Orthoplastic Surgery 8 (2022) 17–25

Contents lists available at ScienceDirect

Orthoplastic Surgery
journal homepage: www.journals.elsevier.com/orthoplastic-surgery

Cohort Study

Graft reposition flap for fingertip injuries

J. Terrence Jose Jerome a, *, Vijay A. Malshikare b
a
Department of Orthopedics, Hand and Reconstructive Microsurgery, Olympia Hospital & Research Centre, 47, 47A Puthur High Road, Puthur, Trichy, Tamilnadu,
620017, India
b
Hand and Wrist Surgeon, Jehangir and 18.52 North Hospital, Pune, India

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: We report our technique, graft reposition flap for fingertip injuries with bone and nailbed loss.
Fingertip amputations Methods: We reconstructed Allen's IV fingertip amputations in 25 patients between 2015 and 2019. The graft
Graft reposition flap reposition flap technique involves reattaching the amputated stump (distal phalanx, free nailbed graft) with
Simple
Kirschner wire. In addition, we reconstructed the volar defect with cross finger flap, thenar flaps, first dorsal
Alternative
Good outcome
metacarpal artery-based flap, volar V–Y advancement flap, and antegrade homodigital flaps.
Results: The mean follow-up was 25 months. (Range, 12–36 months). We classified the results based on nail aesthetics,
finger length, pulp pad, bone consolidation, cosmesis, sensation, pain, range of motion, grip strength, and return to
work. Excellent or good results were achieved in 20 cases. Three cases had fair results, and 1 had poor results. We
observed partial flap necrosis (n ¼ 1), exposure of distal phalanx (n ¼ 1), hook nail (n ¼ 1) and absent nail (n ¼ 1)
Conclusions: This method is simple, reliable, and effective for restoring Allen's type IV fingertip amputation. This
technique can be performed efficiently by surgeons in rural and urban hospitals lacking microsurgical expertise. It
is an excellent alternative option for replantation.

1. Introduction
Distal Fingertip amputations are treated based on the size and ge-
ometry (shape and contour) of the defect, soft tissue loss, and the pres-
ence of exposed bone [1,2]. Various techniques have been described to
reconstruct fingertip injuries and have geographic variations and sur-
geon's preferences [1–4]. Replantation restores function and appearance.
However, the microsurgical services with experienced surgeons are
limited and inconsistently available in rural and certain urban hospitals
worldwide [1]. In addition, there has been a decline in replanting
fingertip amputations because of inadequate confidence in surgical skill,
work schedule disruption, and financial implications [1,2]. Hence, sur-
geons prefer reconstructing fingertips with reliable and straightforward
procedures to restore fingertip function.
Allen has classified fingertip amputations into four types [3]. Type I
injuries involve only the pulp of the finger. Type II includes pulp and nail
loss. Type III has partial terminal phalanx loss and corresponding pulp
and nail loss. Finally, type IV involves the lunule of the nail, pulp, nail,
and partial loss of the terminal phalanx (Fig. 1). The goals of fingertip
reconstruction are good cosmetic appearance, maximum tactile gnosis,
preservation of the finger and thumb length, well-padded pulp, intact
nailbed, and minimized time off work [4].
Treatment options for small (Allen's Type I), medium-size defects
(Type II) are healing by secondary intention under a semi-occlusive
dressing, skin grafting, palmar V–Y plasty, lateral V–Y plasty. and Ven-
kataswami (Oblique) flap [4,5]. Type III amputations are treated by nail
bed graft and homodigital, heterodigital, regional, or distant flaps [1–5].
In large defects (Type IV) with nailbed, bone, and pulp loss, replantation
gives superior functional and aesthetic results [1,2]. Distal replantation is
technically challenging, and failure of replantation or partial soft tissue
loss is expected because of a severe crush injury to the fingertip [5].
We propose a surgical technique of graft reposition flap for fingertip
injuries. This technique involves reattaching the amputated distal pha-
lanx, nailbed graft, and reconstructing the volar defect with pedicled flap
in Allen's type IV fingertip amputations. Our study also proposes that a
graft reposition flap is a simple technique that restores the finger function
and appearance.
2. Material and methods
From 2015 to 2019, we reconstructed 25 patients with Allen's type IV
fingertip amputations (Fig. 1). An ethical committee board approved the
study. There were 21 males and four females with a mean age of 30 years
(range 13–55 years) involving the right side in 16 patients and left side in

