Composite grafts for fingertip amputations: a systematic review : IJS Short Reports

Secondary Logo

Journal Logo

Systematic Review and/or Meta-analysis

Composite grafts for fingertip amputations: a systematic review

Landin, Madeleine L. BSc (Hons)a; Borrelli, Mimi R. MBBS, MSb; Sinha, Vikram BSc (Hons)a; Agha, Riaz BSc (Hons), MBBS, MSc (Oxon), DPhil (Oxon), MRCSEng, FRSA, FHEA, FRSPHc; Greig, Aina V.H. MA, PhD, FRCS (Plast)d,

Author Information
IJS: Short Reports 6(1):p e17, January/March 2021. | DOI: 10.1097/SR9.0000000000000017
  • Open


There is debate in the literature surrounding the management of fingertip amputations. The role of composite grafts lacks clarity in terms of outcomes and complications. Hence, there is a need for an evidence synthesis to guide practice. A search of the databases OVID MEDLINE, PubMed, EMBASE, SCOPUS, The Cochrane Library, and clinical trial registries was conducted, from 1946 to January 2020, using the key terms “fingertip,” “digital tip,” “digit,” “finger,” “thumb,” “amputation,” “replantation,” “reattachment,” “reimplantation,” and “composite graft.” Studies reporting primary data on the outcomes of composite grafts of 5 or more digits were included. The studies included in this systematic review ranged in year of publication from 1959 to 2019. Data extraction included demographic details, functional, esthetic and adverse outcomes. Twenty-three articles were included. Outcome data on composite grafts are heterogeneous and little standardization of measurements exists, making interpretation challenging. Identified factors associated with improved outcomes include lower age, distal amputation levels by cut mechanism and decreased time to operation. Smoking is associated with poorer composite graft outcomes. Although survival rates vary greatly, composite grafting may be useful in certain cases and provide good functional and sensation outcomes with good patient satisfaction.

The fingertip is the segment distal to the insertion of the flexor and extensor tendons on the distal phalanx1,2. A fingertip amputation is the loss of a part of a finger distal to the level of the distal interphalangeal joint (DIPJ). It is a common presentation to the emergency department. Crush injuries from doors are the most common cause of fingertip amputations in children3,4. Treatment aims to restore a painless, minimally shortened digit with durable and sensate skin, preserved function, and a satisfactory esthetic outcome2,5,6.

Microsurgical replantation can produce superior functional and esthetic outcomes7–9, but arterial or venous anastomoses are impossible in certain avulsion amputations or distal crush injuries7, and in small children whose vessels are of smaller diameter10. Composite grafting, where the amputated tip is directly sutured onto the proximal stump, is an alternative option to reconstruct a nonreplantable amputated fingertip. The composite graft is initially nourished by diffusion, and later through neovascularization. Composite grafting is a simple time- and cost-effective technique. It may preserve digital length, and in some cases restore sensory and motor function and a near-normal nail complex10.

Composite grafting has been widely performed for distal fingertip amputations, but variable success rates are reported in the literature. Key complications include infection and necrosis. Consequently, many are hesitant to use composite grafts in adults. There is additional controversy as to which factors influence composite graft success; amputation-reattachment delay, amputation mechanism, and/or level. Although multiple previous case series document composite graft outcomes, there has been no formal synthesis of results. Therefore, a systematic review was conducted to understand the indications, functional and esthetic outcomes, complications, secondary surgery, and factors associated with the success of composite grafting for fingertip amputation. This review aims to help guide evidence-based practice.


The aim of this systematic review was to evaluate the available information in the literature about the survival of composite grafts in the treatment of distal fingertip amputations. The ultimate aim is to help guide evidence-based practice.


This systematic review was conducted in line with the Cochrane Handbook for Systematic Reviews and Interventions11 and is compliant with PRISMA guidelines12. A systematic review protocol was published1, and the systematic review was registered a priori:


Studies included

Original research studies of levels 1–5 of the Oxford Centre for Evidence-based Medicine13 were considered for inclusion if they reported data concerning the relevant outcomes, as well as unpublished data, if methods and data were accessible. No duplicate articles nor articles not reporting primary data were included.


The patient population included children and adults receiving non-microsurgical replantation following distal fingertip amputations, with the aim of reviewing outcomes in these cases in order to elucidate the role of non-microsurgical replantation in the management of distal finger amputations.


The interventions included were composite grafting of the distal tip via non-microsurgical methods following fingertip amputation. Any studies in which microsurgical reconstruction was used were not included. Articles were included if they reported on the survival outcomes of distal fingertip amputations treated with primary composite grafting of the amputated tip. All articles using subcutaneous pocket techniques, “pulp flaps” or microsurgical replantation were excluded, as were articles reporting on data of <5 cases, following previous research9.


The primary outcome measured was graft survival. Secondary outcomes are detailed below.

Search methods and search terms

An electronic database search was conducted on OVID Medline, PubMed, EMBASE, SCOPUS, The Cochrane Library and clinical trial registries using the terms “fingertip” “fingertips” “digital tip” “digital tips” “digit” “digits” “finger” “fingers” “thumb” “thumbs” “amputation” “amputations” “injury” “injuries” “replantation” “replantations” “reattachment” “reattachments” “reimplantation” “reimplantations” “composite graft” ““composite grafts” as keywords combined with the Boolean logical operators “OR” and “AND”. The search was limited to English studies and studies conducted in humans. Duplicated studies were removed.

Identification and selection of studies

Two independent reviewers (M.R.B. and M.L.L.) screened the title and abstract of each of the published articles for inclusion according to the criteria listed in Tables 1–2. Full-length manuscripts were reviewed for articles which met the inclusion criteria, if no abstract was published or if the abstract did not have sufficient information to determine eligibility.

