European Journal of Cardiovascular Medicine

Nearly two-thirds of all hand-related crises and surgical procedures include injuries to the fingers, making them a substantial component of hand trauma cases ^[1,2]. Fine motor skills, aesthetics, and sensory awareness all depend on the fingers. As a result, the patient's damage impacts not just hand function but also their quality of life and productivity at work. These injuries are frequently caused by avulsion, laceration, or crushing processes that occur in household, occupational, and unintentional contexts. In their care, maintaining length, feeling, and function is still crucial ^[3].

The degree of tissue loss, bone involvement, patient comorbidities, and surgeon skill all influence the restoration strategy for the fingertip. Treatment methods vary from skin grafting and secondary intention healing to more intricate procedures including flap reconstructions and composite grafts. The optimal approach should provide quick function recovery, minimum donor site morbidity, and sensate and long-lasting coverage ^[4]. Locoregional flaps have become more popular because of their ease of use, adaptability, and capacity to achieve the majority of reconstructive goals in a single surgical step.

Reverse homodigital island flaps (RHIF), thenar flaps, and homodigital neurovascular flaps are locoregional treatments that have consistently produced both functional and aesthetic results. In the past, immobilisation and many steps were needed for flaps such the cross-finger and abdominal flaps, which prolonged recovery and increased patient pain ^[5]. On the other hand, contemporary locoregional methods provide dependable vascularity, are simpler to harvest, and enable early mobilisation with a lower risk of joint stiffness ^[6].

Covering volar and distal pulp deficits without compromising neighbouring fingers is made possible by the reverse homodigital island flap, which is based on a single neurovascular pedicle. It is particularly appropriate for individuals with high functional demands since it retains joint mobility and protective sensitivity ^[7]. The thenar flap provides a supple and glabrous skin match, resulting in superior tactile recovery and aesthetic harmony, making it perfect for transverse and volar oblique fingertip amputations ^[8]. Although more difficult to do technically, homodigital neurovascular island flaps preserve vascular and sensory continuity, which is essential for delicate fingertip restoration ^[9].

Notwithstanding these benefits, locoregional flaps might cause issues. Postoperative complications include neuropathic pain, cold sensitivity, donor site morbidity, nail abnormalities, venous congestion, and partial or total flap necrosis ^[10,11]. Nonetheless, these issues are rarely encountered, particularly in skilled hands. RHIF survival rates as high as 98.4% were reported in a research by Xu et al. (2021), and mean static two-point discrimination (s2PD) values of 7.2 mm indicated good sensory recovery ^[7]. Similarly, Al-Qattan et al. (2017) showed that over 75% of patients may attain protective sensitivity with well-planned thenar flaps ^[5].

When assessing the effectiveness of flaps, functional measures including range of motion (ROM), return to work time, and aesthetic pleasure are crucial. Regmi et al. (2016) evaluated locoregional flaps and discovered that single-stage flap surgeries were directly associated with early mobilisation and shorter rehabilitation times, which resulted in a faster return to work and everyday activities ^[6]. Furthermore, flaps outperformed grafts or secondary healing in terms of sensory return and visual attractiveness.

Even though they are less common, paediatric patients also greatly benefit from these flap procedures. The long-term effectiveness of RHIF in children was highlighted by Yildirim et al. (2022), who emphasised positive sensory results and few development problems ^[12]. However, issues like stiffness in badly performed surgeries or abnormalities in the donor site's shape highlight the necessity of surgical accuracy and careful case selection.

The advantages of locoregional flaps have also been confirmed by patient-reported results. Bickel (2018) and Chen et al. (2018) emphasised their importance in fingertip reconstruction by highlighting excellent satisfaction rates, reduced complication profiles, and better sensory perception ^[11,13]. Furthermore, in order to maximise customised treatment results, new research supports the integration of patient-specific characteristics including age, occupation, and dominant hand participation into flap selection (Noland SS et al., 2018; Papadopulos NA et al., 2020)^[14,15]. The success rate of locoregional flap surgeries keeps rising because to improvements in anatomical knowledge, surgical education, and microsurgical instrumentation. Nonetheless, there is still substantial fragmentation in the research, with few studies providing thorough, prospective evaluations of many flap types in a single cohort.

