Exploration for Suitable Vessels for Replantation in “The Middle-type” Fingertip Amputation in Early Childhood; A Follow-up to “Validity of Exploration for Suitable Vessels for Replantation in the Distal Fingertip Amputation in Early Childhood: Replantation or Composite Graft”

Introduction: Pediatric digital amputations are rare compared to adult cases. Although the indications for digital replantation in children are generally more liberal and aggressive, they become rather ambiguous when fingertips are involved, especially those of the fingertip at the level of mid nail bed (middle-type). Previously, we reported that exploration in pediatric (6-year-old and younger) middle-type fingertip amputation found suitable vessels for replantation in 50% of times but the result of subsequent replantation was always successful. Moreover, we experienced an overall success rate of 67% in exploration cases including those of subsequent replantation with suitable vessels and composite grafting without suitable vessels. This was higher than a success rate of 57% in cases treated with primary composite grafting without exploration. Recently, we have encountered four additional cases of pediatric middle-type fingertip amputation. Therefore, we reviewed and re-analyzed all our cases to verify the value of exploring suitable vessels for digital replantation over primary composite grafting, especially in early childhood, as a follow-up to our previous report. Method: A retrospective review of cases involving the surgical treatment of young children (6 years or younger), with single-digit complete middle-type fingertip amputations from 1993 to 2016 was conducted. Cases were divided into two groups: cases underwent reattachment as composite graft primarily and cases underwent exploration for suitable vessels for replantation. In the latter group when suitable vessels for replantation were found, replantation was attempted. On the other hand, when no suitable vessels were found, amputated parts were treated as secondary composite graft with or without pocket method. The success of replantation or reattachment as a composite graft was judged on the basis of the clinical records. Results: A total of 17 consecutive cases were identified, including 13 cases that were previously reported and four new cases. Of the four new cases, replantation was successful in three cases, while simple composite grafting failed after exploration in the other case. The probability to find suitable vessels increased to 60% with the addition of three successful replantations. However, the overall success rate for vessel exploration (70%) did not show statistical significance compared to that of primary composite grafting (57%). Conclusion: We, again recommend exploration for amputations at this level with a view to replantation. Where microsurgical replantation is not possible, the use of the pocket technique can lead to a higher chance of graft survival.