Extremity loss due to ischemia is a well-documented complication associated with various conditions, including trauma, vascular disease, and infections [1, 2]. However, ischemia-induced extremity loss resulting from the administration of vasopressors in critically ill patients or symmetrical peripheral gangrene remains a less common but significant challenge for reconstructive surgeons ^[3]. Vasopressors can lead to severe peripheral ischemia and subsequent gangrene in the extremities due to their potent vasoconstrictive effects [4, 5]. Vasopressor-induced gangrene appears to have a positive correlation with medication dosing and duration of intensive care unit (ICU) stay ^[6]. In addition, symmetrical peripheral gangrene can occur in critical illnesses despite vasopressor therapy, indicating a secondary causal role involving the procoagulant-anticoagulant balance in susceptible tissue beds with secondary disseminated intravascular coagulation ^[7]. The patient discussed in this report had asymmetric tissue loss, likely reflecting a “double-hit” of vascular incident in the setting of septic shock induced ischemia. Pollicization of the index finger is an established and effective method of thumb reconstruction following traumatic amputation and for congenital thumb anomalies [1, 8]. The procedure involves transferring the index finger to the thumb position, providing a functional and opposable thumb, to restore prehensile function ^[9]. Studies have highlighted the success of pollicization in traumatic cases, demonstrating excellent thumb range of motion, pinch strength, and overall hand functionality, but we are unaware of previous reports of pollicization following ischemic thumb loss. This case report discusses the management of thumb and forefoot ischemic loss in a previously healthy 48-year-old male who experienced severe extremity ischemia and distal tissue loss following the administration of prolonged high-dose vasopressors for the treatment of septic shock, as well as unrecognized compartment syndrome of the right arm. The patient underwent pollicization using a partially intact index finger, combined with a pedicled radial forearm flap for webspace reconstruction. The flap underwent distal necrosis likely due to perforator damage from prior unrecognized compartment syndrome requiring salvage with acellular dermal matrix (Integra Lifesciences) and full-thickness skin grafting. A free neurotized fasciocutaneous anterolateral thigh (ALT) flap was also used to provide sensate foot reconstruction for foot salvage following transmetatarsal amputation. This report discusses the surgical approach, outcomes, pitfalls, and feasibility of surgical reconstruction in the context of vasopressor-induced distal extremity loss.

Background

A 48-year-old previously healthy male had initially presented to an outside center in septic shock secondary to Streptococcus pneumoniae pneumonia. His 16-day inpatient course was marked by severe shock and multi-system organ failure requiring multiple high-dose pressors (vasopressin, phenylephrine, and epinephrine). He sustained a myocardial infarction and resulting cardiogenic heart failure (EF = 20%). Of note, on hospital day 2 he was noted to have a hematoma of the left wrist following arterial cannulation. Eight days after this he was noted to have ischemic changes to the left hand and bilateral feet, attributed to high-dose pressor requirements, and sustained poor extremity perfusion due to shock physiology. No surgical consultation was sought or interventions performed on his extremities during that admission. Six weeks after discharge he presented to our outpatient clinic for evaluation of dry gangrene of the left hand and bilateral feet. His pulmonary, cardiac, and renal functions were essentially back to his healthy baseline. Left-hand dry gangrene included the left thumb distal to MCP, index distal to PIP, middle and ring pulp only, and small distal to the eponychial fold (Fig. 1). The first webspace was contracted to 20°, and there were healed partial thickness skin injuries involving the dorsoradial hand and volar forearm. He had 2+ palpable radial and ulnar pulses, and the Allen test revealed intact dual perfusion of all remaining digits. He had moderate paresthesia of the median nerve and a positive carpal tunnel compression test, with grossly intact sensation throughout the viable hand and functional thenar musculature and intact thumb opposition. Intrinsics were weak but intact. The digits were stiff but not contracted. FDP, FDS, and extensor functions were intact to the middle, ring, and small fingers. The active range of motion of MCPs was 0–45°; PIPs 0–60°.

He also had dry gangrene of the right foot to the transmetatarsal level (Fig. 2), and all toes of the left foot to varying degrees. The right foot showed mild equinus deformity.

