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,
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.
graft is recommended for patients age 25 years or older,
with gaps of 30 mm or more.
Bone distraction can be
used alone or in combination with a bone graft.
is indicated when bone regeneration does not lead to
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
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,
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.
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.
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
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
Postoperative nail growth is unpredictable, and
sometimes the nail will atrophy and diminish in size.
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.
DISTRACTION OSTEOGENESIS WITH FREE NAIL GRAFT 2545
Vol A, December