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Overall survival rate for 143 digits with complete amputation of the distal phalanx was 78%. Replanted digits that underwent venous anastomosis showed a very high survival rate of 93%. Loss of the distal interphalangeal joint function in subzone IV was significantly inferior to that in subzones II and III. Protective sensation was achieved in 96% of replanted digits. Sensory recovery in the absence of nerve repair was significantly worse for avulsion injury than for crush injury. Nail deformity tended to be increased for replanted digits in subzone III or with crush-type injury. Successful venous anastomosis appears to offer the best way to promote survival of replanted digits. If venous anastomosis is infeasible, a replanted digit can survive with any methods for venous drainage in subzones II and III, but does not survive in subzone IV. To minimise nail deformity, repair of the germinal matrix is necessary.

Radial or ulnar oblique amputations treated by nailbed levelling and local digital flap reconstruction can result in significantly shortened fingertip, narrowed pulp and nail shape distortion. A VY type flap containing bone, sterile matrix, and skin was conceptualised to restore nail and pulp contour for coronal oblique amputations. Technical details and a clinical case are discussed.

A volar advancement flap based on V-Y concept for fingertip reconstruction is described. The crescent flap utilises curved incision to preserve fingertip contour and distal digital crease. Satisfactory outcome was achieved in two patients who underwent fingertip reconstruction using this technique. Its advantages are technical simplicity, minimal donor morbidity, and may be used in situation where conventional V-Y incision is unsuitable.

Allen type IV fingertip amputations were treated by a modified technique, when the replantation is difficult to be performed or not an option. The pre-existing technique involves nail bed grafting and local flap. In the modified technique, a free bone graft is added, bone and free nail bed repositioned and pulp reconstruction by local flap. This can be best described "graft reposition on flap" (GRF). GRF was found to be simple and cost effective. It allows preservation of finger length and a fully functional and cosmetically acceptable nail.

The graft on flap method, a useful option for the restoration of fresh fingertip amputation, was applied to the reconstruction of the short fingertip stumps resulting from the initial amputated stump plasties. As a modification, a nail bed graft from the big toe and a small cubic iliac bone graft were substituted for the lost tissues normally reduced as a composite graft in fresh cases. Upon follow-up ranging from 1 to 8 years, the grafted bone was found to have been resorpted in all cases. For the reconstruction of short fingertip stumps after the initial amputated stump plasties, acceptable results have not yet been achieved using the graft on flap method.

Background: The preferable reconstructive surgical options for Allen type IV finger amputation is replantation. The viable alternate option is bone and nail bed graft repositioning on local flaps. The wider scope of this “graft reposition on flap” (GRF) technique was introspected.

Methods: Fifteen patients who sustained type IV amputations of finger tip were operated between 2013 and 2017 by GRF technique. The results, range of motions, functional out come and its feasibility were analyzed and evaluated. A technical modification of GRF was also described within this series of patients.

Results: All patients had good nail bed survival and well settled local flaps. Static two-point discrimination (2PD) was of 6.4 mm (average). 14/15 patients had an acceptable shortening of 4mm (average). Overall patients were happy after surgery and returned back to their work. All had excellent range of movements and 0 VAS. The follow up was 1 to 5 years (mean 2.8 years). Wound infection was seen in one patient whom after debridement developed gross shortening and thick nail. None developed nail deformity.

Conclusions: The GRF provided an alternative option for Allen type IV amputations of finger tip. It can be well executed in all reconstructive surgical units and in those with a learning curve for replantations surgeries. The results of GRF were proportionate with the available surgical options in terms of appearance, function and outcomes.

An exceptional case like our patient who was a 24-year-old man presented 6 weeks after type 4 Allen amputation to his right index finger where primary surgical stump closure was done, presented to us with the amputated distal part warm preserved. The reposition of distal amputated part using the authors described GRF (Graft Reposition on Flap) technique was done and followed. Good consolidation and bone graft union, good nail with near normal pulp and normal sensation with good functional outcome was achieved at the one-year final follow up.

Background: There are numerous flaps described for the treatment of fingertip amputation. Most flaps do not address the shortened nail resulting from amputation. Proximal nail fold (PNF) recession is a simple procedure that exposes the hidden portion of the nail and improves the aesthetic appearance of an amputated fingertip. The aim of this study is to measure the size and aesthetic outcomes of the nail following fingertip amputation in patients treated with PNF recession compared to those treated without PNF recession.

Methods: This study was conducted between April 2016 and June 2020 and included patients with a digital-tip amputation who underwent a local flap or shortening closure for reconstruction. All suitable patients were counselled for PNF recession. In addition to demographic, injury and treatment data, the length and area of the nail were measured. The outcomes were assessed at a minimum of 1 year after surgery and included measurement of the size of the nail, patient satisfaction and aesthetic outcomes. A comparison of the outcomes was done between patients who underwent PNF recession versus those who did not.

Results: Out of 165 patients treated for fingertip injury, 78 underwent PNF recession (Group A) and 87 did not undergo PNF recession (Group B). In Group A, the nail length was 72.54% (SD: 14.4) and the nail plate area was 74.35% (SD: 13.96) compared to the contralateral uninjured nail. These results were significantly better (p = 0.000) compared to Group B where the values were 36.49% (SD: 8.45) and 35.8% (SD: 8.4), respectively. The patient satisfaction and aesthetic outcome scores were also significantly higher in Group A patients (p = 0.002).

Conclusions: The size and aesthetic outcomes of the nail following fingertip amputation in patients treated with PNF recession are better compared to those treated without PNF recession.

Level of Evidence: Level III (Therapeutic)