Hand splintage following surgery for dystrophic epidermolysis bullosa

A review of the management of the hand in dystrophic epidermolysis bullosa

The hand deformities associated with dystrophic epidermolysis bullosa lead to a mitten-like hand with significant loss of function. The pattern of their development is discussed. Although the digits can be released and divided surgically, the deformity is recurrent. This study provides a review of the literature on the management of the hand in this disease and a discussion of the role of therapy in maintaining hand function.

Surgical treatment and postoperative splinting of recessive dystrophic epidermolysis bullosa

Digital contractures and pseudosyndactyly, common manifestations in recessive dystrophic epidermolysis bullosa, cause significant functional impairment. The deformities progress with time, although surgery may delay the progression. The role of surgical intervention, hand therapy, and the use of prolonged splinting was examined in seven children (nine hands) with recessive dystrophic epidermolysis bullosa with an average age of 5 years, 8 months (range, 1 year, 10 months to 16 years, 4 months). The technique of surgery, postoperative regimen, and splinting differ from those previously reported. Surgery includes "de-cocooning" the hand and fingers, manipulating contracted joints, and full-thickness skin grafting to dermal defects. Surgery and the postoperative regimen of rigid night splints and web-retaining gloves for day wear has allowed arrest or minimal progression of contractures in complaint patients in short-term follow-up study of an average of 17 months (range, 12-28 months). An interdisciplinary team of physicians and surgeons, therapists, and nurses makes this care regimen possible and influences family compliance.

[Anesthesia for hand surgery in patients with epidermolysis bullosa]

OBJECTIVE

To report on the anaesthetic management with axillary block of patients suffering from recessive dystrophic epidermolysis bullosa (RDEB), undergoing repetitive surgery of the hand.

STUDY DESIGN

Retrospective analysis of a case series.

PATIENTS

Twenty-two patients, including 11 children less than 8-year-old and with a body weight under 20 kg, treated since 1988, were considered.

METHODS

For surgery, including usually three stages at a 7-day interval, an axillary block was placed when feasible, after oral premedication midazolam (0.1-0.2 mg.kg-1) with a 25 gauge needle in patients of less than 30 kg of body weight and 22 gauge beyond. The local anaesthetic mixture included 2% lidocaine (5-10 mg.kg-1) and 0.5% bupivacaine (2-3 mg.kg-1). A catheter for repetitive injections had not been inserted. For children less than 10-year-old a parent was present in the theater during all the course of operation.

RESULTS

Between 1988 and 1995, 22 patients underwent 160 operative interventions on 54 hands. Regional anaesthesia was used in 142 cases, including 140 axillary and 2 interscalene blocks. General anaesthesia was only required in 20 cases, either alone or associated with regional anaesthesia. The success rate of axillary blocks was 98%.

DISCUSSION

For surgery of the hand in patients with RDEB, we switched in 1988 from general anaesthesia with ketamine to axillary block, even in young children, as it is closer to the no-touch principle, which is essential to prevent from blistering. In comparison to general anaesthesia, regional anaesthesia raises neither the problems of airway and vascular access, nor those of instrumental monitoring. The main factors of success with regional anaesthesia are technical skills, expertise in the management of patients with RDEB and parental presence in the operating room which makes the procedure less stressful for children.

[Anesthesia for hand surgery in patients with bullous epidermolysis]

Epidermolysis bullosa is a rare genetic disease, characterized by the formation of bullae in the skin and squamous epithelium following minimal trauma. The majority of surgical indications specific to this disease concern autosomal recessive dystrophic epidermolysis bullosa (RDEB). Hand surgery is one of the fields of surgery involved. The cicatricial course of the lesions results in retraction and pseudosyndactylization of the fingers, sometimes leading to complete destruction of the hand. Since 1988, we have treated 23 patients, including 11 children under the age of 8 years and weighing less than 20 kg. 185 procedures were performed by two anaesthetists, using regional plexus blocks in 157 cases and general anaesthesia in only 28 cases. This series is comparable in number, to that reported by the London team, which prefers general anaesthesia. Regional anaesthesia has been previously used, but only following general anaesthetic induction. Our approach, based on the experience of a hand surgery center, is in marked opposition with this standard paediatric approach. Regional anaesthetic techniques, particularly in the upper limb, present many advantages in addition to their feasibility in small children: efficacy, simplicity, postoperative analgesia, and outpatient comfort. In the context of the specificities and difficulties encountered in the management of these patients suffering from epidermolysis bullosa, the authors demonstrate the value of first-line regional anaesthesia, even in very young children (less than 3 years). The presence of a parent in the operating room is a valuable aid, which is still insufficiently used, but which should be used with conviction for the benefit of all concerned.