Arterial-Only Anastomosis for Fingertip Avulsion Amputations as a Reliable Strategy with Favourable Survival Rates and Functional Outcomes for: a Retrospective Study

Arterial-Only Anastomosis for Fingertip Avulsion Amputations as a Reliable Strategy with Favourable Survival Rates and Functional Outcomes for: a Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Arterial-Only Anastomosis for Fingertip Avulsion Amputations as a Reliable Strategy with Favourable Survival Rates and Functional Outcomes for: a Retrospective Study Zefu Weng, Ailifeire Ainiwaer, Wenquan Ding This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8658090/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Mar, 2026 Read the published version in BMC Surgery → Version 1 posted 16 You are reading this latest preprint version Abstract Background While not all fingertip avulsion amputations progress to necrosis after replantation, studies that examined survival rates of replanted digits or key influencing outcomes in fingertip avulsion amputations are lacking. Therefore, we investigated the incidence of postoperative vascular crises, survival rates of replanted digits, functional outcomes, and factors influencing outcomes in patients with fingertip avulsion amputations treated with arterial-only anastomosis. Methods A retrospective study was conducted on 194 completely amputated fingertips replanted at Ningbo No. 6 Hospital between March 2017 and December 2024. Only digital arteries or arterial arch branches were identifiable for anastomosis; venous anastomosis was not feasible. Group 1 included 84 patients with 98 avulsion amputations, and Group 2 included 82 patients with 96 clean-cut amputations. Postoperative vascular crises were recorded, and management—anticoagulation, thrombolysis, or intermittent bleeding—was tailored to arterial or venous compromise. Survival rates of replanted digits were assessed, and functional outcomes of surviving fingertips were compared between the groups. Results Arterial flow was restored in all 194 digits. Arterial crises occurred in 28 digits (22 in Group 1; 6 in Group 2), whereas venous crises occurred in 86 digits (44 in Group 1; 42 in Group 2). In 22 digits (12 in Group 1; 10 in Group 2), venous crises preceded arterial crises. A total of 65 digits developed necrosis (42 in Group 1; 23 in Group 2). Overall survival rate was 66.5% (57.1% in Group 1; 76.0% in Group 2). Functional scores for surviving digits were excellent in both groups. Conclusions Despite lower survival than conventional arterial–venous anastomosis, arterial-only replantation for fingertip avulsion amputations achieves survival rates exceeding 50% and provides good function and cosmetic outcomes due to the absence of tendons and joint injury. Replantation should therefore remain a recommended option in clinical practice. Fingertip Amputation Replantation Anastomosis Microsurgery Ischemia Neovascularisation Haemostasis Haemorrhage Thrombosis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Fingertip amputations are common injuries that occur in occupational environments and daily activities. The primary treatment option for these injuries is stump revision and replantation. However, stump revision can compromise the function and appearance of the injured digit. Advances in microsurgical techniques, expanding knowledge of fingertip microanatomy, and increasing functional demands have made replantation of fingertip avulsion amputations—once considered contraindicated—a routine surgical procedure [ 1 ]. The fingertip, located distal to the nail root, has unique anatomical features characterised by few terminal vessels and small-calibre lumens. Digital arteries within the amputated fingertip can sometimes be identified and anastomosed under a microscope. However, fingertip veins are extremely small, lie superficially beneath the volar pulp dermis, and are frequently severely damaged during digital injuries. Consequently, suitable veins for anastomosis are rarely available (Fig. 1 ). Replantation with arterial-only anastomosis often leads to arteriovenous circulatory disorders, postoperative venous crises, and eventual necrosis of replanted digits, leading to replantation failure [ 2 ]. According to the Tamai classification [ 3 ], distal phalanx amputations are characterised into two types: type I, extending from the proximal edge of the lunula to the fingertip, and type II, extending from the distal interphalangeal joint to the lunula. Most fingertip amputations are Tamai type I, for which replantation typically relies on arterial-only anastomosis. This technique does not involve establishing venous drainage, resulting in the absence of physiological perfusion. Spontaneous venous drainage can be established relatively quickly because of the small tissue volume in the fingertip, its relative tolerance to low perfusion, and rich vascular supply. Postoperative adjuncts, including small incisions to promote bleeding or nail bed bleeding, are often used to facilitate venous drainage [ 4 ]. Medical leeches have also been used to promote venous drainage; however, their associated survival rate is markedly lower than those achieved with venous anastomosis [ 5 ]. Our clinical observations indicate that not all fingertip avulsion amputations progress to necrosis after replantation. However, our literature identified no studies that examined survival rates of replanted digits or key influencing outcomes in fingertip avulsion amputations. Therefore, we conducted a retrospective study of patients with fingertip avulsion amputations to investigate the incidence of postoperative vascular crises, the survival rate of replanted digits, key prognostic factors, and functional outcomes. Methods This retrospective study investigating the incidence of postoperative vascular crises, survival rate of replanted digits, key prognostic factors, and functional outcomes of patients with fingertip avulsion amputations was approved by the Ethics Committee of Ningbo No. 6 Hospital. We included 194 patients with complete fingertip amputations who underwent replantation at Ningbo No. 6 Hospital, between March 2017 and December 2024. Among these patients, 84 of 98 fingertip avulsion amputations were assigned to Group 1, whereas 82 of 96 clean-cut amputations were assigned to Group 2. The inclusion criteria were as follows: (1) during replantation, only digital arteries or branches of the arterial arch were identifiable and suitable for anastomosis, and venous anastomosis was not feasible; (2) arterial blood flow was successfully restored in the replanted digits during