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Elameenetal.
Journal of Orthopaedic Surgery and Research (2024) 19:765
https://doi.org/10.1186/s13018-024-05230-9
REVIEW
Factors predicting composite grafts
survivability inpatients withngertip
amputations; asystematic review
andmeta-analysis
Ali Mohamed Elameen1, Asmaa Ali Dahy2*, Ahmed Abu‑Elsoud3 and Amany Attalah Gad2
Abstract
Background Fingertip amputation is a commonly encountered injury in emergency settings. Composite grafting
is a non‑microsurgical alternative maintaining digit length with no donor site morbidities. This meta‑analysis was con‑
ducted to retrieve factors associated with composite graft survivability among patients with fingertip amputations.
Methods A literature review throughout twelve databases was performed on 24 July 2023. All clinical studies com‑
paring the patients‑related, trauma‑related, or amputation‑related variables among patients with survived and non‑
survived composite grafting were eligible for meta‑analysis. Single‑arm studies reported the potential predictors
of composite graft survival among patients with fingertip injuries treated with composite grafting were included.
Results This review included ten articles with 720 fingertips composite grafting. Of them, 526 grafts survived,
with a pooled overall survivability of 72.8%. There was a significant association between younger age (OR 2.31,95%CI
1.10, 4.87, P = 0.03), level of amputation (I) (OR 0.31,95% CI 0.14 to 0.67, P = 0.003), and successful composite grafting.
There was no statistically significant (P = 0.449) impact of time to composite grafting on the likelihood of composite
graft survivability.
Conclusion Composite grafting is a feasible and effective procedure for restoring aesthetically functional dig‑
its among patients with traumatically amputated fingertips. The composite graft survived among the majority
of the patients, with a more significant survival pattern among younger populations and patients with more distal
amputations.
Level ofevidence Level III.
Keywords Composite graft, Survival, Fingertip, Amputations
Introduction
Fingertip amputation is a commonly encountered
injury in emergency settings. It is a segmental loss of
the digits distal to the distal interphalangeal joint. It
accounts for approximately two-thirds of all hand inju-
ries among the pediatric population [1]. Crush injuries
are the most attributable cause of digital tip amputa-
tions among pediatrics. Fingertip amputations are
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Journal of Orthopaedic
Surgery and Research
*Correspondence:
Asmaa Ali Dahy
Asmaa.Ali10@azhar.edu.eg
1 Department of Plastic and Reconstructive Surgery, El‑Sahel Teaching
Hospital, Cairo, Egypt
2 Department of Plastic and Reconstructive Surgery, Faculty of Medicine
For Girls, Al‑Azhar University, Nasr City, Cairo, Egypt
3 Department of Plastic and Reconstructive Surgery, Faculty of Medicine
(Assiut Branch), Al‑Azhar University, Cairo, Egypt
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Page 2 of 16
Elameenetal. Journal of Orthopaedic Surgery and Research (2024) 19:765
associated with debilitating functional and psychologi-
cal consequences. is includes poor sensory recov-
ery, hypersensitivity, cold intolerance, and infection.
Furthermore, patients may experience multiple finger
deformities and disfigurements, resulting in long-term
disabilities [2, 3]. e ideal interventions for fingertip
amputations should restore minimally shortened and
painless fingers with sensate and durable skin coverage
with preserved functional and cosmetic outcomes [4].
Fingertip replantation is the ideal procedure for fin-
gertip amputations. It re-establishes immediate vas-
cularity to the compromised amputated fingertip,
maintaining a stable and durable digit [5]. However,
this demanding technique necessitates particular
equipment, prolonged surgical experience, and well-
prepared infrastructures. Furthermore, the complex
vascularity of the distal phalanx makes replantation
techniques impossible in certain circumstances [6].
is includes too distal amputations, crushing injury,
avulsion injury, or inadequate vessel state for vascular
anastomosis. Non-microsurgical techniques provide
a feasible alternative to fingertip replantation in non-
replantable settings. is includes healing by secondary
intention, skin grafts, loco-regional flaps, or reposi-
tioning of the amputated part as a composite graft [7].
