Sensory outcome of fingertip replantations without nerve repair

Sequential Clinical Recovery after Replantation for Complete Finger Amputation in Tamai Zone 1

Background  The clinical results of replantation for an amputated distal finger are functionally acceptable. However, few reports exist regarding sequential clinical postoperative recovery. The purpose of this study was to examine the clinical recovery at every 3 months up to 1 year postoperatively. Methods  Nineteen patients (16 patients were men), representing 19 fingers with complete amputation at Tamai's zone 1 and replanted successfully, were included in this study. Total active motion (TAM), grip strength (GS), Semmes-Weinstein monofilament (SW) test result, static two-point discrimination (s2PD), and Disability of the Arm, Shoulder, and Hand (DASH) score questionnaire results were obtained postoperatively at 3, 6, 9, and 12 months. Pulp atrophy and nail deformity were assessed at 12 months postoperatively. Results  The postoperative %TAM (compared to the uninjured side, 81.8 ± 18.1 at 3 months vs. 91.5 ± 11.9 at 6 months, p  < 0.01), %GS (compared with the uninjured side, 61.3 ± 25.9 at 3 months vs. 78.3 ± 20.4 at 6 months, p  = 0.02), s2PD (excellent and good/poor; 7/12 at 3 months vs. 18/1 at 6 months, p  < 0.01), and DASH scores (26.1 ± 23.1 at 3 months vs. 12.0 ± 12.9 at 6 months, p  < 0.01) recovered significantly from 3 to 6 months but did not change significantly from 6 months onward. The SW test results showed a significant recovery between 3 and 12 months postoperatively (2.83 and 3.61/4.31, 6.65, and undetectable, 1/18 at 3 months vs. 7/12 at 12 months, p  = 0.04). The DASH score at 12 months postoperatively was significantly associated with %TAM ( r  = -0.64, p  < 0.01) and %GS ( r  = -0.58, p  < 0.01) at 12 months postoperatively and age ( r  = 0.52, p  = 0.02). Five fingers had pulp atrophy and four fingers had nail deformity. Conclusion  This 1-year follow-up study showed the sequential clinical recovery after replantation for complete amputation in Tamai zone 1. Postoperative %TAM, %GS, and the DASH score recovered significantly between 3 and 6 months but significant recovery up to 1 year was not observed.

Effects of external bleeding and hyperbaric oxygen treatment on Tamai zone 1 replantation

INTRODUCTION

Tamai zone 1 replantation poses a challenge due to the very small size of the vascular structures; often there is no vein for anastomosis. Replantation may have to be done with only an arterial anastomosis. In our study, we aimed to evaluate the success of replantation by combining external bleeding and hyperbaric oxygen treatment (HBOT) in Tamai zone 1 replantation.

METHODS

Between January 2017 and October 2021, 17 finger replantation patients who underwent artery-only anastomosis due to Tamai zone 1 amputation received 20 sessions of HBOT with external bleeding after the 24th postoperative hour. Finger viability was assessed at the end of treatment. A retrospective review of outcomes was performed.

RESULTS

Seventeen clean-cut finger amputation patients were operated on under digital block anaesthesia with a finger tourniquet. No blood transfusion was required. In one patient, complete necrosis developed and stump closure was performed. Partial necrosis was observed in three patients and healed secondarily. Replantation in the remaining patients was successful.

CONCLUSIONS

Vein anastomosis is not always possible in fingertip replantation. In Tamai zone 1 replantation with arteryonly anastomosis, post-operative HBOT with induced external bleeding appeared to shortened the hospital stay and was associated with a high proportion of successful outcomes.

Repair of fingertip defect with reverse digital artery island flap and repair of donor site with digital dorsal advancement flap

Objective

The reverse digital artery island flap (RDAF) is widely used in repairing fingertip skin defects based on its good appearance and practicability. However, the donor area of the flap needs skin grafting, which can lead to complications. This retrospective study explored the clinical application of digital dorsal advance flap (DDAF) in repairing the donor site of the reverse digital artery island flap.

Method

From June 2019 to February 2022, 17 patients with a soft tissue defect of the finger had been restored with the reverse digital artery island flap, and at the same time, the donor area was repaired with digital dorsal advance flap (DDAF). The sensitivity, the active range of motion (ROM) and patient satisfaction were assessed after the operation.

Results

All flaps survived completely without skin grafting with only one linear scar. The sensory and motor functions of all patients recovered well. Assessment based on the Michigan Hand Outcomes Questionnaire (MHQ) showed satisfactory functional recovery for all patients.

