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Comparison of two treatments for fingertip amputation :
b a retrospective cohort study
h [electronic resource] /
by Karen Olson.
[Tampa, Fla.] :
University of South Florida,
ABSTRACT: Purpose: To compare the costs and length of disability for conservative treatment versus skin grafting of distal finger and thumb tip amputations. Methods: Thirty-five zone I finger or thumb tip amputations in thirty-five workers in the Southeastern United States were included in this study. Twenty-four were treated with conservative treatment (bandaging to protect the wound). Eleven were treated with skin grafting. The total cost of medical care, total cost including wage replacement, and the length of disability were compared between the two groups. Impairment at the end of treatment was considered. Results: Even when the cost of wage replacement was taken into account, the total cost for skin graft treatment for these injuries is significantly higher. The length of disability was not statistically different between the two treatment groups. There was not a significant difference in impairment reported at the end of treatment. Conclusion: This study did not demonstrate any economic or medical advantage for treating zone I finger or thumb tip amputations with skin grafts. The size of the defect in the skin graft group was significantly larger, though, and the results obtained in this comparison may not allow us to draw valid conclusions about the comparison of these two treatments.
Thesis (M.S.)--University of South Florida, 2007.
Includes bibliographical references.
Text (Electronic thesis) in PDF format.
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Advisor: Stuart Brooks, M.D.
x Public Health
t USF Electronic Theses and Dissertations.
Comparison of Two Treatments for Finger Tip Amputation: A Retrospective Cohort Study by Karen Olson M.D. A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Public Health Department of Environmental and Occupational Health College of Public Health University of South Florida Major Professor: Stuart Brooks M.D. Rony Francois M.D., Ph.D. Thomas Truncale D.O., MPH Date of Approval: July 16, 2007 Keywords: trauma, hand, skin graf t, secondary intention, treatment Copyright 2007, Karen Olson M.D.
i Table of Contents List of Tables................................................................................................................. .....ii Abstract....................................................................................................................... .......iii Introduction................................................................................................................... ......1 Background and significance..............................................................................................2 Study Design................................................................................................................... ....5 Study Population............................................................................................................... ..6 Data Collection Methods....................................................................................................8 Results........................................................................................................................ .......11 Discussion..................................................................................................................... ....16 Conclusions.................................................................................................................... ...19 References..................................................................................................................... ....20
ii List of Tables Table 1: Characterist ics of Study Subjects .......................................................................10 Table 2: Frequency of Injury by Digit...............................................................................11 Table 3: Comparison of Cost and Lost time by Treatment Type......................................12 Table 4: Comparison by Treatment Type Matched For Injury Size..................................12
iii Comparison of Two Treatments for Finger Tip Amputation: A Retrospective Cohort Study Karen Olson M.D. ABSTRACT Purpose: To compare the costs and length of disability for conservative treatment versus skin grafting of distal finger and thumb tip amputations. Methods: Thirty-five zone I finger or thum b tip amputations in thirty-five workers in the Southeastern United States were in cluded in this study. Twenty-four were treated with conservative treatment (bandaging to prot ect the wound). Eleven were treated with skin grafting. The total cost of medical ca re, total cost including wage replacement, and the length of disability were compared betw een the two groups. Impa irment at the end of treatment was considered. Results: Even when the cost of wage replacement was taken into account, the total cost for skin graft treatment for these inju ries is significantly higher. The length of disability was not statistically different be tween the two treatment groups. There was not a significant difference in impairment reported at the end of treatment. Conclusion: This study did not demonstr ate any economic or medical advantage for treating zone I finger or thumb tip amputati ons with skin grafts. The size of the defect in the skin graft group was significantly larg er, though, and the result s obtained in this comparison may not allow us to draw valid conclusions about the comparison of these two treatments.
1 Introduction Specific Aim: The specific aim of this study was to compare two treatments for distal finger or thumb tip amputations in a population of workers from the Southeastern United States. The first method of treatme nt was conservative management, usually bandaging the digit to keep it clean and cove red. The second method of treatment was a simple full or split thickness skin graft to cover the open area. These two treatments were compared in terms of several outcomes: total cost, medical cost, wage replacement cost, length of disability, and impairm ent at the end of treatment. Research Question: Is skin grafting a more cost effective treatment for distal fingertip amputations than c onservative treatment in a population of workers in the Southeastern United States? Null Hypothesis #1: The time to heal fo r a fingertip amputation is the same whether treated by skin grafti ng or treated conservatively. Null Hypothesis #2: The total cost of medical treatment and lost wages for an injured worker with a fingertip amputation is the same whether treated by skin grafting or treated conservatively.
