Intensive hands-on microsurgery course provides a solid foundation for performing clinical microvascular surgery.

PURPOSE: Microvascular surgery requires highly specialized and individualized training; most surgical residency training programs are not equipped with microsurgery teaching expertise and/or facilities. The aim of this manuscript was to describe the methodology and clinical effectiveness of an international microsurgery course, currently taught year-round in eight countries. METHODS: In the 5-day microsurgery course trainees perform arterial and venous end-to-end, end-to-side, one-way-up, and continuous suture anastomoses and vein graft techniques in live animals, supported by video demonstrations and hands-on guidance by a full-time instructor. To assess and monitor each trainee's progress, the course's effectiveness is evaluated using "in-course" evaluations, and participant satisfaction and clinical relevance are assessed using a "post-course" survey. RESULTS: Between 2007 and 2017, more than 600 trainees participated in the microsurgery course. "In-course" evaluations of patency rates revealed 80.3% (arterial) and 39% (venous) performed in end-to-end, 82.7% in end-to-side, 72.6% in continuous suture, and 89.5% (arterial) and 62.5% (venous) one-way-up anastomoses, and 58.1% in vein graft technique. "Post-course" survey results indicated that participants considered the most important components of the microcourse to be "practicing on live animals", followed by "the presence of a full-time instructor". In addition, almost all respondents indicated that they were more confident performing clinical microsurgery cases after completing the course. CONCLUSIONS: Microvascular surgery requires highly specialized and individualized training to achieve the competences required to perform and master the delicate fine motor skills necessary to successfully handle and anastomose very small and delicate microvascular structures. The ever-expanding clinical applications of microvascular procedures has led to an increased demand for training opportunities. By teaching time-tested basic motor skills that form the foundation of microsurgical technique this international microsurgery-teaching course is helping to meet this demand.

Rupture Rate, Functional Outcome and Patient Satisfaction after Primary Flexor Tendon Repair with the Modified 4-Strand Core Suture Technique by Tsuge and Using the Arthrex FiberLoop® with Early Motion Rehabilitation.

PURPOSE: Our hypothesis was that the rupture rate after primary flexor tendon repair in the modified 4-strand core suture technique using the FiberLoop® (Arthrex, Munich, Germany) is lower than in other suture materials and functional outcome and patient satisfaction are superior compared to the current literature. PATIENTS AND METHODS: A 2-stage retrospective, randomized follow-up study of 143 patients treated with the Arthrex FiberLoop® after flexor tendon injury in zones 2 or 3 from May 2013 to May 2017 was performed. In the 1st stage, the rupture rate of all patients was assessed after a follow-up of at least one year by interview to exclude revision surgery. In the 2nd stage, 20% of the patients could be randomly clinically examined. Functional parameters, such as finger and wrist range of motion measured by goniometer, grip strength measured by Jamar dynamometer (Saehan, South Korea), patient satisfaction measured by school grades (1-6), pain levels measured by visual rating scales (0-10) and functional outcome according to the DASH-score were assessed. The Buck-Gramcko and Strickland scores were calculated. The length of sick leave was recorded. RESULTS: A rupture rate of 2.1% was recorded. 29 patients (20%) were followed up at a mean of 34 ± 7.5 months postoperatively. 10.3% of these patients had an incomplete fingertip palm distance. The mean postoperative grip strength was 24 ± 3.1 kg. 93% of the patients were very satisfied with the treatment. No patient complained of pain postoperatively. The mean postoperative DASH score was 6.7 ± 2.8 points. The mean Buck-Gramcko score was 14 ± 0.2 points. 93% of the patients had excellent and 7% good results according to the Strickland score. 67% of patients had a work accident and returned to work at a mean of 4 ± 0.2 months postoperatively. 31% of patients suffered a non-occupational injury and returned to work at a mean of 3 ± 0.4 months postoperatively. CONCLUSIONS: Primary flexor tendon repair in the modified 4-strand core suture technique using the Arthrex FiberLoop® has proven to be a viable treatment option in our series. The rupture rate was lower than in other suture materials. It leads to acceptable pain relief, grip strength and functional outcome. LEVEL OF EVIDENCE: IV; therapeutic.

Inter-Rater Reliability of Magnetic Resonance Imaging in Comparison to Computed Tomography and Wrist Arthroscopy in SLAC and SNAC Wrist.