Conclusions

Reconstruction using RDAF combined with DDAF represents an effective alternative for repairing fingertip skin defects.

Reverse Flow Shunt Restricted Free Venous Flap for a Ring Avulsion Injury

Arterialized venous flaps can be an excellent option for reconstruction of digital defects. Previously, they remained unpopular owing to the high rate of venous congestion. Different techniques of restriction of the arteriovenous shunting have been described to mitigate this problem. In this article, the authors discuss a unique case whereby a reverse flow shunt restricted venous flap was used in an Urbaniak type III ring avulsion.

Investigation of Predictors of Successful Replantation of Distal Digits at the Nail Bed Level: The Contribution of Digital Nerve Repair to Survival Rate

BACKGROUND

Replantation of amputated digits at the nail bed level is surgically challenging and differs from replantation at a more proximal amputation level. This study aimed to determine the predictors influencing the success rate of fingertip replantation.

METHODS

Overall, 239 digits of 226 patients who underwent replantation surgery from August of 2009 to March of 2020 were considered. A total of 15 independent variables (i.e., sex; age; injured hand; digit; history of smoking; history of hypertension or diabetes; injury mechanism; amputation level; ischemia duration; surgeon's expertise; numbers of repaired arteries, veins, and nerves; and the need for a vein graft) were investigated for their effects on the survival of the replanted digits.

RESULTS

Of all 239 digits, 190 (79.5 percent) survived. Univariate analysis indicated that non-crush-avulsion injury, expertise and experience of the surgeon, vein repair, and nerve repair contributed to increasing the survival rate. Binary logistic regression analysis demonstrated that injury mechanism, vein repair, and nerve repair were significant predictive factors. In addition, in non-vein-repaired, blunt cut, or Ishikawa subzone II cases, digital nerve repair contributed significantly to promote the success rate relative to vein-repaired, crush-avulsion-type injury, and subzone I cases.

CONCLUSIONS

Vein repair, nerve repair, non-crush-avulsion injury, and surgeon's expertise and experience were the predictors for successful replantation. Intraoperative vein and nerve repair are recommended to improve the survival rate of fingertip replantation at the nail bed level.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Assessment of sensory outcomes after successful fingertip replantation with or without nerve repair according to amputation level

BACKGROUND

Good sensory outcome in fingertip replantation is a major part of the success of reconstruction and using the finger. Although some sensorial outcomes have been reported in various series in the literature, there is no controlled study, which demonstrates the anatomical levels where nerve repair should or should not be performed. We aimed to assess sensorial outcomes of fingertip amputations with or without nerve coaptation according to amputation level.

METHODS

Between January 2013 and July 2018, patients with Tamai Zone 1 and Zone 2 amputations underwent replantation. The patients were divided two main groups. Patients underwent nerve coaptation were grouped as Group 1, and those coaptation not performed as Group 2. In addition, subgroups were designed according to level of the amputation. Tamai zone 1 amputations were grouped as groups 1a and 2a. Tamai zone 2 amputations were grouped as groups 1b and 2b. The mean age was 30.8 ± 30.8 years in Group 1a, 33.2 ± 12.6 years in Group 1b, 34.1 ± 13.6 years in Group 2a, 34.3 ± 11.1 years in Group 2b. Type of injury were evaluated as clean cut (with knife, saw etc.), moderately crushed, and severely crushed and/or avulsion. In Group 1a, one prominent branch of the nerve was repaired, and in Group 1b, the nerve in both side was repaired. The mean duration of replantation in Group 1a was 1 h and 40 min (1 h and 15 min-2 h), whereas this time was 1 h and 15 min (1 h - 1 h and 35 min) in Group 2a. Then, 2 h 15 min (1 h and 55 min-2 h and 50 min) in Group 1b, and 2 h (1 h and 45-2 h 25 min) in Group 2b. Mean age, type of injury and length of follow-up were statistically compared. Sensorial outcome was evaluated by 2-point discrimination test and the Semmes-Weinstein test.