Composite grafting is a non-microsurgical alternative
to maintain the digit length without donor site morbid-
ities. e successful rate of complete composite graft-
ing survivability is nearly 17%, while partial graft taken
is approximately 81% among the pediatric population
[8]. It is a simple, cost-effective, and time-effective pro-
cedure that preserves the digital length and partially
restores the motor and sensory functions of the finger
with a near-normal nail complex architecture. How-
ever, the composite graft is associated with consider-
able adverse events such as infection, necrosis, color
mismatches, and poor sensibility [9].
e composite graft is an alternative option to recon-
struct a non-replantable amputated fingertip. How-
ever, there is significant controversy to which factors
enhance composite graft success after fingertip ampu-
tations. Previous studies highlighted the impact of the
level of injury, time to grafting, amputation mecha-
nism, smoking status, and comorbidities. However, the
findings of previously published studies are inconsist-
ent with the difference in survivability rate [10, 11].
erefore, this systematic review and meta-analysis
was conducted to retrieve the patients-related, trauma-
related, and amputation-related factors of composite
graft survivability among patients with fingertip ampu-
tations. Recognizing such evidence is crucial to ensur-
ing a better prognosis and optimizing an individualized
decision-based approach for patients with traumatic
fingertip amputations.
Methods
is meta-analysis was performed parallel with the
Preferred Reporting Items for Systematic Reviews and
Meta-Analysis (PRISMA) guidelines [12] and the rec-
ommendations of the Cochrane collaboration [13]. e
methodology of the study was registered in the PROS-
PERO (CRD42023459514) database. (Supplementary
Table1).
Literature search
e literature was reviewed through twelve databases
on 24 July 2023. e following databases were searched
using individualized search strings customized for each
database: PubMed, ISI, Google Scholar, Scopus, NYAM,
SIGLE, VHL, Clinical trials, mRCT, Cochrane Collabo-
ration, EMBASE, and ICTRP. ere were no limitations
regarding age, gender, the language of publication, eth-
nicity, definitions of amputations, graft survivability,
and study regions. Citation tracking, cross-referencing,
and reviewing the references of the eligible articles were
carried out to retrieve all possible relevant articles. e
following keywords were used; ‘Digits’, ‘Fingertip’, ‘Fin-
gertips’, ‘ ‘Digital Tips’, ‘Fingers’, ‘Digital Tip’, ‘Digit’, ‘Fin-
ger’, ‘umb’, ‘umbs’, ‘Graft’, ‘Grafts’. (Supplementary
Table2).
Study selection
All clinical studies comparing the patients-related,
trauma-related, or amputation-related variables among
patients with survived and non-survived composite
grafting were eligible for meta-analysis. Single-arm stud-
ies reported the potential predictors of composite graft
survival among patients with fingertip injuries treated
with composite grafting were included. Non-compara-
tive studies or irrelevant articles were ineligible. Stud-
ies with unextractable data, review articles, guidelines,
comments, case reports, animal studies, letters, posters,
books, or editorials were not included.
e articles retrieved from the screening process were
exported to an Excel sheet after the initial removal of the
duplicated reports using EndNote X9[14]. e screening
processes were performed to reveal the finally eligible
studies for data extraction.
Data extraction andquality assessment
e study-related data were retrieved from the articles
that were finally analyzed. is included the study ID,
study region, study URL, study design, and study period.
e methodology-related data were extracted, including
the eligibility criteria, diagnostic criteria of amputation
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Elameenetal. Journal of Orthopaedic Surgery and Research (2024) 19:765
levels, population, and follow-up protocol. e number
of composite grafts was stratified by the pattern of sur-
vivability into complete, partial, and failed survivability.
e patients’ related data, encompassing age, gender,
and comorbidities, were retrieved. Trauma-related fac-
tors were extracted, including mechanism of injury,
mode of trauma, time to composite grafting, contamina-
tion, affected hand, affected fingers, number of affected
fingers, and associated injuries. e amputation-related
data were retrieved, including the level of amputation,
composition of the amputated part, transport mode,
bone exposure, fracture type, and adequate preservation
of the amputated part. Management-related data, such
as the application of Lipo-prostaglandin, ice-cooling,
and hyperbaric oxygen, were retrieved. e time since
injury in the survived and failed composite grafts groups
was extracted from Murphy etal., 2017 usingWebPlot-
Digitizersoftware [15]. e quality of the analyzed arti-
cles was evaluated using the National Institute of Health
(NIH) quality assessment tool [16]. A detailed description
of classifications of fingertip amputations is described in
the (supplementary Table3).
Data analysis
e prevalence of composite graft survival was calculated
by pooling the event rate and 95% confidence intervals
(CIs) for each study, then calculating the effect sizes of
all articles to estimate the overall event rate with 95%CI.
