Post-traumatic composite graft fingertip replantation in both adults and children

Abstract

Composite graft fingertip replacement (CGFR) can maintain digital length and a normal nail complex when microvascular replantation of traumatically amputated fingertips is unfeasible. However, there remains reluctance to perform CGFR in adults owing to perceived poor outcomes compared with children, despite a lack of supporting evidence. We report CGFR outcome in adults and children. A prospectively collated patient information database identified CGFR attempts over five consecutive years. Patient demographics and co-morbidities, injury mechanisms and details (including Ishikawa levels), timing of surgical interventions and outcomes were documented. One hundred thirty-one CGFRs were attempted in 130 patients (106 in children under 16). Ishikawa amputation level or CGFR outcome was not documented in 21 excluded cases. Despite a significant association between adulthood and smoking, complete or partial graft survival was excellent in both adults and children (86% and 89%, respectively). Adults and children were significantly more likely to sustain laceration and crush injuries, respectively. These results challenge the near-universal scepticism held against CGFR in adults. Partial graft survival can appear discouraging when mummified eschar conceals regenerating tissue beneath. We emphasise the importance of patience in the clinical management of fingertip injuries treated by CGFR with two representative cases where the graft was considered ‘completely necrotic’ but ultimately survived to generate normal nail growth with an excellent cosmetic and functional result.