The aim of the study was to assess the inter-rater reliability of magnetic resonance imaging (MRI) in comparison to computed tomography (CT) and wrist arthroscopy in patients with scapholunate (SLAC) or scaphoid non-union advanced collapse (SNAC) as well as to evaluate a grading score of cartilage lesions. A total of 42 patients (36 male, 6 female) at a mean age of 45 years (range: 19-65 years) with a SLAC or SNAC wrist who had a preoperative MRI and CT scan as well as underwent arthroscopy of the wrist between 2013 and 2018 were included in this study. Cartilage lesions, as assessed by MRI, CT and wrist arthroscopy, were classified by two hand surgeons in three stages. Inter-rater reliability was evaluated using the Kendall Tau-b test as well as the chi-square test to analyze for trend. The correlation between cartilage lesions, classified by arthroscopy and MRI, was low. A moderate correlation between CT and arthroscopy staging was shown. The highest inter-rater correlation was found between MRI and CT staging. An additionally performed logistic regression showed that progression of cartilage lesions as shown in MRI scans correlates with a restriction of range of motion (ROM). The level of cartilage lesion may be more severely classified in an MRI than during arthroscopy. Arthroscopy remains the gold standard in detecting cartilage lesions and thus in the decision-making process of the definitive treatment in carpal collapse.

Evaluation of the American Society of Anesthesiologists Physical Status Classification System in Risk Assessment for Lower Extremity Reconstruction with Free Tissue Transfer.

BACKGROUND: The applicability of free flap reconstruction for lower extremity (LE) defects in high-risk patients continues to require ongoing review. The aim of this study was to analyze the risk factors, management, and outcome of LE free flap reconstruction in high-risk (American Society of Anesthesiologists [ASA] class 3 or 4) patients. METHODS: A retrospective chart review was performed for all patients who underwent LE reconstruction in our Institution (Level I Trauma Center) from 2013 to 2019. Medical records and the authors' prospectively maintained database were analyzed with respect to ASA class, comorbidities, and postoperative complications. All patients were treated using the same pre-, intra-, and postoperative multidisciplinary approach. RESULTS: A total of 199 patients were analyzed. Sixty-six flaps were transferred in 60 patients with an ASA class 3 or higher. High-risk patients did not present a higher rate of flap loss or LE amputation. The overall flap success rate was 92%. There were five flap losses in high-risk patients. Three of these five patients underwent a successful second free flap reconstruction. The overall success rate of LE reconstruction in high-risk patients was 90%. Four patients with successful free flap ended up in LE amputation due to bone infection and two patients underwent an amputation after the first free flap failure. CONCLUSION: Free flap reconstruction for LE defects in high-risk patients is a safe and reliable procedure for selected patients when an experienced multidisciplinary team is involved. Bone infection was the only variable associated with LE amputation.

Reconstruction of Large Bone Defects and Complex Non-Unions Using a Free Fibular Bone Graft and a Supplementary Allograft. / Rekonstruktion großer Knochendefekte sowie komplexer Pseudarthrosen mittels freier Fibulatransplantation und eines additiven Allografts.

Large bone defects or complex pseudarthrosis represent an interdisciplinary challenge. Established surgical procedures include autogenous cancellous bone graft, the Masquelet technique or bone transfer via segment transport as well as free microvascular bone transplantation. However, the successful use of all these techniques requires a specialized center with great interdisciplinary expertise. In the following case series we describe the technique of free fibula transplantation and additional allograft. In both cases a good functional result with full mechanical strength of the affected extremity and satisfactory patient comfort has been achieved. In the second case, implant failure with the necessity of revision endoprosthetics occurred during the procedure.

[The distally based dorsal metacarpal artery flap (DMCA)]. / Retrograd gestielte Lappenplastiken der dorsalen Metakarpalarterien (DMCA).