Mean difference (MD) was used for calculating the sum-
mary effect from continuous variables. Mean and stand-
ard deviation (SD) was calculated from mean and range
or median and range following equations provided by
Hozo etal. [17] e risk ratio (RR) or odds ratio (OR)
with 95% CI was used for reporting the dichotomous var-
iables. e fixed-effect model was applied when a fixed
population effect size was assumed. On the contrary,
the random-effects model was implemented. Statistical
heterogeneity was evaluated using Higgins I2 statistics
and the Cochrane Q (Chi2 test) [18]. Meta-analysis was
performed using Review Manager version 5.4 (Revman
5.4) and Comprehensive Meta-Analysis v3 (CMA V3)
software[19, 20]. e significant difference was revealed
when the probability value (P) < 0.05.
Results
A literature review of twelve databases revealed 1755
potentially relevant articles. Duplicates were initially
excluded, retrieving 1229 reports eligible for screening.
Out of them, 1185 articles were excluded, resulting in 44
studies included for full-text screening. irty-four stud-
ies were ousted, yielding ten articles for data extraction.
Two reports with unextractable data were excluded, and
two were included in the citation tracking method. Ten
articles were eventually eligible for systematic reviewing
and meta-analysis. (Fig.1).
Demographic characteristics oftheanalyzed articles
e present systematic review included ten articles with
720 fingertips composite grafting [7, 21–29]. ere were
eight articles of retrospective design and two of prospec-
tive design. Four articles included patients from South
Korea and three from the United Kingdom. Four stud-
ies implemented the Modified-Ishikawa classification
for fingertip amputations. Five studies included only the
pediatric population; three reports included the adult
population. Of the included 720 composite grafts, 526
grafts showed complete or partial composite graft surviv-
ability. e average age of the included patients hovered
between 4.3 and 46.07years. ere were 274 males and
189 females. e average follow-up period ranged from
8weeks to 14.8months. (Table1).
ere were 336 patients with clean-cut fingertip ampu-
tations. e most affected finger was the middle finger,
succeeded by the index finger, accounting for 66 and 39
fingertips, respectively. ere were 356 patients with fin-
gertip amputations class I and 207 patients with class II
fingertip amputations. ere were 72 patients with fin-
gertip amputations class III. e quality score of the ana-
lyzed retrospective and prospective studies ranged from
60 to 80%, with all articles being good quality apart from
Eberlin etal., [22], which showed a fair quality (Table2).
Prevalence ofcomposite graft survival
Ten articles included 720 patients with composite graft
survival outcomes [7, 21–29]. Out of them, 526 grafts
were survived either partially or completely with a
pooled overall survivability of 72.8% (95%CI 62.5, 81.1;
p < 0.001) in the random-effects model (I2 = 86.11%,
P < 0.001). No evidence of publication bias was detected
based on the results of Egger’s regression test (Inter-
cept = 6.10, P = 0.17). Subgroup analysis based on the pat-
tern of composite graft survivability revealed a complete
survival rate of 28.1% with 95%CI ranging from 13.9 to
48.7%, while the partial survival rate was 40.3% (95%CI
30.1, 51.4; p < 0.001). (Fig.2 A, B and C).
Factors predicting composite graft survivability
Patients related factors
Age
ree articles included 190 patients with compos-
ite grafting, revealed the difference in the mean age
between survived and failed composite graft groups
[23, 26, 27]. Pooling the data revealed no significant dif-
ference between both groups (MD 1.64,95%CI −3.78,
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Elameenetal. Journal of Orthopaedic Surgery and Research (2024) 19:765
7.06, P = 0.55) in the random-effects model (I2 = 43%,
P = 0.17). Consequently, there was a significant associa-
tion between younger age and composite graft survivabil-
ity. Particularly, patients aged < 4years were 2.31 times
more susceptible to composite graft take (OR 2.31,95%CI
1.10, 4.87, P = 0.03) in the random-effects model (I2 = 0%,
P = 0.36). (Fig.3 A and B).
Gender (Males)
e impact of the male gender on composite graft sur-
vivability was assessed in three articles, including 235
patients [21, 23, 27]. ere was no statistical associa-
tion (P = 0.13) between male gender and composite graft
taken (OR 0.43,95%CI 0.14 to 1.28) with a statistical
homogeneity between the included studies (I2 = 33%,
P = 0.22). (Fig.3C).