2 Background and significance Fingertip amputations are a common inju ry, with an incidence each year of approximately 15,000 occupational amput ations and 25,000 non-occupational amputations. The occupational amputations most commonly occur when using machinery. The non-occupational amputations have a bimodal distribution: peak incidence occur among young child ren who get their fingers caught in doors and among older adults, between 55 and 64, who use power tools. Although mortality from distal fingertip am putations is quite rare, the morbidity they cause is significant. All activities requi ring the use of the injured hand are limited. The wound has to be kept clean and dry lim iting hand washing and other activities. The bulk of the bandage limits the use of th e hand for skilled tasks and impairs many activities necessary for daily living. Laborers cannot work or are quite limited in what they can do. Infection is a serious concern. Because this injury impacts oneÂ’s ability to function both at home and at work, the time to heal is important, not only for co mfort but also for produc tivity. The real cost of this injury is not just the cost of treatment but also the cost of disability due to limited use of the hands. In order to look at both the time to heal and the tota l cost of the injury, this study will evaluate a population of work ers. Both the medical costs and wagereplacement costs will be evaluated. Despite the fact that a fingertip amputati ons are a common injury with significant morbidity, there is no consensus as to the best treatment. Review articles on this topic
3 are generally expert opinions[3-5]. The major ity of articles that have been published are case series, detailing a specific technique for treatment and the results which the author(s) have had with that technique[6-13]. There has been at least one study which comp ared two treatments. Hattori, et al, published a retrospective comparison of outcome s in patients who had their distal fingers replanted versus those who ha d the bone shortened and the wound closed primarily. He concluded that successful replantation resu lted in better functional outcome, improved appearance, and higher patient satisfaction. The cost of treatment and the length of disability were substantially great er, though, in the re plantation group. No other studies were found that system atically compared the results from different treatments. This current study compares two treatments for smaller amputations where replantation is not gene rally considered an option. The techniques to repair fi ngertip amputations fall into four general categories. The most conservative method is to banda ge the wound, usually with an occlusive dressing until granulation tissue fi lls in the defect to replace th e lost skin. This is called healing by secondary intention and is cons idered conservative treatment because it involves the least intervention. This treatment is simple to provide, does not require any technical expertise, and is inexpensive. Ve ry good results have been reported by some researchers. Its disadvantage is that healing can take a long time and the finger can be painful, even after it has completely healed. A second technique which can be used is primary closure, where any remaining skin is sutured together over the defect. Th e skin on the fingertip cannot stretch much,
4 though, so the distal bone must often be cut back to accomplish this, leaving the finger shorter than before. Neither patients nor surgeo ns are usually satisfied with this result. A third technique is to cover the defect w ith a partial or full-thickness skin graft. The tissue for the graft can be taken from th e hand, the forearm, or other donor sites on the body. This tissue is sutured in place wi th interrupted sutures and further secured by a bolster dressing. The fourth group of techniques is to use so me type of flap-graft or advancement graft[7, 10-13, 15]. These techniques are mo re complicated, often requiring two operations instead of just one. They are mo st often reserved for amputations which involve most of the distal phalanx, not just the fingertip. Microsurgi cal reattachment is not generally a consideration unless the di git has been amputated at the distal interphalangeal joint (DIP) or proximal to it. This current study only evaluated amputations of the tip of the finger or t humb including the pulp, with no bone injury greater than a distal tuft fracture. There is consensus in the liter ature reviewed that primary closure is rarely the best treatment. Patients treated with this techni que take longer to heal and are left with deformities of the finger. Flap grafts, advancement grafts, and replantation are generally reserved for more severe injuries than this study addresses. None of these treatments were considered in this study. The two remaining repair techniques, c onservative treatment and simple skin grafts, were compared in this study to dete rmine which one heals faster and which one costs less. This study was unique in that the co st of wage replacement was included in the total cost of the injury.
