In situ and split-thickness grafting for nail bed defects with bone exposure: A retrospective case series

Nail bed defects accompanied by bone exposure are challenging to treat because they rarely heal spontaneously and frequently require flap coverage or digit amputation. This study evaluated the postoperative function and appearance of nail bed defects repaired using in situ or split-thickness nail bed grafting. From March 2019 to December 2023, 28 (32 fingers) patients with nail bed defects and bone exposure underwent in situ or split-thickness autologous nail bed grafting. The clinical outcomes were quantitatively evaluated across five domains: nail plate appearance, proximal nail fold adherence, nail bed adherence, complications, and patient satisfaction. The postoperative follow-up was 12 months. Excellent and good postoperative effects were achieved for 90.6% of the fingers (29/32). Four complications or clinically important adverse-event cases were identified, comprising three score-defined poor outcomes and one additional good-outcome case with severe occupational dissatisfaction. One of the score-defined poor-outcome cases required a secondary outpatient procedure; no recurrent bone exposure, secondary flap coverage, or digital amputation occurred. Nail bed grafting may provide a useful reconstructive option for selected nail bed defects with bone exposure. In this preliminary case series, these techniques were straightforward and generally yielded favorable nail growth with a low rate of major complications; however, larger comparative studies are needed to validate these findings and refine clinical indications.