Replantation of Fingertip Amputation by Palmar Pocket Method in Children

Abstract

Sir: The success of replantation for fingertip amputation is required from a cosmetic perspective. Common procedures for replantation have included microsurgery and composite grafting. Fingertip amputations in children are difficult to treat by microsurgical replantation. In 1979, Brent1 reported a new replantation method for amputated distal phalangeal parts of fingers without vascular anastomosis by using a subcutaneous pocket. Starting in 1996, we modified this method and used a palmar pocket for fingertip amputation in 10 children when vascular anastomosis was not feasible. The patients are summarized in Table 1.Table 1: Summary of CasesFractured bone segments were fixed with Kirschner wires, and the amputated part was reattached to the amputation stump without vascular anastomosis. The amputated part was deepithelialized to the middermal layer using a scalpel after reattaching it to the digit. A 1.5-cm transverse incision was performed in the ipsilateral palm and the subcutaneous layer was undermined bluntly to make a pocket. The reattached part was inserted into the pocket and sutured to the palmar skin to prevent the inserted digit from pulling out. After approximately 2 weeks, the replanted part was removed carefully from the pocket, and some active bleeding was noted from the replanted part. The palmar skin was then sutured. Epithelialization was complete at approximately 2 weeks after the second operation, and thereafter the replanted part gradually became stable (Fig. 1).Fig. 1.: (Above, left) Preoperative dorsal view of the injured finger. (Above, right) The reattached finger in the palmar pocket. (Below, left) Dorsal view of the replanted finger 7 months after surgery. (Below, right) Palmar view of the replanted finger 7 months after surgery.All patients recovered completely. A hooked nail deformity did not occur. There were no cases of severe flexion contracture, infection, or pulling out from the pocket. Inadvertent injury to the digital nerves and arteries traversing the palm did not occur when the pocket was made. When microsurgical treatment is not feasible for fingertip amputation, a composite graft is usually used for restoring the length of the finger; however, this method does not have a good success rate.2 The composite graft is sustained by plasma imbibition until revascularization by means of the amputation stump. Proximal to the center of subzone I3 (Fig. 2), the amputated part is too large for adequate extra blood supply for survival to be provided from the amputation stump. With the pocketing method, the deepithelialized composite piece was inserted into a subcutaneous pocket, which provided more blood. We speculated that because the buried fingers were kept implanted for approximately 2 weeks, improved survival in the replanted fingertips may well have resulted from revascularization by means of the exposed dermal elements in conjunction with revascularization by means of the proximal digital segment. As a pocket site, Brent chose the contralateral chest, whereas other authors4,5 chose the abdomen. Originally, we used pockets in the chest or abdomen, but most patients were anxious about pulling out the pocketed finger, and it was particularly difficult for children to keep the position during a long pocketing period. To avoid these problems, we chose the ipsilateral palm as a pocket site. In conclusion, the palmar pocket method is a simple and reliable operation for fingertip amputation when microsurgery is difficult and composite graft is not reliable and is more comfortable for children than pocketing in the chest or abdomen.Fig. 2.: Subzones of the distal part of the finger classified by Ishikawa.Jun Arata, M.D. Department of Plastic and Reconstructive Surgery Kyoto Medical Center Hospital Fushimiku, Kyoto, Japan Kozo Ishikawa, M.D. Department of Plastic and Reconstructive Surgery Otsu Red Cross Hospital Nagara, Otsu, Japan Haruo Soeda, M.D. Department of Orthopedic Surgery Kyowa Hospital Fushimiku, Kyoto, Japan DISCLOSURE No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.