Article

Distraction Osteogenesis and Free Nail Graft After Distal Phalanx Amputation

Service of Hand Surgery and Reconstructive Microsurgery, Hospital São Lucas da Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil. Electronic address: .
The Journal of hand surgery (Impact Factor: 1.67). 12/2012; 37(12):2541-6. DOI: 10.1016/j.jhsa.2012.09.008
Source: PubMed
ABSTRACT
To describe the results in patients treated with distraction osteogenesis combined with free nail graft after distal phalanx amputation.
We analyzed 14 patients with distal phalanx amputation (13 women). Mean age was 35 years. There were 9 amputations of the index finger, 3 of the middle finger, and 1 each of the thumb and ring finger. We started bone distraction 7 days after surgery, with 1 mm distraction every 3 days. After bone elongation, we inserted a free composite nail graft at the dorsal tip of the distracted finger. We evaluated distraction length, consolidation time, aesthetic result (using the Foucher and Leclère score), and complications.
The mean bone elongation was 17 mm and mean consolidation time was 149 days. Nail cosmetic results were satisfactory; the mean total Foucher score was 14 out of 20. Mean individual scores were patient's opinion (7.8 out of 10), adequate length (1.2 out of 2.5), adequate alignment (1 out of 1), adequate width (1.8 out of 4), and dorsal scar quality (2.2 out of 2.5). The mean total Leclère score was 14 out of 20. All patients retained sensibility in the grafted area and none had healing abnormalities. The mean opinion about the donor site was 7.5 out of 8. Nail growth less than 50% occurred in 2 patients. Mean follow-up was 62 months.
Distraction osteogenesis combined with free nail graft is a therapeutic option when replantation is not an option or when it fails. However, treatment takes time and requires the involvement of the patient, family, and medical team.
Therapeutic IV.

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Available from: Jefferson Braga Silva, Jul 05, 2015
SCIENTIFIC ARTICLE
Distraction Osteogenesis and Free Nail Graft After
Distal Phalanx Amputation
Jefferson Braga-Silva, MD, PhD, Alexandre V. Padoin, MD, PhD
Purpose To describe the results in patients treated with distraction osteogenesis combined
with free nail graft after distal phalanx amputation.
Methods We analyzed 14 patients with distal phalanx amputation (13 women). Mean age was
35 years. There were 9 amputations of the index finger, 3 of the middle finger, and 1 each
of the thumb and ring finger. We started bone distraction 7 days after surgery, with 1 mm
distraction every 3 days. After bone elongation, we inserted a free composite nail graft at the
dorsal tip of the distracted finger. We evaluated distraction length, consolidation time,
aesthetic result (using the Foucher and Leclère score), and complications.
Results The mean bone elongation was 17 mm and mean consolidation time was 149 days.
Nail cosmetic results were satisfactory; the mean total Foucher score was 14 out of 20. Mean
individual scores were patient’s opinion (7.8 out of 10), adequate length (1.2 out of 2.5),
adequate alignment (1 out of 1), adequate width (1.8 out of 4), and dorsal scar quality (2.2
out of 2.5). The mean total Leclère score was 14 out of 20. All patients retained sensibility
in the grafted area and none had healing abnormalities. The mean opinion about the donor
site was 7.5 out of 8. Nail growth less than 50% occurred in 2 patients. Mean follow-up was
62 months.
Conclusions Distraction osteogenesis combined with free nail graft is a therapeutic option when
replantation is not an option or when it fails. However, treatment takes time and requires the
involvement of the patient, family, and medical team. (J Hand Surg 2012;37A:25412546.
Copyright © 2012 by the American Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Therapeutic IV.
Key words Finger reconstruction, distraction osteogenesis, free nail graft, treatment.
A
MPUTATION OF THE thumb, any amputation in
children, and multiple digit or proximal ampu-
tations generally benefit from replantation.
When the replantation cannot be done because of de-
struction of the pulp or damage to the intima of vessels,
alternative therapy is necessary.
1,2
Many techniques and devices intended to recover an
adequate length of a digit include callus distraction,
microsurgical transfer, and replantation to restore length
and function in proximal phalangeal amputations. Al-
though all components of the finger grow with distrac-
tion and maintain vascularity and sensibility, the ab-
sence of a nail confers a poor aesthetic outcome.
3,4
The
nail is a noteworthy component of the finger. Besides
having aesthetic value, it is important for enhancing
pulp sensibility and stability, and it is necessary for
palmar prehension. In some professions that depend
highly on refined digital pinch, a deficient nail can
cause serious impairment.