the procedure. The exclusion criteria were: (1) absence of a suitable artery for anastomosis in the amputated digit during replantation; (2) extensive subcutaneous vascular network injury caused by crushing, resulting in persistent absence of fingertip skin perfusion after arterial anastomosis. Postoperatively, patients in both groups were admitted to a specialised replantation ward for vascular monitoring and received standard infection prophylaxis, antispasmodic and anticoagulant therapies, and infrared lamp warming. Fingertip perfusion was assessed hourly, and in cases of venous crises, intermittent bleeding was induced through fingertip incisions. The incidence of vascular crises and the survival rates of replanted digits were recorded for both groups. Surviving replanted digits underwent regular follow-up. At six months postoperatively, functional outcomes were assessed using the provisional criteria for digit replantation assessment established by the Chinese Society of Hand Surgery, of the Chinese Medical Association (Additional File 1). The evaluation included total active motion of finger joints, activities of daily living scores, fingertip sensory recovery, blood circulation status, appearance, and return-to-work status. Results Arterial blood flow was successfully restored in all 194 replanted digits. Postoperative arterial crises occurred in 28 digits (22 in Group 1 and 6 in Group 2), whereas venous crises developed in 86 digits (44 in Group 1 and 42 in Group 2). In 22 digits (12 in Group 1 and 10 in Group 2), venous crises occurred before arterial crises. Ultimately, necrosis developed in 65 digits (42 in Group 1 and 23 in Group 2). The overall survival rate was 66.5% (57.1% in Group 1 and. 76.0% in Group 2). According to the provisional criteria for digit replantation assessment established by the Chinese Society of Hand Surgery, of the Chinese Medical Association, the mean functional score of surviving replanted digits was 89.25 ± 4.37 (n = 56) in Group 1 and 92.12 ± 4.40 (n = 73) in Group 2. Both groups demonstrated excellent functional ratings. Typical Cases A, B, C and D of Group 1 are shown in Figs. 2 , 3 , 4 and 5 , respectively. Typical Case A of Group 2 is shown in Fig. 6 . Comparisons between the two groups are presented in Table 1 . Table 1 Comparative Analysis of Outcome Measures Between the Two Patient Groups Outcome Measure Avulsion Amputation Clean-cut Amputation Analysis of Main Causes Survival Rate 57.10% 76.00% 1. More severe arterial contusion in Group 1 increased the risk of thrombosis. 2. More severe soft tissue contusion at the amputation stump in Group 1 resulted in slower formation of granulation tissue bridges. Risk of Vascular Crises 66/98 48/96 1. After arterial-only anastomosis, both groups had a high incidence of postoperative venous crises. 2. Group 1 exhibited more severe arterial contusion and a higher incidence of arterial crises. Sensory Recovery Score Mean (SD) 17.14 (3.02) 17.26 (3.19) Less tissue at the fingertip resulted in decreased nerve regeneration distance. Joint Range of Motion Score Mean (SD) 17.48 (1.64) 18.10 (1.68) Injuries distal to the middle portion of the distal phalanx did not involve the interphalangeal joint, metacarpophalangeal joint or the tendons. Appearance Score Mean (SD) 16.89 (1.76) 17.63 (1.80) 1. Group 1 had more severe tissue damage, greater shortening, mild atrophy, hyperpigmentation, and more scarring. 2. Digits with prolonged vascular crises tended to have more severe atrophy. Discussion Distal phalanx amputations of the fingers, particularly those occurring distal to the whorl of the volar pulp, exhibit anatomical characteristics that often permit only arterial anastomosis during replantation [ 6 ]. Although arterial perfusion is generally adequate after replantation, the absence of venous drainage disrupts vascular balance, causes congestion, and lowers the survival rate of replanted digits. Multiple factors influence the success of arterial-only anastomosis in distal phalanx replantation. A key determinant of tissue healing appears to be the early formation of granulation tissue bridging the amputation site. Neovascularisation within this granulation tissue establishes a pathway for venous drainage, restores vascular balance, and contributes to the survival of replanted digits. However, published evidence specifically addressing this mechanism remains limited. Our clinical observations indicate that the absence of necrosis within the first postoperative week generally predicts the survival of replanted digits. During this period, the colour and capillary refill of the replanted digits typically return to normal. We hypothesised that this improvement corresponds to the completion of granulation tissue bridging at the amputation site, which typically occurs approximately one week postoperatively. In this study, the severity of soft-tissue contusion at the amputation stump differed between the two groups, resulting in variations in the time required for granulation tissue bridging. In the avulsion group, granulation tissue reconstruction needed more time, and some digits developed necrosis before bridging was complete, which contributed to a lower survival rate compared with the other group. Accordingly, during the replantation of avulsion amputations, we conducted a detailed assessment of soft-tissue contusion and performed more extensive debridement of devitalised tissue. This approach reduced the time needed for postoperative granulation tissue bridging and modestly improved survival. Digital amputations distal to the middle portion of the distal phalanx do not involve key structures, such as joints or tendons, responsible for finger movement. Therefore, successful replantation generally leads to the favourable recovery of motor function [ 7 ]. Wong et al. reported that, even without nerve repair, skin two-point discrimination can recover substantially after distal phalanx replantation [ 8 ]. From an Asian perspective of aesthetics, the partial loss of a finger is often regarded as a disability and a form of bodily imperfection. Consequently, patients with amputations distal to the middle portion of the distal phalanx typically have a strong desire for replantation to preserve finger integrity, and report a high level of postoperative satisfaction. Hence, this type of finger amputation should be actively considered for replantation in clinical practice. Here, both groups achieved satisfactory outcomes in sensory recovery, joint range of motion, and appearance of replanted digits, while patient satisfaction was particularly