Comorbidities
Smoking e impact of smoking on the outcomes of
composite graft survivability was evaluated in four arti-
cles, including 247 patients [23, 24, 26, 27]. In the ran-
dom-effects model (I2 = 72.28%, P = 0.013), there was no
statistically significant association between smoking and
composite graft survivability (OR 1.435,95%CI 0.341 to
6.034, P = 0.622). (Fig.3D).
Diabetes mellitus Two studies, including 112 patients,
evaluated the impact of diabetes mellitus on composite
graft survivability [24, 26]. ere was no statistically sig-
nificant association (P = 0.51) between diabetes mellitus
and the composite graft outcomes, with an OR of 0.13,
ranging from 0 to 60.99 with a significant heterogene-
ity between the included studies (I2 = 87%, P = 0.006).
(Fig.3E).
Hypertension e association between hypertension
and composite graft taken was assessed among 96 patients
within two articles [26, 27]. ere was no statistically
significant difference between failed and survived com-
posite grafts groups (OR 0.46,95%CI 0.15, 1.45, P = 0.19)
with homogeneity between the included studies (I2 = 0%,
P = 0.35). (Fig.3F).
Fig. 1 PRISMA 2020 flow diagram for updated systematic reviews which included searches of databases, registers, other sources, and screening
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Elameenetal. Journal of Orthopaedic Surgery and Research (2024) 19:765
Table 1 Demographic characteristics of the included studies
Study ID Study region Study design Study period Diagnostic
criteria Study
population Follow-up period Sample Size Outcomes
Survived Failed Complete Partial Failed
Number Number Number Number Number
1 Borrelli et al.,
2018[21]UK Retrospective January 01 2006
and 31 December
2016
Modified‑Ishikawa Pediatric 4.65 ± 10.85 months 59 41 13 46 41
2 Butler et al.,
2016[7]UK Retrospective October 2006
and April 2013 Modified‑Ishikawa Pediatric 1.8 months 43 54 10 33 54
3 Eberlin et al.,
2015[22]USA Retrospective January 2007
to December
2012
NR Pediatric 137 days
(4.5 months) 26 13 3 23 13
4 Eo et al., 2018 [23] South Korea Retrospective March 2008
and September
2017
Das Pediatric
and Adult Popula‑
tion
3 months 84 10 NR NR NR
5 Heistein
and Cook, 2003
[24]
USA Prospective
cohort December 1997
to June 2000 Allen Pediatric
and Adult Popula‑
tion
1 (5–8 days)
and 12 weeks
after the injury
48 9 30 18 9
6 Lee et al., 2023[25] South Korea Retrospective January 2013
and December
2017
Allen Adult 8 weeks 28 27 NR NR NR
7 Lee et al., 2020
[26]South Korea Retrospective January 2015
and July 2020 Ishikawa Adult 6 months 121 20 94 27 20
8 Lim et al., 2019
[27]South Korea Retrospective January 2007
and December
2017
Das Adult NR 25 16 NR NR NR
9 Moiemen
and Elliot, 1997
[28]
UK Prospective
cohort June 1989
to January 1993 Modified‑Ishikawa Pediatric 14.8 months 36 13 11 26 13
10 Murphy et al.,
2017[29]Australia Retrospective January 2003
to December
2014
Modified‑Ishikawa Pediatric NR 56 11 30 26 11
Study ID Age (Years) Gender Smoking Time Delay > 6h
Males Females
Survived Failed Survived Failed Survived Failed Survived Failed Survived Failed
Mean ± SD Mean ± SD Number Number Number Number Number Number Number Number
1 Borrelli et al., 2018[21] NR NR 32 25 27 16 NR NR 45 49
2 Butler et al., 2016[7] 4.3 (1–15)* NR NR NR NR NR NR NR NR
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Elameenetal. Journal of Orthopaedic Surgery and Research (2024) 19:765
SD, standard deviation; NR, non-reported; UK, United Kingdom; USA, United States of America
*data reported using median and range
Table 1 (continued)
Study ID Age (Years) Gender Smoking Time Delay > 6h
Males Females
Survived Failed Survived Failed Survived Failed Survived Failed Survived Failed
Mean ± SD Mean ± SD Number Number Number Number Number Number Number Number
3 Eberlin et al., 2015[22] NR NR 24 15 NR NR NR
4 Eo et al., 2018 [23] 40 (1–68)* 37 (25–51)* 60 9 24 1 28 6 15 5
5 Heistein and Cook, 2003 [24] NR NR 19 9 2 10 NR NR
6 Lee et al., 2023[25]40.93 ± 11.84 46.07 ± 18.00 NR NR NR NR 10 6 NR NR
7 Lee et al., 2020 [26]38.4 ± 17.0 74 87 NR NR NR NR
