Ectopic acanthosis nigricans occurring in a child after syndactyly repair

Skin grafts from the groin area were used to repair syndactyly of the fourth and fifth fingers in an 8-month-old infant with oculodentodigital dysplasia (ODD). At 12 years of age, he developed hyperpigmented velvety plaques at the repair sites. This patient is the first reported case of acanthosis nigricans (AN) occurring in a graft site after syndactyly repair. We propose the term ectopic acanthosis nigricans to describe the phenomenon of AN occurring in transplanted skin away from the original donor site.

[Polydactyly and syndactyly as the most common congenital disorders of the limbs]

Polydactyly is a common hereditary disorder in which extra or vestigial digits are present on the one or both sides of the extremities. It is ten times more frequent in Blacks than in Whites. Polydactyly occurs both in a sporadic form and in a hereditary form. In polydactyly type A, the extra digits contains phalanges, in polydactyly type B, there is no skeletal structure. The extra digit is made by skin only. Syndactyly type I exists when the connection is at the level of skin, in type II the phalanges of the fingers are connected. For syndactyly correction, combined use of "Z"-method incision and full-thickness free skin grafts are the most common method of treatment. A new method is based on a straight incision and free skin grafts. The scars after the serial excision are placed on the midlateral lines. The final scars are minimal, and good functional and cosmetic result is obtained.

Surgical treatment of simple syndactylism with secondary deep digital flexor tendon contracture in a Basset Hound

A five-month-old, female Basset Hound was presented for lameness associated with a fused 3rd and 4th digital pad on the left hind limb (simple incomplete syndactyly), and secondary contracture of the deep digital flexure tendon of the 3rd and 4th digit. An onychectomy of the third phalanx of the third and fourth digits was performed. Following the operation, the dog gained good use of the affected limb for one month until intermittent non-weight bearing lameness developed. A second surgery was performed six months later, partially removing the second phalanx of digits three and four. Follow-up reports indicate that the dog is doing well and is without lameness. This is the first report of deep digital flexor tendon contracture and surgical treatment of this complication in canine simple syndactylism.

A life-threatening complication of the arterial tourniquet in Timothy syndrome

An infant with Timothy syndrome, a congenital syndrome resulting in a long QT interval and high risk of death in childhood, is presented along with his perioperative management. Characteristic life-threatening arrhythmias thought to be caused by excess sympathetic stimulation secondary to an arterial tourniquet are described.

Application of external fixation for management of hand syndactyly

We present the method for management of syndactyly based on guided gradual and coordinated separation of finger phalanges and metacarpal bones by means of an original external fixator in order to grow soft tissue stock in the interdigital web spaces for their subsequent Z-plasty. Unlike traditional methods of treatment, the interdigital soft tissue bulk is grown by distraction only at the expense of local tissues. Cutaneofascial grafting is avoided as it damages the donor site and causes ugly scarring.

Reconstruction of syndactyly and polysyndactyly of the toes with a dorsal pentagonal island flap: a technique that allows primary skin closure without the use of skin grafting

Syndactyly and polysyndactyly are common congenital conditions involving the foot, and surgery to reconstruct the toes may be indicated for cosmetic, psychological, and practical reasons. A dorsal flap is traditionally used for web space reconstruction, with skin grafts for the bases of the toes. Skin grafting has associated morbidity and can result in pigmentation mismatch. Single-stage direct closure with a specially designed flap has advantages including a reduction of morbidity from avoidance of skin grafting and shorter surgery. Four patients (6 feet) were included in the study. There were 2 cases of syndactyly and 2 cases of polysyndactyly. Bilateral involvement occurred in 2 patients. The average age was 18 months at time of first surgery. Direct closure was achieved with a dorsal pentagonal island flap with dorsal and plantar triangular flaps. The average duration of follow-up was 19.8 months. At final follow-up, all patients had acceptable web depth and pulp contour. The distance between the proximal interphalangeal joints of adjacent toes and the web slope of the reconstructed web space were acceptable. Complications included partial synechiae, cellulitis, and keloid formation. The dorsal pentagonal island flap is an acceptable technique in providing another means for single-stage reconstruction of the web space in syndactyly and polysyndactyly. Good functional and cosmetic outcomes can be expected. However, the potential complication of keloid formation can affect cosmesis and overall outcome, and must be understood by patients and parents.

Reconstruction of the first web space in symbrachydactyly using the reverse radial forearm flap

PURPOSE

To present a new approach for the reconstruction of severe first web contractures using a distally based reverse radial forearm flap in symbrachydactyly patients.

METHODS

This study included 6 hands in 5 patients. Subjective evaluation included appearance, parent satisfaction (and patient satisfaction when appropriate), and ability to perform daily activities such as thumb-index grasp and pinch at follow-up evaluations. We measured the angle between the first and second rays using a goniometer at maximum radial abduction, and pinch and grasp strengths were evaluated as an objective assessment.

RESULTS

The average follow-up period was 2 years. All parents and patients were happy with the aesthetic appearance. They were completely satisfied in their daily living activities. The average first web angle measurement was 56 degrees . An average of 39 degrees of improvement of web measurement was achieved. For the unilateral 4 patients, the average pinch strength measurement was 80% of the normal contralateral hand and the grip strength was 75% of the normal contralateral hand.