high among younger and unmarried patients. The distal phalanx has a small tissue volume and relatively low metabolic demand. Hence, it is theoretically less dependent on venous drainage than more proximal phalanges, which provides a physiological basis for the arterial-only anastomosis approach. Arterial patency is a prerequisite for the survival of replanted digits. We found that the two types of amputations distal to the middle portion of the distal phalanx showed a large disparity in the degree of arterial contusion, with differences in the likelihood of arterial spasm or thrombosis after arterial anastomosis. Consequently, the incidence of arterial crises and, ultimately, the survival rates differed between the two groups. Intraoperatively, we observed that in clean-cut digital amputations, the arterial contusion length was short, and excision of the contused segment resulted in a relatively low risk of thrombosis. Conversely, in avulsion amputations of the digit, the length of arterial contusion was longer. If the entire contused arterial segment were excised, direct anastomosis would be performed under significant tension. If superficial vein grafting was intended to repair the digital artery after excision, the extremely small vessel diameter distal to the middle portion of the distal phalanx—especially at or beyond the digital arterial arch—would greatly increase the technical difficulty of vascular grafting procedures, and would not guarantee anastomotic potency. Therefore, vascular grafting for arterial reconstruction is generally not suitable for fingertip amputations. Some patients first developed venous crises, followed by arterial crises. This progression results from worsening venous congestion, which is usually indicative of a poor prognosis. When venous drainage is obstructed, congestion involves the entire venous system and extends to the capillary network, resulting in a marked increase in intravascular pressure and ultimately forcing cessation of arterial inflow. Prompt intermittent bleeding at the fingertip incision helps prevent this scenario by exchanging stagnant blood in the digit with fresh blood, thereby buying time for granulation tissue to bridge the amputation stump. Surgical techniques that increase the contact surface for granulation tissue growth during digital replantation distal to the middle portion of the distal phalanx may help improve the survival rate of the amputated part. Puhaindran et al. evaluated outcomes of digital replantation with replanted digits buried under a palmar skin flap (dermal pocketing) and reported an 85% success rate [ 9 ]. These favourable outcomes may be attributed to the additional nutrients provided by the flap and to neovascularisation within the newly formed granulation tissue, which improves venous drainage of the digit. Nevertheless, the use of pedicled palmar or abdominal flaps to pocket replanted digits often leads to complications, such as joint stiffness, which limits the widespread application of this method. Our team has developed a novel technique combining artificial dermal chambers with fibroblast growth factor to promote granulation tissue bridging, thereby reducing tissue congestion caused by impaired venous drainage. This technique has demonstrated promising results in animal experiments and is expected to be translated into clinical practice in the near future. Limitations of this study This study adopted a single-center retrospective design, which may introduce certain limitations. Conclusion In patients with fingertip avulsion amputations who receive arterial-only anastomosis without venous anastomosis, the survival rate of replanted digits, although lower than that achieved with conventional arterial and venous anastomosis, still exceeds 50%. Since this amputation type does not involve tendons or joints, satisfactory functional recovery and favourable cosmetic outcomes can be achieved. Therefore, replantation should be actively considered for such amputations in clinical practice. Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Ningbo No. 6 Hospital. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Ethics Committee of the Ningbo No. 6 Hospital. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no conflicts of interest. Funding This research was funded by “Ningbo Clinical Research Centre for Orthopaedics, Sports Medicine & Rehabilitation, grant number 2024L004”, “Ningbo Top Medical and Health Research Program, grant number 2022020506”, “Zhejiang Medical and Health Science and Technology Plan Project, grant number 2025KY301” and “Zhejiang Traditional Chinese Medicine Science and Technology Plan Project, grant number 2025ZX018”. Authors' contributions Conceptualization, W.D. and Z.W.; methodology, Z.W.; software, A.A.; validation, W.D., Z.W.; formal analysis, W.D.; investigation, W.D.; resources, W.D.; data curation, A.A.; writing—original draft preparation, W.D.; writing—review and editing, W.D.; visualization, Z.W.; supervision, W.D.; project administration, W.D.; funding acquisition, W.D. All authors have read and agreed to the published version of the manuscript. Clinical trial number Not applicable. References Van Handel AC, Pet MA. Fingertip replantation: Technique details and review of the evidence. Hand Clin. 2021;37:53-65. Hayashi K, Hattori Y, Chia DSY, Sakamoto S, Sonezaki S, Doi K. Fingertip replantation: Surgical technique, tips, and tricks. Plast Reconstr Surg. 2024;153:168-71. Dadaci M, Ince B, Altuntas Z, Bitik O, Kamburoglu HO, Uzun H. Assessment of survival rates compared according to the Tamai and Yamano classifications in fingertip replantations. Indian J Orthop. 2016;50:384-9. Hara T, Kurimoto S, Kurahashi T, Kuwahara Y, Takeshige H, Urata S. Limiting levels of fingertip replantation without venous anastomosis. J Hand Surg Am. 2024;49:1274.e1. Venkatramani H, Roberto A, Safa B, Chen C, Lee DC, Chen J. Distal fingertip replantation: Indications, strategy and postoperative management. J Hand Surg Eur Vol. 2024;49:403-11. Wang CH, Wei N, Wei CY. Anatomical study of the fingertip artery in Tamai Zone I: Clinical significance in fingertip replantation. J Reconstr Microsurg. 2017;33:e3-4. Özdemir FDM, Uzun H, Özdemir E, Aksu AE. Comparative assessment of fingertip replantation in paediatric and adult patients within a single institution. J Hand Surg Eur Vol. 2021;46:877-82. Wong C, Ho PC, Tse WL, Cheng S, Chan DKC, Hung LK. Do we need to repair the nerves when replanting distal finger amputations? J Reconstr Microsurg. 