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. 2013 Jan 12;8(2):139–145. doi: 10.1007/s11552-012-9487-0

A systematic review of outcomes of revision amputation treatment for fingertip amputations

Keming Wang 1, Erika Davis Sears 2, Melissa J Shauver 3, Kevin C Chung 4,5,✉
PMCID: PMC3653002  PMID: 24426910

Abstract

Purpose

The purpose of this study was to conduct a systematic review of outcomes of fingertip revision amputation for fingertip amputation injuries in the English-language literature to provide best evidence of functional outcomes.

Methods

A MEDLINE literature search was performed to identify studies that met the following criteria: (1) reported primary data; (2) included at least five cases of primary revision amputation treatment following digit amputation injury; (3) reported finger or thumb amputation at or distal to the distal interphalangeal (DIP) joint or interphalangeal (IP) joint, respectively; (4) presented at least one of the following outcomes: static two-point discrimination (2PD), cold intolerance, arc of motion (AOM) of metacarpophalangeal (MCP) joints, proximal interphalangeal joints (PIP), DIP joints, or return-to-work time.

Results

Thirty-eight studies met the inclusion criteria. Twenty-seven studies reported 2PD, 20 studies reported cold intolerance, eight studies reported AOM, and 18 studies reported return-to-work time after revision amputation of fingertip injuries. The mean 2PD was 5.6 mm. On average, 24 % of patients experienced cold intolerance. AOM at the PIP joint was reported in four studies and averaged 94°. DIP joint AOM was presented in four studies and averaged 66°. Thumb MCP and IP joint AOM was presented in three and four studies, respectively. Mean thumb MCP joint AOM was 54° and that of the IP joint was 71°. The mean return-to-work time was 47 days.

Conclusions

On average, fingertip revision amputation can achieve almost normal sensibility and satisfactory motion and patients can expect to return to work on average approximately 7 weeks after surgery.

Keywords: Fingertip amputation, Hand surgery outcomes, Systematic review, Treatment

Fingertip amputation, involving the distal interphalangeal joint (DIP) for fingers and the interphalangeal (IP) joint for the thumb [23], is the most common amputation injury treated by hand surgeons. Sixty-three percent of patients do not undergo replantation [38]. Revision amputation of the fingertip may result in the loss of skin, fingernail, or digit length, which may lead to functional deficits. Some previous studies have reported normal sensibility [51] whereas other studies have reported inadequate outcomes [22]. Outcomes of fingertip injuries have not been examined critically in an evidence-based manner by applying systematic review principles. Although fingertip replantation results in acceptable outcomes if successful [42], the outcomes of revision amputation are not well-known. Amputation should be critically examined to determine if its outcomes are sufficiently poor to support an increased effort in replanting these distal amputated parts.

Most studies, including a recent systematic review [42], focused on outcomes of fingertip amputation treated with replantation, but little attention has been given to outcomes after revision amputation. Furthermore, the current literature on revision amputation lacks the rigorous evidence necessary to evaluate outcomes compared to replantation. Current studies that report outcomes after revision amputation suffer from small sample size and present varied outcomes. In order to inform clinical decision-making between the two treatment options, outcomes after revision amputation treatments need to be arduously evaluated. Systematic review is a rigorous tool for evidence-based medical practice and can be used in the clinical setting to synthesize available data to determine the best evidence [10] for outcomes of revision amputation treatment for fingertip amputations. However, no such review of the evidence has been performed. The purpose of this study is to conduct a systematic review of the English language literature on revision amputation treatment of fingertip amputation injuries to provide the best available evidence of functional outcomes, including sensibility, arc of motion (AOM), and return-to-work time. We hypothesize that revision amputation treatment will have acceptable functional outcomes.

Materials and Methods

Literature Search

We performed a literature search using MEDLINE in March 2012 to summarize outcomes after primary revision amputation treatment of fingertip injuries. We defined the fingertip as the portion of the digit at or distal to the DIP joint of the fingers or the IP joint of the thumb. We used the key words “fingers”, “thumb”, or “finger injuries” combined with “amputation, traumatic” or “replantation” to identify studies. Studies were limited to those of humans and those published in English.

