A Systematic Review and Comparison of Outcomes Following Simple Syndactyly Reconstruction With Skin Grafts or a Dorsal Metacarpal Advancement Flap

Graftless Syndactyly Release

Syndactyly release aims to address skin deficits by resurfacing web spaces and sides of digits to allow independent digital motion while minimizing the risk of web creep and scar contractures. Conventional methods include the use of a dorsal and interdigitating flaps with full-thickness skin grafts. More recently, there have been several descriptions of "graftless" syndactyly release without skin grafts, thus avoiding a further (usually distant) donor site. However, the indications of when and when not to use these techniques remain unclear. In addition, the inevitable scarring from extra recruitment of local adjacent skin is perhaps underemphasized. In this article, we revisit the trilobed flap technique which serves to balance the amount of skin needed for resurfacing digits while minimizing local donor site scarring. The geometry and nuances of the flap inset are illustrated in detail to guide those embarking on this technique. The trilobed syndactyly release technique is a reproducible, safe, and reliable method for the release of simple syndactyly.

Pedicled palmar intermetacarpal perforator flap for skin-graftless syndactyly release: Anatomical study and clinical application

INTRODUCTION

Dorsal hand skin flaps have been described in order to avoid digit skin grafting in syndactyly release. Although these skin-graftless techniques present a lower rate of long term complications, they result in unsightly dorsal scarring and worse patient satisfaction. We describe a novel technique using an intermetacarpal palmar flap by performing an anatomic study and clinical application.

MATERIALS AND METHODS

Ten colored-latex-injected fresh upper limbs were used to study the palmar cutaneous perforators to second to fourth intermetacarpal space skin flaps designed elliptical, its width extending from the center of each involved ray and measuring 40%-50% the length of the palm.

RESULTS

The anatomical study revealed a mean 2.77 (range 1 to 4) cutaneous perforators originating from either the common or proper digital vessels for every intermetacarpal space and measuring 0.4 mm (range 0.3 to 0.5 mm) in diameter.

CLINICAL APPLICATION

This flap, measuring a mean of 21.5 mm (range 20 to 23 mm) in length and 9.5 mm (range 9 to 10 mm) in width, was used to release simple syndactylies in three patients of mean age 24 months (range = 18-30 months). After skin incision, cutaneous septa to the digital canal were released to permit flap advancement to the web space. Cutaneous perforators were not dissected. Intra-operative palmar-flap advancement provided commissure coverage in all children with no skin grafts needed. Over a mean follow-up of 15 months, no complications occurred, mean palm scar VSS was 2.4 (range 2 to 3) while it was 3 (range 3 to 3) for the commissure scars.

CONCLUSIONS

Skin-graftless syndactyly release using a palmar intermetacarpal flap seems both reliable and easy-to-perform.

LEVEL OF EVIDENCE

Therapeutic IV.

Efficacy of a fingertip reconstruction technique using the tongue-shaped flap and advancement flap for repairing congenital syndactyly with osseous fusion of the distal phalanges

BACKGROUND

To explore the clinical efficacy of using tongue-shaped flaps and advancement flaps to reconstruct the fingertips in congenital syndactyly patients with osseous fusion of the distal phalanges.

METHODS

From January 2016 to January 2019, 12 patients with congenital syndactyly, involving 30 digits in total, presented to our hospital and were surgically treated with tongue-shaped flaps, as well as with advancement flaps to reconstruct the fingertips. The flap infection rate, necrosis rate and any other early complications were recorded. Fingertip aesthetics were reported according to the modified Bulic scale. A questionnaire was used to assess the satisfaction of the patients' family members.

RESULTS

All cases were thoroughly reviewed. The postoperative period for inclusion in this study ranged from 36 to 60 months, with an average follow-up time of 45 months. During this period, no complications such as infection and/or necrosis of any flap were observed. Significant improvements in finger aesthetics and functioning compared to preoperative values were observed in most cases. Based on the modified Bulic scale, of 30 fingertips, an excellent result was obtained for 3, a very good result for 13, a good result for 13 and a poor result for just 1. Family members were satisfied with the treatment outcome.

CONCLUSIONS

This technique employing tongue-shaped flaps and advancement flaps to reconstruct fingertips is effective, which enables the attainment of favourable aesthetic and functional outcomes in congenital syndactyly patients with osseous fusion of the distal phalanges.