Table 1 - Study inclusion and exclusion criteria.
Inclusion criteria
 Primary data
 Outcomes of “composite grafts” or “non-microsurgical replantation” of the amputated part
 Graft survival
 Report on ≥5 cases
 Articles written in English
Exclusion criteria
 Composite graft pocketing
 Microsurgical vascular anastomosis
 Use of additional skin flaps or pulp flaps
 Incomplete data
 Cases of composite graft as a secondary revision

Table 2 - Secondary outcomes.
Follow-up period
Reported adverse outcomes, including revision surgery
Findings of any additional factors associated with graft survival (eg, age, smoking, diabetes)
Sensory outcomes
Functional outcomes
Esthetic outcomes

Quality scoring

The Grading of Recommendation Assessment, Development and Evaluation (GRADE) system was used to assess the methodological quality of included studies.


Characteristics of included studies are presented as counts and percentages. Continuous data are expressed as means (or median values where stated). Meta-analysis was not performed as only one study reported comparative data on outcomes of composite grafting compared to other methods of managing distal fingertip amputations.


The search yielded a total of 5790 articles, after 2061 duplicates were removed, 3729 underwent title and abstract screening (stage 1), and 119 articles underwent full-text screening (stage 2). A total of 23 articles met the full inclusion criteria (Fig. 1)10,14–35.

Figure 1:
Flow diagram showing the number of articles at each step of screening12.

Article demographics

The articles included covered data collection from 1959 to 2019 (Table 3). The majority of the work published on composite grafting outcomes was conducted in Japan (n=5), followed by the United Kingdom (n=4) and the USA (n=4), Korea (n=3), Italy (n=3), Australia (n=1), Taiwan (n=1), Turkey (n=1) and France (n=1). The highest level of evidence of our included studies was 4, corresponding to a randomized controlled trial (RCT) by Kusuhara et al29. In terms of article quality, every study had a GRADE score of “very low”, with the exception of the aforementioned RCT conducted by Kusuhara et al29 which was graded as “moderate”.

Table 3 - Demographic characteristics of included articles.
References Location Oxford Level of Evidence Grade Score No. of Patients
Douglas19 USA IV Very low 17
Rose et al33 USA V Very low 7
Hirase23 Japan IV Very low 32
Hirase24 Japan IV Very low 10
Moiemen and Elliot31 UK IV Very low 50
Adani et al14 Italy IV Very low 7
Heistein and Cook22 USA III Very low 53
Son et al34 South Korea III Very low 56
Kankaya et al27 Turkey IV Very low 23
Dagregorio and Saint-Cast18 France IV Very low 19
Urso-Baiarda et al35 UK IV Very low 108 (digits)
Eo et al10 SouthKorea IV Very low 24
Chen et al17 Taiwan IV Very low 27
Kusuhara et al29 Japan I Moderate 18 (digits)
Imaizumi et al26 Japan IV Very low 10
Butler et al16 UK III Very low 97
Eberlin et al20 USA IV Very low 39
Kiuchi et al28 Japan IV Very low 27
Idone et al25 Italy IV Very low 8
Murphy et al32 Australia IV Very low 96
Eo et al21 Korea IV Very low 94
Borrelli et al15 UK IV Very low 100
Losco et al30 Italy IV Very low 14

Patient demographics

In total, the number of reported patients included across all studies was 810, with 264 females (Table 4). In addition, Urso-Baiarda et al35 reported on 108 digits and Imaizumi et al26 on 18 digits, with the number of patients not specified. The mean age of participants per study ranged from 2.432 to 43.2 years28 (range 0–74)28,32 and each article reported on anywhere from 7 to 108 digits, with a mean of 41.5 digits33,35. The majority of included studies reported on outcomes of a single digit composite grafting per study participant, with five articles reporting outcomes of more than one digit per patient17,22,24,28,34.

