoma, which can threaten the skin graft or compress the vein grafts, again leading to replant failure. The author describes the immediate reconstruction of the crushed soft tissue envelope and avulsed vessels with an arterialized venous flow through flap (VFTF).

Between July 2000 and September 2002, 6 VFTFs were utilized during replantation of digits in 6 patients. All replants were classified as Adani type IVd or complete amputations distal to the superficialis insertion. All flaps were arterialized in an artery-vein-artery (A-V-A) fashion reconstructing the arterial segmental defect. Two flaps were designed with parallel venous segments and used to reconstruct the digital artery (A-V-A) and dorsal vein (V-V-V) simultaneously. All flaps were harvested from the distal volar forearm. Flap size ranged from 1-2 X 3-5 cm. Vessel length ranged from 2-5 cm (artery) and 1-2 cm (vein). Fluoroscopy and pencil Doppler were used to monitor the flaps. Follow-up evaluation ranged from 3 months to 2 years. Follow-up evaluation included survival, instances of partial necrosis, and long-term vascular patency.

All replanted digits survived. All VFTFs survived without instances of partial necrosis. No hematoma or other post-operative complication was noted. Fluoroscopy revealed a 2-3 times rise and fall consistent with adequate tissue perfusion in all flaps. All flaps were supple and showed good skin quality and adequate color match. All donor sites were closed primarily.

Transplantation of an arterialized VFTF is a reliable method for restoring vascular inflow and reconstructing soft tissue cover in selected patients after ring avulsion amputation. With correct design one flap can simultaneously restore arterial inflow and venous outflow. The use of VFTFs may lead to decreased complications and increased survival in these complicated replants. In addition, creation of a supple soft tissue envelope may lead to better functional return. We recommend their use with studied application.