UNCORRECTED PROOF RESTORATION OF FUNCTION AND SENSITIVITY UTILIZING A HOMODIGITAL NEUROVASCULAR ISLAND FLAP AFTER AMPUTATION INJURIES OF THE FINGERTIP SOKRATIS E. VARITIMIDIS, ZOE H. DAILIANA, ARISTIDIS ZIBIS, MICHALIS HANTES, KONSTANTINOS BARGIOTAS and KONSTANTINOS N. MALIZOS From the Department of Orthopaedics, University of Thessaly Medical School, Larissa, Greece Sixty-three fingertip amputations in 50 patients were reconstructed using a homodigital neurovascular island flap technique based on a single neurovascular pedicle without further shortening of the distal phalanx. The procedure was carried out under regional anaesthesia, using a tourniquet and magnifying loupes. All of the flaps survived and achieved normal or adequate two- point discrimination without any painful scar or cold hypersensitivity. Fifteen patients had some loss of distal interphalangeal joint extension. The technique is simple and presents an excellent method for fingertip reconstruction in Allen type II, III and IV injuries. Journal of Hand Surgery (British and European Volume, ]]]]) ]: ]: ]]]–]]] Keywords: ’, ’, ’ INTRODUCTION The pulp of the fingertip is that part of the finger with the richest vasculature and the highest density of nerve ends. A normal digital pulp is vital to the interaction between the brain and the upper extremity required in the finest daily activities. The contribution of the digital pulp to key pinch and tip pinch depends mainly on its neurovascular integrity. Pulp support by the nail is also needed for tip pinch and key pinch (Rosenthal, 1983). Injury of the fingertip is the most common injury of the hand and fingertip amputation is the most common amputation in the upper extremity. Injuries to the fingertip may involve loss of the skin, subcutaneous fat, part of the nail, bone or all of these. Loss of sensation after fingertip amputation causes a degree of disability which depends on which finger has been injured, the level of amputation, and the site (radial or ulnar) of the injury. Surgery in the hand should aim at preservation of adequate and functional length of the digits, immediate coverage of the wound, preservation of sensibility at the distal pulp, adequate distal interpha- langeal joint motion, a painless scar, short hospital stay and morbidity and early return to work and other daily activities (Stevenson, 1992). However, management of these injuries is controversial. Authors opinions on treatment vary from healing of the wound by secondary intention (Allen, 1980) to covering of the exposed bone with digital flaps of various kinds (Atasoy et al., 1970; Foucher et al., 1989; Lanzetta et al., 1995; O’Brien, 1968; Smith and Elliot, 2000). In this study we present the results of a large series of patients who were treated with homodigital neurovas- cular island flaps based on a single neurovascular pedicle to reconstruct amputated fingertips. The technique used in this series is a variant of the techniques used by Foucher, Lanzetta, and Smith and Elliot (Foucher et al., 1989; Lanzetta et al., 1995; Smith and Elliot, 2000). MATERIALS AND METHODS Between 1995 and 2002, 77 fingertip amputations in 62 patients were reconstructed within the first 24 hours after the injury, using a homodigital neurovascular island flap technique. Twelve patients were lost to follow-up and were not included in the study. Thus, the study includes 63 fingertip injuries in 50 patients (36 men and 14 women). The mean patient age was 35 years, with a range from 2.5 to 64 years. Twenty-seven injuries occurred in the right hand and 36 in the left hand. The thumb was injured in two cases, the index in 25, the middle finger in 19, the ring finger in 10, and the small finger in seven cases. These injuries included agricultur- al, industrial and domestic injuries. To describe the level of fingertip amputation, Allen’s four-type classification was used as it offers a compre- hensive description of the injury (Allen, 1980). Type I is an amputation of the distal pulp only, Type II is an amputation through the nailbed, Type III is an amputation at the level of the proximal nail fold and Type IV is an amputation at the base of the distal phalanx (Fig 1). According to Allen’s classification, the injuries in this series were classified as type II in 14 cases, type III in 35, and type IV in 14 cases. Contraindications to use of the procedure included avulsion injuries, injuries to the neurovascular bundle (recent or old), a severely contaminated wound and underlying angiopathy. Age was not considered a contraindication. An Allen test for patency of both digital arteries was always done before electing to carry out the procedure. 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87 89 91 93 95 ARTICLE IN PRESS 3B2v8:06a=w ðDec 5 2003Þ:51c XML:ver:5:0:1 YJHSB : 1269 Prod:Type:FTX pp:125ðcol:fig::NILÞ ED:ChandraShekar PAGN:Jay SCAN:Saravanan 1