2010;26:347-54. Puhaindran ME, Paavilainen P, Tan DMK, Peng YP, Lim AYT. Dermal pocketing following distal finger replantation. J Plast Reconstr Aesthet Surg. 2010;63:1318-22. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.docx Additional file Additional file 1 (.docx) Provisional criteria for the functional assessment of digit replantation by the Chinese Society of Hand Surgery, Chinese Medical Association Cite Share Download PDF Status: Published Journal Publication published 26 Mar, 2026 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 09 Feb, 2026 Reviewers agreed at journal 06 Feb, 2026 Reviews received at journal 04 Feb, 2026 Reviewers agreed at journal 30 Jan, 2026 Reviews received at journal 30 Jan, 2026 Reviews received at journal 30 Jan, 2026 Reviews received at journal 29 Jan, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers invited by journal 29 Jan, 2026 Editor invited by journal 27 Jan, 2026 Editor assigned by journal 24 Jan, 2026 Submission checks completed at journal 24 Jan, 2026 First submitted to journal 21 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8658090","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":583341445,"identity":"67fb7515-6973-43c1-8e10-ac98b3911308","order_by":0,"name":"Zefu Weng","email":"","orcid":"","institution":"Ningbo University","correspondingAuthor":false,"prefix":"","firstName":"Zefu","middleName":"","lastName":"Weng","suffix":""},{"id":583341446,"identity":"75fa2367-0a81-4a85-b898-7decefa5d285","order_by":1,"name":"Ailifeire Ainiwaer","email":"","orcid":"","institution":"Ningbo University","correspondingAuthor":false,"prefix":"","firstName":"Ailifeire","middleName":"","lastName":"Ainiwaer","suffix":""},{"id":583341447,"identity":"ea18febd-60da-47f9-9511-298195b6815d","order_by":2,"name":"Wenquan Ding","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIie3QMUvEMBTA8ZZAXdLOOfS8rxAJuOjgR4nL3dI6Z3A4l3QR5xPEz9DJ+YUH3hLpeqCDILjYoW43iOcbC9LW0SH/IYSQX9okikKh/xh25tCa08Nkr4Q/k9it/Fxl3Oth0jmRYWrx/F6cyUGRrVP84OZlWq2fALlnCysiHW3NQy+ZYDY/4f5dVf5CuzuTFHb/CuJr/9xLJPJjVdD/VJBLaDwv7AFoFtsx8k2kbiSkViwSoeUYUW/Fksgmly61Uo+SCX2FfT2iut00kh5ZH1l6ZDd0l6z26nN1idObOldta3azWVm6163pJ1QiaIiX3SUY2k+x9hcJhUKhULcfxSNmawZKq74AAAAASUVORK5CYII=","orcid":"","institution":"Ningbo No.6 Hospital","correspondingAuthor":true,"prefix":"","firstName":"Wenquan","middleName":"","lastName":"Ding","suffix":""}],"badges":[],"createdAt":"2026-01-21 10:08:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8658090/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8658090/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-026-03692-8","type":"published","date":"2026-03-26T16:10:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":101654292,"identity":"3c008026-4afb-46d8-99dc-bea2cab31283","added_by":"auto","created_at":"2026-02-02 09:43:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":449368,"visible":true,"origin":"","legend":"\u003cp\u003eFingertip amputation case: arterial anastomosis was possible, but no suitable veins were available for anastomosis. (a) Arteries were distributed in the fingertip. (b) Arterial anastomosis was performed during replantation, but no suitable veins for anastomosis could be identified.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-8658090/v1/d690a4a00e57f51de6808109.png"},{"id":101654293,"identity":"a95b6a9c-08d3-406f-8a0f-98c1a1eeaec3","added_by":"auto","created_at":"2026-02-02 09:43:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":592158,"visible":true,"origin":"","legend":"\u003cp\u003eA 24-year-old man underwent replantation for an avulsion-type amputation distal to the middle portion of the distal phalanx of the right index finger. A–B: Avulsion-type amputation distal to the middle portion of the distal phalanx of the right index finger. C-D: Fracture level and fixation. E: Immediate postoperative view showing restoration of blood supply. F–G: Mild atrophy of the replanted finger observed at follow-up, with acceptable appearance. H–I: Good flexion and extension function of the affected finger.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-8658090/v1/a4edd5d1dccd45509ba81211.png"},{"id":101654291,"identity":"88e17522-fbee-4499-932e-7b0b106b0e77","added_by":"auto","created_at":"2026-02-02 09:43:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1071230,"visible":true,"origin":"","legend":"\u003cp\u003eA 33-year-old woman underwent replantation for an avulsion-type amputation distal to the middle portion of the distal phalanx of the right middle finger. A–B: Avulsion-type amputation distal to the middle portion of the distal phalanx of the right middle finger. C: Fracture level and fixation. D: Immediate postoperative view showing restoration of blood supply. E–F: Good appearance of the replanted finger observed at follow-up. G–H: Good flexion and extension function of the affected finger.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-8658090/v1/1d2b9873aa2f88d9d1a95735.png"},{"id":101654295,"identity":"6fb841f2-2bb4-4493-b835-abe4c2d3c558","added_by":"auto","created_at":"2026-02-02 09:43:25","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":700438,"visible":true,"origin":"","legend":"\u003cp\u003eA 42-year-old woman underwent replantation for an avulsion-type amputation distal to the middle portion of the distal phalanx of the right middle finger. A–B: Avulsion-type amputation distal to the middle portion of the distal phalanx of the right middle finger. C-D: Fracture level and fixation. E: Immediate postoperative view showing restoration of blood supply. F–G: Good appearance of the replanted finger observed at follow-up. H–I: The movement of the distal interphalangeal joint is slightly restricted.\u003c/p\u003e","description":"","filename":"Fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-8658090/v1/51c6c88e2e9b6f4c1e5ea5e0.png"},{"id":101753733,"identity":"0db7416e-2651-4f08-948d-3d5286b19ccc","added_by":"auto","created_at":"2026-02-03 10:40:39","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":690534,"visible":true,"origin":"","legend":"\u003cp\u003eA 30-year-old man underwent replantation for an avulsion-type amputation distal to the middle portion of the distal phalanx of the left thumb. A–B: Avulsion-type amputation distal to the middle portion of the distal phalanx of the left thumb. C-D: Fracture level and fixation. E: Immediate postoperative view showing restoration of blood supply. F–G: Good appearance of the replanted finger observed at follow-up. H–I: The movement of the interphalangeal joint is slightly restricted.