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Hand Surgery, Vol. 20, No. 1 (2015) 173–179 © World Scientific Publishing Company DOI: 10.1142/S0218810415970035
NEW TECHNIQUE “GRAFT REPOSITION ON FLAP” IN ALLEN TYPE IV AMPUTATION: A REPORT OF SIX CASES Vijay A. Malshikare
Hand Surg. 2015.20:173-179. Downloaded from www.worldscientific.com by MCGILL UNIVERSITY on 02/26/15. For personal use only.
Consultant Hand and Wrist Surgeon, Jehangir Hospital 32, Sassoon Road, Pune 411001, India Received 2 May 2014; Revised 3 July 2014; Accepted 3 July 2014; Published 20 January 2015 ABSTRACT Allen type IV fingertip amputations were treated by a modified technique, when the replantation is difficult to be performed or not an option. The pre-existing technique involves nail bed grafting and local flap. In the modified technique, a free bone graft is added, bone and free nail bed repositioned and pulp reconstruction by local flap. This can be best described \graft reposition on flap" (GRF). GRF was found to be simple and cost effective. It allows preservation of finger length and a fully functional and cosmetically acceptable nail. Keywords: Fingertip Amputation; Graft Reposition; Flap.
INTRODUCTION
reconstruction with simultaneous local flap and nail bed grafting is a much simpler method but in Allen type IV, it leads to shortening of the finger and nail deformity, as the remaining bone has inadequate support.7,8 We have described a preferred modified technique to address fingertip amputations. It involves fixing the separate bone and full thickness nail bed retrieved from the amputated part and pulp reconstruction. Reattached of bone and free nail bed separately as graft \graft reposition" and flap cover on graft hence described as \graft reposition on flap" (GRF). We have confined use of GRF to Allen type IV, when replantation of the fingertip was considered unfeasible.
The nail is not just an ornament but is a functionally important part of the fingertip. It protects the distal finger and improves the stability and sensibility of the pulp.1 In practically all cultures, the presence of a nail at the tip of the finger and a normal finger length are highly valued by both sexes for cosmesis and to pick up small objects (needles, pins, etc.). Fingertip injuries are often distal and treated according to the amount of soft tissue loss and the exact level of the injury. Allen’s classification is commonly used to describe the level of fingertip amputation.2 Type I injuries involve the pulp only. Type II injuries include the pulp and nail bed. Type III injuries include partial loss of the distal phalanx plus corresponding losses of pulp and nail. Type IV injuries involve the lunula, distal phalanx, and pulp with nail bed loss. Replantation gives a good functional and cosmetic result,3–6 but is technically demanding, requires microsurgical skills, adequate facilities and therefore not always possible. Fingertip
PATIENTS AND METHODS Six fingertip amputations in six patients were treated between 2012 and 2013. All of the patients were male and an average
Correspondence to: Dr. Vijay A. Malshikare, Consultant Hand and Wrist Surgeon, Jehangir Hospital, 32, Sassoon Road, Pune 411001, India. Tel: (+91) 982-2443304, E-mail: [email protected] 173
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age was 24.5 years (range 16–32 years). All except four were right handed, three were manual workers and none of them were smokers. Digits involved were the index finger (N ¼ 4) and the middle finger (N ¼ 2). The mechanism of injury was crushing with complete amputation in five patients and clean severance in one patient. Most of the amputations were due to workplace accidents, accounting for four cases, one was household injury and one road traffic accident. All patients brought the amputated finger part to hospital. All patients were treated under regional anaesthesia. Patients were asked about nail growth, finger length, mobility, cold intolerance and donor site problem as well as the inconvenience. Sensitivity was evaluated with two-point discrimination (Weber’s static test).
SURGICAL TECHNIQUE Patients presenting with Allen type IV amputation and infeasible replantation were included for GRF procedure (Fig. 1). Step 1 The amputed finger tip was debrided and full thickness nail bed graft and bone were separated from the amputated part (Fig. 2). The severed distal bone was immobilized to the proximal amputated stump with an axial 21G needle or by the K-wire (0.8 mm). The nail bed graft was sutured as full thickness nail graft with 6–0 chromic catgut (Ethicon) to the remaining bed (Fig. 3).
Fig. 1
Severe crushed amputation of a long finger (Allen type IV).
Fig. 2
Full thickness nail bed (A) and bone (B) grafts are harvested.