OBJECTIVE: Regional flap for the reconstruction of combined skin and soft-tissue defects of the fingers or the distal parts of the palm. INDICATIONS: Full-thickness soft-tissue defects of the fingers dorsally up to the distal interphalangeal joint, of the fingers palmarly up to the middle phalanx, or of the distal parts of the palm. CONTRAINDICATIONS: Damage of the dorsal metacarpal artery or of the distal anastomosis by trauma or previous operation. Ongoing infections. SURGICAL TECHNIQUE: Preoperative Doppler examination. Planning of a flap using the proximal or distal anastomosis of the metacarpal artery with the palmar system as its pivot point. Raising of an adipofascial flap including as many veins as possible. Alternatively, the metacarpal artery can be raised alone as a fascial flap. Tension-free insertion of the flap into the defect. To avoid venous congestion, we do not recommend subcutaneous tunneling of the flap. The skin bridge should be incised instead. POSTOPERATIVE MANAGEMENT: Loose cotton dressing, periodic monitoring, bed rest for 5 days. After 3 days active and passive physiotherapy can start. Suture removal after 14 days. RESULTS: Reliable and relatively secure flap with a flap loss rate up to 20% in literature. The donor site can be closed primarily up to a flap width of 2 cm. The fourth metacarpal artery is missing in up to 30% of the cases.

[Possible applications of free microsurgical fibula transplantation in the reconstruction of complex bone defects in the extremities: review of the literature and case series]. / Einsatzmöglichkeiten der freien mikrochirurgischen Fibulatransplantation in der Rekonstruktion komplexer ossärer Defekte an den Extremitäten ­ Literaturübersicht und Fallserie.

BACKGROUND: Extensive osseous defects of the extremities following trauma and tumour resection represent a major challenge for plasticreconstructive surgical teams. Defect reconstruction by free microsurgical fibula transplantation has become a standard method but is associated with a considerable rate of complications. The aim of the present work is to provide an up-to-date overview of the various reconstruction methods and to report our personal experiences with free fibula transplantation in a case series. PATIENTS AND METHODS: The literature search on the subject was performed on Pubmed and Web of Science, and a retrospective collection of data was conducted based on our own cases, including clinical and radiological data. RESULTS: From 2007 to 2018, free fibula transplantation was performed in 11 patients under the guidance of the senior author (MS). The defects were a result of pseudarthrosis in four cases, osteitis in three, and a tumour in two cases. Two patientssustained a primary defect due to a high-energy trauma. In nine cases the upper limb was affected; only two had the defect in the lower limb. No graft failure was observed. In eight cases, an osteoseptocutaneous graft was taken; in two cases there was a post-operative loss of the skin island. Fibula length ranged between 5 and 22 cm. In all cases, bony integration of the graft was complete. The range of motion in the affected limb after physiotherapy was very good to satisfactory. CONCLUSION: Extensive bone defect reconstruction using free fibula flaps is undoubtedly the gold standard method, but the high rate of complications described in the literature necessitates a strict indication in due consideration of possible alternatives. Close cooperation between the disciplines of plastic reconstructive surgery and trauma orthopaedics is indispensable.

"Cat and dog bite injuries of the hand: early versus late treatment".

INTRODUCTION: Animal bites of the hand are common injuries in the emergency department. Serious complications may occur if those injuries are not treated adequately. The purpose of the study was to examine if there is a difference between the treatment of animal bite injuries at an early stage (first treatment within the first 24 h after injury, group I) versus a later stage (first treatment more than 24 h after injury, group II) retrospectively. MATERIALS AND METHODS: Between January 2010 and March 2016, a total of 69 patients with cat and dog bite injuries were treated in our hospital emergency room (ER). 45 patients arrived at the ER within 24 h after the injury (group I). 24 patients were treated more than 24 h after injury for the first time (group II). A retrospective study with evaluation of the clinical data including wound aspect, tissue damage, treatment, and antibiotics was performed. RESULTS: In group I, 27 were outpatients and 18 were in-house patients with an average hospitalization period of 3.3 days ± 1.12 days. 16 patients were treated conservatively. An operation was performed in 29 patients and in 3 patients a second look surgery was necessary. In group II, 5 patients were outpatients and 19 were inpatients with an average hospitalization period of 5.8 days ± 1.9 days. An operation was performed in 22 patients, and 2 were treated conservatively. In five patients, a second look surgery was necessary in group II. CONCLUSION: The study demonstrates that an early treatment of cat and dog bite injuries leads to less second-look operations and a shorter hospitalization. Hence, animal bite injuries of the hands should be treated immediately to avoid further complications. LEVEL OF EVIDENCE: Level 3, therapeutic.

[Plastic surgery in the German second medical licensing examination]. / Die Plastische Chirurgie im 2. Staatsexamen.

