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Wall LB, Goldfarb CA. Syndactyly Reconstruction Technique Utilizing Skin Substitute. Tech Hand Up Extrem Surg 2024; 28:60-61. [PMID: 38385451 DOI: 10.1097/bth.0000000000000473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Syndactyly reconstruction often times leaves areas of skin deficit that require coverage for healing. Numerous techniques have been reported to address the deficits, including graftless technique, which utilizes mobilization of adjacent skin for coverage, full-thickness skin grafting, and skin substitute grafts. The technique described here demonstrates the ease of the use of skin substitutes for coverage in syndactyly reconstruction and reports the expected outcomes.
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Affiliation(s)
- Lindley B Wall
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO
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Kelley NH, Shaver TL, Morrell NT. Reconstruction of a Pediatric Distal Phalanx Amputation With Stacked Integra Dermal Substitute: A Case Report. Cureus 2024; 16:e58856. [PMID: 38800231 PMCID: PMC11116031 DOI: 10.7759/cureus.58856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
Finger amputations in children present unique challenges and require special considerations compared to their adult counterparts. Maximizing length and preserving fingertip bulk and sensation is essential for maintaining a functional digit. Synthetic dermal substitutes have been recently used for soft tissue coverage for pediatric syndactyly as well as burn injuries; however, the literature discussing pediatric amputation cases with soft tissue damage proximal to the bony level is limited.In this case, we report a two-year-old patient who developed dry gangrene of her right index finger after multiple rabbit bites and underwent an amputation through the distal interphalangeal joint. Circumferential soft-tissue debridement proximal to the tip of the middle phalanx was required, leaving substantial exposed bone with no soft tissue envelope. We report our experience of single-stage stacking Integra dermal substitute directly onto the exposed bone to provide both finger bulk and soft tissue coverage.The patient displayed no functional limitations three years post-surgery.For instances when local or distant flap coverage may not be feasible, we present a novel technique to reconstruct, provide bulk, and preserve length in pediatric finger amputations. This case highlights that the utility of dermal substitutes is expanding and are providing more technical options.
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Affiliation(s)
- Naomi H Kelley
- Orthopedics Hand Surgery, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Tori L Shaver
- Orthopedics Hand Surgery, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Nathan T Morrell
- Orthopedics Hand Surgery, University of New Mexico Health Sciences Center, Albuquerque, USA
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McCarter JH, Zeledon RA, Cole SH, Layon SA, Nguyen JL. Common Pediatric Hand Anomalies. Semin Plast Surg 2023; 37:275-286. [PMID: 38098681 PMCID: PMC10718657 DOI: 10.1055/s-0043-1777096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Upper extremity congenital anomalies in the newborn are second only to congenital heart anomalies. Some of the more commonly encountered upper extremity anomalies are trigger thumb, thumb hypoplasia, polydactyly, syndactyly, and amniotic band syndrome. While some conditions occur in isolation, others are known to commonly occur in association with syndromes. Familiarity with these conditions is important not only to provide adequate evaluation and workup of these patients but also to deliver appropriate surgical intervention and prepare parents with appropriate expectations. In this article, we outline the etiology, classification, surgical management, and outcomes of these five commonly encountered upper extremity congenital anomalies.
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Affiliation(s)
- Jacob H. McCarter
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Ricardo A. Zeledon
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Samuel H. Cole
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Sarah A. Layon
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Jenny Lee Nguyen
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
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Shah A, Bohn DC, Van Heest AE, Hu CH. Congenital Upper-Limb Differences: A 6-Year Literature Review. J Bone Joint Surg Am 2023; 105:1537-1549. [PMID: 37624908 DOI: 10.2106/jbjs.22.01323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
➤ The Oberg-Manske-Tonkin (OMT) classification of congenital hand and upper-limb anomalies continues to be refined as our understanding of the genetic and embryonic etiology of limb anomalies improves.➤ We have conducted an evaluation of graft and graftless techniques for syndactyly reconstruction; strengths and drawbacks exist for each technique.➤ Treatment for radial longitudinal deficiency remains controversial; however, radialization has shown promise in early follow-up for severe deformities.➤ Recent emphasis on psychosocial aspects of care has demonstrated that children with congenital upper-limb differences demonstrate good peer relationships and marked adaptability.
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Affiliation(s)
- Ayush Shah
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
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Patel NK, Toyoda Y, Grunzweig KA, Shah AS, Mendenhall SD. Recent Advancements in the Diagnosis and Treatment of Congenital Hand Differences. J Am Acad Orthop Surg 2023; 31:766-782. [PMID: 37384928 DOI: 10.5435/jaaos-d-23-00302] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/26/2023] [Indexed: 07/01/2023] Open
Abstract
Congenital hand and upper limb differences include a wide spectrum of structural abnormalities that affect functional, appearance, and psychosocial domains of affected children. Ongoing advances in the understanding and treatment of these differences continue to shape management. Over the past 10 years, new developments have been made in areas of molecular genetics, noninvasive treatments, surgical techniques, and outcome measures in several commonly seen congenital hand differences. Applying these advances in knowledge and management of congenital hand differences will enable surgeons to achieve the best outcomes possible for these children.