RESULTS

According to the Semmes-Weinstein test, 33% of the fingers tested were normal, 58% had diminished light touch, 8% had diminished protective sensation, and 0% had loss of protective sensation in Group 1a; In Group 1b, these values were 35% (7/20), 55% (11/20), 10% (2/20), 0%; in Group 2a, 38% (6/16), 56% (9/16), 6% (1/16), 0%; in Group 2b, 25% (4/16), 44% (7/16), %25 (4/16), 6% (1/16), respectively Mean static two-point discriminations in Groups 1a, 1b, 2a, and 2b were 4.17 ± 0.58, 4.55 ± 0.69, 4.25 ± 0.68, and 5.9 ± 1.26 mm, respectively. The mean follow-up duration was 24 months in Group 1a, 24 months in Group 1b, 26 months in Group 2a, 21 months in Group 2b. Then, 17 (3 in Group 1a, 6 in Group 1b, 4 in Group 2a, 4 in Group 2b) of the 64 fingers were clean cut amputation, 45 (9 in Group 1a, 14 in Group 1b, 11 in Group 2a, 11 in Group 2b) were moderately crushed amputation, and 2 (1 in Group 2a, 1 in Group 2b) were severely crushed and/or avulsion injury. There was no statistically significant difference between groups 1a and 2a (p = .71). On the other hand, there was a statistically significant increase in sensory outcomes of patients in Group 1b compared to Group 2b (p = .009). There was no statistically significant between the groups in terms of mean age, type of injury and length of follow-up.

CONCLUSION

We think that nerve repair does not have a positive effect on sensorial recovery in Tamai Zone 1 amputations, but nerve coaptation should be performed in Tamai Zone 2 replantations if possible for better sensorial result.

Long-Term Outcomes of Successful Fingertip Replantation: A Follow-Up of at Least 10 Years

BACKGROUND

The purpose of this study was to evaluate the long-term outcome of successful fingertip replantations with more than 10 years of follow-up after surgery.

METHODS

A total of 34 successfully replanted digits in 31 patients with a mean period to follow-up of 16.5 years were included in this study. The main outcome measures were time to return to work, pain, cold intolerance, sensory recovery, nail deformity, grip strength, range of motion of the thumb interphalangeal or finger distal interphalangeal joint, fingertip atrophy, nonunion, bone shortening, use in activities of daily living, and patient satisfaction.

RESULTS

None of the patients reported chronic pain. No cold intolerance was experienced in 32 digits. Semmes-Weinstein monofilament testing showed recovery of protective sensation in 27 digits. The moving two-point discrimination test showed excellent or good recovery in 91 percent of the patients. Sensory recovery was satisfactory, and there was no significant difference regardless of nerve repair or injury type. Moderate to severe nail deformity was found in six digits. Fingertip atrophy was evaluated by comparing the volume of the replanted fingertip with the contralateral digit. The volume was 82 ± 17 percent of the contralateral normal side. There was no significant difference in the volume comparing the level of amputation, injury type, or incidence of postoperative vascular complication. Ninety-seven percent of the patients were satisfied with the results.

CONCLUSION

Long-term outcome of fingertip replantation more than 10 years after surgery was found to be favorable.

Mangled finger salvage using cross-finger revascularization

Background

Mangled finger with impaired arteria digitalis communis remains to be a challenge for replantation surgery due to the limited amount of tissue to work with.

Methods

Out of 554 hands with total finger amputations treated by replantation of finger/fingers from July 2012 to June 2018, there were 7 cases of damaged arteria digitalis communis, all of which were replanted by anastomosing distal adjacent radial/ulnar digital artery to distal end of ulnar/radial digital artery of amputation finger, and 2 veins were anastomosed for each finger. A skin pedicle was made by suturing both dorsal and palmar skin of adjacent fingers, and detachment was performed 4 weeks postoperatively.

Results

The survival rate was 100%. Mean total active motion was 191.4° (ranging from 170 to 220°). Mean 2-point discrimination was 8 mm static (ranging from 6 to 11 mm), and mean grip strength was 35.3 kg (range, 29 to 40 kg).

Conclusions

Based on our experience, cross-finger revascularization is an effective and safe alternative for mangled finger salvage when arteria digitalis communis is damaged, and good functional prognosis can be expected.

Efficiency in Replantation/Revascularization Surgery

Digital replantation and revascularization have evolved significantly since the first published reports in the 1960s. Advances in techniques and instruments have made these once formidable procedures a routine part of hand surgery training. Despite this, the frequency of successful outcomes for replantation may be on the decline in the United States. This review summarizes key mechanisms and innovations used to maximize efficiency when presented with a digital replantation, from the moment the patient arrives in the emergency department until the time of discharge.