Table 4 - Amputation details and patient demographics.
References No. Patients Mean Age & Range (y) No. Females No. Digits Smoking or Comorbidity Status Mechanism of Injury Amputation Classification System Amputation Level Follow-up (mo)
Douglas19 17 17 Causative injury described in 7
Rose et al33 7 7 Described in 3 All through lanula Range 6–72 mo
Hirase23 32 32
Hirase24 10 11 Hirase DP 1: 6 DP 2a: 3 DP 2b: 2 1 y
Moiemen and Elliot31 50 5.7 (1–14) 12 50 Crush (door): 38 Crush (other): 9 Cut: 3 Modified Ishikawa Level 1a: 4 Level 1b: 17 Level 2: 21 Level 3: 8 14.8
Adani et al14 7 24 (4–60) 1 7 Crush (door): 3 Crush (other): 3 Sharp amputation: 1 Hirase Level 1: 1 Level 2: 3 Level 3: 2 1 amputation of finger pulp 2 y total
Heistein and Cook22 53 28 (1–71) 19 57 Smokers: 12 Alcohol: 23 Diabetes: 6 Crush: 19 Avulsion: 18 Guillotine: 16 Other DP1: 36 DP2: 21 All had 12 wk follow up
Son et al34 56 28 (1–60) 13 60 Crush: 32 Guillotine: 24 Avulsion: 4 Other (Relation to lanula) Zone I: 31 Zone II: 14 Zone III: 15 Checked at 2 wk
Kankaya et al27 23 32.41 (1.5–57) 4 23 Smokers: 8 Diabetes: 3 Hypertension: 1 Diabetes & hypertension: 1 Hirase Zone 1: 2 Zone 2: 15 Zone 3: 6 12.4
Dagregorio and Saint-Cast18 19 39.7 (25–58) 7 19 Crush (transverse): 3 Crush (oblique): 3 Sharp (oblique): 8 Sharp (transverse): 5 Ishikawa Level I: 8 Level II: 7 Level III: 4 All checked 9–12 mo
Urso-Baiarda et al35 Median: 5.9 108 No diabetes* Smoking: 21% adults Steroid use: 2% children, 5% adults Ishikawa Mean healing time Children: 68 d Adults: 82 d
Eo et al10 24 31.2 (1–67) 13 24 Smokers: 5 No diabetes or atherosclerosis Crush: 15 Cut: 9 Das & Brown Type 1: 13 Type 2: 10 Type 3: 1 8–17
Chen et al17 27 40.5 (20–65) 5 31 Crush: 21 Cut: 10 Allen Type 2: 9 Type 3: 22 11.7
Kusuhara et al29 18 Ishikawa All subzone 2 All checked at 3 wk
Imaizumi et al26 10 Distal: 4.8 Middle: 3 (1.67–6.75) 10 All avulsion/crush Modified Allen Distal: 3 Middle: 7 2.63
Butler et al16 97 4.3 (1–15) 42 97 Crush: 94 Cut: 3 Moeimen’s modification of Ishikawa’s classification Level 1a: 12 Level 1b: 51 Level 2: 32 Level 3: 2 1.8 mean
Eberlin et al20 39 5.9 (1–22) 15 39 Crush (door): 24 Mechanical device: 6 Crush (other): 5 Laceration: 2 Sport: 1 Strangulation: 1 All distal to finger DIPJ/thumb IPJ 4.5 mean
Kiuchi et al28 27 43.2 (1–74) 5 32 Crush avulsion: 16 Clean cut: 6 Blunt Cut: 10 Ishikawa Subzone 1: 4 Subzone 2: 17 Subzone 3: 6 Subzone 4: 5 2.8
Idone et al25 8 34.3 (24–45) 1 8 Sliding door: 3 Crush: 2 Saw: 2 Knife: 1 Allen Level 1: 2 Level 2: 3 Level 3: 3 10
Murphy et al32 96 Median: 2.4 (0–16) 57 96 Crush: 89 Laceration: 4 Not recorded: 3 Moeimen’s modification of Ishikawa’s classification *Level 1a: 16 Level 1b: 36 Level 2: 13 Level 3: 2 2.23
Eo et al21 94 39 (1–68) 25 94 Smoker: 34 Nonsmoker: 60 Cut: 60 Crush: 34 Das & Brown Type 1: 44 Type 2: 31 Type 3: 19 Mean 3
Borrelli et al15 100 4.41 (0.08–15.83) 43 100 Sickle cell disease: 1 HIV: 1 NAI: 1 Crush: 75 Avulsion: 13 Laceration: 12 Modified Ishikawa Level 1a: 3 Level 1b: 26 Level 2: 42 Level 3: 16 Oblique: 13 4.65
Losco et al30 14 40 (24–52) 2 14 Smokers excluded Peripheral vascular disease 2 All sharp Hirase All 2a or 2b 12
*As documented in original article.
DIPJ indicates distal interphalangeal joint; HIV, Human Immunodeficiency Virus; IPJ, interphalangeal joint; NAI, nonaccidental injury.

Amputation details

Of the included studies, 1810,14–22,25,26,28,30–34 reported the mechanisms of amputation and the remaining 523,24,27,29,35 did not (Table 4). Most amputations followed crush injuries. In 2 studies (Rose et al33 and Douglas19) injury details were only included for a few patients. Of note, there was significant heterogeneity in the description of amputation level, making it difficult to compare results; across the 23 studies included, 6 different amputation classification systems were used. Four articles did not include a classification system19,20,23,33. The Ishikawa18,28,29,35,36 and modified Ishikawa15,16,31,32,36 were the most commonly used systems, but the Allen17,25,26,37, Hirase14,24,27,30, and Das and Brown10,21,38 classifications were used by at least 2 of the studies reviewed. Two articles used their own classification systems22,34 that were not endorsed by articles published after these manuscripts. While all the classification systems base categories on different anatomical landmarks, more distal amputations predominated.

Factors affecting graft take

Twelve studies looked specifically at factors predictive of graft failure15,16,20–22,27–29,31,32,34,35(Table 4). In the study by Eo et al21, crush injury was independently associated with graft failure, whereas distal cutting amputations grafted within <5 hours from injury were associated with good results in bivariate analysis. Time to operation was found to be a statistically significant factor in graft survival by Moiemen and Elliot31, however, 4 studies showed no statistically significant effect of time to operation15,16,20,32. In adult patients, comorbid and smoking status are factors likely important in predicting graft take, however, they were frequently underreported in all the 17 studies reporting outcomes in adults10,14,17–25,27,28,30,33–35. Smoking and comorbidity status were only reported in 7 of all the 23 articles reviewed10,15,21,22,27,30,35. However, when analyzed as a factor, smoking status significantly decreased the chance of fingertip graft survival; Heistein et al22 reported that in adult patients, smoking was the only significant factor independently associated with graft loss. Kankaya et al27 also reported that 3 of the 6 composite graft failures (partial or total graft loss) were in smokers. The RCT by Kusuhara et al29 found no statistically significant increase in survival from the application of topical basic fibroblast growth factor (b-FGF).