5 Study Design This study addressed the questions posed in the hypotheses us ing a retrospective cohort of workers from the Southeastern Unite d States who sustained finger or thumb tip amputations between January 1, 2004 and December 31, 2006. They were identified using the database of a large WorkersÂ’ Compensation insurance company. Information about the cases was abstracted from the claim records maintained by the insurance company. Cases which meet the inclusion criter ia were divided into two cohorts based on the treatment they received: skin graft or conservative treatment. One outcome which was evaluated was tota l cost of medical treatment and lost wages. A second outcome which was evaluate d was length of disabi lity. Other issues which were considered included any remaini ng impairment at the end of treatment such as numbness or hypersensitivity affecting the use of the hand. Because this study utilized records which were already in existence and did not involve recording any informa tion which could identify the sp ecific patients or be linked back to their personal information, an applica tion for Â‘ExemptÂ’ status was filed with the University of South Florida Institu tional Review Board, and was approved.
6 Study Population The study population included all worker s from 18 to 65 years old with an isolated, zone one (distal to the base of the nail bed) traumatic amputation of the finger or thumb tip whose insurance benefits were ma naged by Heritage Summit Healthcare in the Southeastern United States. The date when these injuries occurred was between January 1, 2004 and December 31, 2006. The records for this population are accessible in the electronic data base of the insurance company. The target population for this study is workers from 18 to 65 years old in the United States who are treated for this type of injury. The results are applicable to workers around the world depending on the circumstance s surrounding their inju ry and treatment. The results may be applicable to the non-occupa tional injuries of this type which occur in adults. The application of these results to th e treatment of small children who sustain this type of injury would be limited because pe rforming simple skin grafts on their fingers would be more difficult without sedation. Childre n may also heal better with conservative treatment than their adult counterparts. Cases were identified through a computer search of diagnostic codes for 885.0, traumatic amputation of the thumb without complication; 886.0, traumatic amputation of the finger without complication; and 883.0, ope n wound of the finger or thumb. Inclusion criteria included treatment by one of the two methods being compared. Exclusion criteria will include 1) other major traumatic injuries; 2) any bone involvement proximal to the tuft of the distal phalanx; and 3) a skin defect greater than
7 three square centimeters. A practical exclusi on criterion which occurred in the course of the study was lack of medical r ecords about treatment. This wa s rare as providers of care are not paid unless the insurance company rece ives the medical record. In these cases, no apparent treatment was provided and no lost wages were paid. Retention of subjects was not an issue. Because workersÂ’ compensation insurance covers all benefits for a specific injury, all treatment was managed by the insurance company even if the worker changed jobs or moved. Some records were missing, though. In some cases, the adjustor had commented that the treating physic ian had released the patient to light duty, full duty, or put them at MMI on a specific date. No medical record from that date was scanned into the file, t hough. In these cases, the adjustorÂ’s memo was considered to be accurate. In order to minimize the problem of missi ng information in the charts, standard information which is consistently recorded in workersÂ’ compensation cases has been identified for comparison in this study. This was supplemented with information abstracted from the records of treatment.
8 Data Collection Methods The database maintained by the insurance company includes all payments made for medical treatment, wage replacement, a nd legal services. All medical records for treatment of the covere d injury are scanned into the da tabase. In addition, information from the employer, the health care provide r, and the worker is documented by the adjustor according to workersÂ’ compensation requirements. The payment information and the adjustor information is generally quite complete. The medical records may vary in both completeness and legibility according to provider. As described above, cases we re identified by a systematic search of the database by diagnostic codes, 8830, 885.0, and 886.0. Identif ying those cases which were treated with skin grafting was aided by a second sear ch of the database for procedure codes related to skin grafts on the hands 14040, 15000, 15120, and 15050. The charts were further evaluated according to the inclusion and exclusion criteria as defined under the study population section. The charts were reviewed for information on the nature of the injury. This included the size of the defect, any bony invol vement, the mechanism of injury and the level of the amputation. The size of the defect was very difficult to determine from the available records. Actual measurements we re almost never recorded. The size of the defect was estimated based on the anatomical description of the inju ry, radiology reports, and drawings in the medical records.