* Corresponding author.
E-mail addresses: terrencejose@gmail.com (J.T.J. Jerome), vijay0077877@rediffmail.com (V.A. Malshikare).

https://doi.org/10.1016/j.orthop.2022.03.002
Received 11 January 2022; Received in revised form 14 March 2022; Accepted 16 March 2022
2666-769X/© 2022 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Limited. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
J.T.J. Jerome, V.A. Malshikare Orthoplastic Surgery 8 (2022) 17–25

Fig. 1. A and B: A 24-year-old software engineer had Allen's type IV amputation right thumb (case No.12). C and D: radiographs of the right thumb posteroanterior
and lateral view, respectively. E Harvested amputated distal phalanx, nailbed, and nail plate (Case No 12). F Reattaching the nail bed, distal phalanx to the proximal
bone with Kirschner wires. Kirschner wires are cut short. G Suturing the nailbed over the dorsum of the distal phalanx. H Cross finger flap raised from the dorsum of
the index finger. I The cross-finger flap inset over the volar defect.

Table 1
Fingertip injuries details.
Patient Sex/Age (years) Finger/ thumb Injury Flap

1 M/25 Thumb Volar oblique FDMA

2 M/28 Index Transverse Cross finger flap
3 M/19 Thumb Transverse Cross finger flap
4 M/21 Thumb Transverse Cross finger flap
5 M/24 Ring Dorsal oblique Volar V-Y advancement flap
6 M/38 Ring Transverse Antegrade homodigital flap
7 F/24 Index Transverse Cross finger flap
8 M/23 Thumb Transverse Cross finger flap
9 M/21 Thumb Transverse Cross finger flap
10 M/28 Index Transverse Thenar flap
11 M/26 Thumb Transverse Cross finger flap
12 M/24 Thumb Transverse Cross finger flap
13 F/32 Thumb Transverse Cross finger flap
14 M/48 Index Transverse Thenar flap
15 M/24 Index Transverse Cross finger flap
16 M/42 Middle Transverse Thenar flap
17 M/26 Thumb Volar oblique Cross finger flap
18 M/55 Index Transverse Cross finger flap
19 M/32 Middle Volar oblique Thenar flap
20 M/36 Thumb Transverse Cross finger flap
21 M/19 Thumb Volar oblique Thenar flap
22 M/40 Thumb Transverse Cross finger flap
23 M/30 Middle Transverse Cross finger flap
24 F/40 Middle Transverse Cross finger flap
25 M/13 Middle Transverse Thenar flap

FDMA- First Dorsal Metacarpal Artery flap

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J.T.J. Jerome, V.A. Malshikare Orthoplastic Surgery 8 (2022) 17–25

Fig. 2. A and B A 36-year-old factory worker with right thumb amputation. (Case No.20). C Harvesting the nailbed, nail plate, and amputated portion of the distal
phalanx. D Predrilling the distal phalanx promotes neovascularization and bone-nailbed incorporation. However, it does not interfere with the stability provided by
the Kirschner wire fixation.

9 patients (Table 1). Transverse amputation was seen in 20 patients, volar
oblique in 4 patients, and dorsal oblique in 1 patient. The thumb was
involved in 12 patients, the index finger in 6 patients, the middle finger in
5 patients, and the ring finger in 2 patients. Most injuries were crush (18
cases) or guillotine type (7 cases), all caused by machine injuries or
knives. All patients brought the amputated part to the hospital. Our study
excluded Allen’s type I-III from this study because these injuries can be
managed with established surgical methods [1–5]. The work has been
reported in line with the STROCSS criteria [6].
2.1. Surgical technique
We operated on our patients under the supraclavicular block and arm
tourniquet. The amputated part was washed with normal saline, and