Surgical technique

Surgical technique and reporting on specific operative details varied (Table 5). Classic composite grafting (ie, no modifications) was the most commonly used method, with 19 of the included articles adopting this technique10,14–16,18–26,28–32,34. The cap technique, whereby the proximal stump is de-epithelialized and the amputated part modified so as to allow for maximal contact between the stump and amputated part, was adopted in three studies17,27,33. Fingertip amputations (ie, distal to the DIPJ) almost always involve the nailbed, however, only 11 of the 23 studies specifically describe repair of the nail bed14–18,20,22,25–27,31 and Murphy et al32 describe removal. Part of the management (and “preservation”) of the nailbed involves management of the nail; the nail may be removed and sutured back onto the nailbed to act as a splint to guide new nail growth or discarded due to contamination. When discarded, other material (most commonly foil) can be used as a splint, or surgeons may not use a splint at all. Three of the 12 articles mentioning nailbed management describe removing and resuturing the nail bed22,26,31. Dagregorio and Saint-Cas18 and Chen et al17 stated that the nail bed was preserved. Proximal part trimming was only reported in 3 articles, that is those using the cap technique17,27,33. Heistein and Cook22 were the only authors to explicitly state that proximal part trimming had not been performed. Defatting of the amputated part was performed in 5 studies15–18,27. Removal of small fragments of bone was performed in three studies16,20,32 and in 5 cases15,17,27,28,33 bone removal or trimming were reported. Prostaglandin E-1 (PGE-1) was the most commonly used pharmacological adjunct and was reported in 5 articles10,21,23,24,28. Tetanus antitoxin/prophylaxis was administered in 2 articles19,27. Kusuhara et al29 reported using b-FGF. Cooling (either preoperatively or postoperatively) was reported in 12 articles10,14,16,19,21–25,27,31,32. Splinting was reported in 10 studies15,17–20,22,31–34 and antibiotics were used in 1410,14–16,20–22,27,28,30–34.

Table 5 - Operative technique and graft survival outcomes.
References Composite Grafting Technique Mean Time to Surgery (h) Nail Bed Preservation Proximal Part Trimming Amputated Part Defatting Bone Removal/Trimming Bony Fixation Pharmacological Adjuncts Cooling Used Splint Antibiotics Used Outcomes (Graft Survival) %
Douglas19 Classic Variable suture Variable tetanus antitoxin Variable Variable CS: 88.2 PS: 11.8
Rose et al33 Cap Yes Yes No Yes Ointment CS: 71 PS: 29
Hirase23 Classic PGE 1 Variable No cooling S: 23.8 Cooling S: 81.8
Hirase24 Classic No PGE 1 Yes S: 90.9
Moiemen and Elliot31 Classic Complete: 3.9 Partial: 7 Failed: 7.8 Nail removed and nail bed sutured No No Kirschner wire in 3 cases Variable preoperative Yes (nail) Yes CT: 22 PT: 52 F: 13
Adani et al14 Classic Sutured Variable longitudinal Kirschner No Yes Yes CS: 57.1 PS: 28.6 NS: 14.3
Heistein and Cook22 Classic 2.27 Nail removed and nail bed sutured No No Variable Kirschner wire No Variable preoperative Yes (nail) Yes CS: 52.6 PS: 31.6 NS: 15.8
Son et al34 Classic Yes Ointment S: 70 F: 30
kankaya et al27 Cap Yes Yes Yes Yes Tetanus prophylaxis Variable Yes CT: 73.9 PT: 17.4 NT: 8.7
Dagregorio and Saint-Cast18 Classic All <4 h Nail bed sutured 7-0 Variable Variable needle Yes (nail) Success: 52.6 PT: 15.7 F: 31.6
Urso-Baiarda et al35 Median 6.5 CS/PS: Adults: 85.7 Children: 88.5
Eo et al10 Classic 5 Lipo PGE 1 Yes Wash & ointment CS: 91.7
Chen et al17 Cap Yes Yes Yes Variable Yes CT: 93.5
Kusuhara et al29 Classic b-FGF Tissue survival: 100%: 27.8 >75%: 33.3 50-75%: 11.1 <50%: 27.8
Imaizumi et al26 Classic Nail removed and nail bed sutured* Variable Kirschner wire* No Distal Success: 33.3 Middle Success: 57
Butler et al16 Classic Complete: 6.5 Partial: 7.2 Nil: 6.7 Variable Variable Small fragments No Preoperative Yes CT: 10 PT: 34 NT: 56
Eberlin et al20 Classic If necessary No Small fragments No No Yes Yes CT: 7.7 PT: 59 NT: 33.5
Kiuchi et al28 Classic Yes 19 PGE 1 drips Variable CS: 18.8 PS: 53.1 NS: 28.1
Idone et al25 Classic Sutured Longitudinal Kirschner No Yes CS: 75 PS: 25
Murphy et al32 Classic 7.5 median Removed No Small fragments Variable preoperative Yes Yes NT: 31 PT: 52 CT: 16
Eo et al21 Classic 4 Kirschner wire Lipo PGE 1 Yes Ointment S: 89 F: 11
Borrelli et al15 Classic <6 h: 25% Variable Variable Yes Kirschner wire use in 1 case Variable Yes CS: 13 PS: 46 NS: 41
Losco et al30 Classic 2.2 20-G needle Yes Normal healing: 60 Minimal necrosis: 40
*Method as reported by Moiemen.
b-FGF indicates basic fibroblast growth factor; CS, complete survival; CT, complete take; F, failed; GT, graft take; Lipo, liposomal; NS, no survival, NT, no take; PGE-1, Prostaglandin E 1; PS, partial survival; PT, partial take; S, survived/successful.

Graft survival

The primary outcome variable was graft survival. Graft survival rates, however, varied significantly between studies, and importantly, so did the definition of graft survival (Tables 5–9). The lowest reported complete graft take was 7.7%20 the highest graft take was 93.5%17. Ten articles stratified graft survival into complete, partial or no survival10,14,19,22,25,28–30,33,35; however, 3 articles binarized21,26,34 graft survival into “success” or “failure,” and 7 1articles reported healing in terms of graft take16–18,20,27,31,32. Furthermore, the definitions of graft success and failure were not standardized, with few articles citing previous work to ensure consistency (Fig. 2).