Step 2 Thenar flap was harvested from the radial side of the proximal thumb crease and a transposition flap approach to close the donor defect primarily. The flap was sutured to nail folds with 3-0 nylon to cover pulp loss and bone. The flap should protrude beyond the tip, providing extra skin which will recontour to a rounded tip. It was ensured that
Fig. 3 The distal bone is immobilized with an axial needle with free nail bed grafting (graft reposition).
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nail bed was placed on the raw surface of the flap, thereby covering the dorsal surface of exposed tip of terminal phalanx (Figs. 4–7). Step 3 The nail plate was then repositioned in the nail fold to prevent the formation of synechiae between the nail fold and the injured nail bed. The finger was immobilized for two weeks in a below-elbow dorsal slab. Thenar flap division and insetting of the flap to the finger was done after 14–18 days and patients were reviewed at three months interval.
Hand Surg. 2015.20:173-179. Downloaded from www.worldscientific.com by MCGILL UNIVERSITY on 02/26/15. For personal use only.
Fig. 4
Design of thenar flap on the radial side of proximal thumb crease.
RESULTS
Fig. 5
A transposition flap approach to close the donor defect primarily.
Fig. 6
The final insetting of thenar flap.
All cases were treated on an ambulatory basis. There was no problem in healing of flap. In two patients, nail bed growth problems were developed after two weeks and subsequently, one was replaced by a partial thickness nail bed graft and the other was treated with V-Y plasty. It was observed thin primary nail on the grafted nail bed about three weeks after grafting, after which the newly formed nail became more natural in appearance and thickness (8 to10 months). All patients underwent physiotherapy in the form of active and passive joint movement. A static dorsal orthosis was used in almost all cases to prevent PIP flexion contracture. The range of motion of DIP and PIP joints were full (0 to 80 and 0 to 100 ), except one patient who developed DIP and PIP stiffness due to late division of flap (after three weeks) but it resolved with static dorsal splint. All the patients were followed for an average 12 months. Table 1 shows patient data and functional results after 12 months. No marked difference in digit length and nail appearance (Fig. 8) observed in four patients and remaining two patients observed shortening and an irregular contour of nail. However, no hooking was observed. Static two-point discrimination gave an average of 6.2 mm in all patients. Five of six patients said they had no inconvenience in daily living or working activities. One had mild inconvenience. All patients used their hands normally, none excluded the injured finger when gripping, and all used their fingertips in pinching and picking up small objects normally. There was no scar tenderness at the donor site and surgical scar of donor side was away from contact site of palm (Fig. 9). None of the patients developed cold intolerance or neuroma formation and most notably no flexion contracture in the recipient digit.
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Fig. 7 Schematic presentation of GRF in Allen type IV finger amputation. (A) Full thickness nail bed graft (a) and bone (b) are harvested. The severed distal bone is immobilized with an axial needle and free nail bed grafting (B) and (C) harvesting thenar flap radially and in the proximal thumb crease and insetting. Asterisk indicates nail bed graft should place on the dorsal surface of exposed tip of terminal phalanx and raw surface of the flap.
Table 1
Cases 1 2 3 4 5 6
Patient Data and Functional Results.
Age (Years)
Sex
Finger
Injury Geometry
Methods
18 17 22 27 31 32
M M M M M M
Middle Middle Index Index Index Index
Lateral oblique Transverse Lateral oblique Volar oblique Volar oblique Volar oblique
BþNBþTF BþNBþTF BþNBþ VYP BþNBþTF BþNBþTF BþNBþ TF
Complication
Finger Length (N) (mm)
Finger Length (R) (mm)
N --- R = S (mm)
Nail bed growth problem Nail bed growth problem
23 25 25 27 24 24
20 20 20 24 13 16
3 5 5 3 11 8
Note: B ¼ Bone, NB ¼ Nail bed, TF ¼ Thenar flap, VYP ¼ V-Y plasty, N ¼ Normal opposite same fingertip, R ¼ Reconstructed fingertip, S ¼ Shortening.