5
Nonvascularized composite nail graft is an estab-
lished method for nail reconstruction that is easily
reproducible and simple to execute. However,
From the Service of Hand Surgery and Reconstructive Microsurgery, Hospital São Lucas da Pontifical
Catholic Universityof Rio Grande do Sul, Porto Alegre, Brazil.
Received for publication May 14, 2012; accepted in revised form September 14, 2012.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Corresponding author: Jefferson Braga-Silva, MD, PhD, Service of Hand Surgery and Recon-
structiveMicrosurgery,HospitalSãoLucasdaPontificalCatholicUniversityofRioGrandedoSul,Av.
Ipiranga 6690/216, Porto Alegre, RS 90610-000, Brazil; e-mail: jeffmao@terra.com.br.
0363-5023/12/37A12-0015$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2012.09.008
©  ASSH Published by Elsevier, Inc. All rights reserved. 2541
Page 1
some authors have reported unpredictable results.
2
The objective of this report was to describe an
alternative technique for the reconstruction of dis-
tal phalanx amputations, consisting of callus dis-
traction combined with free nail graft, which can
be used in selected patients.
MATERIALS AND METHODS
We conducted a retrospective study to evaluate a series
of 14 patients treated with distraction osteogenesis and
a free nail graft. Inclusion criteria for the procedure
were all patients with distal phalanx amputation not
treated with replantation or with replantation failure
(Fig. 1), who were willing to undergo a long treatment
that involved 3 surgical procedures, and who were able
to be away from work. Patients required medical fol-
low-up and family support during the whole treatment.
We carried the first 2 procedures out under axillary
block and the third under axillary block and local an-
esthesia in the donor toe.
Finger distraction
Initially, we placed a monopolar external fixator (Or-
thofix, Milan, Italy) in the ends of the middle phalanx,
which allowed digital elongation. We always placed 2
pins (0.8 mm in diameter) at the proximal ends. We
used 1 or 2 pins in the distal portion, where the prefer-
ence was to use 2 pins, except when there was no space
( 4 mm) for the second pin (Fig. 2). We opened the
periosteum through a longitudinal incision on the dorsal
side and performed an osteotomy in the middle portion
of the middle phalanx, allowing elongation. Bone dis-
traction was started 7 days after surgery, with 1 mm
distraction every 3 days. The patient and family mem-
bers were advised about how to proceed with distrac-
tion.
Bone grafting
When the finger was long enough for functional pinch,
we stopped the distraction. We based this measurement
not on the finger of the other hand, but rather on the
measurement for which the functional pinch was ade-
quate, which corresponded to the estimate of the orig-
inal length of the finger. At this time, we performed
bone grafting (second surgery) in all patients because
there was not enough regenerated bone. We derived
cancellous graft from the distal radius on the same side.
We again made a dorsal longitudinal incision in the
finger and inserted the grafting material (Fig. 3). The
fixator was maintained during the bone grafting to give
stability.
There was then a waiting period until the end of bone
consolidation, which we evaluated by x-ray (Fig. 4).
Free nail graft
The third surgical procedure was to remove the external
fixator and transfer a nail complex from the foot to the
hand. We made an H-shaped incision in the finger. We
FIGURE 1: Patient with distal phalanx amputation.
FIGURE 2: Middle phalanx with external fixator.
FIGURE 3: X-ray after grafting.
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used the proximal portion to bury the proximal portion
of the nail complex. The distal portion of the H created
an ideal receptor bed for integration of the composite
graft, and the transposition of the distal segment of the
H gave a better shape to the tip with a skin graft from
the hypothenar area. A free composite toe nail graft
contained the nail, nail bed, nail matrix, and periosteum
(Figs. 5, 6). The nail complex was sutured in this pocket
(Fig. 7).
We closed the toe and the distal part of the
finger with full-thickness skin grafts from the hy-
pothenar area.
We evaluated distraction length, consolidation time,
aesthetic result for the nail (Foucher score) and the
donor site (Leclère score), and complications at 18
months’ follow-up after the free nail graft.
6,7
Table 1
presents the parameters used to assess the nail, and the
donor site are described in Table 2.
Continuous data are expressed as mean SD, and
maximum and minimum values are given when impor-
tant. We used Student t-test to assess the significance of
differences between 2 percentages. We used chi-square
test to assess the significance of differences between
subgroups. P .05 was considered statistically signif-
icant.