\u003c/p\u003e","description":"","filename":"Fig5.png","url":"https://assets-eu.researchsquare.com/files/rs-8658090/v1/32972a7062f7da9f50855f40.png"},{"id":101753036,"identity":"58aec966-16a4-4711-b943-8a5ae94aed25","added_by":"auto","created_at":"2026-02-03 10:38:58","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":759654,"visible":true,"origin":"","legend":"\u003cp\u003eA 19-year-old man underwent replantation for a clean-cut amputation distal to the distal portion of the distal phalanx of the left thumb. A–B: Clean-cut amputation distal to the distal portion of the distal phalanx of the left thumb. C-D: Fracture level and fixation. E: Immediate postoperative view showing restoration of blood supply. F–G: Mild atrophy of the replanted finger observed at follow-up, with acceptable appearance. H–I: Good flexion and extension function of the affected finger.\u003c/p\u003e","description":"","filename":"Fig6.png","url":"https://assets-eu.researchsquare.com/files/rs-8658090/v1/48f857c39d09fcc141b4c0f2.png"},{"id":105754954,"identity":"9e2f34fa-3099-443f-98d8-765ccfcf9a11","added_by":"auto","created_at":"2026-03-30 16:23:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4728992,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8658090/v1/5b18dcab-dc23-407a-aba2-ac062a812920.pdf"},{"id":101654296,"identity":"6189f876-e508-4178-a0c5-8ae24b6b2943","added_by":"auto","created_at":"2026-02-02 09:43:25","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20361,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional file\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdditional file 1 (.docx) Provisional criteria for the functional assessment of digit replantation by the Chinese Society of Hand Surgery, Chinese Medical Association\u003c/p\u003e","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8658090/v1/a636ef9f8d2b9a84d760cc24.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Arterial-Only Anastomosis for Fingertip Avulsion Amputations as a Reliable Strategy with Favourable Survival Rates and Functional Outcomes for: a Retrospective Study","fulltext":[{"header":"Background","content":"\u003cp\u003eFingertip amputations are common injuries that occur in occupational environments and daily activities. The primary treatment option for these injuries is stump revision and replantation. However, stump revision can compromise the function and appearance of the injured digit. Advances in microsurgical techniques, expanding knowledge of fingertip microanatomy, and increasing functional demands have made replantation of fingertip avulsion amputations\u0026mdash;once considered contraindicated\u0026mdash;a routine surgical procedure [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The fingertip, located distal to the nail root, has unique anatomical features characterised by few terminal vessels and small-calibre lumens. Digital arteries within the amputated fingertip can sometimes be identified and anastomosed under a microscope. However, fingertip veins are extremely small, lie superficially beneath the volar pulp dermis, and are frequently severely damaged during digital injuries. Consequently, suitable veins for anastomosis are rarely available (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Replantation with arterial-only anastomosis often leads to arteriovenous circulatory disorders, postoperative venous crises, and eventual necrosis of replanted digits, leading to replantation failure [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAccording to the Tamai classification [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], distal phalanx amputations are characterised into two types: type I, extending from the proximal edge of the lunula to the fingertip, and type II, extending from the distal interphalangeal joint to the lunula. Most fingertip amputations are Tamai type I, for which replantation typically relies on arterial-only anastomosis. This technique does not involve establishing venous drainage, resulting in the absence of physiological perfusion. Spontaneous venous drainage can be established relatively quickly because of the small tissue volume in the fingertip, its relative tolerance to low perfusion, and rich vascular supply. Postoperative adjuncts, including small incisions to promote bleeding or nail bed bleeding, are often used to facilitate venous drainage [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Medical leeches have also been used to promote venous drainage; however, their associated survival rate is markedly lower than those achieved with venous anastomosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur clinical observations indicate that not all fingertip avulsion amputations progress to necrosis after replantation. However, our literature identified no studies that examined survival rates of replanted digits or key influencing outcomes in fingertip avulsion amputations. Therefore, we conducted a retrospective study of patients with fingertip avulsion amputations to investigate the incidence of postoperative vascular crises, the survival rate of replanted digits, key prognostic factors, and functional outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis retrospective study investigating the incidence of postoperative vascular crises, survival rate of replanted digits, key prognostic factors, and functional outcomes of patients with fingertip avulsion amputations was approved by the Ethics Committee of Ningbo No. 6 Hospital. We included 194 patients with complete fingertip amputations who underwent replantation at Ningbo No. 6 Hospital, between March 2017 and December 2024. Among these patients, 84 of 98 fingertip avulsion amputations were assigned to Group 1, whereas 82 of 96 clean-cut amputations were assigned to Group 2. The inclusion criteria were as follows: (1) during replantation, only digital arteries or branches of the arterial arch were identifiable and suitable for anastomosis, and venous anastomosis was not feasible; (2) arterial blood flow was successfully restored in the replanted digits during the procedure. The exclusion criteria were: (1) absence of a suitable artery for anastomosis in the amputated digit during replantation; (2) extensive subcutaneous vascular network injury caused by crushing, resulting in persistent absence of fingertip skin perfusion after arterial anastomosis.