DISCUSSION Netscher and Meade have emphasised that there is no unanimity regarding the best treatment of fingertip amputation because an evaluation of published results is problematic.9 Allen type IV amputations leave short sterile matrix and are typically treated by complete ablation of the nail bed and germinal matrix with closure by a palmar advancement flap or reconstruction by nail bed grafting and local flap is usually carried out. Unfortunately, nail deformities are common and as the remaining bone has inadequate length for satisfactory nail growth results in shortening of finger. Management of type IV fingertip amputations are challenging, as these treatments
often fail to meet the patient’s desire to retain the nail and finger length. To restore the original nail bed and most important underlying bone support which provide a critical factor in preventing the development of a hook nail deformity,10 replantation is an available technique. Successful replantation results in an almost normal finger, but requires high levels of microvascular skill. Amputation level is beyond the base of finger nail (germinal layer) and anastomosing vascular arcade of the fingertip and the terminal arterial branches are small in this area (0.2–0.5 mm diameter in adult)11 and no dorsal vein, which poses a problem for venous return. The amount of tissue
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Hand Surg. 2015.20:173-179. Downloaded from www.worldscientific.com by MCGILL UNIVERSITY on 02/26/15. For personal use only.
(A)
Fig. 9 At 12 months, healing of donor site and surgical scar is away from contact area of palm.
(B)
(C) Fig. 8 (A) The comparative view of opposite side of the digit length after 12 months. (B) An appearance and growth of the nail. (C) Pulp contour with the transfer of finger print from a donor site after 12 months in another patient.
to be replanted varies greatly depending on the crushing and type of amputation, whether transverse or with a palmar or dorsal extension. They are associated with expensive and prolonged postoperative care and the failure of replantation or partial soft tissue necrosis is common. We have developed a useful alternative when replantation is impossible and not an option. The aim of surgical technique is to restore the original finger length, preserve its cosmetic appearance and avoid the onset of severe nail deformities. The modified technique involves transferring bone and full thickness nail bed \graft reposition" and local flap cover on graft. Increasing the area of contact and reducing the size of tissue with a vascular bed is known to increase the survival rate.12 Flap was selected depending on geometry and volar loss of amputed finger. The pulp and exposed bone were covered by a thenar flap in five patients and by palmar V-Y flap13 in one patient. Venkataswami flap,14 cross finger flap and homodigital innervated flap are an alternate option. We prefer thenar flap due to perfect tissue match, abundance of subcutaneous tissues and its inconspicuous donor site. Thenar flap was designed so as to lie in the proximal thumb crease and be based radially. This lessens PIP flexion of the recipient digit without altering the requirement for early splintage. All patients were young and had very good compliance. Physiotherapy and dorsal orthosis played a special role in patients’ rehabilitation.
January 14, 2015
Hand Surg. 2015.20:173-179. Downloaded from www.worldscientific.com by MCGILL UNIVERSITY on 02/26/15. For personal use only.
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(A)
Trials in which amputated fingertip injuries were treated with nail bed grafting and local flap have been reported and results were least favourable when amputations were through the nail fold.8 Hwang et al. performed fingertip reconstructions for more proximal fingertip amputations (Allen type IV) using local or distinct flaps combined with nail bed grafts in place of ablation of the nail matrix and results were favourable in Allen type II or III and unfavourable in Allen type IV.7 The GRF has been an alternative procedure in badly crushed amputations involving the lunula, distal phalanx, and pulp with nail bed loss, which have been deemed nonreplantable by microsurgery. The technique itself is simple, easy, reliable, and most importantly cost-effective. The nail bed and bone are not discarded even in crushed amputed part. It does not require advance skills and can be done by a welltrained resident or fellow. We have been able to recommend with confidence to patients. The limitation of the current study is a small sample size, but due to promising results, a large scale study of GRF in Allen type IV fingertip amputation is required. There is no financial support. There is no any financial and personal relationship with other people or organisations.
ACKNOWLEDGEMENTS Dr. Philippe Saffar, Dr. Abhijeet Wahegaonkar, Dr. Kiranjit Singh and Dr. Kaushik Kulkarni for their kind help. (B) Fig. 10 (A) Pre-operative radiograph. (B) Radiograph shows healing of bone graft with bone resorption after 1 year.
All patients had shortening of the fingers. These shortening were due to bone resorption from the distal fragments (Fig. 10). Four out of six patients had mild shortening and other two had marked shortening due to nail bed growth problems. This nail bed growth problems were presumably because of suture related nail bed ischemia and/or torsion of flap therefore, avoided sutures in the base or tip of the flap (only suture the sides) and a transposition flap approach to close the donor defect primarily. Therefore, the author adopted this approach and avoided nail bed growth problems in following four patients.