Fingertip replantation (zone I) without venous anastomosis: clinical experience and outcome analysis

PURPOSE

The purpose of this study was to report our experience of fingertip replantation without venous anastomosis using alternate method to counter post-operative venous congestion.

METHODS

30 Patients (18 men and 12 women) with 30 fingertip amputations (Tamai zone I) were treated with artery-only anastomosis fingertip replantation between March 2010 and July 2014. Postoperative venous outflow was maintained by allowing bleeding through wound gaps combined with topical (12500u:250mlNS) and systemic (4000 IU SC once daily) heparin. The outcomes of replantation were evaluated using standard evaluating systems.

RESULTS

The average duration of hospital stay was 10 days (range 7-14 days). Twenty-eight (93 %) replanted fingertips survived. Five replanted fingertip experienced postoperative vascular crisis. The estimated post-operative blood loss was about 200-450 ml (mean, 292 ml). Follow-up period ranged from 12 to 24 months (average, 18 months). At final follow-up examinations, the average value of static two point discrimination test was 5.6 mm (range 3-9 mm) and Semmes-Weinstein monofilament test was 3.35 g (range 2.83-4.56 g). The mean range of motion of distal interphalangeal joint was 65.2° (range 0-90°) and all patients returned to their work within 7-18 weeks (average, 11 weeks).

CONCLUSION

Artery-only fingertip replantation can provide satisfactory cosmetic and functional results. Adequate venous outflow can be obtained by allowing minimal external bleeding through wound gaps combined with topical and systemic heparin.

Controlled continuous systemic heparinization increases success rate of artery-only anastomosis replantation in single distal digit amputation: A retrospective cohort study

Replantation is a prime indication for distal digital amputation, as it helps restore hand aesthetics and functions; however, venous anastomosis is often not feasible. Previous studies used systemic anticoagulation in distal digital artery only anastomosis replantation surgery to improve replantation success rate, however, which yielded limited level of clinical evidence. This study aimed to compare controlled continuous heparinization (CCH) and intermittent bolus heparinization (IBH) for surgical outcome and clinical variables after single distal digital artery only anastomosis replantation surgery.A single-institution, retrospective cohort study was performed. Out of 324 patients who underwent digital replantation surgery, we focused the study for the Zone I and II single distal digital amputation patients excluding confounding factors. Sixty-one patients were included in this study and underwent artery-only anastomosis replantation surgery with postoperative CCH (34 patients) or IBH (27 patients) protocols. The CCH group targeted activated partial thromboplastin time (aPTT) at 51 to 70 seconds, monitoring aPTT levels every eight hours and administering 100 mg of aspirin per day. The IBH group received 300 mg of aspirin per day and underwent IBH (12,500 U). Both groups received intravenous prostaglandin E1 drips (10 μg). To verify the factors affecting the success rate of the heparin protocol, patient factors, clinical factors, and operative factors were extracted from the medical records. Statistical analysis with inverse probability of treatment weights propensity score methods compared treatment outcomes and clinical variables.The CCH group's replantation success rate was higher (91.17% vs 59.25%), and the transfusion rate was increased (P = 0.032). However, the significant decrease in hemoglobin levels (>15%) did not differ between the groups (P = 0.108). Multivariable logistic regression analysis with potent univariate variables (P < .10) revealed that CCH was a statistically significant variable in replantation success rate (P = 0.004). Neither the major bleeding complications nor the significant decrease in patients' platelet levels were observed in both groups.Our study suggests that CCH after artery-only anastomosis replantation surgery in Zone I and II distal digital replantation is a safe method to improve the replantation success rate and may provide a guideline for use of the anticoagulation method following artery-only anastomosis distal digital replantation surgery.

Interdigital direct neurorrhaphy for treatment of painful neuroma due to finger amputation

BACKGROUND

Painful neuroma following amputation is a disabling condition for which treatments are not usually satisfactory. The aim of this study is to retrospectively evaluate the results of interdigital neurorrhaphy after neuroma resection as an option for the surgical treatment of painful digital neuroma.

METHOD

We retrospectively analyzed data from seven patients submitted to interdigital neurorrhaphy for treatment of digital neuroma. For evaluation of the results, the visual analog scale (VAS) for pain assessment, measurements with Simmens-Weinstein filaments and a handgrip dynamometer, and quantification of the Disabilities of the Arm, Shoulder and Hand (DASH) score were all performed. The mean improvements on the VAS and DASH scores were calculated.