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J.T.J. Jerome, V.A. Malshikare Orthoplastic Surgery 8 (2022) 17–25

debridement was done. The volar pulp tissues were excised, and the Table 2
nailbed was separated from the remnant distal phalanx. The nail plate Fingertip injuries outcome assessment score.
was kept for covering the nailbed after surgery. We performed multiple Score
predrilling (1 mm) of the distal phalanx cortices to promote early neo-
Nail Normal 1
vascularization from the pedicled flap (Fig. 2). The amputated distal Small nail 2
phalanx was reattached to the proximal portion of the distal phalanx with Split nail or deformed nail 3
a single or two axial Kirshner wires (1 or 1.25 mm) passing from distal to Hook nail 4
proximal under direct vision. This avoided injury to the flap and made Absent nail 5
Finger length (length Distal third 1
retrieval safe and easy after the bone consolidation. The Kirshner wire compared with normal Middle third 2
was kept distally or proximally out and close to the skin. The nail bed was side length from volar crease) Proximal third 3
placed over the dorsal cortex of the distal phalanx and sutured with 6- Pulp Well padded 1
0 chromic catgut (Ethicon Inc). (Fig. 1). Pulp atrophy 2
Bone Fracture united (consolidated) or 1
Various types of flaps were used for the volar defect. We used cross
Normal
finger flap for transverse amputations (n ¼ 16), thenar flaps for index and Nonunion 2
middle finger amputations (n ¼ 6), volar V–Y advancement flaps for Bone shortening 3
dorsal oblique amputations (n ¼ 1), and first dorsal metacarpal artery Cosmesis Satisfactory 1
flap for thumb amputations (n ¼ 1) and anterograde homodigital flap Not satisfactory (color mismatch) 2
Sensation (2-PD) <6 mm 1
(n ¼ 1) for the ring finger amputation. The nailbed was sutured to the 7–10 mm 2
margin of the flap. We placed the nail plate within the preserved nail fold Cold intolerance 3
to act as a splint, prevent synechia formation between nailfold and Absent sensation/hyperalgesia 4
nailbed and prevent nailbed necrosis. The donor site was covered with a Pain No pain 1
Mild 2
full-thickness skin graft harvested from the antecubital area in the same
Moderate 3
forearm. In a few cases, we harvested partial thickness skin graft from the Severe 4
thenar eminence for the donor site and noted good cosmesis (color Range of motion (TAM) 75–100% 1
match). We applied compressive wet dressings and left the nail plate in 50–74% 2
place for 4–6 weeks. <49% 3
Grip strength 75-100% 1
50-74% 2
2.2. Post-operative care <49% 3
Return to work Regular job 1
Restricted job 2
All patients had dorsal splints in the postoperative period. The cross-
Unable to work 3
finger flap and thenar flap were divided at two weeks, and therapy was
started on both injured and donor's fingers to prevent stiffness. The
Kirshner wire was removed at 4–6 weeks and allowed activities.
4. Discussion

2.3. Outcome assessment
Fingertip injuries outcome score [7] was simple, reliable, consistent
and a meaningful method to assess the outcome of fingertip injuries.
The score was based on nail aesthetics, finger length, pulp pad, bone
consolidation, cosmesis, sensation, pain, range of motion, grip strength,
and return to work. (Table 2). The results were noted in the final
follow-up, and scores were assigned prospectively. The authors deter-
mined the score and valued the outcome based on the score (Tables 3
and 4). The pain and the cosmesis were recorded based on the patient’s
observation. We noted good nail growth in most cases (Figs. 3–5). In the
score, the normal finger length was divided into three parts from the
volar crease to the fingertip and compared it with the injured finger.
3. Results
The follow-up ranged from 12 to 36 months (mean follow-up of 25
months). The average shortening of all patients noted was 4.5 mm. In our
series, we also observed split or deformed nails (n ¼ 3) (Fig. 6), hook
nails (n ¼ 1), and absent nails (n ¼ 1). We had partial flap necrosis in one
patient, which healed well with semi-occlusive dressings. One patient
had exposure to distal phalanx because of inadequate flap cover, and we
trimmed it in the outpatient clinic. The bone was consolidated in most
cases. The mean two-point discrimination was 7.5 mm (range, 5–10 mm).
Eight patients reported cold intolerance, and two had dysesthesia in the
early follow-up, which improved over time. At the follow-up, most pa-
tients are pain-free with a good range of motion, grip strength, and
cosmesis. Twenty patients returned to previous work at an average of 16
weeks. Three patients had fingers stiffness, and none had donor site
morbidity.
There are a wide variety of surgical methods for reconstructing Allen's
IV fingertip amputations, and all aim for preserving fingertip length,
sensation, and restoring shape to the nail [1–5]. Successful replantation
gives superior functional and esthetic results, but distal replantation is
technically challenging. Also, there are reported late complications in
replantations such as tendon adhesions, malunion, nonunion, neuroma,
and cold intolerance [8]. The success of replantations depends on the
availability of a microsurgical team, equipment, and dedicated moni-
toring unit. In addition, there are still diverse views for replantations
among different countries [1,2]. Therefore, more reliable methods are
necessary for Allen's Type IV fingertip amputation. Also, we need a
reconstructive procedure, which is simple, reliable, and performed by
most surgeons in rural and urban hospitals with a lack of microsurgical
expertise.
Various authors have described reattaching the nailbed grafts com-
bined with flaps. They have also noted cold intolerance, neuroma, partial
flap and nailbed graft loss, claw or hook nail, flexion contractures, PIP
joint extension deficit, and partial bone resorption [9–18].
Similarly, various studies analyzed the role of composite grafting in
adult fingertip injuries [19,20] of which, notably, Chen et al. reported
Table 3
Results.
Results Score value Patients
Excellent 12 16 (64%)
Good 13–18 4 (16%)
Fair 19–24 4 (16%)
Poor >24 1 (4%)