References 1. Bunnell S, Surgery of the nerves of the hand, Surg Gynaecol Obstet 44:145, 1927. 2. Allen M, Conservative management of fingertip injuries in adults, Hand 12:257–265, 1980. 3. Chen CT, Wei FC, Chen HC, Chuang CC, Chen HT, Hsu WM, Distal phalanx replantation, Microsurgery 15:77–82, 1994. 4. Foucher G, Norris RW, Distal and very distal replantation, Br J Plast Surg 45:199–203, 1992. 5. Hattori Y, Doi K, Sakamoto S, Yamasaki H, Wahegaonkar A, Fingertip replantation, J Hand Surg 32A:548–555, 2007. 6. Tamai S, Digital replantation: Analysis of 163 replantations in an 11year period, Clin Plast Surg 5:195–197, 1978. 7. Hwang E, Park BH, Song SY, Jung HS, Kim CH, Fingertip reconstruction with simultaneous flaps and nail bed grafts following amputation, J Hand Surg 38A:1307–1314, 2013.
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8. Raja Sabapathy S, Venkatramani H, Bharathi R, Jayachandran S, Reconstruction of finger tip amputations with advancement flap and free nail bed graft, J Hand Surg 27B:134–138, 2002. 9. Netscher D, Meade RA, Reconstruction of finger to amputations with full-thickness perionychial grafts from the retained part and local flaps, Plast Reconstr Surg 104(6):1705–1712, 1999. 10. Kumar VP, Satku K, Treatment and prevention of \hook nail" deformity with anatomic correlation, J Hand Surg 18A(4):617–620, 1993. 11. Yamano Y, Replantation of the amputated distal part of the fingers, J Hand Surg 10A:211–218, 1985.
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12. Lee PK, Ahn ST, Lim P, Replantation of fingertip amputation by using the pocket principle in adult, Plast Reconst Surgr 24:525–530, 1999. 13. Atasoy E, Triangular volar skin flap to the fingertip, in Strauch B, Vasconez LO, Hall-Findlay EJ (eds.), Grabb’s Encyclopaedia of Flaps, Vol. 2, Boston, Little, Brown and Company, pp. 805–808, 1990. 14. Venkataswami R, Subramanian N, Oblique triangular flap: A new method of repair for oblique amputations of the fingertip and thumb, Plast Reconst Surg 66:296–300, 1980.
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Hand Surgery, Vol. 20, No. 1 (2015) 173–179 © World Scientific Publishing Company DOI: 10.1142/S0218810415970035
NEW TECHNIQUE “GRAFT REPOSITION ON FLAP” IN ALLEN TYPE IV AMPUTATION: A REPORT OF SIX CASES Vijay A. Malshikare
Hand Surg. 2015.20:173-179. Downloaded from www.worldscientific.com by MCGILL UNIVERSITY on 02/26/15. For personal use only.
Consultant Hand and Wrist Surgeon, Jehangir Hospital 32, Sassoon Road, Pune 411001, India Received 2 May 2014; Revised 3 July 2014; Accepted 3 July 2014; Published 20 January 2015 ABSTRACT Allen type IV fingertip amputations were treated by a modified technique, when the replantation is difficult to be performed or not an option. The pre-existing technique involves nail bed grafting and local flap. In the modified technique, a free bone graft is added, bone and free nail bed repositioned and pulp reconstruction by local flap. This can be best described \graft reposition on flap" (GRF). GRF was found to be simple and cost effective. It allows preservation of finger length and a fully functional and cosmetically acceptable nail. Keywords: Fingertip Amputation; Graft Reposition; Flap.
INTRODUCTION
reconstruction with simultaneous local flap and nail bed grafting is a much simpler method but in Allen type IV, it leads to shortening of the finger and nail deformity, as the remaining bone has inadequate support.7,8 We have described a preferred modified technique to address fingertip amputations. It involves fixing the separate bone and full thickness nail bed retrieved from the amputated part and pulp reconstruction. Reattached of bone and free nail bed separately as graft \graft reposition" and flap cover on graft hence described as \graft reposition on flap" (GRF). We have confined use of GRF to Allen type IV, when replantation of the fingertip was considered unfeasible.