Pollicization and webspace reconstruction

The operation began with the amputation of the gangrenous thumb at the MCP joint, the index finger at the PIP joint, and the other fingers at the distal phalanx. A modified Ezaki incision was designed (Fig. 3). The extremity was partially exsanguinated, and the tourniquet was inflated to 250 mmHg. We began the pollicization by making an incision on the palmar aspect at the 2^nd webspace, identifying the 2^nd common neurovascular bundle. The radial digital artery of the middle finger was ligated and internal neurolysis of the 2^nd common digital nerve was performed to gain sufficient nerve length to allow for tension-free transfer of the index finger into the thumb position. The A1 pulley was completely released. Dorsally, 3 robust veins to the index finger were identified and preserved. These were dissected proximally, leaving the draining veins with the adipofascial flap. This was then elevated off the extensor mechanism. Next, the intermetacarpal ligament (between the 2^nd and 3^rd metacarpal heads) was divided, the lateral bands were divided, and the 2^nd metacarpal was exposed proximally. The second metacarpal was cleared circumferentially, and the pedicle was protected while the metacarpal osteotomy was performed with an oscillating saw. The volar soft tissue flap was then elevated off the thenar musculature and radial aspect of the thumb and left in continuity with the palm to create a large dermal pedicle in addition to the neurovascular pedicles and veins to prevent congestion. The thumb metacarpal osteotomy was then performed to prepare for fusion, and the first web space contracture was released which required substantial release of fibrotic tissue and excision of the non-viable adductor pollicis muscle. The pollicized index finger was then positioned on the first metacarpal in abduction, pronation, and opposition, and fixated with two longitudinal Kirschner wires. The resulting webspace soft tissue defect measured 8 cm by 10 cm. A posterior interosseous artery flap was designed to resurface this area. However, was aborted due to a lack of perforating vessels visualized in the septum from the posterior interosseous artery to the flap. We then proceeded with a reverse radial forearm flap. An intraoperative Doppler-based Allen’s test was performed again confirming adequate dual perfusion of the hand. Retrograde flow was also assessed with an Acland clamp applied to the radial artery intraoperatively. The flap was then elevated in a standard proximal to distal direction. Excellent retrograde flow was noted after proximal artery division. It was noted as we entered the midportion of the forearm that the deep flexor compartment, including a portion of the FDP and the entirety of the pronator quadratus and flexor pollicis longus, were necrotic and completely non-viable, though the superficial forearm flexors were healthy in appearance. The dissection was completed until the flap could be inset into the webspace defect without tension. We did note a lack of visible perforators in the septum but given the usual high density of small perforators and reliability of the flap, we proceeded. The flap appeared perfused after elevation and inset. Finally, a carpal tunnel release was performed followed by skin grafting of the forearm donor defect. Fig. 4 shows the intraoperative reconstruction following pollicization and webspace reconstruction with flap coverage. A splint was applied, and windows were cut to assess the vascularity of both the pollicized index finger as well as the radial forearm flap. The patient was discharged the next day, with a viable appearance of the pollicized digit and portion of the flap visible through the window.

Revision webspace reconstruction

At the patient’s first follow-up (post-operative day 7) it was noted that the radial forearm flap was non-viable distal to the first webspace volarly. He returned to the operating room for debridement and placement of a dermal matrix (Integra) with a wound VAC bolster. The dermal matrix incorporated well and 3 weeks later the patient underwent full-thickness skin grafting from the left groin which healed uneventfully.

Midfoot amputation and reconstruction

Eight weeks later, Lisfranc level amputation of the right midfoot was completed by the orthopedic surgery team, as well as Achilles lengthening, and tibialis anterior transfer posterior tibialis tendon open release for ankle rebalancing. The next day, he was taken for a free neurotized ALT flap (Fig. 5). An incision was made along the course of the medial plantar artery and nerve from the wound to just posterior to the medial malleolus. The ALT flap was designed using standard landmarks for a flap 8 cm wide by 20 cm long. Flap dissection began medially, identifying and including the lateral femoral cutaneous nerve (LFCN) and a second sensory branch from the femoral system. The deep muscular fascia was exposed along the medial incision and the interval between the vastus lateralis and rectus femoris was developed. The flap was then elevated in a standard subfascial manner on two septocutaneous perforators, with perfusion verified by SPY intraoperative angiography. Arterial and two venous anastomoses were completed with a 2.5 mm coupler, the Heifetz clamps were removed, and good flow was shown across the anastomosis. LFCN was coapted to the medial plantar nerve and the medial femoral sensory nerve to a dorsal proximal branch of the medial plantar nerve with 9-0 nylon epineurial suture and Tisseel fibrin glue.

The patient healed well following the FTSG with no further wound issues. Fig. 6 shows the final reconstruction of the hand. The metacarpal osteotomy site did not unite by 16 weeks, and revision osteosynthesis was performed with plate and screws which united uneventfully. The midfoot reconstruction flap healed well. A final thinning revision for the ALT flap was done 3 months after the initial surgery to enable shoe fit. (Fig. 7).