8 Lim et al., 2019 [27] 40.08 (16–65)* 42.19 (20–76)* 16 15 9 1 8 NR NR NR
9 Moiemen and Elliot, 1997 [28] NR NR NR NR NR NR NR NR 22 10
10 Murphy et al., 2017[29] NR NR NR NR NR NR NR NR 37 16
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Elameenetal. Journal of Orthopaedic Surgery and Research (2024) 19:765
Table 2 Trauma related data and quality assessment of the included studies
Study ID Mechanism of Injury Aected Fingers
Cut Avulsion Crushed Thumb Index nger Middle nger Ring nger Little nger
Survived Failed Survived Failed Survived Failed Survived Failed Survived Failed Survived Failed Survived Failed Survived Failed
Number Number Number Number Number Number Number Number Number Number Number Number Number Number Number Number
1 Borrelli et al.,
2018[21]49 26 3 10 7 4 NR NR NR NR NR NR NR NR NR NR
2 Butler et al.,
2016[7]NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR
3 Eberlin et al.,
2015[22]2 1 24 1 6 15 9 8
4 Eo et al., 2018
[23]58 2 26 8 10 0 20 1 31 5 16 3 7 1
5 Heistein
and Cook,
2003 [24]
10 6 11 7 7 12 NR NR NR NR NR NR NR NR NR NR
6 Lee et al.,
2023[25]25 9 2 16 NR NR NR NR NR NR NR NR NR NR
7 Lee et al., 2020
[26]128 33 NR NR NR NR NR NR NR NR NR NR
8 Lim et al., 2019
[27]18 3 NR NR 7 13 2 2 8 4 9 6 4 1 2 3
9 Moiemen
and Elliot, 1997
[28]
NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR
10 Murphy et al.,
2017[29]NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR
Study ID Level of amputation Quality
assessment
1a 1b II III
Survived Failed Survived Failed Survived Failed Survived Failed
Number Number Number Number Number Number Number Number % Decision
1 Borrelli et al., 2018[21] 3 0 14 12 26 16 8 8 80 Good
2 Butler et al., 2016[7] 4 8 26 25 12 20 1 1 70 Good
3 Eberlin et al., 2015[22] NR NR NR NR NR NR NR NR 60 Fair
4 Eo et al., 2018 [23] 43 1 26 5 15 4 80 Good
5 Heistein and Cook, 2003 [24] NR NR NR NR NR NR NR NR 80 Good
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Elameenetal. Journal of Orthopaedic Surgery and Research (2024) 19:765
NR, non-reported
Table 2 (continued)
Study ID Level of amputation Quality
assessment
1a 1b II III
Survived Failed Survived Failed Survived Failed Survived Failed
Number Number Number Number Number Number Number Number % Decision
6 Lee et al., 2023[25] 12 9 13 13 3 5 70 Good
7 Lee et al., 2020 [26] 77 9 35 9 17 6 2 9 80 Good
8 Lim et al., 2019 [27] 14 3 6 4 5 9 80 Good
9 Moiemen and Elliot, 1997 [28] NR NR NR NR NR NR NR NR 70 Good
10 Murphy et al., 2017[29] 14 2 32 4 10 3 0 2 70 Good
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Elameenetal. Journal of Orthopaedic Surgery and Research (2024) 19:765
Fig. 2 Forest plot of summary analysis of the A Event rate and 95% CI of the prevalence of the overall composite graft survivability. B The event rate
and 95% CI of the prevalence of the complete composite graft survivability. C The event rate and 95% CI of the prevalence of the partial composite
graft survivability. The size of the black squares is proportional to the statistical weight of each trial. The grey diamond represents the pooled point
estimate. The positioning of both diamonds and squares (along with 95% CIs) beyond the vertical line (unit value) suggests a significant outcome
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Elameenetal. Journal of Orthopaedic Surgery and Research (2024) 19:765
Amputation-related factors
Time frominjury tocomposite grafting
Two studies reported the difference between the sur-
vived and failed composite grafts regarding the time from
injury to composite grafting [7, 23]. ere was no statis-
tically significant difference between both groups (MD
−2.67,95%CI −8.48, 3.13, P = 0.37) with heterogeneity
between the included studies (I2 = 85%, P = 0.010). e
association between time delay to composite grafting was
evaluated within five studies, including 265 patients [21,
23, 25, 28, 29]. ere was no statistically significant asso-
ciation (P = 0.449) between composite graft survivability
and time delay > 6h with an OR of 0.730, ranging from
0.323 to 1.649, in the random-effects model (I2 = 55.6%,
P = 0.060). (Fig.4 A and B).