RESULTS

The mean follow-up was 28.3 months. All patients presented some degree of improvement in upper limb functionality and pain, and handling the affected finger was possible in all cases. The mean improvement on the VAS and DASH scores was 29.8 and 55.5 %, respectively. No patients presented long-term complications.

CONCLUSION

Although this study was based on a small number of patients, it indicates that interdigital neurorrhaphy seems to be a feasible surgical treatment for painful digital neuroma.

Repair and reconstruction of thumb and finger tip injuries: a global view

In this review, an international group of senior hand surgeons was asked to provide their currently used methods, views, and advice on thumb and fingertip repair. The basic requirements and methods of thumb and fingertip repair are first outlined, followed by descriptions of the methods favored by individual units or surgeons. More recent innovative methods and modifications are described and challenging topics are discussed. This review ends by illustrating and discussing a few exploratory treatments that hold promise of greatly changing future perspectives of this common clinical problem.

Homodigital artery flap reconstruction for fingertip amputation: a comparative study of the oblique triangular neurovascular advancement flap and the reverse digital artery island flap

This fingertip reconstruction study retrospectively compared sensory recovery and active range of motion outcomes in neurovascular island advancement and reverse digital artery island flaps. Seventeen oblique triangular flaps and 14 reverse digital artery island flaps were performed for nail bed level fingertip amputations (Ishikawa subzone II). There was no significant difference between the two procedures in the Semmes-Weinstein monofilament test and range of motion results. For static and moving two-point discrimination tests, however, those with a reverse digital artery island flap required a longer period for sensory recovery compared to those with an oblique triangular advancement flap. This trend equilibrated at 12 months after surgery showing no significant difference in both static and moving two-point discrimination tests between the procedures.

Challenges in measuring outcomes following digital replantation

In the early period of replantation surgery, the emphasis was on digit survival. Subsequently, with better microsurgical techniques and instrumentation, the focus has shifted to function and in recent years to consideration of cost-effectiveness. Despite over 40 years of effort in refining digital replantation surgery, a rigorous evaluation of the outcomes of digital replantation has not been performed. This is because of the many confounding variables that influence outcome comparisons. These variables include the mechanism of injury (guillotine, crush, avulsion), the injury itself (total, near total, subtotal, partial amputation), and the surgical procedure (replantation, revascularization). In addition, the traditional outcome measures (two-point discrimination, range of motion, grip strength, or the ability to return to work) are reported inconsistently and vary widely among publications. All these factors make meaningful comparison of outcomes difficult. The recent emphasis on outcome research and cost-effectiveness necessitates a rethinking in the way we report outcomes of digital replantation. In this article, the authors summarize the challenges in assessing outcomes of digital replantation and explain the need to measure outcomes using rigorous clinical research designs that incorporate cost-effectiveness studies in the research protocol.

Challenges in fingertip replantation

Fingertip amputation is a challenging injury to manage. Among various reconstructive procedures, replantation results in superior outcome, but is seldom considered in many institutions. From the identification of vessel ends to reanastomosis of the submillimeter vessels, fingertip's highly specialized anatomy requires technical excellence. By addressing these anatomic challenges, fingertip replantation can be a routine reconstructive option for microvascular surgeons.

Upper extremity replantation: current concepts

BACKGROUND

Upper extremity replantation is a procedure that has revolutionized hand surgery. Since its introduction, a rapid evolution has occurred with a shifting focus from implant survival to optimization of functional outcomes and surgical efficiency. In this review, the current concepts surrounding the indications for replantation, variations in surgical technique, the factors affecting outcomes, and future directions of the specialty are analyzed.

METHODS

A literature review was performed of all recent articles pertaining to digit, hand, and upper extremity replantation surgery. Particular emphasis was placed on comparative studies and recent meta-analyses.

RESULTS

The indications and contraindications for replantation surgery are largely unchanged, with mechanism of injury remaining one of the most important determinants of implant survival. With advances in surgical technique, improved outcomes have been observed with avulsion injuries. Distal tip replantations appear to be more common with improved microsurgical techniques, and for these distal injuries, digital nerve and vein repair may not be necessary. Cold ischemia time for a digit amputation should not preclude transfer to a replantation facility or significantly affect the decision to perform a replantation. However, transferring physicians should thoroughly review the options with patients to prevent unnecessary transfers, which is an area where telemedicine may be useful.

CONCLUSION

This review provides an update on the current concepts of the practice of replantation and the treatment and management of patients with upper extremity amputations.