BACKGROUND: There are 230 defined objectives in the national competency-based catalogue of learning goals in surgery (NKLC) for undergraduate surgical education in Germany. These teaching objectives should be met by the students at the end of their undergraduate education, regardless of their career choice afterward. Assessment drives learning, and thus, alignment of the second state examination and the learning objectives of the NKLC seems reasonable. This study analyses the amount of plastic surgery-based learning objectives in the NKLC. Subsequently, we compared these results with the plastic surgery questions of the German second medical licensing examination compiled by the Central German Institute for Medical and Pharmaceutical Examinations (IMPP). METHODS: Plastic surgery teaching objectives in the NKLC were identified by five plastic surgeons. Exam questions from autumn 2009 to autumn 2014 (number of exams = 11) were retrospectively analyzed, and all exam questions addressing plastic surgery-related objectives were evaluated. The analysis included the total number of questions, mean number of questions for each examination, and the number of questions for each learning objective. RESULTS: Thirty-four learning objectives of the NKLC were identified as "plastic surgery-related" (14.8 % of all NKLC learning objectives). One of these was classified as "only covered by plastic surgery". Ninety-six questions (2.8 % of the total number of 3480 questions) addressed plastic surgery related objectives. Per exam, an average of 8.7 ± 4.0 questions (minimum, 4; maximum, 15) addressed plastic surgery-related learning objectives. During the study period, six learning objectives were not tested at all (2.6 % of all NKLC learning objectives). CONCLUSIONS: Questions focusing on plastic surgery-related learning objectives are not frequent in the second medical licensing examination. Presumably, medical students do not prioritize these objectives and might not have sufficient knowledge of the topics at the beginning of their medical career. A better adjustment of the state examinations and the NKLC seems desirable for plastic surgery-related learning objectives.

Impact of microbial findings on plastic reconstructive surgery outcomes in patients with deep sternal wound infection after cardiac surgery.

Deep sternal wound infection (DSWI) is a life threatening complication after cardiac surgery. In severe cases, flaps are needed to cover the wound. However, it is controversial if an aseptic environment is necessary at the time of wound closure. This is a retrospective study of 73 patients with DSWI treated by debridement and local or free flap from June 2008 until December 2017. The influence of positive microbiological findings at the time of plastic reconstructive surgery on reoperation rate and length of in-hospital stay was analyzed. Microbiological exams revealed positive results in 47 (64.4%) and no results in 26 patients. Reoperation had to be performed in 21.3% (positive cultures) versus 15.4% (p = .54), mean in hospital stay was 24.1 days (positive cultures) versus 21.8 days (p = .39) and in-hospital mortality was 6.4% (positive cultures) versus 7.7% (p = .83). Positive microbial findings at the time of plastic reconstructive surgery in patients with DSWI are not associated with a higher reoperation or mortality rate or a longer in-hospital stay. Repeated debridement and vacuum-assisted therapy to achieve negative microbial results might not be necessary in the treatment of these patients.Key messagesPositive microbial findings at the time of plastic reconstructive surgery in patients with deep sternal wound infection seems not to be associated with a higher reoperation or mortality rate or a longer in-hospital stay.The influence of positive microbiological findings at the time of plastic reconstructive surgery on reoperation rate and length of in-hospital stay was analyzed in 73 patients with deep sternal wound infection.Microbiological exams revealed positive results in 47 (64.4%) and no results in 26 patients. Reoperation had to be performed in 21.3% (positive cultures) versus 15.4% (p = .54), mean in hospital stay was 24.1 days (positive cultures) versus 21.8 days (p = .39) and in-hospital mortality was 6.4% (positive cultures) versus 7.7% (p = .83).

[Treatment of Metacarpal and Phalangeal Fractures]. / Behandlung der Mittelhand- und Phalangenfrakturen.

Metacarpal and phalangeal fractures are the second most frequent fractures of the upper extremity. Treatment goal is to restore the function of the injured hand. Due to better understanding of anatomy and biomechanics as well as the development of locking and low-profile implants for osteosynthesis of such fractures, there is a growing safety when choosing the operative treatment for the correct indication. Nevertheless, conservative treatment of these injuries still plays an important role.

Analysis of #PlasticSurgery in Europe: An Opportunity for Education and Leadership.

