Replantation of Fingertip Amputation by Using the Pocket Principle in Adults

Abstract

There are several treatment modalities for zone 1 or zone 2 fingertip amputations that cannot be replanted by using microsurgical techniques, such as delayed secondary healing, stump revision, skin graft, local flaps, distant flaps, and composite graft. Among these, composite graft of the amputated digit tip is the only possible means of achieving a full-length digit with a normal nail complex. The pocket principle can provide an extra blood supply for survival of the composite graft of the amputated finger by enlarging the area of vascular contact. The surgery was performed in two stages. The amputated digit was debrided, deepithelialized, and reattached to the proximal stump. The reattached finger was inserted into the abdominal pocket. About 3 weeks later, the finger was removed from the pocket and covered with a skin graft. We have consecutively replanted 29 fingers in 25 adult patients with fingertip amputations by using the pocket principle. All were complete amputations with crushing or avulsion injuries. Average age was 33.64 years, and men were predominant. The right hand, the dominant one, was more frequently injured, with the middle finger being the most commonly injured. Of the 29 fingers, 16 (55.2 percent) survived completely and 10 (34.5 percent) had partial necrosis less than one-quarter of the length of the amputated part. The results of the above 26 fingers were satisfactory from both functional and cosmetic aspects. Twenty of the 29 fingers, which had been followed up for more than 6 months (an average of 16 months), were included in a sensory evaluation. Fifteen of these 20 fingers (75 percent) were classified as "good" (static two-point discrimination of less than 8 mm and normal use). From the overall results and our experience, we suggest that the pocket principle is a safe and valuable method in replantation of zone 1 or zone 2 fingertip amputation, an alternative to microvascular replantation, even in adults.

Factors Affecting Composite Graft Survival in Digital Tip Amputations

“…He first denuded (debrided and defatted) the amputated tip, reattached it to the stump, and then put it into a subcutaneous pocket on the abdomen. Lee and colleagues, 13 Foucher and Citron, 9 and Hirase 10 also used modified replacement regimens.…”

Treatment of Fingertip Amputation in Adults by Palmar Pocketing of the Amputated Part

“…In addition, it remains unclear whether this method would also be appropriate for adults [12]. It is generally known that the survival of a composite graft cannot be expected in the fingertip amputation in the Tamai zone I and II, particularly in adults [3,11,12]. It has therefore been proposed that the amputated fingertip should be placed in the subcutaneous tissue for 2 to 3 weeks to improve the survival of the replantation of the amputated fingertip using the a composite graft.…”

“…Rose et al [8] and Uysal et al [9] described the "cap" technique for enhancing composite graft survival by increasing the contact area between the distal amputated fingertip and the amputated stump. Several reports have described the pocket method [3,13,14,16-20]. The replantation of the amputated finger using subcutaneous pocketing was first proposed by Gilles in 1940.…”

Composite Grafting for Traumatic Fingertip Amputation in Adults: Technique Reinforcement and Experience in 31 Digits

“…However, the good outcomes reported for a composite graft of fingertip amputations has focused on children, and it is unclear whether this method is appropriate for adults. 3,20 Several methods have been applied with the aim of increasing the survival rate of composite grafting in adults. Hirase 21 reported cooling the entire recipient site until neovascularization of the graft develops.…”