Distal digital replantation

BACKGROUND

Hand surgeons have been hesitant to perform distal digital replantation because of the technical challenges and the perception of a high cost-to-benefit ratio. Recent studies, however, have shown high survival rates and excellent functional and aesthetic results, providing renewed enthusiasm for distal replantation.

METHODS

The authors reviewed the literature and summarize key points regarding the surgical treatment, perioperative care, and outcomes of distal digital replantation. They describe specific techniques and considerations for surgical repair in each of four distal zones as described by Sebastin and Chung.

RESULTS

Zone 1A replantation involves an artery-only anastomosis of a longitudinal pulp artery. Venous anastomosis first becomes possible in zone 1B. Zone 1C involves periarticular amputations where arthrodesis of the distal interphalangeal joint is usually indicated. Repair of the artery, vein, and nerve is technically optimal in zone 1D, where venous anastomosis should be performed. Overall, survival rates for distal digital replantation are similar to those reported for more proximal replantation. The literature reports good outcomes regarding nail salvage, fingertip sensibility, and range of motion, with restoration of length and aesthetic appearance.

CONCLUSIONS

Distal replantation performed at institutions that specialize in microsurgery and specifically tailored to the level of injury is associated with good survival, function, and patient satisfaction and superior aesthetic outcome. More prospective data are needed to evaluate the cost of treatment, psychological outcomes, and functional outcomes of distal replantation compared with revision amputation.

A systematic review of the outcomes of replantation of distal digital amputation

BACKGROUND

The aim of this study was to conduct a systematic review of the English literature on replantation of distal digital amputations to provide the best evidence of survival rates and functional outcomes.

METHODS

A MEDLINE search using "digit," "finger," "thumb," and "replantation" as keywords and limited to humans and English-language articles identified 1297 studies. Studies were included in the review if they (1) present primary data, (2) report five or more single or multiple distal replantations, and (3) present survival rates. Additional data extracted from the studies meeting the inclusion criteria included demographic information, nature and level of amputation, venous outflow technique, nerve repair, recovery of sensibility, range of motion, return to work, and complications.

RESULTS

Thirty studies representing 2273 distal replantations met the inclusion criteria. The mean survival rate was 86 percent. There was no difference in survival between zone I and zone II replantations (Tamai classification). There was a significant difference in survival between replantation of clean-cut versus the more crushed amputations (crush-cut and crush-avulsion). The repair of a vein improved survival in both zone I and zone II replantation. The mean two-point discrimination was 7 mm (n = 220), and 98 percent returned to work (n = 98). Complications included pulp atrophy in 14 percent of patients (n = 639) and nail deformity in 23 percent (n = 653).

CONCLUSIONS

The common perception that distal replantation is associated with little functional gain is not based on scientific evidence. This systematic review showed a high success rate and good functional outcomes following distal digital replantation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Revascularization of complete and incomplete distal finger amputations in children below 2 years of age: a report of three cases

Three cases of fingertip amputation at the level between the distal phalanx and the nail base in children below 2 years of age were treated by replantation or revascularization. The injury was complete in two, and incomplete in one. All three fingerstips survived with artery anastomosis without the need for a blood transfusion. In two venous anastomosis failed and venous drainage was achieved by 3-hourly pinprick. Survival of an amputated finger can be expected in cases where venous reconstruction is not possible, provided that there is adequate venous drainage.

Replantation surgery

The current concepts of replantation surgery, a procedure that has been practiced for half a century, can be discussed in terms of patients' demands and expectations, present indications for the procedure, available evidence that influences decision making, and technical refinements practiced to produce better outcomes.

Fingertip replantation at or beyond the nail base in children

Although success of digital replantations in children has been reported by many authors, the very distal fingertip replantation remains technically demanding. The aim of this article is to review our experience with fingertip replantations at or distal to the nail base in pediatric patients and evaluate the clinical outcomes. From October 2000 to May 2007, 12 pediatric fingertips amputated at or distal to the nail base were replanted. Only one artery was anastomosed for revascularization with or without nerve repair; vein drainage was provided by the controlled bleeding technique. Eleven of the 12 replants (91%) survived; one replant of crushed digit failed. An average of 26 month (range, 6 to 36 months) follow-up revealed excellent restoration of finger motion and appearance. The regained static 2-point discrimination (S2PD) sensation was from 3.2 to 5.0 mm (mean, 4.2 mm). Both the parents and the children were satisfied with the final results. In conclusion, fingertip replantation in children allows good functional and esthetical recovery and should be attempted if technically feasible.