BACKGROUND: Prior studies demonstrate that social media are used by plastic surgeons to educate and engage. The hashtag #PlasticSurgery has been studied previously and is embraced by American plastic surgeons and journals; however, no studies have examined its use or adoption across Europe. METHODS: A retrospective analysis of 800 tweets containing the words "plastic surgery" or the hashtag #PlasticSurgery in four of the most spoken European languages worldwide excluding English (Spanish, #CirugiaPlastica; French, #ChirurgiePlastique; Portuguese, #CirurgiaPlastica; and German, #PlastischeChirurgie) was performed. The following were assessed: identity of author, subject matter, use of the hashtag #PlasticSurgery in each language, whether posts by surgeons and academic institutions were self-promotional or educational, and whether a link to a journal article or a reference in PubMed was provided. RESULTS: Seventeen percent and 3 percent of analyzed tweets came from plastic surgeons or academic institutions, respectively; only 17.5 percent of them were for educational purpose. None of them had any digital link to a peer-reviewed article or a scientific journal. CONCLUSIONS: This study demonstrates the low participation of plastic surgeons and academic institutions in social media (especially for education) in four of the major world languages. Social media should be considered in Europe as an opportunity to increase leadership, improve education, and spread knowledge of plastic surgery by board-certified plastic surgeons.

Exploration of the axillary nerve through an open posterior endoscopic-assisted (OPEA) approach: First clinical experience.

INTRODUCTION: Previous studies have described a segment of the axillary nerve (AN) that cannot be surgically explored through the deltopectoral and posterior surgical open approaches (blind zone). We present the first two cases using an endoscopic-assisted approach to explore the AN through a posterior approach. MATERIAL AND METHODS: Two patients were evaluated, in whom clinical, electrodiagnostic testing, and MRI could not localize the level of the AN dysfunction. An open posterior endoscopic-assisted (OPEA) approach was performed 4 and 9 months after injury in an attempt to visualize all segments of the AN. Photographs and videos were taken to evaluate the intraoperative visualization of the AN and provide long-term clinical follow-up. RESULTS: Almost the entire AN was visualized with the scope through the OPEA approach, avoiding the deltopectoral approach. No AN lesion was found during the nerve exploration. A triceps branch to AN transfer, using the previous posterior approach, was performed. Patients in both groups achieved a deltoid muscle function of BMRC grade 4 after 24 and 9 months, respectively. CONCLUSION: The exploration of the AN through the OPEA approach was a useful strategy to visualize the blind zone of the AN without requiring the addition of a deltopectoral approach. We believe this novel technique has a role in selected cases of AN injury.

Impact of Soong grading on flexor tendon ruptures following palmar plating for distal radial fractures.

The purpose of this study was to evaluate flexor tendon injuries following palmar plating of distal radial fractures relative to the Soong grade. This retrospective cohort study included 113 patients who underwent palmar plate removal after a distal radial fracture between 2010 and 2016. In 13 patients, a greater than 50% injury of the flexor pollicis longus tendon was observed. Of these, nine patients were classified as Soong grade 2, four as Soong grade 1 and none as grade 0. The difference between the Soong groups was statistically significant (p = 0.006). Flexor tenosynovitis was present in eight patients (7%) and more likely in patients with a higher Soong grade (p = 0.026). We conclude that higher Soong grades are associated with significantly more flexor tendon complications. Therefore, elective removal of the palmar plate after union of the fracture should be considered in patients with Soong grades 1 and 2. Level of evidence: IV.

[The importance of hand surgery in the German Medical Licensing Examination]. / Die Handchirurgie im 2. Staatsexamen.

BACKGROUND: The national competency-based catalogue of learning objectives in surgery (NKLC) for undergraduate surgical education in Germany consists of 230 objectives and defines competence levels for each objective. These levels range from "competence level 1: factual knowledge" to "competence level 3: independent action". The German second state examination is not based on these objectives, although it is known that assessment drives learning. This study analyses the proportion of hand surgery-based learning objectives in the NKLC and compares the results with the hand surgery questions of the German second medical licensing examination compiled by the Central German Institute for Medical and Pharmaceutical Examinations (IMPP). METHODS: Hand surgery teaching objectives in the NKLC were identified by five hand surgeons. All exam questions addressing these objectives were identified in the German second medical licensing examinations held from autumn 2009 through autumn 2014 (n = 11). The analysis included the number of hand surgery questions for each examination, the number of learning objectives and the different levels of competence. RESULTS: Forty-seven learning objectives of the NKLC were identified as "hand surgery-related" (20.4 % of all NKLC learning objectives). Nine of them were classified as learning objectives that were "only covered by hand surgery" (3.9 % of all NKLC learning objectives). Two hundred and twenty questions (6.3 % of the total number of 3480 questions) addressed hand surgery-related objectives. Per exam, an average of 20 ± 8.2 questions (minimum: 9; maximum: 37) addressed a hand surgery-related learning objective. An average of 0.5 ± 0.7 questions per exam were related to objectives that only covered hand surgery (minimum: 0; maximum: 2). During the study period, 16 learning objectives were not tested at all (13.7 % of all NKLC learning objectives). These untested objectives included 5 objectives of competence level 1 (10.6 % of all NKLC learning objectives). Six of the 9 objectives that are only covered by hand surgery were not assessed at all. CONCLUSIONS: The number of hand surgery-based learning objectives in the NKLC appears to be high. However, many of these learning objectives are not addressed in the second medical licensing examination. We recommend better adjustments between the state examinations and the NKLC.