Repair of fingertip defect with reverse digital artery island flap and repair of donor site with digital dorsal advancement flap

Objective

The reverse digital artery island flap (RDAF) is widely used in repairing fingertip skin defects based on its good appearance and practicability. However, the donor area of the flap needs skin grafting, which can lead to complications. This retrospective study explored the clinical application of digital dorsal advance flap (DDAF) in repairing the donor site of the reverse digital artery island flap.

Method

From June 2019 to February 2022, 17 patients with a soft tissue defect of the finger had been restored with the reverse digital artery island flap, and at the same time, the donor area was repaired with digital dorsal advance flap (DDAF). The sensitivity, the active range of motion (ROM) and patient satisfaction were assessed after the operation.

Results

All flaps survived completely without skin grafting with only one linear scar. The sensory and motor functions of all patients recovered well. Assessment based on the Michigan Hand Outcomes Questionnaire (MHQ) showed satisfactory functional recovery for all patients.

Conclusions

Reconstruction using RDAF combined with DDAF represents an effective alternative for repairing fingertip skin defects.

Omega Flap Technique: Revisiting Conventional Wisdom

Various surgical techniques have been described for the release of syndactylized fingers. In our experience, the omega flap technique, which includes a dorsal truncated flap and an anchor incision on the volar side, stands out as a good technique to release syndactyly. Incidentally, in symbrachydactyly also, the fused digits can be released using this technique. Despite this, we could find no reference in the recent years. We would like to stress the ease and importance of this technique, hoping many practicing hand surgeons will benefit from this. Our purpose was to revisit this technique and expose it to the younger generation of hand surgeons. We have operated on 20 cases of syndactyly of different types-simple, compound, and complex-and 5 cases of symbrachydactyly. In all cases, the omega flap on the dorsum and anchor incision on the volar aspect of the finger forming 2 lateral palmar flaps were used. The release of syndactyly was satisfactory in all patients. There was no flap necrosis. None of these cases have required secondary surgery because the primary releases were adequate. Release of syndactyly had been a problem for centuries. Awareness of the disability was insufficient in earlier days; currently, they seek early medical care. The release should be complete. These children must be able to achieve the form and function of the hand, and additionally precision to work. We believe that the use of omega flap and anchor flap is a good procedure for syndactyly release.

Separation of congenital embryonic syndactylies in children: dorsal or volar flap? About a comparative retrospective series

Congenital syndactylies account for 1 to 2 out of 2000 birth defects. Although several types of syndactylies exist, we only studied embryonic syndactylies. The goal of our study was to compare 2 types of coverage flap for the reconstruction of the finger web spaces: a volar flap described by Blauth and a dorsal flap described by Gilbert. Between 1993 and 2015, children affected by simple and complex syndactylies (partial or complete) were treated in 2 french pediatric hospitals and were selected for our analytic, comparative, retrospective review. The 2 hospitals used different surgical techniques: one used a volar flap described by Blauth and the other a dorsal flap described by Gilbert. The children were followed up to look for signs according to the stages of the Classification of Withey and to evaluate a global result according to the score of Withey. Our secondary criteria of judgement were the aspect of the surgical scar according to the VSS (Vancouver Scar Scale) and the satisfaction of the parents and children. The age of the children, need for a surgical revision and time of last follow- up were also studied. We found statistically significant differences between group I (volar flap) and group II (dorsal flap) in favor of the volar flap: higher scores of Withey (even when the number of commissures was increasing) and better VSS (regardless of the number of web spaces treated). There was no statistically significant difference between the 2 groups in terms of age, follow-up, or rate of surgical revision. All in all, the volar flap presented less sequelae in terms of scar retraction. Regardless of the flap used, the cosmetic results of the full-thickness skin graft used impacted the result both on the receiving site (dyschromia, hairiness) and the donor site.

Comparing Results of Syndactyly Operated Children Younger and Older Than 1 Year

INTRODUCTION

Syndactyly has a cosmetic, functional, and psychosocial impact, and surgical treatment is indicated in most cases. This study aimed to retrospectively identify whether patients undergoing surgical release of syndactyly younger than 1 year presented different results compared with those operated older than 1 year.

METHODS

Patients were assessed through photographic records by 3 independent specialist surgeons for the quality of scar, presence of web creep, rotational, flexion-extension, and lateral flexion deformities using the Withey score.

RESULTS

Thirty-four patients were included in the study, totaling 51 commissures operated. The score was higher in the group operated younger than 1 year (5.83 ± 2.39) compared with the group older than 1 year (3.94 ± 1.93), being statistically significant, with a P value of 0.011.

CONCLUSIONS

Children with syndactyly operated younger than 1 year have worse postoperative outcomes measured by the Withey score than those operated older than 1 year.

