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Composite Cap Grafting for Fingertip Amputations in Pediatric Patients: Predictors of Success and Clinical Recommendations
John R Vaile, BS
1; Vinay Rao, MD, MPH
2; Omkar S. Anaspure, BA
2; Manisha Banala, BBA
3; Sarah L. Struble, MD
2; John A. Tipps, BA
2; Apurva S Shah, MD MBA
1,3; Benjamin Chang, MD
2; Shaun D Mendenhall, MD
1,41The Children's Hospital of Philadelphia, Philadelphia, PA; 2Children's Hospital of Philadelphia, Philadelphia, PA; 3Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; 4University of Utah, Salt Lake City, UT
Introduction: Fingertip injuries are the most common injuries of the hand, and often occur after a crush force. When an amputated fingertip is too small for microvascular replantation, composite grafting aims to close the wound and restore function, digit length, and hand appearance. In the pediatric population, composite grafting is often the preferred reconstructive approach due to challenges associated with microsurgical replantation. However, the main disadvantage of cap grafting is unpredictability; published success rates range widely from 0% to 93.5%. Furthermore, there is a lack of consensus regarding the factors associated with graft success as well as the expected clinical course. We hypothesized there is an age threshold under which there is a statistically higher rate of graft success. Secondarily, we hypothesized there is a time threshold over which there is a statistically higher rate of graft success.
Materials and Methods: After IRB approval, a retrospective chart review was performed on all patients who received a cap graft for distal fingertip amputation. Inclusion criteria were patents
<18 years old with partial or complete amputation at or distal to the DIP in the fingers or IP in the thumb. Demographic data, injury characteristics, procedural details, and outcomes were collected. Primary outcome was graft success defined clinically at the last follow-up visit after the index procedure. Secondary outcomes included complications and time to graft failure. Multivariate logistic regression was performed to identify predictors of graft success.
Results: 60 fingertips from 59 patients were included in this study. The average age was 4.6±4.4 years old, and 57% were male. The most common digit involved was the middle (30.0%, n=18), and the most common injury mechanism was blunt force (81.7%, n=49). Overall composite graft success rate was 71.7% (n=43). Complications included revision amputation (8.3%, n=5), nail deformity (3.3%, n=2), and infection complicated by osteomyelitis (1.7%, n=1). Subgroup analysis did not reveal a statistically significant difference in age between graft success (5.8±4.4 years old) and graft failure (7.1±4.5years old) (p=0.33). Furthermore, when a composite graft failed, the average time to failure was 14.3±13.3 days.
Conclusions: - Composite grafting for fingertip amputations is a viable option for pediatric patients with a success rate of 71.7% in this cohort.
- There is no statistically significant difference in age between composite graft success (8±4.4 years old) and composite graft failure (7.1±4.5 years old) (p=0.33).
- On average, composite graft failure occurred by 14.3±3 days from the index procedure.
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