Mechanism ofinjury
Crushing injury Four articles evaluated the impact of
crushing injury on composite graft survivability [21, 23,
26, 27]. ere was no statistically significant association
between crushing injury and composite graft survivabil-
ity with an OR of 4.77 and 95%CI; 0.55 to 40.97 with a
P-Value of 0.15 (I2 = 90%, P < 0.001). (Fig.4C).
Cut injury Five studies, including 347 patients, assessed
the impact of clean-cut amputations on the survival out-
comes of composite grafts [21, 23, 24, 26, 27]. Pooling the
data in the random-effects model (I2 = 81.94%, P < 0.001)
revealed no significant impact of the cut amputations
on the likelihood of composite graft survivability (OR
2.719,95%CI 0.743 to 9.951, P = 0.131). (Fig.4D).
Levels ofamputations
Modied‑ishikawa classication
Level of amputation (1a) Four articles included 405
patients evaluated the impact of the level of amputation
(1a) on the composite graft survivability [7, 21, 25, 29].
ere was no statistically significant association between
patients with fingertip amputations level 1a and com-
posite graft survivability (OR 1.48,95%CI 0.78 to 2.84,
P = 0.23) with homogeneity between the included articles
(I2 = 7%, P = 0.36). (Fig.5A).
Level ofamputation (1b) e association between the
level of amputation (1b) and composite graft survivability
was reported in four articles that included 405 patients [7,
21, 25, 29]. ere was no statistically significant associa-
tion between the level of amputation (1b) and composite
graft survivability (OR 0.93,95%CI 0.58, 1.50, P = 0.77)
with homogeneity between the included articles (I2 = 48%,
P = 0.12). (Fig.5B).
Level of amputation (II) Seven studies included 177
patients evaluated the impact of the level of amputation
(II) on composite graft survivability [7, 21, 23, 25–27,
29]. Pooling the data in the fixed-effect model (I2 = 0%,
P = 0.68) revealed no statistically significant association
between level of amputation (II) and composite graft sur-
vivability (OR 1.33,95%CI 0.89, 1.99, P = 0.17). (Fig.5C).
Das classication
Level ofamputation (I)
ree articles evaluated the impact of the level of ampu-
tation (I) using Das classification on the composite
graft survivability [23, 26, 27]. Patients with the level of
amputation (I) were more susceptible to having a suc-
cessful composite grafting (OR 0.31,95%CI 0.14 to 0.67,
P = 0.003) in the fixed-effect model (I2 = 47%, P = 0.08).
(Fig.5D).
Discussion
Composite grafting for fingertip amputations is a worth-
while technique in cases where replantation is impossi-
ble. e usability of composite grafting has been reported
in previous reviews; however, the survival rates and fac-
tors associated with composite graft survivability have
yet to be investigated conclusively in the literature [9].
e present meta-analysis revealed an overall compos-
ite graft survivability of 72.8%, complete survivability of
28.1%, and partial survivability of 40.3%. Composite graft
survivability was more pronounced among the pediat-
ric population, particularly patients aged less than four
years and patients with amputation level (I). Smokers
and patients with crushing injuries were at higher risk
(See figure on next page.)
Fig. 3 Forest plot of summary analysis of the A Mean difference (MD) and 95% CI of the difference in the mean age between survived and failed
composite graft groups B Odds ratio (OR) and 95% CI of the impact of young age < 4 years on the likelihood of composite graft survival
between survived and failed composite graft groups C Odds ratio (OR) and 95% CI of the impact of male gender on the likelihood of composite
graft survival between survived and failed composite graft groups D Odds ratio (OR) and 95% CI of the impact of smoking on the likelihood
of composite graft survival between survived and failed composite graft groups E Odds ratio (OR) and 95% CI of the impact of diabetes mellitus
on the likelihood of composite graft survival between survived and failed composite graft groups. F Odds ratio (OR) and 95% CI of the impact
of hypertension mellitus on the likelihood of composite graft survival between survived and failed composite graft groups. Size of the green
or blue squares is proportional to the statistical weight of each trial. The grey diamond represents the pooled point estimate. The positioning
of both diamonds and squares (along with 95% CIs) beyond the vertical line (unit value) suggests a significant outcome (IV = inverse variance)
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Elameenetal. Journal of Orthopaedic Surgery and Research (2024) 19:765
Fig. 3 (See legend on previous page.)