Over the course of three years, this study intends to assess the functional and cosmetic results of several locoregional flaps used for fingertip damage restoration in a tertiary care facility. By concentrating on important indicators such flap survival, static two-point discrimination, joint mobility, time to return to work, and complication rates, the study aims to offer evidence-based understanding of how effective these treatments are. The research also takes into account patient satisfaction as a crucial factor in determining the outcome of surgery. By doing this, it hopes to improve clinical judgement in the treatment of fingertip damage and direct future reconstructive techniques.

Study Design and Setting:

This prospective observational study was conducted at the Department of Plastic Surgery, Princess Esra Hospital, affiliated with Deccan College of Medical Sciences, Hyderabad. The study duration was from May 2022 to May 2025.

Sample Size and Participants:

A total of 40 patients with fingertip injuries requiring flap reconstruction were enrolled. All participants provided written informed consent. The study was approved by the institutional ethics committee.

Inclusion Criteria:

• Patients aged 4 to 40 years
• Traumatic fingertip injuries involving pulp, nail bed, or volar defects unsuitable for primary closure
• Patients requiring coverage via locoregional flap techniques
• Willingness to comply with follow-up protocol

Exclusion Criteria:

• Crush injuries involving multiple fingers
• Underlying bone infection or malignancy
• Peripheral vascular disease or uncontrolled diabetes
• Patients undergoing secondary flap reconstruction

Surgical Technique: Patients were evaluated preoperatively, and flap selection was based on defect location, size, and orientation. Three types of locoregional flaps were used:

1. Reverse Homodigital Island Flap (RHIF): Based on a neurovascular pedicle, elevated from the same finger and rotated to cover the distal defect.
2. Thenar Flap: Elevated from the thenar eminence and advanced or transposed for volar oblique injuries.
3. Homodigital Neurovascular Flap: Islanded on one neurovascular bundle and tunneled to cover fingertip pulp defects.

All flaps were performed under regional anesthesia with tourniquet control. Donor sites were primarily closed or skin grafted as needed. Postoperative dressings were applied with care to avoid flap compression.

Postoperative Care and Follow-Up: Patients were monitored for flap viability, complications, and rehabilitation. Sutures were removed by day 10–14. Follow-up assessments were conducted at 2 weeks, 1 month, 3 months, and 6 months postoperatively.

Outcome Measures:

• Flap survival (complete/partial/necrosis)
• Static two-point discrimination (s2PD) at 6 months
• Range of motion (PIP and DIP joints)
• Return-to-work duration
• Complications (venous congestion, cold intolerance, pain, nail deformity)
• Patient satisfaction (Likert scale)

Statistical Analysis: Descriptive statistics were used to summarize demographic and outcome data. Mean ± SD was calculated for continuous variables, and proportions for categorical data. All analyses were performed using SPSS version 25.0.

Table 1: Patient Demographics

The baseline characteristics of the 40 research participants are summarised in this table. With a standard deviation of 12.3 years, the average age was 34.8 years. Thirteen ladies and twenty-seven guys made up the majority. The occupational risk of fingertip injuries is highlighted by the fact that the majority of patients (60%) were manual labourers. Seventy percent of injuries happened to the dominant right hand.

Figure 1

Table 2: Type of Flap Used

The distribution of flap types used in fingertip reconstruction is seen in this table. The most often used procedure was the Reverse Homodigital Island Flap, which was employed in 60% of instances (24 patients). 15% of patients had the Homodigital Neurovascular Flap, whereas 25% of patients had thenar flaps.

Figure 2

Table 3: Outcome Measures

Important clinical outcomes are shown in this table. with full survival in 97.5% of instances, flap survival was high. Favourable sensory recovery was indicated by the mean static two-point discrimination (s2PD) of 7.4 mm at 6 months. The PIP and DIP joints' range of motion was mainly unaffected (mean PIP: 89.2°, DIP: 64.7°). Rapid functional recovery was demonstrated by the average time to return to work, which was 6.2 weeks.

