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Page 2 of 7 Ercin et al. Plast Aesthet Res 2020;7:38 I http://dx.doi.org/10.20517/2347-9264.2020.56

INTRODUCTION
The first successful finger replantation was performed by Tamai, and major advances in replantation
[1]
surgery have been made since then . Today, the survival of the replanted finger is no longer a sufficient
criterion for success; rather, functional recovery is considered crucial.

Distal replantations, and especially those distal to the distal interphalangeal joint, are technically difficult,
[2]
but many are likely to be functionally successful . Adequate vascular repair affects replant viability in the
short term, but functional success is largely affected by bone fixation. The rate of the union in distal phalanx
bone fractures is quite high; however, nonunion sometimes occurs due to inadequate fixation, segmental
[3]
bone loss, soft tissue problems, and infection . Patients with nonunion often experience instability, pain,
and radiological abnormalities. In those cases, a bone graft may be required.

Although not very popular, the olecranon bone graft is a useful option for this type of an operation due to
the minimal donor morbidity and its ease of use in small bone defect reconstruction and nonunion therapy.
To our best knowledge, few studies have evaluated the use of the olecranon bone graft as a treatment for
nonunion after distal finger replantation. Our aim in this report was to present our experience of using
olecranon grafts in our nonunion patients undergoing distal replantations.

METHODS
This study included a total of 14 (13 male and 1 female) patients who developed nonunion or segmental
bone loss after replantation surgery between 2013 and 2019. Finger amputations of these patients were
distal to the distal interphalangeal joint. Four amputations were at the Tamai zone 2 level and ten
amputations were at the Tamai zone 1 level. The mean age was 34.5 years (range 19-54). Two patients
had multiple finger amputations. Seven patients had crush amputations and seven patients had avulsion
amputations. Two patients had segmental bone loss secondary to injury during the first surgery, and these
defects were not reconstructed in the first operation to avoid vascular problems. In the other 12 patients,
nonunion was diagnosed at the end of the fourth month based on radiological and clinical findings.

During the initial treatment, K-wires were used for all amputated fingers. Infection occurred in 3 patients,
partial necrosis of the nail plate in 6 patients, segmental bone loss in 2 patients before initial surgery, and
possibly inappropriate fixation in 3 patients that caused nonunions. The initial injuries were located at the
arthrodesis site in 1 patient, at the tuft in three patients, and at the shaft of the distal phalanx in 10 patients.

All patients showed radiological and clinical findings (deformity, pain, and discomfort) before cancellous
bone grafting. The overall mean time delay before the secondary treatment was 3.9 months (range
1-5 months).

Surgical technique
All surgeries were performed by two senior surgeons under axillary regional anesthesia. A 3 cm incision
for bone graft harvesting was made starting 1-1.5 cm distal to the tip of the olecranon [Figure 1]. The
periosteum was incised and elevated off the donor site of the olecranon. A cortical fenestra was elevated
and preserved to expose the medullary space. The cancellous bone graft was harvested with an osteotome.
The cortical piece was replaced and closed after harvesting the graft to prevent irregularity at the donor site.
Cancellous bone grafts were used in all patients. The periosteum was repaired with absorbable sutures, with
the skin sutured individually. Postoperatively, no splint was used for elbow immobilization.

The recipient site was reached through a unilateral incision made either lateral to the nail plate or through
the nail plate, depending on the nail plate situation. The fibrous tissue was removed at the nonunion line