The nail is not just an ornament but is a functionally important part of the fingertip. It protects the distal finger and improves the stability and sensibility of the pulp.1 In practically all cultures, the presence of a nail at the tip of the finger and a normal finger length are highly valued by both sexes for cosmesis and to pick up small objects (needles, pins, etc.). Fingertip injuries are often distal and treated according to the amount of soft tissue loss and the exact level of the injury. Allen’s classification is commonly used to describe the level of fingertip amputation.2 Type I injuries involve the pulp only. Type II injuries include the pulp and nail bed. Type III injuries include partial loss of the distal phalanx plus corresponding losses of pulp and nail. Type IV injuries involve the lunula, distal phalanx, and pulp with nail bed loss. Replantation gives a good functional and cosmetic result,3–6 but is technically demanding, requires microsurgical skills, adequate facilities and therefore not always possible. Fingertip
PATIENTS AND METHODS Six fingertip amputations in six patients were treated between 2012 and 2013. All of the patients were male and an average
Correspondence to: Dr. Vijay A. Malshikare, Consultant Hand and Wrist Surgeon, Jehangir Hospital, 32, Sassoon Road, Pune 411001, India. Tel: (+91) 982-2443304, E-mail: [email protected] 173
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age was 24.5 years (range 16–32 years). All except four were right handed, three were manual workers and none of them were smokers. Digits involved were the index finger (N ¼ 4) and the middle finger (N ¼ 2). The mechanism of injury was crushing with complete amputation in five patients and clean severance in one patient. Most of the amputations were due to workplace accidents, accounting for four cases, one was household injury and one road traffic accident. All patients brought the amputated finger part to hospital. All patients were treated under regional anaesthesia. Patients were asked about nail growth, finger length, mobility, cold intolerance and donor site problem as well as the inconvenience. Sensitivity was evaluated with two-point discrimination (Weber’s static test).
SURGICAL TECHNIQUE Patients presenting with Allen type IV amputation and infeasible replantation were included for GRF procedure (Fig. 1). Step 1 The amputed finger tip was debrided and full thickness nail bed graft and bone were separated from the amputated part (Fig. 2). The severed distal bone was immobilized to the proximal amputated stump with an axial 21G needle or by the K-wire (0.8 mm). The nail bed graft was sutured as full thickness nail graft with 6–0 chromic catgut (Ethicon) to the remaining bed (Fig. 3).
Fig. 1
Severe crushed amputation of a long finger (Allen type IV).
Fig. 2
Full thickness nail bed (A) and bone (B) grafts are harvested.
Step 2 Thenar flap was harvested from the radial side of the proximal thumb crease and a transposition flap approach to close the donor defect primarily. The flap was sutured to nail folds with 3-0 nylon to cover pulp loss and bone. The flap should protrude beyond the tip, providing extra skin which will recontour to a rounded tip. It was ensured that
Fig. 3 The distal bone is immobilized with an axial needle with free nail bed grafting (graft reposition).
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nail bed was placed on the raw surface of the flap, thereby covering the dorsal surface of exposed tip of terminal phalanx (Figs. 4–7). Step 3 The nail plate was then repositioned in the nail fold to prevent the formation of synechiae between the nail fold and the injured nail bed. The finger was immobilized for two weeks in a below-elbow dorsal slab. Thenar flap division and insetting of the flap to the finger was done after 14–18 days and patients were reviewed at three months interval.
Hand Surg. 2015.20:173-179. Downloaded from www.worldscientific.com by MCGILL UNIVERSITY on 02/26/15. For personal use only.
Fig. 4
Design of thenar flap on the radial side of proximal thumb crease.
RESULTS
Fig. 5
A transposition flap approach to close the donor defect primarily.
Fig. 6
The final insetting of thenar flap.
All cases were treated on an ambulatory basis. There was no problem in healing of flap. In two patients, nail bed growth problems were developed after two weeks and subsequently, one was replaced by a partial thickness nail bed graft and the other was treated with V-Y plasty. It was observed thin primary nail on the grafted nail bed about three weeks after grafting, after which the newly formed nail became more natural in appearance and thickness (8 to10 months). All patients underwent physiotherapy in the form of active and passive joint movement. A static dorsal orthosis was used in almost all cases to prevent PIP flexion contracture. The range of motion of DIP and PIP joints were full (0 to 80 and 0 to 100 ), except one patient who developed DIP and PIP stiffness due to late division of flap (after three weeks) but it resolved with static dorsal splint. All the patients were followed for an average 12 months. Table 1 shows patient data and functional results after 12 months. No marked difference in digit length and nail appearance (Fig. 8) observed in four patients and remaining two patients observed shortening and an irregular contour of nail. However, no hooking was observed. Static two-point discrimination gave an average of 6.2 mm in all patients. Five of six patients said they had no inconvenience in daily living or working activities. One had mild inconvenience. All patients used their hands normally, none excluded the injured finger when gripping, and all used their fingertips in pinching and picking up small objects normally. There was no scar tenderness at the donor site and surgical scar of donor side was away from contact site of palm (Fig. 9). None of the patients developed cold intolerance or neuroma formation and most notably no flexion contracture in the recipient digit.