Pollicization is an established surgical technique primarily employed in pediatric cases for congenital thumb aplasia or hypoplasia, with initial descriptions dating back to 1950 [10, 11]. In pediatric patients, pollicization often yields excellent functional outcomes, with a 2024 systematic review reporting grip strength in the range of 52–76% and lateral pinch and key grip strength of approximately 50% of the contralateral hand ^[8]. A separate study reviewed 459 pollicization procedures and found an infrequent complication rate of 4.8%, with predominant vascular issues in nature ^[12]. While pollicization in children has been more thoroughly documented, its application in adult trauma and other adult cases is less common. However, one international study showed that surgeons had optimistic expectations regarding functionality and outcome with pollicization, which could lead to pollicization being considered more favorable in cases of traumatic thumb amputation or loss due to other causes, such as infection or vascular compromise ^[13]. Although studies are limited, published results are positive, with a cohort study of 7 adult patients treated with index finger pollicization following traumatic amputation having excellent post-operative function and satisfactory results ^[14]. Another study with a cohort of 8 adult patients found over 50% of patients having excellent post-operative function and satisfactory results ^[15]. Given the success of pollicization in adult trauma cases, its application in vasopressor-induced limb loss was utilized. The reconstruction of the midfoot following transmetatarsal amputation is similarly important to preserve lower extremity function. The midfoot is used for balance, gait, and distribution of pressure during movement, and the reconstruction should look to restore function where possible [16,17]. An ALT flap is commonly used in reconstruction due to ample size, long pedicle, and ability to include sensory nerves within the flap, which is ideal for covering complex defects and restoration of protective sensation through nerve coaptation [18,19]. A 2020 systematic review of neurotized free tissue transfer for foot reconstruction found that patients who underwent neurotization by nerve coaptation had improved sensory characteristics, quicker return to ambulation and activities of daily living, and decreased ulcer formation ^[18]. Another study from 2023 of 20 patients found similar results, additionally indicating improved overall foot function according to the Maryland foot function evaluation standard, with 8 patients receiving an excellent result, 10 patients receiving good, and only 2 patients with middle evaluations ^[19]. This surgical approach not only works to reestablish the functional architecture of the foot but also to minimize the risk of subsequent complications that are common in areas that bear significant mechanical stress. Vasopressor-induced limb loss is a severe complication arising from the use of vasopressors in critically ill patients. These medications, while essential for maintaining central perfusion in conditions such as septic shock, can lead to significant peripheral ischemia and subsequent tissue necrosis, with no standard guideline of prevention or management of vasopressor-induced limb ischemia [20, 21]. While studies are still ongoing, with botulinum toxin showing promising results as a treatment for pressor-induced hand ischemia, sometimes surgery is the only option [3, 22]. Hand surgeries in this population are challenging due to the extensive tissue damage and the compromised vascularity. However, functional outcomes have been noted, with one case series of three adult patients finding overall weakness but improving quality of life and ability to perform daily tasks post-surgery ^[23]. Furthermore, Volkmann contracture, a condition resulting from increased compartment pressure leading to ischemia and muscle necrosis, can impact the success of regional flaps ^[24]. In this case, the patient likely experienced undiagnosed compartment syndrome during his ICU admission, leading to ischemic damage of the deep forearm flexors. This likely also compromised septocutaneous perforators critical to the perfusion of a radial forearm flap. This case strengthens the argument for the importance of careful monitoring and early recognition of ischemic complications in patients receiving high doses of vasopressors especially when arterial cannulation is used, as well as the successful outcome of pollicization to reconstruct areas impacted most by ischemia. The use of local or regional flaps in this population should be considered high risk. Unfortunately, there was partial flap loss of the distal radial forearm segment, necessitating the use of the skin substitute Integra, a bilayer dermal regeneration template that facilitates the formation of the dermis ^[25]. This was subsequently covered with a full-thickness skin graft from the patient’s groin. In this case, Integra was employed to manage areas of poor-quality skin and granulation tissue, providing a stable foundation for further reconstruction. Regarding bony fixation, K wires were chosen, which ultimately resulted in non-union requiring a second step for revision fixation but held structures in alignment while soft tissues healed. At the time of pollicization, we did not feel it was safe to perform the exposure needed for rigid plate fixation but could have considered a headless compression screw. In conclusion, this case report demonstrates the successful use of pollicization for thumb reconstruction and free ALT flap in transmetatarsal amputation in a patient with vasopressor-induced digit loss. It also highlights the challenges associated with vasopressor-induced limb loss and the impact of undiagnosed compartment syndrome on reconstructive options in achieving favorable outcomes.

This case demonstrates an approach for reconstruction of prehensile function and sensate foot salvage following vasopressor-induced distal loss of multiple extremities, with a focus on specific challenges and pitfalls.

This manuscript represents the feasibility of complex reconstructive strategies, including pollicization and free flap reconstruction, in patients with vasopressor-induced ischemic limb loss. It highlights the importance of individualized surgical planning and multidisciplinary care to optimize functional and esthetic outcomes in high-risk patients.