Included studies met the following criteria:

  1. Study reported primary data

  2. Study included at least five cases of primary revision amputation following digit amputation injury of any mechanism, where treatment included open treatment, primary closure, split-thickness skin grafting, full-thickness skin grafting, local, or regional flap closure

  3. Study reported outcomes of finger or thumb amputation at or distal to the DIP joint or IP joint, respectively

  4. The study presented at least one of the following outcomes: static two-point discrimination (2PD), cold intolerance, AOM of metacarpophalangeal (MCP) joints, IP joints, proximal interphalangeal (PIP) joints, DIP joints, or return-to-work time

The following manuscripts were excluded:

  1. Cases of secondary revision amputation performed after failure of replantation

  2. Amputation injuries treated using microsurgery, such as toe-to-thumb transfer

  3. Amputation injuries treated with composite graft

We first screened the titles and abstracts of the identified studies. Next, we performed full-article reviews of studies in which no abstract was published or if the content was unclear based on abstract review. If several articles presented data from the same author, we determined the techniques they performed as well as the time period patients were treated to verify that data from the same patient sample was not duplicated in this systematic review.

Data Analysis

For each study meeting our inclusion criteria, we recorded study characteristics, patient demographic information, mean follow-up time, and functional outcomes. Functional outcomes included one or more of the following: (1) static 2PD, (2) cold intolerance, (3) AOM, and (4) return-to-work time. The weighted mean of each functional outcome was calculated based on sample sizes of each included study using the following method: (1) multiply the mean outcome of each study by the study sample size, (2) sum the products to get the total value, (3) sum the sample sizes to get the total weight, and (4) divide the total value by the total weight to provide a weighted mean for each outcome. We defined presence of cold intolerance as having at least moderate cold intolerance. Thus, we did not include patients with mild or slight cold intolerance in our summary statistics due to the high prevalence of slight or mild cold intolerance in this patient population [44].

Results

We identified 1,538 studies through our MEDLINE search (Fig. 1). The abstract and title review narrowed the field to 124 studies that underwent full text review. Upon further review, 38 studies met the inclusion/exclusion criteria [1–9, 12–18, 21, 22, 25–30, 32, 35, 37, 39–41, 43–47, 49, 50, 52] (Table 1). The included studies were published between 1972 and 2011, and a total of 1,009 fingertip amputations were treated. Twenty-seven studies reported 2PD outcomes [2, 3, 6, 8, 9, 14, 16, 18, 21, 25–27, 29, 30, 32, 35, 37, 39–41, 43, 45–47, 49, 50, 52], 20 studies reported cold intolerance outcomes [1–3, 6, 7, 9, 14, 17, 22, 28–30, 39, 41, 43–45, 47, 49, 50, 52], eight studies reported AOM outcomes [5, 9, 21, 22, 40, 43, 44, 50], and 18 studies reported return-to-work time [4, 7, 12–17, 21, 22, 25, 28, 29, 32, 39, 44, 47, 49]. The mean 2PD was 5.6 mm (Table 2). On average, 24 % of patients experienced cold intolerance (Table 3). AOM at the PIP joint was reported in four studies and averaged 94° (Table 4). DIP joint AOM outcomes were presented in four studies and averaged 66° (Table 4). Thumb MCP and IP joint AOM outcomes were presented in three and four studies, respectively (Table 5). Mean thumb MCP joint AOM was 54° and mean thumb IP joint AOM was 71°. The mean return-to-work time was 47 days (Table 6).

Fig. 1.

Fig. 1

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Flow chart of database search, including number of citations identified at each level of search

Table 1.