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Fig. 7 Schematic presentation of GRF in Allen type IV finger amputation. (A) Full thickness nail bed graft (a) and bone (b) are harvested. The severed distal bone is immobilized with an axial needle and free nail bed grafting (B) and (C) harvesting thenar flap radially and in the proximal thumb crease and insetting. Asterisk indicates nail bed graft should place on the dorsal surface of exposed tip of terminal phalanx and raw surface of the flap.
Table 1
Cases 1 2 3 4 5 6
Patient Data and Functional Results.
Age (Years)
Sex
Finger
Injury Geometry
Methods
18 17 22 27 31 32
M M M M M M
Middle Middle Index Index Index Index
Lateral oblique Transverse Lateral oblique Volar oblique Volar oblique Volar oblique
BþNBþTF BþNBþTF BþNBþ VYP BþNBþTF BþNBþTF BþNBþ TF
Complication
Finger Length (N) (mm)
Finger Length (R) (mm)
N --- R = S (mm)
Nail bed growth problem Nail bed growth problem
23 25 25 27 24 24
20 20 20 24 13 16
3 5 5 3 11 8
Note: B ¼ Bone, NB ¼ Nail bed, TF ¼ Thenar flap, VYP ¼ V-Y plasty, N ¼ Normal opposite same fingertip, R ¼ Reconstructed fingertip, S ¼ Shortening.
DISCUSSION Netscher and Meade have emphasised that there is no unanimity regarding the best treatment of fingertip amputation because an evaluation of published results is problematic.9 Allen type IV amputations leave short sterile matrix and are typically treated by complete ablation of the nail bed and germinal matrix with closure by a palmar advancement flap or reconstruction by nail bed grafting and local flap is usually carried out. Unfortunately, nail deformities are common and as the remaining bone has inadequate length for satisfactory nail growth results in shortening of finger. Management of type IV fingertip amputations are challenging, as these treatments
often fail to meet the patient’s desire to retain the nail and finger length. To restore the original nail bed and most important underlying bone support which provide a critical factor in preventing the development of a hook nail deformity,10 replantation is an available technique. Successful replantation results in an almost normal finger, but requires high levels of microvascular skill. Amputation level is beyond the base of finger nail (germinal layer) and anastomosing vascular arcade of the fingertip and the terminal arterial branches are small in this area (0.2–0.5 mm diameter in adult)11 and no dorsal vein, which poses a problem for venous return. The amount of tissue
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Hand Surg. 2015.20:173-179. Downloaded from www.worldscientific.com by MCGILL UNIVERSITY on 02/26/15. For personal use only.
(A)
Fig. 9 At 12 months, healing of donor site and surgical scar is away from contact area of palm.
(B)
(C) Fig. 8 (A) The comparative view of opposite side of the digit length after 12 months. (B) An appearance and growth of the nail. (C) Pulp contour with the transfer of finger print from a donor site after 12 months in another patient.
to be replanted varies greatly depending on the crushing and type of amputation, whether transverse or with a palmar or dorsal extension. They are associated with expensive and prolonged postoperative care and the failure of replantation or partial soft tissue necrosis is common. We have developed a useful alternative when replantation is impossible and not an option. The aim of surgical technique is to restore the original finger length, preserve its cosmetic appearance and avoid the onset of severe nail deformities. The modified technique involves transferring bone and full thickness nail bed \graft reposition" and local flap cover on graft. Increasing the area of contact and reducing the size of tissue with a vascular bed is known to increase the survival rate.12 Flap was selected depending on geometry and volar loss of amputed finger. The pulp and exposed bone were covered by a thenar flap in five patients and by palmar V-Y flap13 in one patient. Venkataswami flap,14 cross finger flap and homodigital innervated flap are an alternate option. We prefer thenar flap due to perfect tissue match, abundance of subcutaneous tissues and its inconspicuous donor site. Thenar flap was designed so as to lie in the proximal thumb crease and be based radially. This lessens PIP flexion of the recipient digit without altering the requirement for early splintage. All patients were young and had very good compliance. Physiotherapy and dorsal orthosis played a special role in patients’ rehabilitation.