Surgical Outcomes and Predictive Factors of Medial Toe Excision for Polysyndactyly of the Fifth Toe

BACKGROUND

We aimed to report surgical outcomes and analyze prognostic factors of medial toe excision for polysyndactyly of the fifth toe.

METHODS

We reviewed the details of 139 consecutive patients who underwent surgery for postaxial polydactyly of the foot from 2009 to 2018. Among these, 83 patients (90 feet) with polysyndactyly of the fifth toe, treated by medial toe excision (between the duplicated toes) and reconstruction of the fourth web space using a dorsal rectangular flap, were included. The toe alignment and stability were restored by chondroplasty and soft tissue balancing without an osteotomy. A full-thickness skin graft was performed in 52 feet. The mean age at surgery was 27.1 ± 17.5 months and the mean duration of follow-up was 42.8 ± 24.9 months.

RESULTS

At the last follow-up, a relatively small size of the reconstructed toe was observed in 19 feet (19/90, 21.1%). Proximal duplication level (metatarsal or proximal phalanx type) and preoperative hypoplasia of the remaining toe were related to the small postoperative size. Valgus deformity of the remaining toe was observed in 2 feet (2/90, 2.2%). We observed 17 cases with delayed healing or early postoperative wound infection. Among these, 7 cases (7/90, 7.8%) showed postoperative thickening or advancement of the web, which was not observed in cases without wound problems. No cases had functional disturbance or pain.

CONCLUSION

The overall surgical outcomes were satisfactory without an osteotomy. Patients with a proximal duplication level or preoperative hypoplasia of the remaining toe should be informed of its possible small size postoperatively.

LEVELS OF EVIDENCE

Level IV, retrospective case series.

Syndactyly

Here we present an interesting case of simple syndactyly and provide a narrative review of its incidence, associations and management.

New Simple Technique for Syndactyly Release

Can good functional and cosmetic result be achieved in syndactyly separation using a straight midline incision with a hexagonal dorsal skin flap?

National Patterns in Surgical Management of Syndactyly: A Review of 956 Cases

Purpose: Being one of the most common congenital hand malformations, syndactyly is repaired by orthopedic, plastic, and fellowship-trained general surgeons. Limited multi-institutional outcomes analyses regarding incidence, timing, and type of repair exist. Methods: All syndactyly cases performed over a 5-year period from 2012-2016 were isolated from the National Surgical Quality Improvement Program Pediatric database. Patient demographics, surgical factors, perioperative outcomes, and risk factors were analyzed using χ², Fisher exact, and t-test analysis. Results: A total of 956 patients who underwent syndactyly repair were identified. Most cases were simple syndactyly with nearly even case distribution among plastic and orthopedic surgeons. Most patients were men and Caucasian. Mean age at the time of surgery was 2.6 years. Most cases were performed as outpatient surgery. Patients of plastic surgeons had significantly more airway abnormalities and shorter operative times. Patients with complex syndactyly had significantly more ventilator dependence, tracheostomy, and comorbidities when compared with those with simple syndactyly. Cases with complex syndactyly also had longer operative times and a higher rate of superficial surgical site infections. Conclusions: Syndactyly repair is a safe procedure with few major or minor reconstructive complications regardless of the surgical specialty or syndactyly type. Patients with complex syndactyly have significantly more preoperative comorbidities with comparable outcomes. orthopedic surgeons have significantly longer operative times than plastic surgeons, likely due to caring for increased number of patients with complex syndactyly.

Outcomes of Pediatric Syndactyly Repair Using Synthetic Dermal Substitute

PURPOSE

Full-thickness skin grafts are classically used for areas of skin deficit in syndactyly reconstruction surgery. However, skin grafting requires additional time under anesthesia and includes donor site morbidity. Synthetic dermal substitute has produced favorable web creep and scar appearance outcomes in syndactyly reconstruction. We sought to validate these results using objective outcome measures.

METHODS

All patients who had undergone syndactyly reconstruction with synthetic dermal substitute with 1-year follow-up were identified. We included 23 webs in 16 patients; 2 were lost to follow-up. Median age at surgery was 27 months; 7 patients were female. Five webs were revision surgeries. Two patients had a diagnosis of amniotic constriction band, and 3 had symbrachydactyly. All webs were assessed from blinded clinical photos. Outcome measures included web creep assessment (range, 0-5) and Vancouver Scar Scale.

