Composite Grafting for Pediatric Fingertip Injuries

Abstract

Background Fingertip injuries are common in the pediatric population. Composite grafting is a frequently used technique for distal amputations in children given the reported success rate. We sought to study the early clinical results of composite grafting for fingertip injuries in the pediatric population. Methods A retrospective review was performed over a 5-year period at a tertiary care pediatric hospital to identify those patients who underwent composite grafting of fingertip injuries. Patients were included if they were 18 years old or younger and sustained an injury distal to the distal interphalangeal joint (or thumb interphalangeal joint). Demographic information was recorded. Graft viability was characterized as no take, partial take, or complete take. The number of secondary procedures and number and duration of follow-up appointments were recorded. Hypothesis testing was done using ordinal logistic regression analysis. Results Thirty-nine patients underwent fingertip composite grafting. The mean age was 5.9 years (1-18 years); there were 24 males (61.5 %) and 15 females (38.5 %). Thirteen patients had no graft take (33.3 %), 23 patients had partial take (59.0 %), and three patients had complete take (7.7 %). Only four patients underwent secondary revision (10 %). The median number of follow-up appointments was 3 and the average follow-up time was 4.5 months. Age did not appear to have a statistically significant influence on graft take. Conclusions Fingertip composite grafts rarely take completely even in young children. Despite poor viability, however, most patients will have at least partial graft take and do not undergo additional reconstructive procedures.

Composite Grafts for Pediatric Fingertip Amputations: A Retrospective Case Series of 100 Patients

“…Due to time elapsed in the work-up to surgical intervention, 75% of patients were operated on after 6 hours. Although only a small group of patients were operated on directly and before 6 hours, no difference in outcomes between transfer patients and direct admissions was found in this study, replicating findings by Eberlin et al 25 On the other hand, Moiemen and Elliot 5 found that amputations repaired as composite grafts more than 5 hours after amputation were less likely to survive. This 5-hour cutoff point; however, was later criticized for being arbitrary and not the classic 6-hour “ischemic” time and not identified as independent predictor of graft success in logistic regression, 25 with 2 subsequent larger case series failing to replicate the findings.…”

“…Although only a small group of patients were operated on directly and before 6 hours, no difference in outcomes between transfer patients and direct admissions was found in this study, replicating findings by Eberlin et al 25 On the other hand, Moiemen and Elliot 5 found that amputations repaired as composite grafts more than 5 hours after amputation were less likely to survive. This 5-hour cutoff point; however, was later criticized for being arbitrary and not the classic 6-hour “ischemic” time and not identified as independent predictor of graft success in logistic regression, 25 with 2 subsequent larger case series failing to replicate the findings. 7 , 8 Due to the retrospective nature of this study, it was difficult to assess the actions taken in the interim period before surgery; however, it has been noted that quick replacement of the fingertip immediately after injury could contribute to improved graft survival.…”

“… 7 , 8 Due to the retrospective nature of this study, it was difficult to assess the actions taken in the interim period before surgery; however, it has been noted that quick replacement of the fingertip immediately after injury could contribute to improved graft survival. 25 There was also no difference in graft take between grafts replaced before or after the 6 hour “ischemic” time. Six hours has been identified as the time after which devascularised muscle undergoes irreversible ischemic damage.…”

“…Four was chosen as a cutoff age following Butler et al, 8 who stratified patients into 3-yearly age groups and found a higher chance of graft survival in children under 4 years of age. Other studies have not supported a significant impact of age on graft success, 6 , 7 , 18 , 19 , 25 but all these studies used different populations or age categories. Crush injuries were more likely to fail than avulsion injuries, a finding not previously reported in composite grafts; however, avulsion injuries are commonly cited as having poor functional outcomes after replantation due to the extensive damage to skin, nerves, and vessels in such injuries.…”

Usefulness of avulsed fingertip skin for reconstruction after digital amputation

“…Survival rate for the composite graft has been reported to be approximately 50% or less (varying depending on avulsion level or extent), and the size not exceeding 1 cm has been recommended. Thus, when treatment with the composite graft is selected, the treatment plan needs to be devised, taking into consideration prolongation of the duration of injury, possible need for additional surgery upon appearance of partial necrosis, and possible loss of avulsed finger skin [2,3]. For fingertip reconstruction with a local flap, the homodigital dorsal skin flap, reverse digital artery flap, and thenar flap are generally used.…”