Objective: Reconstruction of the mutilated hand is one of the most difficult challenges for hand surgeons. When multiple digits are amputated, orthotopic digital replantation of the available remnants may not adequately restore hand function. In such cases, heterotopic digital replantation may provide a more functional reconstruction. Patients and Methods: Between 1997 and 2008, 29 patients with mutilating hand injuries were treated with heterotopic digital replantation at our institution. A retrospective chart review was conducted to determine the details of the injury, indications for heterotopic digital replantation, and functional outcomes. Results: In total, 100 digits were amputated from 29 patients’ hands. Thirty-nine digits underwent heterotopic digital replantation, 20 digits had orthotopic digital replantation, and 41 stumps were terminalized. The survival rate of digits treated by heterotopic digital replantation and orthotopic digital replantation was 87.2% (34/39) and 95% (19/20), respectively. Tripod pinch was achieved in 82.8% (24/29) of patients following replantation and any secondary reconstructive surgery that was required. Conclusions: Heterotopic digital replantation is a practical and reliable method for achieving optimal hand function following mutilating hand injuries. It is particularly indicated when orthotopic digital replantation of the available amputated parts would yield a suboptimal result. The principles are to restore a functional thumb in the first instance, followed by at least 2 adjacent fingers against which the thumb can oppose.
