Two-stage reconstruction of apert acrosyndactyly

Clinical and operative risk factors for complications after Apert hand syndactyly reconstruction

This study evaluated how Apert hand syndactyly presentations and reconstructive techniques influence reconstruction outcomes. All cases at a major paediatric hospital between 2007 and 2022 were analysed, including 98 web space reconstructions in 17 patients. Overall, 62% of hands developed complications and 15% required revision surgery. Upton hand type was significantly associated with postoperative complication incidence, specifically including range-of-motion deficits, flexion contracture, web creep and revision surgery. More severe syndactylies may benefit from additional measures to reduce complications. Rectangular commissural flaps showed 1.9 times greater complication risk than interdigitating triangular flaps, including 11.2 times greater risk of web creep. Zigzag volar finger flaps showed 1.8 times greater complication risk than straight-line incisions, including 3.8 times greater risk of web creep. Our study showed that interdigitating triangular commissural flaps and straight-line volar finger incisions are preferable to rectangular commissural and zigzag finger flaps in most cases of Apert hand syndactyly to minimize complications.

LEVEL OF EVIDENCE

III.

Congenital nail abnormalities

Congenital nail disorders are an uncommon presenting symptom which can be difficult to diagnose and manage. Nail diseases in the pediatric population differ from those in adults in terms of diagnosis, approach and management. In most cases, they do not require treatment and resolve with growth. Physicians need to be able to recognize them, to reassure the parents. The most frequently encountered pathologies associated with nail disorder are syndactyly, acrosyndactyly, symbrachydactyly, macrodactyly, Wassel I thumb duplication, Kirner's deformity and congenital onychodysplasia of the index finger. Treatment usually consists in surgical correction of the deformity. Nail malformation can also be an aspect of a systemic disease. It may provide a clue for screening, and should not be overlooked. Nail conditions can be the first sign of nail-patella syndrome, ectodermal dysplasia, dyskeratosis congenita, epidermolysis bullosa, pachyonychia congenita or lung disease. Medical treatment is therefore discussed on a case-by-case basis.

Outcomes of Apert Syndrome Hand Reconstruction With Tilapia Skin: A Prospective Study

BACKGROUND

Tilapia skin has already been used in various medical scenarios, but there are no studies showing the use of tilapia skin for hand reconstruction in Apert syndrome. The objective of this study is to determine whether the use of tilapia skin during graft bed preparation for children with Apert syndrome can shorten wound reepithelialization intervals, reduce the number of dressing changes, and decrease patient discomfort.

METHODS

This is a prospective study on consecutive patients with Apert syndrome who underwent hand reconstruction at our Hospital. Patients were divided into 2 groups: (1) a control group consisting of patients who underwent conventional digit separation hand reconstruction surgery (2) an experimental group consisting of patients who underwent similar digit separation hand reconstruction surgery that commenced with the placement of a thin layer of tilapia skin at the raw commissures during a first operation, which was subsequently replaced by an autologous skin graft during a second operation staged 10 days postoperatively. Pain assessment was performed using the Visual Analog Scale. The number of dressing changes was also assessed. A T test compared the total number of dressings changes and pain data.

RESULTS

Experimental group patients (n = 8) required an average of 9.4 days of daily dressing changes, and control group patients (n = 5) required an average of 20.8 days of daily dressing changes ( P < 0.05) and tended to experience significantly less pain when compared with patients in the control group ( P = 0.079).

CONCLUSION

Tilapia skin can shorten wound reepithelialization intervals by reducing the total number of dressing changes.

Satisfying Clinical and Functional Results in 12 Apert Children Treated With Soft Tissue Distractor

BACKGROUND

The complex syndactyly in Apert syndrome hands is challenging to operate. The synostosis and tightness of skin between third and fourth digits lead to severe coverage problems during ray release. A soft tissue distractor can simplify the release with the aim to keep all 10 fingers.

METHODS

A retrospective follow-up of 12 patients/24 hands, median age 8 years (6 to 17 y), 6 boys and 6 girls, operated between 2000 and 2013 was done from 2015 to 2016. The surgical management started with syndactyly release of the first and fourth web, and later of the second. The third stage was placing a soft tissue distractor on the third and fourth finger after osteotomy on the synostosis between them. Four weeks of distraction and 2 weeks of rest resulted in regenerated skin between the digits giving much better coverage of the released digits at time of separation 6 weeks later. Assessment of hand function, grip strength and completion of the Patient Reported Outcome Measure CHEQ was performed.

RESULTS

Soft tissue coverage at the time of digit separation was considerably facilitated. We experienced 2 infections in 2 hands. In 18/24 hands median 2 (1 to 3) small full thickness skin grafts were needed, usually for coverage of the base of the digits. All wounds healed well. The children managed different practical tasks well, alternating between best functioning grip depending on the activity. According to CHEQ, the children did median 19 (13 to 27) activities independently and median 8 (2 to 15) nonindependently, of a total of 29. Peak strength values for 10/12 children were for the right hand median 17.8% (9.6% to 40.6%) of normative data and for left hand median 13.6% (2.4% to 20.5%) of normative data.

CONCLUSION

Soft tissue distraction facilitates the treatment of acrocephalosyndactyly hands, giving 5-fingered hands. Apert children manage many activities independently but struggled with fine motor skills demanding strength.

LEVEL OF EVIDENCE

Level IV evidence.

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.

Apert syndrome: A consensus on the management of Apert hands

INTRODUCTION

Apert Syndrome is a congenital condition characterised by primary craniosynostosis, midfacial malformations and complex symmetrical malformations of the hands and feet. The hands demonstrate one of the most complex collections of congenital upper limb deformities, posing a significant challenge for the paediatric hand surgeon. This study examines the extant literature and current practice of the four UK specialist craniofacial units regarding the management of Apert hands in order to provide a basis for guideline development.