The activin-follistatin anti-inflammatory cycle is deregulated in synovial fibroblasts.

BACKGROUND: Activin A and follistatin exhibit immunomodulatory functions, thus affecting autoinflammatory processes as found in rheumatoid arthritis (RA). The impact of both proteins on the behavior of synovial fibroblasts (SF) in RA as well as in osteoarthritis (OA) is unknown. METHODS: Immunohistochemical analyses of synovial tissue for expression of activin A and follistatin were performed. The influence of RASF overexpressing activin A on cartilage invasion in a SCID mouse model was examined. RASF and OASF were stimulated with either IL-1ß or TNFα in combination with or solely with activin A, activin AB, or follistatin. Protein secretion was measured by ELISA and mRNA expression by RT-PCR. Smad signaling was confirmed by western blot. RESULTS: In human RA synovial tissue, the number of activin A-positive cells as well as its extracellular presence was higher than in the OA synovium. Single cells within the tissue expressed follistatin in RA and OA synovial tissue. In the SCID mouse model, activin A overexpression reduced RASF invasion. In human RASF, activin A was induced by IL-1ß and TNFα. Activin A slightly increased IL-6 release by unstimulated RASF, but decreased protein and mRNA levels of follistatin. CONCLUSION: The observed decrease of cartilage invasion by RASF overexpressing activin A in the SCID mouse model appears to be mediated by an interaction between activin/follistatin and other local cells indirectly affecting RASF because activin A displayed certain pro-inflammatory effects on RASF. Activin A even inhibits production and release of follistatin in RASF and therefore prevents itself from being blocked by its inhibitory binding protein follistatin in the local inflammatory joint environment.

Long-term outcome of fingertip reconstruction with the homodigital neurovascular island flap.

INTRODUCTION: Fingertip injuries are frequent and several surgical strategies exist to reconstruct the amputated part and restore function and appearance. Yet, long-term results are rarely published. The purpose of this study was to examine the long-term clinical outcome of neurovascular island flaps for traumatic fingertip amputation of Allen type III/IV injuries. MATERIALS AND METHODS: We retrospectively analysed a cohort of patients with traumatic fingertip amputation that underwent reconstruction with a neurovascular island flap from January 2003 to December 2014. No mandatory splinting was applied after surgery. 28 participants (29 fingers) were available for follow-up at mean 8 years after reconstruction. Activities of daily living were measured with the disabilities of the arm, shoulder and hand questionnaire. Grip strength and finger motion were assessed using a Jamar dynamometer and a goniometer. Two-point discrimination and Semmes-Weinstein monofilaments were used to evaluate sensory recovery. RESULTS: No intraoperative complications occurred and all flaps survived. Mean flap size was 4.7 ± 0.6 cm2. Active motion of the fingers was over 95% of the contralateral side at follow-up. Three patients showed mild extension lag of the proximal interphalangeal joint. The grip strength of the affected hand and of each of the affected fingers was over 70% of the contralateral side. In comparison to the contralateral side we did not detect any significant difference for the Semmes-Weinstein monofilament test, but two-point discrimination (5.1 ± 1.7 mm) was significantly impaired. According to the Lim classification 1 of 14 nails with hook nail deformity showed grade 3 breaking of the nail. The DASH score was 16.0. All patients returned to their original occupation and patient satisfaction with the procedure was high. CONCLUSIONS: The risk for disabling flexion contracture seems to be small even without mandatory splinting. Neurovascular island flaps for fingertip amputation of Allen type III/IV injuries are a reliable tool in fingertip reconstruction in the long term.