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Elameenetal. Journal of Orthopaedic Surgery and Research (2024) 19:765
Fig. 4 Forest plot of summary analysis of the A Mean difference (MD) and 95% CI of the difference in the time from injury to composite grafting
between survived and failed composite graft groups B Odds ratio (OR) and 95% CI of the impact of time delay > 6 h to composite grafting
on the likelihood of composite graft survival between survived and failed composite graft groups C Odds ratio (OR) and 95% CI of the impact
of crush injuries on the likelihood of composite graft survival between survived and failed composite graft groups D Odds ratio (OR) and 95% CI
of the impact of cut injuries on the likelihood of composite graft survival between survived and failed composite graft groups. Size of the green
or blue squares is proportional to the statistical weight of each trial. The grey diamond represents the pooled point estimate. The positioning
of both diamonds and squares (along with 95% CIs) beyond the vertical line (unit value) suggests a significant outcome (IV = inverse variance)
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Page 13 of 16
Elameenetal. Journal of Orthopaedic Surgery and Research (2024) 19:765
of composite graft failure despite not being statistically
significant.
Composite graft survivability was associated sig-
nificantly with the pediatric population, crush injuries,
and the level of amputations. ese findings were con-
comitant with Landin et al., 2021 who reported better
composite graft outcomes among younger age, more
distal amputations, and clean-cut injuries with a graft
Fig. 5 Forest plot of summary analysis of the A Odds ratio (OR) and 95% CI of the impact of level of amputation (1a) on the likelihood of composite
graft survival between survived and failed composite graft groups B Odds ratio (OR) and 95% CI of the impact of level of amputation (1b)
on the likelihood of composite graft survival between survived and failed composite graft groups C Odds ratio (OR) and 95% CI of the impact
of the impact of l the level of amputation (II) on the likelihood of composite graft survival between survived and failed composite graft groups
D Odds ratio (OR) and 95% CI of the impact of the level of amputation (I) using Das classification on the likelihood of composite graft survival
between survived and failed composite graft groups. Size of the green or blue squares is proportional to the statistical weight of each trial. The grey
diamond represents the pooled point estimate. The positioning of both diamonds and squares (along with 95% CIs) beyond the vertical line (unit
value) suggests a significant outcome (IV = inverse variance)
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Page 14 of 16
Elameenetal. Journal of Orthopaedic Surgery and Research (2024) 19:765
survivability hovered between 7.7 and 93.5% [9]. Jester
etal., 2023 reported a relatively higher composite graft
survival rate among the pediatric population, accounting
for 81.6%. ey attributed composite graft survivability
to more distal amputations and shorter time to operation
[8]. e central digital artery divides near the end of the
fingertip, with more vascularity in this area, supplied by
the terminal segmental and fibrous hiatus branches. Fur-
thermore, the reduced volume of detached tissues with
more distal amputations required low perfusion with
plasma imbibition and capillary inosculation. is could
explain the high possibility of composite grafts taken with
more distal digital tip amputations [30]. In this respect,
Modified Ishikawa classification levels I and II showed no
significant association with composite graft survivability,
whereas Das classification level I achieved a significant
association. Das classification level I included only distal
pulp loss with no bony or nail involvement. Paradoxically,
Modified Ishikawa classification levels I and II included
distal pulp loss in addition to nail and bony involvement
with more involvement in level II amputations [31, 32].
Composite grafts incorporate only soft tissue require less
metabolic demands to survive, while grafts that incorpo-
rate soft tissue, bones and nails require more metabolic
demands with less potential to survive[30].
Crush injuries are associated with poor composite graft
survivability. is is because of the extensive damage
to the vessels, nerves, and soft tissues of the amputated
part, as well as the remaining stump. Composite grafts
are revascularized via anastomosis between the vessels
of the subcutaneous vascular network at the contact
area between the graft and the remaining digital stump.
is usually occurs within two to five days after grafting.