RESULTS

Of 21 webs, 2 had minimal creep and 16 had none; 3 had clinically relevant creep (grade 2). Vancouver Scar Scale scores for all webs averaged 1.19 (0 is normal). There was normal vascularity in 20 webs, pigmentation was normal in 17 webs, skin pliability was normal in 13 webs, and scar height was flat in 15 webs. On the visual analog scale assessment, surgeons rated the appearance of the 21 webs as an average of 8.8 (range, 5-10). There were no postoperative complications.

CONCLUSIONS

Synthetic dermal substitute is an effective, efficient, and visually satisfactory option for coverage of skin deficits in syndactyly reconstruction. The current heterogeneous sample revealed that this approach can provide satisfactory outcomes for patients, families, and surgeons. Although no surgical complications were noted, the rate of integration and healing has yet to be determined.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Treatment of congenital syndactyly

Defined as the union of two adjacent digits, syndactyly is one of the most common congenital deformities. The severity of the malformation depends on the fusion level, the tissues involved in the union, and whether it is isolated or syndromic. In order to improve the hand's appearance and function, surgery is recommended in the great majority of cases, ideally during early childhood (i.e., before entering school). Web space reconstruction is done using local flaps. Depending on the flap design, digital resurfacing can be done with or without skin grafts. While graftless techniques have shorter operating times and no morbidity associated with skin harvesting, their cosmetic outcomes seem to be worse than those of traditional grafting techniques, with more postoperative complications; furthermore, such techniques cannot be used in all cases, especially those with osteoarticular fusions. When the fingertip is involved, paronychial reconstruction is carried out with pulp flaps. The prognosis for these deformities directly depends on their severity, with excellent outcomes in cases of cutaneous fusion, and much less predictable ones when osteoarticular and/or tendinous tissues are involved.

Dorsal Hexagon Local Flap Without Skin Graft for Web Reconstruction of Congenital Syndactyly

PURPOSE

The ideal web reconstruction for syndactyly requires both satisfactory function and aesthetic appearance. In this study, we report a dorsal hexagon local flap with adequate size and that leaves most of the scars in the interdigital space.

METHODS

Between June 2015 and June 2017, 16 patients (10 males and 6 females) with 22 syndactylies underwent surgical reconstruction using the dorsal hexagon local flap technique. All patients had simple syndactyly. The postoperative evaluation included the quality of scarring, the extent of flexion and extension deformity, web creep, lateral flexion deformity, and rotational deformity of the digit.

RESULTS

All flaps survived and there were no postoperative complications. All patients achieved satisfactory interdigital commissure depth. During 12 to 34 months of follow-up, no case of flexion contracture or web creep after reconstruction was noted.

CONCLUSIONS

The dorsal hexagon local flap is an alternative method for syndactyly reconstruction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Syndactyly release: a comparison of skin graft versus graftless techniques in the same patient

Syndactyly release may be done by skin graft or graftless techniques. We prospectively examined bilateral syndactyly releases in the same patient at one operation. The grafted side was randomized and the contralateral side was done graftless. Fourteen patients had surgery at a mean age of 27 months (range 7-166). The mean follow-up was 52 months (range 6-111). The mean tourniquet time was 97 minutes (range 66-135) for graft and 84 minutes (55-120) for graftless. The mean finger abduction was 57° (32°-80°) for graft and 54° (38°-80°) for graftless. The mean web creep score was 1.2 (0-3) for graft and 2.1 (0-3) for graftless. The mean scar score was 1.9 (1-3) bilaterally. The mean parents' visual analogue scale for graft cosmesis was 7.1 (5-9) and 6.2 (4.3-8) for graftless. The surgeon's visual analogue scale for graft was 7.9 (6.4-9.5) and 6.2 (4-8.7) for graftless. The therapist's visual analogue scale was 7.9 (6.5-10) and 6.4 (4.7-8) for graftless. Although there is a longer tourniquet time with grafting, there may be advantages in appearance and web creep. Level of evidence: II.

A cross-sectional study of long-term satisfaction after surgery for congenital syndactyly: does skin grafting influence satisfaction?

Syndactyly correction without skin grafting is advocated because it prevents graft-related complications and donor site morbidity. In this cross-sectional study, we compared satisfaction among patients who underwent correction with and without skin grafting to determine preference based on subjective and objective parameters. Retrospective chart analysis was performed among 27 patients (49 webs) who were seen at follow-up after a median follow-up period of 7.4 years, at which the Patient and Observer Scar Assessment Scale, the Withey score and a satisfaction survey were used. Notably, there were no significant differences in complication rates or observer rated scar scores. Although the need for an additional surgical procedure was higher after skin grafting, patient-rated satisfaction scores were similar irrespective of the use of grafting. Our data suggest that corrections can best be performed without skin grafts if seeking to minimize the need for an additional procedure, but that the use of skin grafts does not appear to affect patient satisfaction. Level of evidence: IV.