Table 6 - Adverse outcomes.
References Adverse Outcomes Revision Operation (%) Other Details
Douglas19 1 infection 1 ulcer 11.8
Rose et al33 2 digits small areas necrosis 0 Superficial eschar developed in several
Hirase23 Cooling 1 necrosis 1 partial necrosis Non-cooling 56.3 Cooling 1 debridement 1 finger pulp reverse vascular pedicle digital island flap reconstruction Noncooling 16 skin grafts/flaps
Hirase24 1 partial necrosis 9.1 1 split skin graft
Moiemen and Elliot31
Adani et al14
Heistein and Cook22 No infections or serious complications
Son et al34
Kankaya et al27 Superficial necrosis seen in 14 1 infection 8.7 1 skin graft 1 stump management by primary closure debridements were performed on an outpatient basis
Dagregorio and Saint-Cast18 2 cases of partial take healed by secondary intention 5.3 1 cross finger flap adjunct
Urso-Baiarda et al35
Eo et al10 Scab formation was inevitable happened in 11 of 24 8.3 1 revision flap (cross finger) 1 Atasoy’s volar V-Y advancement flap
Chen et al17 2 graft necroses 6.5 1 thenar flap 1 volar V-Y advancement flap
Kusuhara et al29
Imaizumi et al26 No significant complications No blood transfusions
Butler et al16 11 post-operative infection 17 (re-operation or infection) More proximal amputation significantly associated with infection
Eberlin et al20 Indications for revision: patient/family dissatisfaction, persistent pain, or aesthetic deformity 10 2 operative debridement of nonviable tissue 1 debridement and revision amputation 1 debridement and V-Y advancement flap closure
Kiuchi et al28 “There were no complications that affected graft survival”
Idone et al25
Murphy et al32 1 infected necrotic graft 1 necrotic graft 2 1 debridement 1 debridement with local flap
Eo et al21 10.6 5 stump revisions & no reconstruction 3 thenar flaps 2 distal abdominal flaps
Borrelli et al15 17 infections 9 wound healing complications 4 psychological complications 1 hypersensitivity and phantom pain 9 5 debridements for infection/ necrotic material 4 terminalisations of exposed bone
Losco et al30 Minimal necrosis (<1 cm2) in 6 0 Cases of partial necrosis were managed on outpatient basis

Table 7 - Cosmetic outcomes.
References Measurement Method Questionnaire Results Digit Shortening (Average, mm) Nail Bed/Plate Growth & Nail Deformity Other Details
Douglas19 Clinician reported 1st case report: growth of the nail appeared normal 4th: very little shortening 6th: nail growth normal slight scar Case 3: slight thinning of the pad, but finger was normal
Rose et al33 Objective 6 Flat nail growth returned in all digits Pulp pinch averaged 67%
Moiemen and Elliot31 Parental Questionnaire Short digit: 28 (74%) Hooked nail: 22 (58%) Flat pulp: 23 (61%) Response rate: 76%
Adani et al14 Clinician reported Nail deformity was observed in one finger
Kankaya et al27 Objective & clinician reported 6.8 5 patients had nail deformity
Eo et al10 Clinician reported “acceptable appearance”
Butler et al16 Parental questionnaire Abnormal appearance: 28 (67%) Pulp abnormal: 17 (40%) Nail hooked: 20 (48%) Nail absent: 1 (2%) Nail short: 10 (24%)
Idone et al25 Objective Partial nail deformity observed in 3 Remaining 5 normal nail growth & good cosmetic result at lamina
Murphy et al32 Clinician reported 3 hook nail deformity
Borrelli et al15 Questionnaire & objective Finger shortening: 29 (56.9%) Normal nail growth: 26 (51%) Abnormal nail curve: 19 (37.3%) Nail shortening: 47 Absent nail: 3 Normal appearance outcome: Median 3.5/5 3.93 1 hook nail
Losco et al30 Objective 6.9 “No nail lamina deformity was reported”

Table 8 - Sensory outcomes.
References Sensation Assessment Method Two-point Discrimination (mean, mm) Time Point Assessed Questionnaire Answers/Details
Douglas19 Clinician report Approximately 3 wk for sensation to return Partially returned in 72h in some
Rose et al33 2PD 6.5
Moiemen and Elliot31 Parental Questionnaire Tender tip: 10 (26%) Pain cutting nail: 8 (21%)
Adani et al14 Clinician report & 2PD <7 in all patients 2 y None complained of dysesthesia or cold symptoms
Kankaya et al27 Questionnaire & 2PD 7.26 6 mo Zone I (n=2): Pain and cold intolerance were ameliorated after 2 mo Zone 2 (n=15): Patient satisfaction on pain, sensibility, cold intolerance was achieved Zone 3 (n=6): Patients had neither pain nor cold intolerance by the third postoperative month
Eo et al10 2PD 5.5 Some complained of persistent paraesthesia
Chen et al17 Questionnaire & 2PD 6.3 6 mo Numbness over the fingertip: 19 (65.5%) Fingertip tenderness: 4 (13.8%)
Butler et al16 Parental Questionnaire Scar tender: 3 (7%) Cold intolerance: 7 (17%) Hypersensitive: 3 (7%)
Idone et al25 2PD <5 in all No patient complained of dysesthesia or cold intolerance
Borrelli et al15 Questionnaire Reduced: 14 (27.5%) Increased: 10 (19.6%) Normal: 27 (52.9%) Cold intolerance: 9 (17.6%) Numbness: 8 (15.7%) Tender tip/scar: 15 (29.4%)
Losco et al30 2PD & Pain Visual Analogue Scale (VAS) 7.1 (range: 6–9) 12 mo Mean VAS score 1.3
2PD indicates 2-point discrimination, VAS, visual analogue scale.