\u003c/p\u003e \u003cp\u003ePostoperatively, patients in both groups were admitted to a specialised replantation ward for vascular monitoring and received standard infection prophylaxis, antispasmodic and anticoagulant therapies, and infrared lamp warming. Fingertip perfusion was assessed hourly, and in cases of venous crises, intermittent bleeding was induced through fingertip incisions. The incidence of vascular crises and the survival rates of replanted digits were recorded for both groups. Surviving replanted digits underwent regular follow-up. At six months postoperatively, functional outcomes were assessed using the provisional criteria for digit replantation assessment established by the Chinese Society of Hand Surgery, of the Chinese Medical Association (Additional File 1). The evaluation included total active motion of finger joints, activities of daily living scores, fingertip sensory recovery, blood circulation status, appearance, and return-to-work status.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eArterial blood flow was successfully restored in all 194 replanted digits. Postoperative arterial crises occurred in 28 digits (22 in Group 1 and 6 in Group 2), whereas venous crises developed in 86 digits (44 in Group 1 and 42 in Group 2). In 22 digits (12 in Group 1 and 10 in Group 2), venous crises occurred before arterial crises. Ultimately, necrosis developed in 65 digits (42 in Group 1 and 23 in Group 2). The overall survival rate was 66.5% (57.1% in Group 1 and. 76.0% in Group 2). According to the provisional criteria for digit replantation assessment established by the Chinese Society of Hand Surgery, of the Chinese Medical Association, the mean functional score of surviving replanted digits was 89.25\u0026thinsp;\u0026plusmn;\u0026thinsp;4.37 (n\u0026thinsp;=\u0026thinsp;56) in Group 1 and 92.12\u0026thinsp;\u0026plusmn;\u0026thinsp;4.40 (n\u0026thinsp;=\u0026thinsp;73) in Group 2. Both groups demonstrated excellent functional ratings.\u003c/p\u003e \u003cp\u003eTypical Cases A, B, C and D of Group 1 are shown in Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, respectively. Typical Case A of Group 2 is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e. Comparisons between the two groups are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparative Analysis of Outcome Measures Between the Two Patient Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome Measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvulsion Amputation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClean-cut Amputation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnalysis of Main Causes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSurvival Rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e57.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e76.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1. More severe arterial contusion in Group 1 increased the risk of thrombosis.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2. More severe soft tissue contusion at the amputation stump in Group 1 resulted in slower formation of granulation tissue bridges.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisk of Vascular Crises\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66/98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48/96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1. After arterial-only anastomosis, both groups had a high incidence of postoperative venous crises.\u003c/p\u003e \u003cp\u003e2. Group 1 exhibited more severe arterial contusion and a higher incidence of arterial crises.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSensory Recovery Score\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.14 (3.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.26 (3.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLess tissue at the fingertip resulted in decreased nerve regeneration distance.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJoint Range of Motion Score\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.48 (1.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.10 (1.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInjuries distal to the middle portion of the distal phalanx did not involve the interphalangeal joint, metacarpophalangeal joint or the tendons.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAppearance Score\u003c/p\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.89 (1.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.63 (1.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1. Group 1 had more severe tissue damage, greater shortening, mild atrophy, hyperpigmentation, and more scarring.\u003c/p\u003e \u003cp\u003e2. Digits with prolonged vascular crises tended to have more severe atrophy.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDistal phalanx amputations of the fingers, particularly those occurring distal to the whorl of the volar pulp, exhibit anatomical characteristics that often permit only arterial anastomosis during replantation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Although arterial perfusion is generally adequate after replantation, the absence of venous drainage disrupts vascular balance, causes congestion, and lowers the survival rate of replanted digits. Multiple factors influence the success of arterial-only anastomosis in distal phalanx replantation. A key determinant of tissue healing appears to be the early formation of granulation tissue bridging the amputation site. Neovascularisation within this granulation tissue establishes a pathway for venous drainage, restores vascular balance, and contributes to the survival of replanted digits. However, published evidence specifically addressing this mechanism remains limited.\u003c/p\u003e \u003cp\u003eOur clinical observations indicate that the absence of necrosis within the first postoperative week generally predicts the survival of replanted digits. During this period, the colour and capillary refill of the replanted digits typically return to normal. We hypothesised that this improvement corresponds to the completion of granulation tissue bridging at the amputation site, which typically occurs approximately one week postoperatively. In this study, the severity of soft-tissue contusion at the amputation stump differed between the two groups, resulting in variations in the time required for granulation tissue bridging. In the avulsion group, granulation tissue reconstruction needed more time, and some digits developed necrosis before bridging was complete, which contributed to a lower survival rate compared with the other group. Accordingly, during the replantation of avulsion amputations, we conducted a detailed assessment of soft-tissue contusion and performed more extensive debridement of devitalised tissue. This approach reduced the time needed for postoperative granulation tissue bridging and modestly improved survival.