January 14, 2015
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(A)
Trials in which amputated fingertip injuries were treated with nail bed grafting and local flap have been reported and results were least favourable when amputations were through the nail fold.8 Hwang et al. performed fingertip reconstructions for more proximal fingertip amputations (Allen type IV) using local or distinct flaps combined with nail bed grafts in place of ablation of the nail matrix and results were favourable in Allen type II or III and unfavourable in Allen type IV.7 The GRF has been an alternative procedure in badly crushed amputations involving the lunula, distal phalanx, and pulp with nail bed loss, which have been deemed nonreplantable by microsurgery. The technique itself is simple, easy, reliable, and most importantly cost-effective. The nail bed and bone are not discarded even in crushed amputed part. It does not require advance skills and can be done by a welltrained resident or fellow. We have been able to recommend with confidence to patients. The limitation of the current study is a small sample size, but due to promising results, a large scale study of GRF in Allen type IV fingertip amputation is required. There is no financial support. There is no any financial and personal relationship with other people or organisations.
ACKNOWLEDGEMENTS Dr. Philippe Saffar, Dr. Abhijeet Wahegaonkar, Dr. Kiranjit Singh and Dr. Kaushik Kulkarni for their kind help. (B) Fig. 10 (A) Pre-operative radiograph. (B) Radiograph shows healing of bone graft with bone resorption after 1 year.
All patients had shortening of the fingers. These shortening were due to bone resorption from the distal fragments (Fig. 10). Four out of six patients had mild shortening and other two had marked shortening due to nail bed growth problems. This nail bed growth problems were presumably because of suture related nail bed ischemia and/or torsion of flap therefore, avoided sutures in the base or tip of the flap (only suture the sides) and a transposition flap approach to close the donor defect primarily. Therefore, the author adopted this approach and avoided nail bed growth problems in following four patients.
References 1. Bunnell S, Surgery of the nerves of the hand, Surg Gynaecol Obstet 44:145, 1927. 2. Allen M, Conservative management of fingertip injuries in adults, Hand 12:257–265, 1980. 3. Chen CT, Wei FC, Chen HC, Chuang CC, Chen HT, Hsu WM, Distal phalanx replantation, Microsurgery 15:77–82, 1994. 4. Foucher G, Norris RW, Distal and very distal replantation, Br J Plast Surg 45:199–203, 1992. 5. Hattori Y, Doi K, Sakamoto S, Yamasaki H, Wahegaonkar A, Fingertip replantation, J Hand Surg 32A:548–555, 2007. 6. Tamai S, Digital replantation: Analysis of 163 replantations in an 11year period, Clin Plast Surg 5:195–197, 1978. 7. Hwang E, Park BH, Song SY, Jung HS, Kim CH, Fingertip reconstruction with simultaneous flaps and nail bed grafts following amputation, J Hand Surg 38A:1307–1314, 2013.
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8. Raja Sabapathy S, Venkatramani H, Bharathi R, Jayachandran S, Reconstruction of finger tip amputations with advancement flap and free nail bed graft, J Hand Surg 27B:134–138, 2002. 9. Netscher D, Meade RA, Reconstruction of finger to amputations with full-thickness perionychial grafts from the retained part and local flaps, Plast Reconstr Surg 104(6):1705–1712, 1999. 10. Kumar VP, Satku K, Treatment and prevention of \hook nail" deformity with anatomic correlation, J Hand Surg 18A(4):617–620, 1993. 11. Yamano Y, Replantation of the amputated distal part of the fingers, J Hand Surg 10A:211–218, 1985.
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12. Lee PK, Ahn ST, Lim P, Replantation of fingertip amputation by using the pocket principle in adult, Plast Reconst Surgr 24:525–530, 1999. 13. Atasoy E, Triangular volar skin flap to the fingertip, in Strauch B, Vasconez LO, Hall-Findlay EJ (eds.), Grabb’s Encyclopaedia of Flaps, Vol. 2, Boston, Little, Brown and Company, pp. 805–808, 1990. 14. Venkataswami R, Subramanian N, Oblique triangular flap: A new method of repair for oblique amputations of the fingertip and thumb, Plast Reconst Surg 66:296–300, 1980.