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J.T.J. Jerome, V.A. Malshikare Orthoplastic Surgery 8 (2022) 17–25

Table 4
Results.
Patients Nail Finger Pulp Bone Cosmesis 2PD Pain ROM Grip Return Total Complications
length strength to score
work

1 5 2 2 1 2 2 2 1 1 2 20 Absent nail
2 1 2 1 1 1 1 1 1 2 1 12 Nil
3 1 1 1 1 2 1 1 1 1 1 11 Nil
4 1 1 1 1 2 1 1 1 1 1 11 Nil
5 1 1 1 1 1 1 1 1 1 1 10 Nil
6 1 2 1 1 1 1 1 1 1 1 11 Nil
7 1 1 1 1 2 2 1 1 1 1 12 Nil
8 1 1 1 1 2 1 1 1 1 1 11 Nil
9 1 1 1 1 2 1 1 1 1 2 12 Nil
10 1 3 1 1 1 2 1 1 1 1 13 Nil
11 1 1 1 1 1 1 2 1 1 1 11 Nil
12 1 2 1 1 1 2 1 1 1 1 12 Nil
13 2 1 1 1 2 1 1 1 1 1 12 Nil
14 1 1 1 1 1 1 1 1 1 1 10 Nil
15 2 2 1 3 2 2 3 3 1 2 20 Partial flap
necrosis
16 1 2 1 3 1 3 1 2 1 2 17 Nil
17 1 2 1 1 2 1 1 1 1 1 12 Nil
18 1 1 1 1 2 1 1 1 1 1 12 Nil
19 4 3 2 2 2 2 1 1 1 1 19 Hook nail
20 1 1 1 1 1 2 1 1 1 1 11 Nil
21 1 2 1 1 1 2 1 1 1 1 12 Nil
22 1 1 1 1 2 2 1 1 1 1 12 Nil
23 1 2 1 1 1 1 1 1 1 1 11 Nil
24 3 3 2 3 2 4 4 2 3 3 28 distal phalanx
exposure
25 1 2 1 1 1 1 1 1 2 1 12 Nil

2PD ¼ two-point discrimination; ROM ¼ range of motion.

