Post-traumatic composite graft fingertip replantation in both
adults and children
Fulvio G. Urso-Baiarda
Christopher G. Wallace
Received: 21 November 2008 / Accepted: 16 June 2009 / Published online: 9 July 2009
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 regenerat-
ing 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.
Keywords Composite graft fingertip replantation
Although fingertip amputations and avulsions are relatively
common injuries, their treatment is not straightforward.
Microsurgical replantation often provides a reliable means
to salvage digits amputated proximal to the distal interpha-
langeal joint. More distal amputations are usually out with
the technical limitations of microsurgery in most centres.
Replacing the amputated part as a composite graft remains
the only means of potentially achieving a full-length digit
with a normal nail complex in such cases.
Many surgeons are reluctant to perform composite graft
fingertip replacement (CGFR) because of perceived high
failure rates, particularly in adults in whom the technique is
viewed with near-universal scepticism [1–4]. However, the
historical literature contains more reported successes in
adults than children [1, 3, 5, 6], and there is a paucity of
evidence supporting the view that CGFR has a poorer
outcome in adults . This study was designed to
investigate the outcome of CGFR following traumatic
fingertip amputation in adults and children.
Materials and methods
Research was performed in accordance with the ethical
standards laid down in the 1964 Declaration of Helsinki.
F. G. Urso-Baiarda (*)
C. G. Wallace
Queen Victoria Hospital,
East Grinstead, UK
Eur J Plast Surg (2009) 32:229–233