9 The type of treatment was clearly designa ted in the medical records. Those who were instructed to bandage the wound without any other intervention were included in the conservative treatment group. The follow up notes on this group were less frequent and less detailed than those for th e graft group. A note in the chart from the adjustor that the injured worker was working full duty without any problems was accepted as evidence of full healing. Those who had a skin graft had bot h a detailed procedure note in their record and subsequent notes commenting on the success or failure of the graft. Patient characteristics were recorded included age, sex, sm oking history, and medical history. These have been shown to be related to graft survival and may also affect recovery with conservative treatmen t. The mechanism of injury was also recorded. A finger tip amputated cleanly by a kn ife will heal much better than one that is torn off or avulsed. The most damaging t ype of injury is a crush injury. The dates when the injured worker was allowed to return to light duty and full duty were recorded. Maximum Medical Improve ment (MMI) is a workersÂ’ compensation term designating that further treatment will result in no further improvement. This may reflect complete healing from an injury, or there may be a residual impairment from the injury. The date the injured worker wa s said to be at MMI was recorded. At MMI, any residual impairment is rate d according to state guidelines based on the Guidelines to the Evaluation of Perm anent Impairment published by the American Medical Association. This permanent impairme nt at the time of MMI was recorded when available. It was recorded as zero, if not otherwise recorded. Th is assumption of an impairment of zero is consistent with what the worker would have been paid for their impairment.
10 All costs related to the claim were record ed. No detailed bills were reviewed. The total amount paid for wage replacement, me dical treatment, and legal services was recorded for each claim. The time it took for the worker to return to their job without a ny restrictions was used to approximate the time to heal in this study. The ability to work, with or without restrictions, was addressed in all the record s reviewed. The workerÂ’s injury should be healed when the doctor releases them to work without any restrictions and they are able to do so. The second outcome which was evaluated was total cost. The medical costs and wage replacement costs are both documented in the workersÂ’ comp file. The average weekly wage (AWW) of each worker will be recorded. The total wage replacement paid to each worker will be recorded. Total medical will be recorded. Before these costs can be compared, an adjustment may have to be made if the AWW differs between the two cohorts.
11 Results The query using 883.0 for open wound of the finger or thumb, generated a list of several thousand claims. The combined que ry for 885.0, traumatic amputation of the thumb, and 886.0, traumatic amputation of the fi nger generated a list of 101 claims. On review, thirty-five of these met the inclusi on and exclusion criteri a. Twenty-four were treated conservatively; eleven had skin grafts. The mean age of these two groups was 33 years. The average size of the wound was sma ller in the conservative treatment group by 0.5 cm. This approached statistical signi ficance with an Exact Test value on Wilcoxon Sum Rank testing of 0.08. Table 1: Characterist ics of Study Subjects Gender Age Race Smoking History Alcohol Medical History Injured Digit Injury Size cm3 Mechanism Male 25 White Yes Social No Lthumb 25 Sharp Cut Male 24 Unknown Unknown Unknown No Lthumb 50 Sharp Cut Female 32 White Unknown None No Rthumb 50 Sharp Cut Male 33 Other Unknown None Yes Lthumb 50 Sharp Cut Male 25 Unknown Yes Social Yes Lthumb 100 Unknown Male 32 Unknown Yes None Unknown Rindex 100 Avulsed Male 25 Unknown Yes Daily No Lthumb 100 Sharp Cut Male 40 Unknown Yes None Yes Rmiddle 100 Sharp Cut Male 37 Unknown Unknown Unknown Unknown Lthumb 100 Sharp Cut Male 26 Hispanic Unknown None No Lthumb 100 Rough Cut Male 35 White Yes Unknown No Lmiddle 100 Sharp Cut Male 43 Unknown Yes Unknown No Lthumb 100 Sharp Cut Male 43 White No Social Yes Lthumb 100 Crushed Male 23 Hispanic Yes Social No Rthumb 150 Sharp Cut Male 20 White No None No Lindex 150 Rough Cut Male 23 Unknown No None No Lthumb 150 Sharp Cut Male 31 White No Social No Rmiddle 150 Crushed
12 Gender Age Race Smoking History Alcohol Medical History Injured Digit Injury Size cm3 Mechanism Male 23 White No Social No Lthumb 150 Rough Cut Male 49 Unknown No Social Yes Lthumb 200 Sharp Cut Male 32 Unknown No None Yes Lthumb 200 Rough Cut Male 43 Hispanic No None No Rthumb 200 Crushed Male 19 White Unknown None No Lthumb 200 Sharp Cut Male 54 Other Yes None Yes Lthumb 200 Rough Cut Male 50 White No None Yes Lindex 200 Avulsed Male 18 Hispanic Unknown Unknown No Rthumb 100 Sharp Cut Male 18 Unknown Unknown Unknown Unknown Rthumb 150 Sharp Cut Male 20 Hispanic No None No Lthumb 150 Sharp Cut Male 31 Hispanic No None No Lthumb 150 Crushed Male 37 Unknown Unknown Unknown 3 Lindex 200 Crushed Female 45 Unknown Unknown Unknow n Unknown Lthumb 200 Sharp Cut Male 52 Unknown Yes Social No Lthumb 200 Rough Cut Male 41 Unknown No None No Lthumb 200 Rough Cut Male 27 Unknown Unknown None Unknown Lthumb 200 Rough Cut Male 51 White Yes Daily Yes Lthumb 200 Rough Cut Male 25 White Yes Dail y No Lthumb 250 Avulsed Thirty-three of the injured workers were male. The digit inju red most often was the left thumb. It accounted for more than 65% of the injuries.