Demographic characteristics of patients undergoing fingertip amputation

Yeara First author Study location No. of patients Male Female Mean age or range (years) Mean follow-up, months (range) No. of digits
1972 Freiberg Canada 10 – – 4–79 – 10
1977 Farrell USA 17 – – – – 21
1977 Fox USA 18 – – – 6 22
1978 Frandsen Denmark 24 24 1A 3C 34 32 (6–57) 24
1980 Louis USA 33 29 4 16–70 8 38
1982 Ma Hong Kong 140 130 10 35 6 140
1985 Kappel USA 23 19 5 – 6 23
1985 Tupper USA 16 15 1 34 71 (12–132) 20
1989 De Smet Belgium 108 90 18 33 6 112
1989 Foucher France 64 53 11 34 15–72 64
1994 Foucher France 41 37 4 34 36 (12–72) 43
1995 Adani Italy 11 9 2 37 26 (7–43) 11
1995 Lanzetta Canada 25 21 4 38 30 (6–48) 25
1996 Tsai USA 16 12 4 43 62 16
1997 Adani Italy 25 25 7 37 27 (8–52) 25
2000 Borman Turkey 19 10 7 25 4 (0.8–17) 25
2000 Buckley UK 19 19 0 44 76 (40–96) 21
2001 Karamursel Turkey 6 5 1C 19–66 10 11
2001 Kim Korea 14 16 7 33 6 15
2001 Özdemir Turkey 9 6 3 – 9 (3–18) 9
2001 Pelissier France 14 12 2 42 13 (6–20) 15
2002 Baumeister Germany 25 34 2 42 27 25
2002 Cao China 5 8 3 29 29–33 5
2003 Laoulakos Greece 9 8 1 41 6–30 9
2005 Adani Italy 22 14 8 34 – 22
2005 Varitimidis Greece 50 36 14 35 46 (14–94) 63
2006 Hattori Japan 23 18 5 45 21 23
2006 Tuncali Turkey 9 8 1 33 12 9
2007 Ozyigit Turkey 7 6 1 33 18 (12–24) 7
2008 Sano Japan 11 8 3 44 12–21 14
2008 Woon Singapore 9 8 1 50 4 (1–15) 9
2009 Bakhach France 13 12 1 40 – 15
2009 Omokawa Japan 15 11 4 41 48 15
2009 Shao China 11 8 3 36 27 (25–34) 11
2010 Chen China 11 – – 30 32 (26–47) 11
2010 Yazar Turkey 66 56 10 32 18 70
2011 Hammouda Qatar 6 6 0 29 9–12 6
2011 Wang China 5 9 2 4 15 (10–32) 5
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– not reported, A adult, C child

aStudies listed in chronological order

bDid not include patients lost to follow-up

Table 2.

Sensibility outcomes after fingertip amputation

Yeara Author No. of digits 2PD (mm)
1972 Freiberg 10 6.0
1977 Fox 22 4.0
1980 Louis 29 3.5
1982 Ma 140 5.4
1985 Kappel 23 8.3
1985 Tupper 20 5.7
1994 Foucher 43 7.0
1995 Adani 11 12.0
2000 Borman 25 4.3
2001 Karamursel 11 6.0
2001 Kim 15 4.2
2001 Ozdemir 9 4.5
2001 Pelissier 15 8.0
2002 Cao 5 4.2
2003 Laoulakos 9 8.0
2005 Adani 22 9.0
2005 Varitimidis 63 4.0
2006 Tuncali 9 6.3
2007 Ozyigit 7 4.7
2008 Sano 14 4.3
2008 Woon 9 3.3
2009 Omokawa 15 8.4
2009 Shao 11 4.6
2010 Chen 11 5.0
2010 Yazar 70 5.7
2011 Hammouda 6 4.0
2011 Wang 5 3.4
Mean 2PD after fingertip amputationb 624 5.6
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2PD two-point discrimination

aStudies listed in chronological order

bWeighted averages based on sample size of each study

Table 3.