\u003c/p\u003e \u003cp\u003eDigital amputations distal to the middle portion of the distal phalanx do not involve key structures, such as joints or tendons, responsible for finger movement. Therefore, successful replantation generally leads to the favourable recovery of motor function [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Wong et al. reported that, even without nerve repair, skin two-point discrimination can recover substantially after distal phalanx replantation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. From an Asian perspective of aesthetics, the partial loss of a finger is often regarded as a disability and a form of bodily imperfection. Consequently, patients with amputations distal to the middle portion of the distal phalanx typically have a strong desire for replantation to preserve finger integrity, and report a high level of postoperative satisfaction. Hence, this type of finger amputation should be actively considered for replantation in clinical practice. Here, both groups achieved satisfactory outcomes in sensory recovery, joint range of motion, and appearance of replanted digits, while patient satisfaction was particularly high among younger and unmarried patients.\u003c/p\u003e \u003cp\u003eThe distal phalanx has a small tissue volume and relatively low metabolic demand. Hence, it is theoretically less dependent on venous drainage than more proximal phalanges, which provides a physiological basis for the arterial-only anastomosis approach. Arterial patency is a prerequisite for the survival of replanted digits. We found that the two types of amputations distal to the middle portion of the distal phalanx showed a large disparity in the degree of arterial contusion, with differences in the likelihood of arterial spasm or thrombosis after arterial anastomosis. Consequently, the incidence of arterial crises and, ultimately, the survival rates differed between the two groups. Intraoperatively, we observed that in clean-cut digital amputations, the arterial contusion length was short, and excision of the contused segment resulted in a relatively low risk of thrombosis. Conversely, in avulsion amputations of the digit, the length of arterial contusion was longer. If the entire contused arterial segment were excised, direct anastomosis would be performed under significant tension. If superficial vein grafting was intended to repair the digital artery after excision, the extremely small vessel diameter distal to the middle portion of the distal phalanx\u0026mdash;especially at or beyond the digital arterial arch\u0026mdash;would greatly increase the technical difficulty of vascular grafting procedures, and would not guarantee anastomotic potency. Therefore, vascular grafting for arterial reconstruction is generally not suitable for fingertip amputations.\u003c/p\u003e \u003cp\u003eSome patients first developed venous crises, followed by arterial crises. This progression results from worsening venous congestion, which is usually indicative of a poor prognosis. When venous drainage is obstructed, congestion involves the entire venous system and extends to the capillary network, resulting in a marked increase in intravascular pressure and ultimately forcing cessation of arterial inflow. Prompt intermittent bleeding at the fingertip incision helps prevent this scenario by exchanging stagnant blood in the digit with fresh blood, thereby buying time for granulation tissue to bridge the amputation stump.\u003c/p\u003e \u003cp\u003eSurgical techniques that increase the contact surface for granulation tissue growth during digital replantation distal to the middle portion of the distal phalanx may help improve the survival rate of the amputated part. Puhaindran et al. evaluated outcomes of digital replantation with replanted digits buried under a palmar skin flap (dermal pocketing) and reported an 85% success rate [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These favourable outcomes may be attributed to the additional nutrients provided by the flap and to neovascularisation within the newly formed granulation tissue, which improves venous drainage of the digit. Nevertheless, the use of pedicled palmar or abdominal flaps to pocket replanted digits often leads to complications, such as joint stiffness, which limits the widespread application of this method. Our team has developed a novel technique combining artificial dermal chambers with fibroblast growth factor to promote granulation tissue bridging, thereby reducing tissue congestion caused by impaired venous drainage. This technique has demonstrated promising results in animal experiments and is expected to be translated into clinical practice in the near future.\u003c/p\u003e \u003cp\u003eLimitations of this study\u003c/p\u003e \u003cp\u003eThis study adopted a single-center retrospective design, which may introduce certain limitations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn patients with fingertip avulsion amputations who receive arterial-only anastomosis without venous anastomosis, the survival rate of replanted digits, although lower than that achieved with conventional arterial and venous anastomosis, still exceeds 50%. Since this amputation type does not involve tendons or joints, satisfactory functional recovery and favourable cosmetic outcomes can be achieved. Therefore, replantation should be actively considered for such amputations in clinical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Ningbo No. 6 Hospital. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Ethics Committee of the Ningbo No. 6 Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by \u0026ldquo;Ningbo Clinical Research Centre for Orthopaedics, Sports Medicine \u0026amp;\u0026nbsp;Rehabilitation, grant number 2024L004\u0026rdquo;, \u0026ldquo;Ningbo Top Medical and Health Research Program, grant number 2022020506\u0026rdquo;, \u0026ldquo;Zhejiang Medical and Health Science and Technology Plan Project, grant number 2025KY301\u0026rdquo; and \u0026ldquo;Zhejiang Traditional Chinese Medicine Science and Technology Plan Project, grant number 2025ZX018\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, W.D. and Z.W.; methodology, Z.W.; software, A.A.; validation, W.D., Z.W.; formal analysis, W.D.; investigation, W.D.; resources, W.D.; data curation, A.A.; writing\u0026mdash;original draft preparation, W.D.; writing\u0026mdash;review and editing, W.D.; visualization, Z.W.; supervision, W.D.; project administration, W.D.; funding acquisition, W.D. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eVan Handel AC, Pet MA. Fingertip replantation: Technique details and review of the evidence. Hand Clin. 2021;37:53-65.