Table 9 - Functional outcomes and patient satisfaction.
References Measurement Method Results Patient Satisfaction
Douglas19 Clinician report Case 3: negligible stiffness Case 4: ankylosis at distal joint
Moiemen and Elliot31 Parental Questionnaire Difficulty cutting nail: 11 (29%) Digit use “normal”: 34 (90%)
Adani et al14 All patients used their hands normally
Kankaya et al27 Clinician report Zone 1: full functional and aesthetic satisfaction Zone 2: satisfaction with aesthetic and sensation outcomes Zone 3: —
Dagregorio and Saint-Cast18 Clinician report All fingers were functional
Chen et al17 Questionnaire 4 (13.8%) experienced limitation in use of hand Very satisfied: 24 (82.8%) Moderately satisfied: 2 (6.9%) Slightly satisfied: 1 (3.4%) Completely unsatisfied: 2 (6.9%)
Butler et al16 Parental Questionnaire 2 parents (5%) reported functional deficit Parents reported ∼45% complete graft survival
Idone et al25 Clinician report All patients were able to normally use their digits also for pinching and picking up small objects
Borrelli et al15 Questionnaire Time before using hand/finger in normal activities: 1–2 wk: 3 (5.9%) 2–4 wk: 11 (21.6%) 1–2 mo: 10 (19.6) 2–6 mo: 18 (35.3%) >6 mo: 9 (17.6%) Satisfaction with appearance mean 4/5
Losco et al30 Questionnaire & objective Mean Q-DASH score: 1.8 Mean motion at IPJ: 48 degrees All patients returned to work in 4.3 wk Esthetic satisfaction: Excellent: 8 (57.1%) Good: 5 (35.7%) Fair: 1 (7.1%)

Figure 2:
Mean percentage of composite graft survival/take/success10,14–22,25,27–29,31–34.

Adverse outcomes

Adverse outcomes were reported by 17 of the 23 studies10,15–24,26–28,30,32,33(Table 6). Adverse outcomes were inconsistently reported on and in varying degrees of detail. Necrosis was the most commonly reported adverse outcome, with 9 studies reporting this17,20,21,23,24,27,30,32,33 and rates ranging from 2.08%32 to 60.9%27. Infections were reported in 5 articles15,16,19,27,32 and rates ranged from 1%32 to 17%15. The most commonly included category of adverse outcome was reoperation, with rates ranging from 033 to 56.3%23. The total complication rate was 15.6%10,15–24,26–28,30,32,33 (Fig. 3).

Figure 3:
Mean revision rate10,15–21,23,24,27,30,32,33.

Cosmetic outcomes

Eleven articles reported cosmetic outcomes10,14–16,19,25,27,30–33. Questionnaires were used in 3 studies15,16,31, and the remaining eight studies were clinician reported/objectively stated (Table 7). Of the 4 studies reporting on finger shortening measurements, the mean digit shortening was 5.9 mm15,27,30,33. The questionnaire formats used were heterogeneous. The questionnaire responses indicate that poor cosmetic outcomes are common, specifically with regards to nail deformity and shortening15,16,31. However, the results by Borrelli et al15 indicate that patients reported normal digit appearance at a median score of 3.5/5 on a Likert scale (Fig. 4).

Figure 4:
Mean digit shortening15,27,30,33.

Sensory outcomes

Eleven of the 23 articles reported specifically on sensory outcomes following composite grafting10,14–17,19,25,27,30,31,33(Table 8). Of these studies, objective method of 2-point discrimination was adopted in 7 articles10,14,17,25,27,30,33. The measurements were conducted between 6 months17,27 and 2 years14 postoperatively. The mean 2-point discrimination post composite grafting was 6.5 mm, which is only slightly greater than normal range for certain individuals (manual laborers). However, in normal individuals the average range is between 2 and 3 mm10,17,27,30,33,39. The mean 2-point discrimination score excludes the results from Idone et al25 and Adani et al14, as these studies reported only ranges. Losco et al30 were alone in using the Pain Visual Analogue Scale as another objective measure of sensation outcomes and the mean score indicated very mild pain30,40. Questionnaires were used in 5 studies15–17,27,31; however, the questions and format styles varied greatly. The questionnaire responses show favorable sensation outcomes in the majority of patients, however, symptoms such as cold intolerance are commonly reported, and range from 014 to 65%17 (numbness). Douglas et al19 were the only authors to report sensation outcomes based on clinical observation (Fig. 5).

Figure 5:
Mean 2-point discrimination10,17,27,30,33.

Functional outcomes

In total, ten studies reported on the functional outcomes following composite grafting14–19,25,27,30,31(Table 9). Losco et al30 were the only authors to use objective measure, and graded functional recovery using the Q-DASH score and measured movement at the IPJ. The results of this indicates minimal disability30,41,42 but with lessened motion at the IPJ43. The other studies recorded functional outcomes with questionnaires, however, each study used a unique questionnaire with different questions15–17,30,31. Results based on clinician reports showed that all patients used their hands normally or that all digits were functional14,18,25,27 with the exception of Douglas19, who only reported on functional outcomes of 2 patients. Of the 4 articles that reported on patient satisfaction with the results, the responses were favorable and showed that the majority of patients were pleased with the end result15,17,27,30.


Composite grafting is a simple technique for restoring the amputated fingertip in cases where microvascular replantation is not possible. This technique has most frequently been used to repair pediatric fingertip amputations due to the small caliber of affected vessels and the relative regenerative capacity of juvenile tissues7. To date, there has been no formal synthesis of results across individual studies. Therefore, we conducted the first systematic review of composite grafting for distal fingertip amputations to investigate whether it is a viable and worthwhile technique and what factors are most predictive of graft survival.

A total of 23 individual studies were reviewed in this systematic review. Across all studies, the success rates of composite grafting were highly variable, ranging from 7.7%20 to 93.5%17. Adverse outcomes were common with infection rates as high as 17%15 and reoperation rates of up to 56.3%23. The functional and sensory outcomes were favorable with high patient satisfaction. However, cosmetic outcomes were not optimal as detailed from the questionnaire responses and clinical reports, which show that finger shortening, and nail deformities are common. However, and importantly, the evidence available to date was of poor quality. Indeed, only one study was the level 1a (the highest level) according to the Oxford criteria. This study by Kusuhara et al29; however, this study did not compare composite grafting to alternative methods for managing fingertip amputations not suitable for replantation (ie, stump management by primary closure), but rather compared success of grafting with and without application of b-FGF. In fact, no comparative studies looked at outcomes of composite grafts versus not grafting, and the majority of published articles were retrospective case series (level 4)10,14,15,17–21,23,25–28,30–32,35. Another factor limiting study was the low participant number. A minority of available studies included >50 patients15,16,21,22,31,32,34,35.