The results obtained for Foucher and Leclère scores
are described as mean values followed by the maximum
possible value (which are given in Tables 1 and 2),
followed by the range and SD.
Our institutional review board approved this re-
search.
FIGURE 4: Bone consolidation after elongation.
FIGURE 5: The H flap and the free nail complex graft.
FIGURE 6: Dermis de-epithelialized and folded at the finger’s
pulp.
FIGURE 7: Nail complex and fixation to the distal part of the
elongated digit.
TABLE 1. Classification of Cosmetic Results by
Foucher Score
Rating Factors Included in Foucher Score Points
Patient’s opinion about final nail appearance 10
Proper length of nail 2.5
Alignment of appropriate nail 1
Proper nail width 4
Quality of dorsal scar 2.5
Total 20
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RESULTS
From November 2002 to May 2009, we selected 14
patients with distal phalangeal amputations (13
women). Mean age was 35 16 years (range, 16–55
y). There were 9 amputations of the index finger, 3
amputations of the middle finger, and 1 amputation
each of the thumb and the ring finger (P .05). We
evaluated the data 18 months after the free nail graft,
but there was also a mean follow-up of 62 months and
as long as 10 years for some patients. Mean bone
elongation was 17 2 mm (range, 15–20 mm). All
patients received a bone graft. Mean consolidation time
was 149 22 days (range, 113–188 d).
The mean total Leclère score was 13.6 out of 20
(range, 13–15; SD, 0.63). All patients retained sensi-
bility in the grafted area, and none had healing abnor-
malities. The mean opinion about the donor zone was
7.5 out of 8 (range, 7–8; SD, 0.51) (Fig. 8).
Nail cosmetic results were satisfactory. The mean
total Foucher score was 13.9 out of 20 (range, 10.0
16.5; SD, 2.3). Mean individual score results were
patient’s opinion (7.8 out of 10; range, 68; SD, 0.7),
adequate length (1.2 out of 2.5; range, 0–1.5;
SD, 0.5), adequate alignment (1 out of 1; SD 0),
adequate width (1.8 out of 4; range, 0–3.5; SD 1.1),
and dorsal scar quality (2.2 out of 2.5; range, 0–3.5;
SD 1.1). Nail growth less than 50% occurred in 2
patients (Fig. 9).
One patient had bone deviation that resulted in in-
terruption of treatment. There were no other complica-
tions. All patients had improved pinch function, and
none reported sensibility impairment.
DISCUSSION
The reference standard for the treatment of a finger
amputation in zone I is replantation, although hypersen-
sitivity, cold tolerance, and long-term trophic changes
can result in a poor outcome even under the best con-
ditions. However, when this cannot be done because of
technical difficulty or because the fragment is in poor
condition, an alternative is digital elongation.
Matev reported finger distraction in 1979
8
and suc-
cessfully treated 3 patients who had had thumb ampu-
tations. Since then, there have been many reports using
bone distraction for hypoplastic congenital anomalies
and trauma correction.
3
Even with a 2-step procedure
separated by patient-controlled bone distraction, there
have been high satisfaction rates. We hypothesized that
satisfaction in patients was related to preoperative coun-
seling and the understanding of surgical steps and pos-
sible complications. Success depends on patient and
family motivation. Callus distraction strains tissues
TABLE 2. Leclère’s Classification of Aesthetic Results of Foot Donor Site
Rating Factors
Included Points
Patient’s opinion about
final appearance of
donor toe
8
Shortening of toe 4 4 normal 3 distal to DIP level 2 DIP Level 1 between PIP
and DIP
Quality of scar 4 4 P3 minor 3 sensitive 2 hypertrophic 1 hypertrophic
and painful
Sensitivity of tip of toe 2 2 2 points discrimination
5
1 2 points discrimination
between 5 and 10
0 hyperesthesia
Tip coverage 2 2 normal 1 poor 0 very poor
Total 20
DIP, distal interphalangeal; PIP, proximal interphalangeal.
FIGURE 8: Scar in the donor site 120 months postoperatively.
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slowly, and bone grows along with soft tissue, nerves,
and vessels. The digit does not show vascular or sen-
sory impairment because elongation is continuous, pro-
gressive, and slow. Bone distraction improves the ap-
pearance and function of the amputated digit,
3
because
the simple enlargement of the finger already improves
function by providing a better pinch (where a smaller
finger has difficulty reaching the thumb).