13 Table 2: Frequency of Injury by Digit Injured Digit Frequency Percent L index 38.57 L middle 12.86 L thumb 2365.71 R index 12.86 R middle 25.71 R thumb 514.29 One of the outcomes which was compared was the cost of treatment. The mean costs for medical treatment were computed for each group and compared. The medical costs in the skin graft group were much hi gher, averaging $4316 compared to $1590 for the conservative treatment gr oup. The Wilcoxon Two Sample Test showed this difference to be statistically significant w ith an Exact Test value of 0.0026. A second aspect to the cost of treatmen t is the amount of time a person is unable to work. Because this was reimbursed for thes e workersÂ’ compensation claims, this cost was added to the medical cost to get the tota l cost of treatment and lost wages. When these were compared, the costs in the skin graft group were still higher, averaging $5,498 compared to $2,403 for the conservative tr eatment group. This difference was also statistically significant with and Exact Test value of 0.00019.
14 Table 3: Comparison of Cost and Lost time by Treatment Type Total Cost Total Med Weeks Lost Treatment N MEAN MEAN MEAN Conservative 24$2,403$1,5902.9 weeks Skin Graft 11$5,498$4,3163.1 weeks The mean average wage was greater in th e skin graft group, so weeks lost from work was compared instead of wages. The diffe rence in the time lost from work between these two groups has no practical significance, therefore statistical significance was not calculated. Because the skin graft gr oup had a larger wound on average, the comparison was repeated using only wounds larger than one square centimeter from both treatment groups. This left 11 in the conservative treatm ent group and 10 in the skin graft treatment group. This did not significantly change the results. Table 4: Comparison by Treatment Type Matched For Injury Size Total Cost Total Medical Cost Weeks Lost Days Before Light Duty Days Before Full Duty Days To MMI Treatment N MEAN MEAN MEAN MEAN MEAN MEAN Conservative 11 $3,082.18$2,399.952.312 31 46 Skin Graft 10 $5,947.92$4,663.563.219 42 88 A final outcome to be compared was th e impairment, if any, at the end of treatment. This impairment reflects any loss of sensation or use of the injured digit. The conservative treatment group had an average PI R of 0.5 compared to an average of 1.2
15 for the skin graft group. Statisti cally, this is almost signif icant with a tw o-sided Exact Test value of 0.08. What the diffe rence really reflects, though, is that one person in each group received a PIR of 11%. There were mo re than twice as many subjects in the conservative group, therefore, the average PIR was lower.
16 Discussion The first major potential bias in this study is the intent -to-treat. This bias poses a difficult problem for retrospective studies of different treatments for a condition. The treatment is not randomly assigned. There may be a very significant difference between the injuries in the two cohor ts which influenced the treating physician to choose one treatment over the other. In this study, c onservative treatment may have been chosen more often when the injury was less severe and the wound was smaller. This would skew the results in favor of conserva tive treatment. If skin grafting is a better treatment, this would bias the study results so that the benefit of skin grafting is not apparent, a type II error. This intent-to-treat bias can be overcome when there are centers where one treatment is preferentially provided. This situ ation exists in Florida where many of these cases occurred. One Occupational Medicine prov ider with six clinics, skin grafting of minor fingertip amputations is routinely provided in stead of conservative treatment. The intent when this study was designed was that many of those cases would be included in the data, overcoming the intent-to-treat bias elsewhere. The current study design did not allow for identification of the providers or preferentially pulling data by provider. This unique situation in Florida does allow for an excellent treatment comparison to be done. This may be attempted again in a future study. A second bias is this study is a selection bias of so rts. The study subjects are identified by a diagnostic code for trau matic amputation. The amputations which we
17 attempted to compare in this study are re latively minor and may have been given a different diagnostic code such as 883.0, ope n wound of the finger, which includes burns, lacerations, and several very common injuries. The injuries which are treated with a skingraft are more likely to be coded correc tly as amputations or discovered when the database is searched for the skin graft pro cedure codes. An attempt was made to search code 883, but this produced a list of claims too large to review within the confines of this study. The quality of information in the medical records was problematic in this study. The information recorded about the skin graf t group was much more complete than that recorded for the conservative group. The skin graft group required a higher level of technical expertise and the notes reflected this. Cases were identified for which the information in the chart was so incomplete th at they could not be used in the study. If these cases differed substantially from cases for which the information was complete, that would affect the validity of the study results. This study looked at fingerti p amputations in workers. When this injury occurs outside the workplace, its highest inciden ce is in young children and older adults. The results of this study would be reasonably appl icable to older adults The healthy-worker effect would probably not be si gnificant when considering workers as compared to older adults who are active enough to be out in their garages using power tools. The results of this study may not be applicable to young child ren. A skin graft which heals very well in an adult might do poorly in a child who cannot keep from disturbing the bandage or it may do better because their tissue is younger and healthier. Young children may also
18 regenerate their skin better than older adults when allowe d to heal conservatively. For these reasons, the results of this study w ould not necessarily a pply to young children.