\u003c/li\u003e\n \u003cli\u003eHayashi K, Hattori Y, Chia DSY, Sakamoto S, Sonezaki S, Doi K. Fingertip replantation: Surgical technique, tips, and tricks. Plast Reconstr Surg. 2024;153:168-71.\u003c/li\u003e\n \u003cli\u003eDadaci M, Ince B, Altuntas Z, Bitik O, Kamburoglu HO, Uzun H. Assessment of survival rates compared according to the Tamai and Yamano classifications in fingertip replantations. Indian J Orthop. 2016;50:384-9.\u003c/li\u003e\n \u003cli\u003eHara T, Kurimoto S, Kurahashi T, Kuwahara Y, Takeshige H, Urata S. Limiting levels of fingertip replantation without venous anastomosis. J Hand Surg Am. 2024;49:1274.e1.\u003c/li\u003e\n \u003cli\u003eVenkatramani H, Roberto A, Safa B, Chen C, Lee DC, Chen J. Distal fingertip replantation: Indications, strategy and postoperative management. J Hand Surg Eur Vol. 2024;49:403-11.\u003c/li\u003e\n \u003cli\u003eWang CH, Wei N, Wei CY. Anatomical study of the fingertip artery in Tamai Zone I: Clinical significance in fingertip replantation. J Reconstr Microsurg. 2017;33:e3-4.\u003c/li\u003e\n \u003cli\u003e\u0026Ouml;zdemir FDM, Uzun H, \u0026Ouml;zdemir E, Aksu AE. Comparative assessment of fingertip replantation in paediatric and adult patients within a single institution. J Hand Surg Eur Vol. 2021;46:877-82.\u003c/li\u003e\n \u003cli\u003eWong C, Ho PC, Tse WL, Cheng S, Chan DKC, Hung LK. Do we need to repair the nerves when replanting distal finger amputations? J Reconstr Microsurg. 2010;26:347-54.\u003c/li\u003e\n \u003cli\u003ePuhaindran ME, Paavilainen P, Tan DMK, Peng YP, Lim AYT. Dermal pocketing following distal finger replantation. J Plast Reconstr Aesthet Surg. 2010;63:1318-22.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Fingertip, Amputation, Replantation, Anastomosis, Microsurgery, Ischemia, Neovascularisation, Haemostasis, Haemorrhage, Thrombosis","lastPublishedDoi":"10.21203/rs.3.rs-8658090/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8658090/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eWhile not all fingertip avulsion amputations progress to necrosis after replantation, studies that examined survival rates of replanted digits or key influencing outcomes in fingertip avulsion amputations are lacking. Therefore, we investigated the incidence of postoperative vascular crises, survival rates of replanted digits, functional outcomes, and factors influencing outcomes in patients with fingertip avulsion amputations treated with arterial-only anastomosis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective study was conducted on 194 completely amputated fingertips replanted at Ningbo No. 6 Hospital between March 2017 and December 2024. Only digital arteries or arterial arch branches were identifiable for anastomosis; venous anastomosis was not feasible. Group 1 included 84 patients with 98 avulsion amputations, and Group 2 included 82 patients with 96 clean-cut amputations. Postoperative vascular crises were recorded, and management\u0026mdash;anticoagulation, thrombolysis, or intermittent bleeding\u0026mdash;was tailored to arterial or venous compromise. Survival rates of replanted digits were assessed, and functional outcomes of surviving fingertips were compared between the groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eArterial flow was restored in all 194 digits. Arterial crises occurred in 28 digits (22 in Group 1; 6 in Group 2), whereas venous crises occurred in 86 digits (44 in Group 1; 42 in Group 2). In 22 digits (12 in Group 1; 10 in Group 2), venous crises preceded arterial crises. A total of 65 digits developed necrosis (42 in Group 1; 23 in Group 2). Overall survival rate was 66.5% (57.1% in Group 1; 76.0% in Group 2). Functional scores for surviving digits were excellent in both groups.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDespite lower survival than conventional arterial\u0026ndash;venous anastomosis, arterial-only replantation for fingertip avulsion amputations achieves survival rates exceeding 50% and provides good function and cosmetic outcomes due to the absence of tendons and joint injury. Replantation should therefore remain a recommended option in clinical practice.\u003c/p\u003e","manuscriptTitle":"Arterial-Only Anastomosis for Fingertip Avulsion Amputations as a Reliable Strategy with Favourable Survival Rates and Functional Outcomes for: a Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-02 09:43:20","doi":"10.21203/rs.3.rs-8658090/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-09T07:10:55+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"189158975256364923453064760631926158545","date":"2026-02-06T19:16:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-04T12:14:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"300590189018263116651533107469535096729","date":"2026-01-31T02:44:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-30T19:54:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-30T15:29:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-30T02:45:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"295838545925650671716351312050118763718","date":"2026-01-29T20:46:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177374575948463649328561955773828561731","date":"2026-01-29T18:48:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"307978535609789418196769081914960792249","date":"2026-01-29T16:41:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25549212071122186627654975065795251337","date":"2026-01-29T16:21:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-29T16:02:07+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-27T15:00:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-24T08:56:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-24T08:55:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-01-21T09:14:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fc4aa77d-ea4c-4709-b773-4b4ff8a5aaf1","owner":[],"postedDate":"February 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T16:18:23+00:00","versionOfRecord":{"articleIdentity":"rs-8658090","link":"https://doi.org/10.1186/s12893-026-03692-8","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2026-03-26 16:10:41","publishedOnDateReadable":"March 26th, 2026"},"versionCreatedAt":"2026-02-02 09:43:20","video":"","vorDoi":"10.1186/s12893-026-03692-8","vorDoiUrl":"https://doi.org/10.1186/s12893-026-03692-8","workflowStages":[]},"version":"v1","identity":"rs-8658090","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8658090","identity":"rs-8658090","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}