Figure 3

Table 4: Complication Rates

The frequency of surgical complications is seen in this table. The most common reported consequence was cold intolerance (17.5%), which was followed by venous congestion (10%) and nail abnormalities (12.5%). Neuropathic discomfort (7.5%) and flexion contractures (5%), on the other hand, were less frequent problems.

Figure 4

Table 5: Patient Satisfaction (Likert Scale)

A 4-point Likert scale was used to gauge patient satisfaction. of the patients who had surgery, 65% said they were "very satisfied" with the results, whilst 25% said they were "satisfied." Overall patient-reported success was strong, with just a tiny percentage of patients reporting being "neutral" (7.5%) or "dissatisfied" (2.5%).

Figure 5: Thenar flap

Figure 6: Vy advancement flap

Figure 7: Vy Flap

Figure 8: Thenar Flap

Figure 9: VY advancement flap

Figure 10: Homodigital island flap for fingertip defect

Because fingertip injuries occur often and are functionally significant, they need to be managed carefully and individually. Reconstruction aims to minimise donor site morbidity and provide a prompt return to daily activities while restoring length, soft tissue covering, protective feeling, and nail function. Lee DH et al. (2017); Choudhary S et al. (2020)^[1,2]. The clinical effectiveness of three frequently used locoregional flaps—the reverse homodigital island flap (RHIF), the thenar flap, and the homodigital neurovascular flap—was assessed in this study.

RHIF was the most commonly used flap in our group (60%) in line with previous research showing its effectiveness in distal fingertip injuries involving exposed bone or tendon.^[3,4] El-Khatib HA et al. (2016); Sebastin SJ et al. (2011). RHIFs have been demonstrated to have positive results in terms of viability and feeling recovery, and they give a good blood supply by reverse flow via the digital artery. Al-Qattan MM et al. (2017) and Regmi S et al. (2016) ^[5,6]. This is corroborated by our results, which show a 97.5% flap survival rate and a mean static two-point discrimination (s2PD) of 7.4 mm, which is comparable to 7.2 mm s2PD values published by Xu et al. (2021) ^[7].

25% of our cases involve the use of thenar flaps, which are frequently appropriate for volar oblique amputations, especially in younger patients. According to Wang J et al. (2021), these flaps offer long-lasting skin covering with good colour and texture matching, although they need to be divided and inset using a secondary method ^[8]. The findings of Al-Qattan et al. (2017), who highlighted the positive sensory effects of thenar flaps with protective feeling restoration in more than 75% of patients, are supported by our findings ^[5].

In this study, the homodigital neurovascular flap was the least often employed procedure (15%). This flap provides sensitive covering and is usually saved for specific applications with high functional requirements, albeit being more technically challenging. Chen W et al. (2017)^[13] state that while the preservation of neurovascular components aids in sensory recovery, donor site morbidity and flexion contracture risks remain issues.

Our study's postoperative functional results, such as the mean range of motion of the PIP and DIP joints (89.2° and 64.7°, respectively), were similar to those found in previous research ^[12]. Because they have a direct impact on hand dexterity and vocational rehabilitation, these measurements are significant. Additionally, the typical recovery period of 6.2 weeks lends credence to the effectiveness of locoregional flaps in guaranteeing prompt mobilisation.

After fingertip repair, cold sensitivity is still a common and difficult side effect, occurring in 17.5% of patients. According to Bickel et al. (2018), cold intolerance is a complex problem associated with vascular alterations and nerve regeneration ^[11]. Our cohort's other problems, which included neuropathic pain (7.5%), nail deformity (12.5%), and venous congestion (10%), represent the usual range of outcomes reported in previous studies by Kraemer BA et al. (2017) and Arneja JS et al. (2016)^[16,17].

Ninety percent of patients were either happy or extremely satisfied, according to a Likert scale used to measure patient satisfaction. This supports the results of Noland et al. (2019), who highlighted the close relationship between reported patient satisfaction and aesthetic results ^[14]. Flap look, tactile recovery, nail shape, and occupational usefulness are some of the factors that affect pleasure.

