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Page 6 of 7 Ercin et al. Plast Aesthet Res 2020;7:38 I http://dx.doi.org/10.20517/2347-9264.2020.56
[9]
Another option for cancellous bone grafting is the distal radius cancellous graft . This graft type has
the important advantage that it can be performed under an axillary block and in the same surgical field.
[9]
The complication rates for harvesting bone grafts over the distal radius are as low as 1.7% , but they
can include fracture at the donor site, local infection, DeQuervain’s tenosynovitis, and neuroma of the
[11]
[11]
superficial radial nerve . Patel et al. reported an overall complication rate, including bone graft failure,
of 4%, as 38 patients (2.3%) required re-grafting with iliac bone, 21 patients (1.3%) developed DeQuervain’s
tenosynovitis, and 2 patients (0.1%) developed superficial radial nerve neuromas.

Although not very popular in previous studies, the olecranon graft is used as the first choice by the authors
for the treatment of a distal phalanx nonunion. This graft has the important advantage that it can be
performed under an axillary block and in the same surgical field. The graft can be used as a bone chip in
amorphous, irregular, and small defects or it can be used as a structural cancellous graft in longitudinal
defects. Harvesting takes about 10 min by the author. In addition to the short duration of the surgery,
its other advantage is that the graft can be easily shaped with a scalpel. The donor site is also distant
from important neurovascular structures, so the dissection can be done quite easily. The site can also be
[12]
harvested with a trephine, which provides a further advantage of minimal scarring .
A major disadvantage of the olecranon graft is that a sufficient graft may not be obtained for large defects.
[3]
[9]
This graft is also not recommended for use in elderly or osteoporotic patients . Ozçelik et al. reported
the successful use of cancellous olecranon grafts for treating nonunion of distal phalangeal fractures in 11
cases.

[13]
The timing of the bone grafting is also important. Jupiter et al. recommended waiting 4 months after the
initial surgery, based on clinical and radiological findings. We haven’t experienced any spontaneous union
after 4 months too. Therefore, we had 12 of our patients wait 4 months for the surgical intervention for
their nonunions. In two patients, the defect present at the replantation stage was evaluated as a segmental
defect. Therefore, after vascular stabilization, grafting was performed without waiting for 4 months.

When using this technique, we preferred a mid-lateral approach to the distal phalanx as it does not disturb
[3]
the vascular circulation. Ozçelik et al. preferred a mid-lateral incision for the 11 patients in their study.
In cases where the nail bed is stable and thick, grafting can also be done through the nail bed. However,
although this approach is more advantageous in terms of exposure, the graft may become exposed
[4]
after dehiscence of the nail bed. Itoh et al. preferred grafting with a mid-palmar incision, which is
advantageous in terms of exposure but has a theoretically higher risk of vascular injury and the possibility
[4]
of painful scarring. With the mid-palmar technique, which Itoh et al. applied in 6 patients, no patient had
any vascular or sensory problems.

In conclusion, we found that olecranon bone grafting is a safe and convenient method for the treatment of
nonunion after distal finger replantation. It can be a preferred first choice for the treatment of nonunions of
distal finger replantations.

DECLARATIONS
Authors’ contributions
Corresponding, writing: Ercin BS
Data search: Ercin BS, Keles MK
Editing discussion part: Kabakas F

Editing: OzcelikIB
Review: Mersa B