Furthermore, capillary neovascularization occurs after
five days of grafting [33, 34]. e non-vascularized com-
posite graft is initially nourished via imbibition, which
is affected remarkably with avulsion and crushing inju-
ries. is finding was parallel with Sears etal., 2011 who
reported poor survivability among patients with finger-
tip avulsion injuries who underwent finger replantation
[35]. Noteworthy, a failed composite grafting may act as
a biological dressing, allowing the underlying wound to
re-epithelialize and granulate. is may preserve the digit
length, affording more sensations relative to immediate
finger terminalization [29].
e present meta-analysis revealed no significant
impact of time to composite grafting on the overall sur-
vivability. Patients treated with composite grafting before
or after six hours after the injury have a similar pattern
of graft survivability. Parallel with this finding, Yu etal.,
2015 reported a lack of significant impact of ischemia
time on the survival rate of finger replantation and high-
lighted the role of cooling preservation on the overall
survivability [36]. Paradoxically, Jester et al., 2023 and
Landin et al., 2021 systematic reviews showed a bet-
ter composite graft taken with a shorter time to grafting
[8, 9]. Previous studies identified the time for success-
ful grafting at six hours based on the time at which de-
vascularized muscles underwent irreversible ischemia
damage. However, fingertip amputations primarily com-
prise soft tissues that can tolerate up to one day of cold
ischemia with fingertip replantation. Appropriate cooling
of the amputated fingertip could enhance composite graft
survivability. Cooling minimizes the tissue’s metabolic
demands and has a bacteriostatic effect, with no further
tissue damage. e time delay may have little impact
on the composite graft survivability, assuming the graft
underwent appropriate cooling preoperatively. Mean-
while, further prospective studies are needed to investi-
gate the impact of time delay intervals on the composite
graft survivability in the context of other confounders
using the appropriate regression analysis [37].
e present meta-analysis revealed factors influenc-
ing the survivability of composite grafting in fingertip
amputations. e study included the largest cohort in the
literature, assessing predictors of composite graft surviv-
ability in different settings and age categories. Conversely,
some limitations may negatively impact the resulting evi-
dence. Most of the eligible studies were retrospective,
conferring a substantial risk of information bias. Subse-
quently, there was significant statistical and methodo-
logical heterogeneity between the analyzed articles. is
heterogeneity may be attributed to the significant varia-
tion between the analyzed articles regarding the recruit-
ment criteria, sample sizes, follow-up period, definition
of the level of the amputation, recognizing graft success,
and demographic characteristics of the included patients.
e resulting statistical heterogeneity was resolved by
applying the random-effects model and doing subgroup
analysis. Further prospective studies with adequate sam-
ples and prolonged follow-up periods are necessary to
mitigate the potential limitations of the analyzed studies.
Conclusions
Composite grafting is a feasible and effective proce-
dure for restoring aesthetically functional digits among
patients with traumatically amputated fingertips. e
composite graft survived among the majority of the
patients, with a more significant survival pattern among
younger populations and patients with more distal
amputations. Subsequently, patients with crushing inju-
ries, more proximal amputations, and smokers were at
higher risk of composite graft failure. Identifying factors
associated with composite graft survivability could help
hand surgeons identify vulnerable populations early and
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Page 15 of 16
Elameenetal. Journal of Orthopaedic Surgery and Research (2024) 19:765
implement preventive measures to minimize the risk of
graft failure in patients with fingertip amputations.
Abbreviations
PRISMA preferred reporting items for systematic reviews and meta‑analysis
MD mean difference
SMD standardized mean difference
CI confidence interval
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s13018‑ 024‑ 05230‑9.
Supplementary file 1.
Acknowledgements
None.
Author contributions
All authors contributed to the study conception and design. Material prepara‑
tion, data collection and analysis were performed by Ali Mohaned Elameen,
Asmaa Ali Dahy, Ahmed Abu‑Elsoud, and Amany Attalah Gad. The first draft
of the manuscript was written by Ali Mohaned Elameen, and all authors
commented on previous versions of the manuscript. All authors read and
approved the final manuscript.
Funding
Open access funding provided by The Science, Technology & Innovation
Funding Authority (STDF) in cooperation with The Egyptian Knowledge
Bank (EKB). The authors declare that no funds, grants, or other support were
received during the preparation of this manuscript.
Availability of data and materials
The datasets used in the present study are available from the first author and
corresponding authors on reasonable request.
Declarations
Ethics approval
This article does not contain any studies with human participants or animals
performed by any of the authors.
Consent to participate
Informed consent is not required as no human subjects were included.
Consent to publish
Informed consent is not required as no human subjects were included.
Competing interests
The authors have no relevant financial or non‑financial interests to disclose.
Received: 7 September 2024 Accepted: 2 November 2024
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