93.5% graft uptake in Allen’s type II and III amputations [20]. However,
though technically simple and saves time, composite grafting is not yet
considered a reliable method for Allen’s type IV amputations.
Apart from the reconstructive surgeries, Allen type IV fingertip
amputation can be managed by revision amputations. This has shorter
recovery and early return to work. But this is associated with hook nail
deformity, short finger, cold intolerance (77%), pulp tenderness, and
reduced range of motion. Unfortunately, there is no comparative study to
analyze the outcomes between revision amputation and reconstructive
methods in fingertip amputations [21].
We describe graft reposition on flap based on the mechanism that the
non-vascularized composite graft gets nourishment initially by the plas-
matic fluid. This fluid fills between the wound base and the graft and gets
absorbed by the graft [10]. The revascularization begins 72–96 h
following the initial imbibition phase, and new blood vessels grow from
the surrounding tissues into the graft [10]. A thick graft acts as a barrier to
plasmatic imbibition, requiring more time for revascularization and a
chance for partial/complete thickness loss [10]. By separating the nail bed
from the bone, we increase the contact area between the nail bed, bone,
and the flap and reduce the size of the graft for better and successful
revascularization [9–13]. Besides, multiple predrilling (1 mm size) of
bone graft promotes early neo-vascularization from the pedicled flap
[9–13]. Also, drilling increases the bone-nailbed incorporation/diffusion
and survival [11,12].
Our study demonstrated that the graft reposition flap technique in type
IV amputation provided excellent to good results in 20 patients (80%).
These patients had restored the maximum finger length, good pulp con-
tour, sensation, bone consolidation, function, and aesthetic outcome.
In most cases, we preferred cross-finger flaps because they are reliable
[13], and quite large and thick, to sufficiently cover the repositioned
bone graft and K wire. The main criticisms of using a cross finger flap are
fingertip sensitivity and the donor site morbidity/stiffness [22]. How-
ever, most of our patients had excellent sensory recovery with no donor
site morbidity. Many authors have also documented a definite sensitivity
recovery after cross finger flap, at 12–18 months post-operative and all
the patients regained subjective sensitivity compared to contralateral
finger [23,24]. We also noted cross finger flap matches the length, pre-
vents recipient stiffness, and allows partial closure of the donor site. In
addition, cold sensitivity and flap color mismatch is noted in our study,
which improved over time.
Our study documented color match with antegrade homodigital
flaps, volar V–Y advancement flaps, and thenar flaps. We preferred
V–Y advancement flaps for dorsal oblique amputation, cross finger
flap, thenar flaps, and antegrade homodigital flaps for transverse or
volar oblique amputations. Our study had partial flap necrosis in one
patient who had the first dorsal metacarpal artery-based flap in the
thumb because of the pedicle kinking. Also, our study noted absent
nails in one patient because of accidental nailbed injuries during the
harvest. So, we recommend caution in separating the nailbed from the
amputated distal phalanx. We believed attaching the nail plate to the
nail bed by suturing at the ends acted as a splint and prevented
nailbed necrosis and adhesions. Multiple small predrilling of the bone
graft promotes neovascularization with the volar flap. Predrilling does
not interfere with the Kirschner wire fixation of the amputated part
with the proximal stump, and we had no inadvertent fractures. We
noted a hook nail in one patient because of a loss of bony support
under the nailbed. Therefore, reattaching the bone with adequate
soft-tissue pulp provided by pedicled flaps will prevent hook nail
deformities.
The limitations of our study are the small sample size. We need a large
prospective study comparing the efficacy of various reconstructive flap
techniques in fingertip amputations. Nevertheless, the authors do not
hesitate to recommend graft reposition flap for Allen type IV fingertip
amputations. This is a simple, straightforward procedure that restores
finger length and sensation. It is an expeditious, simple, and reliable
method that most surgeons can perform.

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J.T.J. Jerome, V.A. Malshikare Orthoplastic Surgery 8 (2022) 17–25

Fig. 3. A and B clinical pictures at the final follow-up. (Case No.12). C and D Radiographs of the bone union at the follow-up.

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J.T.J. Jerome, V.A. Malshikare Orthoplastic Surgery 8 (2022) 17–25

Fig. 4. A and B Final result of Fig. 2 with excellent fingertip score. (Case No.20).

Fig. 5. A.Allen’s type IV amputation of the thumb in a 26-year-old man. (Case No.11). B. Result with an excellent outcome.

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J.T.J. Jerome, V.A. Malshikare Orthoplastic Surgery 8 (2022) 17–25

Fig. 6. A and B Transverse amputation of the index finger, which was reconstruction with a cross finger flap. (Case No 18). C Final result of the pulp with good pulp
contour and length. D Partial nailbed loss occurred, and we noted a short/deformed nail at the final follow-up.

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J.T.J. Jerome, V.A. Malshikare Orthoplastic Surgery 8 (2022) 17–25

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Supplementary data to this article can be found online at https://doi.
org/10.1016/j.orthop.2022.03.002.

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