A major outcome of this systematic review was to investigate factors predictive of graft survival. Smoking status and comorbidities are relevant when using composite grafting on adult patients. Of the 17 studies reporting results with adults, only 7 studies reported on smoking or comorbidity status10,15,21,22,27,30,35. The studies that did report on smoking found, not surprisingly that smoking was associated with poorer outcomes. A multivariable analysis22 found that smoking was an independent factor associated with poorer graft healing. Better graft survival has been linked to decreased time to operation31, lower age15,16, clean-cut injuries21,28, and more distal amputation levels16,28. These findings, in addition to future research, should help clinicians in stratifying patients to being at high risk of poor outcomes from composite grafting. A variety of operative techniques were described, including classic composite grafting and the cap technique. The cap technique has been shown to aid healing through providing increased contact surface between the stump and amputated part. However, the main limitation of this technique is the resulting finger shortening, which, depending on patient and injury factors, may be significant.

A secondary outcome investigated was predictors of poor postoperative outcomes. Adverse events following composite grafting were inconsistently reported among the included studies and only 17 articles reported adverse events10,15–24,26–28,30,32,33. The overall complication rate was 15.6%. The recovery of composite grafts from the data indicate that adverse effects such infection and necrosis are common and that reoperation mostly consists of debridement or the use of additional skin graft or flap procedures10,15–21,23,24,27,30,32,33.

One striking finding of this review is the huge variety in the small number of published studies. Interestingly, in the 23 of studies, 6 different classification schemes were used to describe the level of amputations. One of the more commonly used, the Ishikawa classification adapted to distal fingertip amputations, categorizes amputations in terms of zones of the fingertip based on the nail. It comprises four zones distal to the DIPJ and takes into account the angle of the amputation36. The Hirase classification23,24 is based on the course of the digital artery, whereas the Allen classification includes reference to bony fragments in the amputated stump and advice for management based on the level37. Moreover, descriptions of the types of injuries sustained were not reported in a standardized fashion and five articles did not classify the mechanism of injury23,24,27,29,35. Finally, the definition of graft survival, the main outcome investigated, also significantly varied between studies. One of the main limitations in the data is the reporting of the composite graft healing. Success or failure or graft take is defined differently across the included studies, making comparisons of success rates difficult. As an example of this, a few studies define complete or partial take as success, while others do not. This is reflected in the broad range of success rates across the data which vary from 7.7%20 to 93.5%17. Details of postoperative care such as assessments of recovery and postoperative instructions were also varied and could add significant variability. Despite this heterogeneity making it difficult to compare results and synthesize data across studies, the results from the 23 articles included in this review suggest that composite grafting is a successful management technique for distal fingertip amputations not for microsurgical reconstruction and often yields good functional and sensation outcomes. Cosmetic outcomes may not be optimal; however, this must be considered against the outcomes from primary closure of the stump, which results in loss of the nail complex. Future studies should be additive or adopt previously used classification systems, such as the Ishikawa, which has the advantage of detailing the angle of amputation, which may be significant. Furthermore, future work should use clear definitions of graft success to facilitate homogeneity.


Composite grafting may be a useful technique in the management of distal fingertip amputations in adults and children when microsurgical anastomosis is not possible and may yield good functional and sensation outcomes with good patient satisfaction. However, cosmetic outcomes are less successful, with nail deformity and digit shortening commonly reported. Adverse outcomes are also commonly reported. Current available evidence suggests that composite grafting success is higher in children with more distal amputation levels by a cut mechanism who undergo composite grafting within a few hours from injury. The current available data on composite grafting for distal fingertip amputations is extremely heterogenous and synthesis of results is difficult for this reason. Little standardization exists for detailing injury, amputation, operative or follow-up information and several classifications systems are used. How optimal healing is defined is also a major limitation to interpreting the success of composite grafting. This is reflected in the rates of composite graft take, which vary widely. Further research should aim to address this by using standardized methods of collecting data.


Informed consent: Not applicable

Ethical approval


Sources of funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author contribution

A.G. and R.A: conceived the idea for the review. M.L., M.B., and V.S.: performed the search and screening. M.L., M.B., and A.G.: drafted the manuscript. All authors reviewed the final manuscript.

Conflicts of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)

Trial registration number: reviewregistry655.


Aina V.H. Greig.