The prevalence of cold intolerance outcome after fingertip amputation

Yeara Author No. of digits Cold intolerance (%)
1978 Frandsen 24 50
1980 Louis 38 11
1994 Foucher 41 51
1995 Adani 11 0
1995 Lanzetta 25 80
1996 Tsai 16 38
1997 Adani 25 0
2000 Buckley 21 38
2000 Borman 25 0
2003 Laoulakos 9 0
2005 Adani 22 0
2005 Varitimidis 63 44
2006 Hattori 23 22
2006 Tuncali 9 29
2007 Ozyigit 7 0
2008 Sano 14 0
2008 Woon 9 33
2010 Chen 11 0
2010 Yazar 66 0
2011 Wang 5 0
Mean cold intolerance after fingertip amputationsb 464 24
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aStudies listed in chronological order

bWeighted averages based on sample size of each study

Table 4.

Finger DIP and PIP Joint arc of motion after fingertip amputation

Yeara Author No. of digits DIP (degrees) PIP (degrees)
1996 Tsai 16 54 96
2001 Pelissier 15 64 –
2006 Hattori 23 – 86
2009 Shao 11 86 98
2011 Hammouda 6 69 108
Mean arc of motion after fingertip amputationb 66 (n = 48) 94 (n = 56)
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DIP distal interphalangeal, PIP proximal interphalangeal, – not reported in the study

aStudies listed in chronological order

bWeighted averages based on sample of fingers in study

Table 5.

Thumb MCP and IP joint arc of motion after thumb tip amputation

Yeara Author No. of thumbs MCP (degrees) IP (degrees)
1996 Tsai 2 – 54
2002 Baumeister 25 50 77
2010 Woon 9 64 59
2010 Chen 11 56 70
Mean arc of motion after thumb tip amputationb 54 (n = 45) 71 (n = 47)
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MCP metacarpophalangeal, IP interphalangeal, – not reported in the study

aStudies listed in chronological order

bWeighted averages based on sample of thumbs in study

Table 6.

Return-to-work time after fingertip revision amputation

Yeara Author No. of patients Return-to-work time (days)
1977 Farrell 17 4
1977 Fox 18 10
1978 Frandsen 24 51
1982 Ma 140 53
1985 Kappel 23 67
1989 De Smet 108 50
1989 Foucher 64 61
1994 Foucher 41 43
1995 Lanzetta 25 56
1996 Tsai 16 30
2000 Buckley 19 7
2003 Laoulakos 9 28
2005 Varitimidis 50 36
2006 Hattori 23 30
2007 Ozyigit 7 21
2009 Bakhach 13 106
2011 Hammouda 6 56
2011 Wang 5 35
Mean return-to-work time after fingertip amputationb 608 47
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aStudy listed in chronological order

bWeighted averages based on sample size of each study

Discussion

The aim of fingertip amputation treatment is to maintain as much function as possible in the form of sensibility and AOM. In addition, patients and physicians aim to have patients return to the previous level of employment as soon as possible. According to the American Society for Surgery of the Hand, 2PD is considered normal if it is less than 6 mm [31]. Our review found that mean 2PD following revision amputation was 5.6 mm, which was within normal range. Additionally, the normative AOM reference value of the DIP joint is reported to be 70–90° and that of the PIP joint 100° [33]. We found that after revision amputation, the average AOM of the DIP joint and the PIP joint was 66° and 94°, respectively, which approach the normative value. This systematic review of fingertip amputation injuries treated with revision amputation showed acceptable outcomes. On average, patients have good sensibility, adequate AOM of the IP joints and MCP joints, and return to work approximately 7 weeks after injury.

In general, outcomes after revision amputation of fingertip amputation injuries appear to be similar to functional outcomes reported after fingertip replantation. In a systematic review of outcomes of replantation of fingertip injuries, Sebastin et al. found that of 220 digits reported among 12 studies, the mean 2PD was 7 mm [42]. Based on our review, patients undergoing fingertip revision amputation had slightly better sensibility outcomes.