CONCLUSIONS

The reverse radial forearm flap was found to be a safe and simple method in the reconstruction of severe first web contractures in symbrachydactyly patients. This method provided good coverage of appropriate thickness and skin quality, and supple soft tissue that filled the first web space.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Desyndactylization of the first and second toes using full-thickness autologous skin graft from the ankle

We present a unique case of congenital bilateral simple syndactyly of the first and second toes that was surgically treated using a full-thickness skin graft harvested from the same foot at the lateral aspect of the ankle. This surgical approach eliminates the potential need to involve another surgical team to harvest a donor graft from above the ankle, saving operating room time, anesthesia time, and overall cost to the patient. Cosmetically, scar formation above the ankle is also eliminated.

A nonclassified and unusual polydactyly of the foot

A rare polydactyly of the foot, mixed central and pre-axial type, is described; no other dysmorphic features were present. Early surgery was performed with good results.

Synpolydactyly of the foot in homozygotes

In 2002, we reinvestigated a large synpolydactyly kindred first described in 1995. It was found to have expanded with an increase in number of homozygous offspring. These homozygotes had severe hypoplasia, with synpolydactyly of their hands and feet. We present the clinical, genetic, and surgical findings of this deformity and the histologic findings of the removed bones of the heterozygous and homozygous members. There were 125 affected individuals (113 heterozygotes and 12 homozygotes) of 245 members of the past five generations. We identified seven marriages in which both spouses were affected. Twelve offspring from these marriages had homozygote genetic patterns, hypoplastic synpolydactyly of the hands, and a distinctive foot deformity, with a prominent great toe and syndactylized hypoplastic minor toes. From clinical and surgical perspectives, their hand and foot deformities were different from those of their parents. We surgically treated both feet of four individuals with this deformity, which we called "homozygote foot synpolydactyly." Clinically, the deformity consisted of a supinated prominent great toe, hypoplastic and severely synpolydactylized minor toes, and secondary problems. Radiographically, the bones were underdeveloped, unshaped, and largely fused. Abundant cartilage covering the bones was observed surgically and histologically. Genetically, analysis of HOXD13 identified a 27-base pair duplication with a homozygote pattern. The foot deformity of the homozygotes was so distinctive and complicated that it should be considered a separate foot synpolydactyly type--homozygote foot synpolydactyly.

General anesthesia in a patient with dystrophic epidermolysis bullosa

A 13-year-old boy with epidermolysis bullosa underwent a repair of pseudosyndactyly. He had a long history of bullae formation in the oral cavity and on the pharynx and body surface, and some were active at the time of surgery. We chose inhalational general anesthesia with tracheal intubation using sevoflurane and nitrous oxide. The trachea was successfully extubated after the surgery, and no major bulla formation was observed. General anesthesia with tracheal intubation may be chosen as anesthesia for patients with epidermolysis bullosa.

[Double toe to hand transfer in children with symbrachydactyly]

INTRODUCTION

Symbrachydactyly is fairly frequent congenital malformation that appears during first weeks of pregnancy. The range of clinical presentations goes from hypoplastic fingers to true agenesis. Although it usually appears in a random fashion, sometimes it is associated to other systemic malformations.

PATIENTS AND METHODS

The aim of this study is to check the functional, cosmetic and psychological results of those patients affected of grade IV symbrachydactyly treated using a double second toe transfer. The method employed is a retrospective study of the clinical records from 6 patients (5 males and 1 female) operated in our Department during the last five years. The follow up period was from 3 months to five years.

RESULTS

Transfer from the second toe to the first ray was performed during the first surgical period, while transfer to the fourth ray was done in a second procedure. The mean age for the first operation was 19 months, and 30 months for the second one. There were no flap failure or major surgical complications. Tenolysis and tenoplasty was done in two patients to improve flap function and position. Motion rehabilitation was installed during the postoperative period. Functional, opposing pinch, and cosmetic results were satisfactory. Parents "and patients" psychological acceptance was also good. No walk disturbance was observed.

CONCLUSIONS

Double second toe to hand transfer is a good option for the symbrachydactyly treatment in cases of thumb agenesis. Rehabilitation is the key clue for functional recovery. Surgery improves social and family relationships.

Tissue expansion for reconstruction of an unusual form of complex syndactyly

Tissue expanders can be used over the dorsum of hand and fingers to increase available tissue for flap coverage after release of syndactyly. Herein, we presented an 18-year-old man who had an unusual complex syndactyly in the middle and ring fingers of his right hand. He had also complete fusion of the proximal phalanges. In this report, we described the application of tissue expander to cover separated exposed bones.