1. Mimi R, Borrelli MLL, Agha R, et al. Composite grafts for fingertip amputations: a systematic review protocol. Int J Surg Protoc 2019;16:1–4.
2. Fassler PR. Fingertip injuries: evaluation and treatment. J Am Acad Orthop Surg 1996;4:84–92.
3. Fetter-zarzeka A, Joseph MM. Hand and fingertip injuries in children. Pediatr Emerg Care 2002;18:341–5.
4. Gellman H. Fingertip-nail bed injuries in children: current concepts and controversies of treatment. J Craniofac Surg 2009;20:1033–5.
5. Lemmon JA, Janis JE, Rohrich RJ. Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach. Plast Reconstr Surg 2008;122:105e–117e.
6. Martin C, del Pino JG. Controversies in the treatment of fingertip amputations: conservative versus surgical reconstruction. Clin Orthop RelatRes 1998;353:63–73.
7. Hattori Y, Doi K, Sakamoto S, et al. Fingertip replantation. J Hand Surg 2007;32:548–555.
8. Sebastin SJ, Chung KC. A systematic review of the outcomes of replantation of distal digital amputation. Plas Reconstr Surg 2011;128:723.
9. Wang K, Sears ED, Shauver MJ, et al. A systematic review of outcomes of revision amputation treatment for fingertip amputations. Hand 2013;8:139–45.
10. Eo S, Hur G, Cho S, et al. Successful composite graft for fingertip amputations using ice-cooling and lipo-prostaglandin E1. J Plas Reconstr Aesthet Surg 2009;62:764–770.
11. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, eds. Cochrane Handbook for Systematic Reviews of Interventions (Vol 5), 2nd Edition. Chichester (UK): John Wiley & Sons; 2019.
12. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151:264–9.
13. OCEBM Levels of Evidence Working Group. The Oxford 2011 Levels of Evidence. Oxford Centre for Evidence-Based Medicine. Available at: Accessed August 31, 2020.
14. Adani R, Marcoccio I, Tarallo L. Treatment of fingertips amputation using the Hirase technique. Hand Surgery 2003;8:257–64.
15. Borrelli MR, Dupre S, Mediratta S, et al. Composite grafts for pediatric fingertip amputations: a retrospective case series of 100 patients. Plast Reconstr Surg Glob Open 2018;6:e1843.
16. Butler D, Murugesan L, Ruston J, et al. The outcomes of digital tip amputation replacement as a composite graft in a paediatric population. J Hand Surg Eur Vol 2016;41:164–70.
17. Chen S-Y, Wang C-H, Fu J-P, et al. Composite grafting for traumatic fingertip amputation in adults: technique reinforcement and experience in 31 digits. J Trauma Acute Care Surg 2011;70:148–53.
18. Dagregorio G, Saint-Cast Y. Composite graft replacement of digital tips in adults. Orthopedics 2006;29:22–4.
19. Douglas B. Successful replacement of completely avulsed portions of fingers as composite grafts. Plas Reconstr Surg 1959;23:213–225.
20. Eberlin KR, Busa K, Bae DS, et al. Composite grafting for pediatric fingertip injuries. Hand (N Y) 2015;10:28–33.
21. Eo S, Doh G, Lim S, et al. Analysis of the risk factors that determine composite graft survival for fingertip amputation. J Hand Surg Eur Vol 2018;43:1030–5.
22. Heistein JB, Cook PA. Factors affecting composite graft survival in digital tip amputations. Ann Plas Surg 2003;50:299–303.
23. Hirase Y. Postoperative cooling enhances composite graft survival in nasal-alar and fingertip reconstruction. Br J Plas Surg 1993;46:707–11.
24. Hirase Y. Salvage of fingertip amputated at nail level: new surgical principles and treatments. Ann Plast Surg 1997;38:151–7.
25. Idone F, Sisti A, Tassinari J, et al. Cooling composite graft for distal finger amputation: a reliable alternative to microsurgery implantation. In Vivo 2016;30:501–505.
26. Imaizumi A, Ishida K, Arashiro K, et al. Validity of exploration for suitable vessels for replantation in the distal fingertip amputation in early childhood: replantation or composite graft. J Plas Surg Hand Surg 2013;47:258–62.
27. Kankaya Y, Ulusoy MG, Sungur N, et al. An alternative technique for microsurgically unreplantable fingertip amputations. Ann Plas Surg 2006;57:545–551.
28. Kiuchi T, Shimizu Y, Nagasao T, et al. Composite grafting for distal digital amputation with respect to injury type and amputation level. J Plas Surg Hand Surg 2015;49:224–8.
29. Kusuhara H, Itani Y, Isogai N, et al. Randomized controlled trial of the application of topical b-FGF-impregnated gelatin microspheres to improve tissue survival in subzone II fingertip amputations. J Hand Surg Eur Vol 2011;36:455–60.
30. Losco L, Kaciulyte J, Delia G, et al. Back to basics with distal thumb reconstruction. Easy management of the incomplete amputation. J Invest Surg 2019:1–7. doi: 10.1080/08941939.2019.1672840
31. Moiemen N, Elliot D. Composite graft replacement of digital tips 2. A study in children. J Hand Surg Br Eur Vol 1997;22:346–52.
32. Murphy AD, Keating CP, Penington A, et al. Paediatric fingertip composite grafts: Do they all go black? J Plas Reconstr Aesthet Surg 2017;70:173–7.
33. Rose EH, Norris MS, Kowalski TA, et al. The “cap” technique: nonmicrosurgical reattachment of fingertip amputations. J Hand Surg 1989;14:513–8.
34. Son D, Han K, Chang DW. Extending the limits of fingertip composite grafting with moist‐exposed dressing. Int Wound J 2005;2:315–21.
35. Urso-Baiarda FG, Wallace CG, Baker R. Post-traumatic composite graft fingertip replantation in both adults and children. Eur J Plast Surg 2009;32:229–33.
36. Ishikawa K, Ogawa Y, Soeda H, et al. A new classification of the amputation level for the distal part of the finger. J Jpn Soc Reconstr Microsurg 1990;3:54–62.
37. Allen MJ. Conservative management of finger tip injuries in adults. Hand 1980;12:257–65.
38. Das S, Brown HG. Management of lost finger tips in children. Hand 1978;10:16–27.
39. Dumontier C, Tubiana R Weinzweing J. Physical Examination of the Hand. Plastic Surgery Secrets Plus. Philadelphia, PA: Mosby; 2010:749–54.
40. Haefeli M, Elfering A. Pain assessment. Eur Spine J 2006;15:S17–S24.
41. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand)[corrected]: the Upper Extremity Collaborative Group (UECG). Am J Ind Med 1996;29:602–8.
42. Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire (Quick DASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord 2006;7:44.
43. Barakat M, Field J, Taylor J. The range of movement of the thumb. Hand 2013;8:179–82.

Composite graft; Distal fingertip; Amputation; Reconstruction

Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of IJS Publishing Group Ltd.