METHODS

The current literature was reviewed. Survey-type questionnaires were distributed to the four UK specialist craniofacial units and responses analysed.

RESULTS

Management of the Apert hand is largely dictated by the degree of malformation present. Although all units aim to achieve a five digit hand, variation in the timing of surgery, operative protocols and mobilisation policies exist.

CONCLUSION

The results of this study provide an interesting snapshot of the current management of Apert hands across four UK craniofacial surgery units. The four UK units remain congruent on most areas surrounding the management of Apert hands although some minor inter-unit variation exists. A multidisciplinary approach to management remains fundamental in optimising the regain of function and aesthetically acceptable hands.

Characteristic radiographic features of the central ray in Apert syndrome

We reviewed retrospectively seven patients with Apert acrosyndactyly and measured the size of the capitate ossification centre relative to that of the hamate and determined the relative position of the middle finger metacarpal relative to the ring finger metacarpal. We then compared those parameters in 197 normal children. In all patients, the middle finger metacarpal bone had migrated proximally relative to the ring finger metacarpal and the size of the capitate ossification centre was smaller than that of the hamate. After surgical release of the middle finger, relative proximal migration of the middle finger metacarpal was partially relieved and catch-up growth of the capitate was observed within several months. As fusion of the distal phalanges creates a diamond-shaped configuration, bone growth is markedly impaired in the middle finger ray. Therefore, early separation of the middle finger may be as important as early separation of the border digits.

The Apert hand--angiographic planning of a single-stage, 5-digit release for all classes of deformity

PURPOSE

To demonstrate the utility of computed tomography angiographic planning of a single-stage, complete release of syndactyly in Apert syndrome.

METHODS

Computed tomography angiograms were performed as a preoperative planning tool in 6 patients. Five came to surgery. All had a single-stage operation for complete release of their syndactyly.

RESULTS

Five patients, ranging from Upton type 1 to type 3 Apert hand deformities, have had preoperative computed tomography angiography that delineated the vascular anatomy. This allowed planning and execution of a single-stage syndactyly release in all patients. The preoperative imaging identified noteworthy abnormalities in vascular anatomy that were incorporated into surgical planning.

CONCLUSIONS

The protocol presented allows preoperative planning and single-stage operation for complete release of syndactyly in patients with Apert syndrome.

Reconstruction of the thumb in Apert syndrome

Reconstruction of the hand in Apert syndrome continues to be one of the most daunting challenges in congenital hand surgery. The thumb presents a unique problem in these children, as it is usually short with radial angulation. In addition, there is usually a paucity of skin along the radial side of the thumb. Previous treatment strategies for correction have centered around either on osteotomy of the often fused phalanges, or release of the abnormal abductor pollicis brevis insertion. This paper presents our treatment strategy for this deformity that includes release of the abnormal abductor pollicis brevis insertion, osteotomy, and advancement flaps. By using this approach, we are able to address all of the deforming forces that cause the thumb deformity.

Congenital hand surgery: what's new and what's coming

Congenital hand surgery has advanced during the last 10 years with surgical technique improvements, the incorporation of new technologies, and an enhanced understanding of the basic pathology of upper extremity anomalies. This article reviews the literature with a survey of 70 articles from seven leading journals published in the last 12 years. The author concludes that the next decade should be even more exciting with the incorporation of an improved understanding of tissue engineering and molecular genetics into classification and treatment algorithms. Understanding the genetic pathways of normal, and therefore abnormal, development should allow improved classification schemes and intervention to prevent, modify, or remedy these birth abnormalities.

Reconstruction of the hand in Apert syndrome: a simplified approach

Children born with Apert acrocephalosyndactyly pose great challenges to the pediatric hand surgeon. Reconstructive dilemmas consist of shortened, deviated phalanges and extensive skin deficits following syndactyly release. We present a 10-year review of patients with Apert acrocephalosyndactyly who were treated with a simplified surgical approach. Between 1986 and 1996, 10 patients with Apert syndrome underwent reconstructive surgery of their hands. The overall strategy involved early bilateral separation of syndactylous border digits at 1 year of age, followed by sequential unilateral middle syndactyly mass separation with thumb osteotomy and bone grafting as needed. In these 10 patients, a total of 53 web spaces were released, 49 of which involved osteotomies for complex syndactyly. Only local flaps and full-thickness skin grafts from the groin were used in all cases to achieve soft-tissue coverage. To date, seven of the 53 web spaces have needed revision (revision rate, 13 percent). Eleven thumb osteotomies (nine opening wedge and two closing wedge) were performed. Bone grafts from the proximal ulna or from other digits were used in all cases. To date, none of these thumb osteotomies have needed revision. This early, simplified approach to the complex hand anomalies of Apert acrocephalosyndactyly has been successful in achieving low revision rates and excellent functional outcomes as measured by gross grasp and pinch and by patient and parent satisfaction.

Congenital anomalies: a 25-year overview

Expansion of the discipline of hand surgery and heightened interest in congenital problems have resulted in major advances in the treatment of congenital hand anomalies over the past 25 years. Increased experience with congenital anomalies of the hand has expanded the hand surgeon's knowledge of patterns and relationships between different anomalies resulting in new methods of classification and more logical approaches to treatment. The principles of treatment of the more common anomalies, such as syndactyly, established by prior generations of hand surgeons have been refined in details of technique. New technologies, such as distraction lengthening and free vascularized transfers, have allowed the surgeon to treat new problems and old problems in new ways. In spite of our successes, much remains to challenge hand surgeons in this new millennium, especially in the construction of joints and the expanding field of fetal surgery.