A bone graft was necessary in all our patients. Ac-
cording to the literature, the bone distraction result
depends on the age of the patient, and the time required
for bone elongation also depends on the length.
8
A bone
graft is recommended for patients age 25 years or older,
with gaps of 30 mm or more.
3
Bone distraction can be
used alone or in combination with a bone graft.
3
A graft
is indicated when bone regeneration does not lead to
bone consolidation.
Nail reconstruction can be performed with a free nail
graft or with a vascularized nail flap. One type of
vascularized nail flap is the long pedicle nail flap, vas-
cularized by the arterial inflow from the venous system
(venous flap). Here, a composite flap is raised with the
vascular bundles in the hallux. The flap is based on the
dorsal pedis vessels and the dorsal cutaneous veins of
the foot. They are anastomosed with radial vessels and
cutaneous veins of the hand. This surgery was shown in
1 study
9
to take an average of 7 hours 40 minutes, and
requires long scars to obtain an adequate artery and
vein. Another type is the venous flap, which is dissected
as a free nail graft,
10
but 2 cutaneous veins are pre-
served and arteriovenous anastomoses are done proxi-
mal to the interphalangeal joints. The surgery lasts less
than 4 hours, and the flap is simpler to prepare com-
pared with the long pedicle. The circulation of this flap
can be uncertain because it can result in unpredictable
venous valves and an arteriovenous shunt. Free nail
grafts can generate an adequate nail with partial, com-
posite, or complete nail graft.
2,10,11
Toe-to-hand microsurgical transfer can restore func-
tion and be cosmetically acceptable in the hand, but the
procedure is criticized because of the need of microsur-
gery and the loss of a toe.
12
Moreover, it is not justified
for ring and small finger amputations. Most patients
have normal sensibility 3 years after microsurgical
transfer; however, active motion and pinch strength are
impaired.
13
The lack of a toe is associated with impor-
tant difficulties in walking if the metatarsal head is not
preserved, and it is not accepted by patients in tropical
countries such as ours.
Unlike digit microsurgical transfer, distraction osteo-
genesis combined with free nail graft does not sacrifice
the whole digit. The surgical procedure is simple, with
a fast learning curve and a short surgical time. The
surgery is not stigmatizing, and scars and lack of toenail
can be easily concealed. The surgery has a good cos-
metic result with a minimum morbidity of the donor site
and can be performed with peripheral nerve block.
Nevertheless, this procedure has some drawbacks.
Treatment takes time and requires involvement of the
patient and family, medical support, and time away
from work.
Postoperative nail growth is unpredictable, and
sometimes the nail will atrophy and diminish in size.
2,9
Even if the nail does not acquire an excellent appear-
ance, it can be transformed into an important tool, a
corneous base for an artificial acrylic nail, which is not
possible on the skin.
A limitation of our work was that it was a retrospec-
tive study in which the examiner was the same surgeon
who carried out the procedures. The subjective nature
of part of the score can also be indicated as a limitation,
where the subjective data were based on the opinion of
the patient. We followed the routine of distraction of 1
mm every 3 days in all cases. It was not possible to
verify whether the graft would also be necessary in
cases in which elongation was done more slowly. Also,
there was no concern with respect to the costs of the
treatment. The fact that we treated selected patients who
were motivated made it difficult to compare our find-
ings with those of other studies, because we were deal-
ing with a sample that did not represent the global
picture of patients with this type of lesion. Another
limitation of the study was that we did not obtain
satisfaction data regarding the cost of this procedure for
the patient (multiple operations, recovery times, and
time away from work).
FIGURE 9: Ten years postoperatively: attractively shaped hand
after index finger distraction and grafting.
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This procedure appears to be mostly requested by
female patients whose aesthetic concerns are perhaps
greater. This is evident from our sample, which was
composed almost entirely of women. Every patient
should be inclined to accept the surgical steps involved
and should be willing to collaborate as an active par-
ticipant in the whole treatment process, which is cer-
tainly essential for the success of such a long treatment
involving 3 surgical procedures. This reconstruction
also has a functional purpose to reestablish a bidigital
functional pinch, but aesthetics is of greater concern
when we reestablish the digital segment along with the
nail unit.
The procedure described is only an alternative ther-
apy for a restricted group of patients, where the aim is
not to try to substitute for the reference standard, which
is replantation. It is a treatment option in patients for
whom a toe-to-hand microsurgical transfer might be
considered.
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