Versatile use of the VM-plasty for reconstruction of the web space

The loss of web space may be congenital or acquired. Although local skin flaps are usually preferred, recurrence rate is fairly high. In this study, we used the VM-plasty as a versatile technique to create a web space and expanded its applications. Thirteen patients (7 males and 6 females) with 22 syndactylous webs were operated on using this technique. The web contractures were developed on scarred tissues in 9 patients, whereas only 4 cases presented with primary congenital syndactylies. The skin graft was not used in any of the patients. All the patients gained web functions with a good esthetic appearance without any recurrence. The technique is fairly versatile and can be used both in the hand and foot for congenital complete or incomplete syndactylies and acquired web space contractures. So, we advise the VM-plasty both in primary and recurrent cases with web space loss.

Rational Treatment for Multiple Digit Congenital Absence

A case is discussed in which a young male was born with symbrachydactyly of multiple digits in whom nonvascularized proximal toe phalanges were transferred to the aphalangic digits when he was an infant. This initial surgical procedure was later followed by webspace deepening and ultimately by distraction lengthening of the digits. At 8 years of age, he has a very functional hand with mobile metacarpophalangeal joints in all reconstructed fingers. In fact, he uses this reconstructed right hand as his dominant extremity. The case is discussed in context of phalangeal growth potential, specific indications for this type of reconstruction, and final long-term outcome. This case also helps to recommend rational treatment protocols for similar congenital hand anomalies.

Temporal skin grafts following straight incision for syndactyly correction

For syndactyly correction, combined use of zigzag incision and full-thickness free skin grafts and many modifications have been reported. However, postoperative scars produced by this method on the dorsum and palm are conspicuous, and pigmentation of the grafts can be distressing for patients. In syndactyly correction, not only functional but also esthetic improvement is required. Therefore, we devised a new method, consisting of a straight incision and free skin grafts that are serially excised afterward. The scars after the serial excision are placed on the midlateral lines. Although this method necessitates at least 2 operations, the final scars are minimal, and functionally and cosmetically good results are obtained.

Contrary Intermittent Skin Release of Complete Syndactyly Without Skin Graft in Adults

INTRODUCTION

There are many different surgical treatment techniques of complete syndactyly. Most of them are techniques involving using skin grafts. We developed a surgical technique that does not require skin grafts, which cause problems in the distal nail border pulp and interdigital web space.

MATERIALS AND METHODS

Syndactyly release was performed in 12 web spaces of 11 adult male patients. The average age was 21. In addition to a zig-zag incision, contrary intermittent skin release was performed. Primary coverage of the interdigital web space and nail border pulp was achieved without skin graft.

RESULTS

We obtained good results by the contrary intermittent skin release method that we developed, in adult complete syndactyly patients who had no chance for the surgical treatment due to several reasons, previously.

CONCLUSION

With such a surgical technique, in our cases we obtained successful results, both cosmetic and functional. The presented technique is an alternative method for syndactyly release without using skin graft in adult patients.

Macrodactyly, syndactyly, and localized gigantism of the forefoot. A case report

On the basis of the observation of a rare case of lipomatous macrodactyly of the foot associated with syndactyly in a young child, the authors analyze the anatomopathologic and therapeutic aspects of the pathology and report the data found in the literature. This disease initially requires careful surveillance of its progression, and use of correct footwear. Surgery is indicated when deformity achieves unacceptable values, both functional and cosmetic, in early childhood.

Three-square-flip-flap reconstruction for post burn syndactyly

INTRODUCTION

Burns of the hands may result in the formation of web space contractures-post burn syndactyly. We present our experience using the three-square technique originally described by Bandoh for minor syndactyly.

METHOD

Tissues of the contracted web are regard as forming three facets of a cube. If elevated and transposed 90 degrees on their base the facets will fall into place and line the interior of the cube creating a deepened web-space. The first flap is based on the web itself either dorsally or volarly. The second flap is based distally on one of the fingers. The third flap is based laterally on the other finger. Surgery is followed by a splinting regimen.

RESULTS

The design of the flaps is simple and the operation is easy to perform. This technique has achieved good functional and cosmetic results; there have been no flap losses or significant complications.

CONCLUSION

The three-square-flip-flap is a simple reliable and safe method for the treatment of post burn syndactyly.

Anatomic correction of polysyndactyly of the fifth toe fused with the fourth toe

A new surgical technique for correction of polysyndactyly with the fifth toe fused with the fourth toe was devised. The technique consists of the creation of a dorsal rectangular flap on the dorsum of the syndactyly web for the new fourth web, making a medially based plantar rectangular flap on the plantar surface of the fifth toe, and a sixth toe-tip-based rectangular hinge flap to reconstruct the lateral side of the fourth toe and medial side of the new fifth toe, respectively. All suture lines are intended to be located in the transition of the plantar and dorsal surfaces of the web and digit. This technique is characterised by accurate anatomic reconstruction, which produces better aesthetic results with no wasting of any skin components.

[Verification of thumb-specific muscles in a triphalangeal thumb with magnetic resonance imaging]

The presence of three phalanges in the first digit is considered to be a relatively rare congenital hand malformation. Six groups of this deformity can be distinguished: some digits are opposable, others resemble a non-opposable five-fingered hand. In cases of a hypoplastic thenar region with a restrained opposition, a clear verification of thumb-specific musculature has been hardly possible. We report of the possibility of a non-invasive identification of thumb-specific muscles by means of magnetic resonance imaging.