We found that the mean incidence of cold intolerance was 24 %. After fingertip replantation, cold intolerance was reported in 0–35 % of patients reported in the literature [22, 36, 48]. Hattori et al. compared 23 patients who had undergone fingertip replantation and 23 patients with fingertip revision amputation, and found no statistically significant difference (P > 0.05) between the two groups in cold intolerance: 35 % in fingertip replantation and 40 % in fingertip revision amputation [22]. In another study, Ozcelik et al. evaluated thumb tip replantation in 14 patients and reported that the rate of cold intolerance was 21.4 % [36]. However, in a more recent study, cold intolerance was not reported by any of 24 patients with fingertip replantation [48]. It is important to note, though, that cold intolerance is assumed to be the result of vascular insufficiency and peripheral nerve injury suffered during the original trauma, rather than as a result of treatment [19, 20, 24, 34].

Similar to our experience reviewing outcomes after revision amputation, few studies described joint AOM after fingertip replantation. Sebastin et al. described only three studies reporting AOM after fingertip replantation [42]. Two of the studies reported the percent of normal AOM achieved by the replanted finger. One study [22] reported DIP joint AOM was 49° and PIP joint AOM was 94° in fingertip replantation group, which was similar to the outcomes in our review of revision amputation treatment. In addition, this systematic review showed that DIP and PIP joint AOM were relatively close to the normative values [33].

The return-to-work time after fingertip replantation ranged from 3.2 to 4.0 months in previous published studies [22, 36]. Our systematic review found the return-to-work time following fingertip revision amputation to be 47 days, approximately 1.5 months. Therefore, revision amputation allows patients to return to work in half the time on average than replantation patients.

This systematic review has several limitations. One limitation of our study is that analysis of data in systematic reviews is limited by the manner in which data is presented in the original studies. Studies did not reliably stratify outcomes according to mechanism of injury or demographic characteristics, thus our review was not able to stratify outcomes according to these variables. In addition, there is considerable variability in techniques used for fingertip revision amputation. Eighteen studies used the homodigital island flap [1–3, 6, 14, 15, 21, 26–29, 37, 40, 43, 44, 47, 49, 52], whereas seven studies reported V-Y advancement flap [4, 5, 17, 18, 39, 41, 46] and another two studies reported cross-finger flap treatment [9, 46]. Three studies treated fingertip amputations with dressings and allowed wounds to heal by secondary intention [13, 16, 30]. The remaining studies reported outcomes from more than one method of revision amputation. Only one study reported all of the outcomes of interest for this systematic review [22]. Many studies focused more on techniques rather than presenting functional outcomes. There was limited AOM data given for individual joints. Additional considerations were the variability of outcomes measures. Cold intolerance is a subjective experience that is not easily or reliably measured and return-to-work time can be influenced by many factors not related to injury or treatment.

This systematic review synthesizes the evidence on revision amputation for fingertip amputation injury. The results can aid surgeons and patients when making decisions regarding fingertip replantation and fingertip revision amputation. After fingertip revision amputation, sensation can be similar or better than following fingertip replantation. Cold intolerance, as well as DIP and PIP joint motion is similar to outcomes reported in the literature for replantation treatment. The return-to-work time is shorter than what is reported after fingertip replantation. Thus, for patients who need to return to work sooner, fingertip revision amputation is recommended. Fingertip revision amputation can achieve good sensibility and AOM, in addition to allowing an earlier return-to-work compared to fingertip replantation treatment. Given similar objective functional outcomes, future studies should evaluate health-related quality of life of both treatments. Given the greater cost of performing replantation treatment [11, 38], improved patient-reported quality of life should be demonstrated to justify performing replantation following fingertip amputation injuries.

Acknowledgments

Supported in part by grants from the National Institute on Aging and National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01 AR062066) and from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (2R01 AR047328-06) and a Midcareer Investigator Award in Patient-Oriented Research (K24 AR053120; to Dr. Kevin C. Chung).

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