Aesthetic Comparison of Two Different Types of Web-Space Reconstruction for Finger Syndactyly

BACKGROUND

Syndactyly reconstruction incorporates techniques of applying skin grafts or dorsal advancement flaps without the use of skin grafts. Comparative outcome studies of these two approaches are lacking. The authors' study compares the long-term aesthetic outcomes of these two flap techniques.

METHODS

Forty-five patients were included in the authors' study. The methods of reconstruction used were a dorsally based rectangular flap with skin graft from the groin and a dorsal pentagonal advancement flap without skin grafting. Eighteen independent raters completed a visual analogue scale and a unique classification scale to subjectively assess aesthetic outcomes. The authors used univariate analyses to determine which variables significantly influenced the outcome score. The authors then used multivariable regression models to compare the two flap types.

RESULTS

Dorsally based rectangular flaps with skin graft had statistically significantly better visual analogue scale scores and greater odds of receiving an "excellent" rating compared with dorsal pentagonal advancement flaps.

CONCLUSIONS

Despite the use of skin grafting, with its associated donor-site morbidity, dorsal rectangular flaps may offer better overall aesthetic outcomes for patients. Future comparative studies should incorporate functional and patient-reported outcomes to better assess the optimal reconstruction type.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Central Coalition Osteotomy of Phalangeal Synostoses in the Management of the Type III Apert Hand

PURPOSE

We report a technique in the management of the type III Apert hand. The proposed approach facilitates the creation of a 5-fingered hand in 3 stages.

METHODS

We reviewed records of patients with Apert syndrome and type III hands surgically treated at our institution from 1995 through 2014. In all cases, syndactyly release was performed in 3 stages with prioritization of the border digits. In addition, limited retrograde, axial osteotomies between the phalangeal segments of the conjoined index, middle, and ring fingers were performed during the first stage. Medical records were reviewed for demographics, clinical presentation, operative findings, and postoperative outcomes.

RESULTS

Twelve pediatric patients with type III hands underwent syndactyly release. Median patient age was 10.0, 15.8, and 29.6 months at operative stages 1, 2, and 3, respectively. A thumb and 4 fingers were achieved for all but 1 hand. The median duration of hospital stay was 2 days for each stage. No infections or major complications were observed.

CONCLUSIONS

We demonstrate this method as a safe and effective means of creating 5 digits in the Apert patient with type III hands. Our opinion is that the additional aesthetic and functional gains offset the requirement of a 3-stage approach.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Incidence of Acute Complications Following Surgery for Syndactyly and Polydactyly: An Analysis of the National Surgical Quality Improvement Program Database from 2012 to 2014

PURPOSE

Congenital hand differences are infrequent phenomena, and their treatment represents a relatively small fraction of cases performed by hand surgeons. Little is known about the incidence of wound complications and acute postoperative problems given the relative rarity of these procedures. This study sought to characterize the incidence of complications within 30 days of surgery for congenital hand differences.

METHODS

The National Surgical Quality Improvement Program (NSQIP) contains prospective data regarding 30-day morbidity from 64 pediatric centers across the United States. Data from all available years (2012-2014) were queried for Current Procedural Terminology (CPT) codes pertinent to the treatment of congenital hand differences. Bivariate statistics, Fisher exact tests and Poisson 95% confidence intervals (95% CI) were used to assess the incidence of complications and examine risk factors for these outcomes.

RESULTS

We identified a total of 1,656 congenital hand cases that represented 4 different CPT codes, including surgery for simple syndactyly, complex syndactyly, and polydactyly. The overall incidence of complications was 2.2% (95% CI, 1.6%-3.1%; n = 37) with the most common complication being superficial surgical site infection (1.7%; 95% CI, 1.1%-2.4%) followed by related readmission (0.3%; 95% CI, 0.1%-0.7%). There was a higher incidence of complications observed in patients undergoing complex syndactyly repair (5.2% for complex syndactyly repair vs 2.3% for all others).

CONCLUSIONS

The rate of acute complications following procedures to correct syndactyly and polydactyly is low, the most common of which is superficial surgical site infection. The incidence of acute complications may be helpful in counseling patients and families. We suggest that further research must prioritize collecting data on long-term functional outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.