Due to careful intraoperative planning and flap execution, the rate of flap necrosis was very low (2.5%). This is in line with findings from research on flap vascular integrity and surgical technique. The choice of flap according to patient employment, hand dominance, and damage pattern is one area of focus. The bulk of this group (60%) were manual labourers, who frequently needed long-lasting flaps with quick recovery so they could return to work. RHIF successfully met this need, however thenar flaps were frequently preferred for aesthetic results in patients with high visual demand (such as professionals or young people). Gu JX et al. (2023)^[18].

Despite the fact that all three flap types showed satisfactory results, careful selection is required due to their unique benefits and drawbacks. While thenar flaps could be the most appropriate for volar abnormalities, RHIFs are most suited for dorsal and transverse lesions with little joint involvement. Rebuilding pulp lesions with high sensory needs may benefit from the use of homodigital neurovascular flaps, despite their less frequent usage. Our research contributes to the increasing amount of data demonstrating the effectiveness of locoregional flaps in treating injuries to the fingertip. To learn more about how sensory function, cold sensitivity, and nail regrowth change over time, however, long-term monitoring would be required Chiarini L et al. (2021)^[19].

Because fingertip injuries affect hand function, appearance, and vocational capacity, they must be treated quickly and precisely. Reliable reconstructive alternatives are provided by locoregional flaps, such as Reverse Homodigital Island, Thenar, and Homodigital Neurovascular flaps. Each has unique benefits depending on the patient's demands and the nature of the lesion. Excellent flap survival (97.5%), favourable sensory recovery (mean s2PD 7.4 mm), and intact joint mobility were all observed in this prospective, single-center investigation. The most frequent problem was cold intolerance, and the complication rate was minimal and mostly self-limiting. Significantly high patient satisfaction further supports the efficacy of these methods.

Due to their reliable blood supply and simplicity of use, reverse homodigital island flaps were the most often used and produced very good functional results. While homodigital neurovascular flaps maintained feeling in high-demand situations, thenar flaps offered good tactile and cosmetic recovery, despite the fact that they required phased treatments.

The results highlight the importance of customised flap selection in maximising healing following fingertip injuries, even though the small sample size and restricted follow-up limit generalisability. In contemporary hand surgery, locoregional flaps continue to be quite useful when used with proper patient selection and operative planning. Longer follow-up multicenter investigations are necessary to confirm these results and improve patient selection procedures.

LIMITATIONS

1. Single-Center Study Design: The results of this study might not be broadly applicable to other geographical areas or healthcare systems because it was limited to a single tertiary care facility. Results may be impacted by variations in surgical procedures, facilities, and patient demographics between institutions.
2. Small Sample Size (n=40): The research might not have enough statistical power to identify uncommon problems or minute variations in flap procedures because there were only 40 patients. The variation in patient presentations and surgical outcomes, particularly in severe injuries, would be more accurately represented by a larger cohort.
3. Short Follow-Up Duration: Early results are encouraging, but the short follow-up time makes it difficult to evaluate long-term effects such persistent sensory recovery, cold sensitivity, nail plate abnormalities, and chronic discomfort. Longer follow-up is essential for assessing durability since fingertip injuries frequently have protracted healing periods.
4. Subjective Outcome Measures: Despite its importance, patient-reported pleasure and perceived functional recovery are subjective and sensitive to personal experiences, psychological variables, and expectations. Bias might be introduced by the absence of standardised patient-reported outcome measures (PROMs).
5. Heterogeneity in Flap Selection and Surgical Expertise: Several flap types carried out by surgeons with different degrees of expertise are included in the research. The interpretation of comparative efficacy may be complicated by this variation, which may have an impact on surgical success rates and complication profiles.
6. Lack of Control Group: The ability to directly assess the efficacy of locoregional flaps versus alternative therapies is limited by the lack of a control group, such as patients receiving conservative therapy or skin grafting.

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