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Affiliation(s)
- Niki K Patel
- From the Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia (Patel, and Mendenhall), the Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania (Toyoda), the Perelman School of Medicine at the University of Pennsylvania (Toyoda, Grunzweig, Shah, and Mendenhall), the Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania (Grunzweig, and Shah), and the Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA (Shah, and Mendenhall)
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Mahindroo S, Tabaie S. Syndactyly in the Pediatric Population: A Review of the Literature. Cureus 2023; 15:e36118. [PMID: 36937133 PMCID: PMC10016737 DOI: 10.7759/cureus.36118] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Syndactyly is one of the most common congenital upper extremity deformities. Syndactyly can be described as either simple, involving just the skin and soft tissue, or complex, involving the phalanges. Additionally, syndactyly can be categorized as complete, involving the entire digit (including the nail fold), or incomplete, which does not involve the nail fold. Multiple familial or spontaneous genetic abnormalities can cause syndactyly, and these mutations typically involve the canonical wingless-type (WNT) pathway. Surgical repair of syndactyly is typically done between six to 18 months of age, depending on the type of syndactyly. Regardless of the classification of the syndactyly, the repair is performed before school-going age (except in the case of extremely mild or rare, extremely complex syndactyly). One or more imaging modalities are used to aid the surgeon in deciding the surgical approach for the syndactyly repair. The surgical plan must be clearly communicated with parents to manage expectations of aesthetics and function of the digits post-surgery. In brief, a syndactyly release surgery involves the creation of the web space using a geometrical design of the surgeon's choice, defatting of finger flaps, separation of the digits, and closure with absorbable sutures. However, the approach may vary depending on the patient. A "best" approach for rectifying the difference in surface area of separated versus fused digits has not yet been determined. While this was typically done using a skin graft, the use of alternative methods (most notably, using a synthetic dermal substitute or not using a graft at all and allowing the skin to heal with secondary intention) has been on the rise given the undesirable side effects of a graft. Less commonly, an external fixator can be used to expand soft tissue and skin. In the case of complete syndactyly, the Buck-Gramcko technique is most commonly used for nail flap reconstruction. Complications of the surgery include contracture, web creep, and the need for a second surgery. Thus, parents must be counseled in recognizing signs of complications.
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Affiliation(s)
- Sonal Mahindroo
- Orthopedic Surgery, George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Sean Tabaie
- Orthopedic Surgery, Children's National Hospital, Washington DC, USA
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Reliability and validity of Vancouver Scar Scale and Withey score after syndactyly release. J Pediatr Orthop B 2022; 31:603-607. [PMID: 35502746 DOI: 10.1097/bpb.0000000000000983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study aimed to analyze the reliability and validity of the Vancouver Scar Scale (VSS) and the Withey score after syndactyly release. Over a 3-year period, 13 patients who underwent syndactyly release were evaluated. The mean age at the time of syndactyly release was 12 months (range, 8-18 months), and the mean follow-up period was 29 months (range, 17-52 months). We obtained hand photographs and finger motion videos and collected the satisfaction scores for hand function and cosmesis. Three clinicians evaluated the hand photographs and finger motion video of each patient twice using the VSS and the Withey score. The interobserver and intraobserver reliabilities of the VSS and Withey score were determined using intraclass correlation coefficients (ICCs). The validity of the VSS and Withey score was determined using Spearman's correlation test with the functional and cosmetic satisfaction score. The ICCs for the interobserver reliability of VSS were 0.31 and 0.39 for each measurement, and ICCs for the intraobserver reliability of VSS were 0.46, 0.51, and 0.54 for each observer. The ICCs for the interobserver reliability of the Withey score were 0.74 and 0.70, and the ICCs for the intraobserver reliability of the Withey score were 0.91, 0.74, and 0.96. The Withey score was significantly correlated with the satisfaction score for hand function and hand cosmesis, but the VSS was not. The VSS had poor interobserver reliability and fair intraobserver reliability, whereas the Withey score had good interobserver reliability and excellent intraobserver reliability based on photographic evaluation after syndactyly release.
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An Update and Report Failure of Surgical Syndactyly Repair in Harlequin Ichthyosis. Plast Reconstr Surg Glob Open 2022; 10:e4594. [PMID: 36262679 PMCID: PMC9575953 DOI: 10.1097/gox.0000000000004594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022]
Abstract
Harlequin ichthyosis (HI) is a rare congenital skin disorder caused by irregular epidermal differentiation. Syndactyly in HI is associated with thick hyperkeratotic skin flexion and angulation deformity of the hand and fingers resulting in limited function of the upper extremity. Traditional syndactyly release is limited as full-thickness skin grafts typically used in reconstruction are composed of diseased skin and require donor sites in a patient predisposed for adverse wound healing. This case report is a follow-up to a previous viewpoint written about digital escharotomies in a newborn with HI and outlines a second and fourth webspace syndactyly release with a dermal substitute. Despite early evidence of adequate release and improved hand function, recurrence of syndactyly was observed within 4 months of surgical release. Our experience described within this case report may suggest the limitations and possible alternatives of surgical release of syndactyly in the HI population.
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Andras LM, Abousamra O. What's New in Pediatric Orthopaedics. J Bone Joint Surg Am 2021; 103:287-294. [PMID: 33369978 DOI: 10.2106/jbjs.20.01953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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