19 Conclusions This study showed that finger and thum b tip amputations which are treated by skin grafting have higher medical costs a nd higher total costs including the wage replacement costs than amputations treated c onservatively. No benefit from an earlier return to work was apparent between the tw o groups. The study may not have compared equivalent injuries. Those injuries which were treated with a skin graft were probably more severe. Any future study wh ich looks at this issue must make sure that the injury severity in the treatment groups is comparable so that the comparis on of treatments is accurate.
20 References 1. Work-Related Injury Statisti cs Query System (Work-RISQS) 1999, Centers for Disease Control and Prevention. 2. Martin, C. and J. Gonzalez del Pino, Controversies in the treatment of fingertip amputations. Conservative versu s surgical reconstruction. Clin Orthop Relat Res, 1998(353): p. 63-73. 3. Fassler, P.R., Fingertip Injuries: Evaluation and Treatment. J Am Acad Orthop Surg, 1996. 4 (1): p. 84-92. 4. Hart, R.G. and H.E. Kleinert, Fingertip and nail bed injuries. Emerg Med Clin North Am, 1993. 11 (3): p. 755-65. 5. Russell, R.C. and L.A. Casas, Management of fingertip injuries. Clin Plast Surg, 1989. 16 (3): p. 405-25. 6. Mennen, U. and A. Wiese, Fingertip injuries manageme nt with semi-occlusive dressing. J Hand Surg [Br], 1993. 18 (4): p. 416-22. 7. Foucher, G., et al., The Hueston flap in reconstruc tion of fingertip skin loss: results in a series of 41 patients. J Hand Surg [Am], 1994. 19 (3): p. 508-15. 8. Grossman, J.A. and E.B. Robotti, The use of split-thickness hypothenar grafts for coverage of fingertips and other defects of the hand. Ann Chir Main Memb Super, 1995. 14 (4-5): p. 239-43. 9. Buckley, S.C., S. Scott, and K. Das, Late review of the use of silver sulphadiazine dressings for the treatment of fingertip injuries. Injury, 2000. 31 (5): p. 301-4. 10. Jackson, E.A., The V-Y plasty in the treatm ent of fingertip amputations. Am Fam Physician, 2001. 64 (3): p. 455-8. 11. Adani, R., I. Marcoccio, and L. Tarallo, Treatment of finger tips amputation using the Hirase technique. Hand Surg, 2003. 8 (2): p. 257-64. 12. Hong, J.P., et al., Reconstruction of fingertip and stump using a composite graft from the hypothenar region. Ann Plast Surg, 2003. 51 (1): p. 57-62. 13. Lin, T.S., S.F. Jeng, and Y.C. Chiang, Fingertip replantation using the subdermal pocket procedure. Plast Reconstr Surg, 2004. 113 (1): p. 247-53. 14. Hattori, Y., et al., A retrospective study of functi onal outcomes after successful replantation versus amputation closur e for single fingertip amputations. The Journal of hand surgery, 2006. 31 (5): p. 811-8. 15. Akyurek, M. and T. Safak, Microsurgical replantation of a small segment of thumb volar skin. Ann Plast Surg, 2004. 52 (6): p. 614-6. 16. Heistein, J.B. and P.A. Cook, Factors affecting composite graft survival in digital tip amputations. Ann Plast Surg, 2003. 50 (3): p. 299-303.