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

Refinement of Surgery for Postaxial Polysyndactyly of the Toes: Esthetic Outcome in Japanese Feet

PURPOSE

Treatment for polysyndactyly of the toes aims at cosmetic improvement but the lateroplantar rotation of the new fifth toe remains challenging. This study evaluated our novel surgical procedure for postaxial polysyndactyly of the toes.

MATERIALS AND METHODS

Patients with postaxial polysyndactyly involving the fourth, fifth, and sixth toes treated in 2007 to 2017 with a minimum follow-up duration of 1 year were retrospectively investigated. Our aims of surgery for this condition were to avoid excessive lateroplantar rotation of the new fifth toe by using a proximally elongated plantar "shark-fin flap" and to make the tip of this toe appear to be naturally pointing inward by using the dog-ear component of the flap on the tip of the toe. The excess skin of the shark-fin flap was grafted onto the lateral surface of the fourth toe. Lateroplantar rotation of the fifth toe in these patients was compared with that in photographs of the feet of 96 normal 4-year-old children.

RESULTS

A total of 11 feet in 10 patients (6 male, 4 female; mean age 1.3 years) were analyzed. Syndactyly between the fourth and fifth toes was complete in 3 feet, incomplete at the level of the distal interphalangeal joint of the fifth toe in 5, and incomplete at the level of the proximal interphalangeal joint of the fifth toe in 3. Lateroplantar rotation of the fifth toe, evaluated by the mean angle between 2 intersecting lines extending from the proximal nail fold of the third and fifth toes, was 25 ± 10° in normal feet and 0 ± 12° in operated feet with polysyndactyly. The absolute left-right difference in this angle was 7 ± 5° in normal children and 22 ± 12° in patients with polysyndactyly. Valgus deformity of the new fifth toe improved in all patients during a mean postoperative follow-up of 3.8 years.

CONCLUSIONS

Using our procedure, no excessive lateroplantar rotation has been observed when the tip of the fifth toe is inclined inward using a dog-ear flap component. This procedure could be useful in patients in whom the cosmetic outcome is a priority.

Surgical excision and skin grafting combined with intralesional injection of triamcinolone for the treatment of keloids after syndactyly release

The purpose of this study was to investigate the efficacy of surgery combined with triamcinolone acetonide injection in managing the difficult problem of keloid formation after syndactyly release. Twenty-two patients with keloid formation after syndactyly release were retrospectively reviewed. They were divided into a simple surgery group and a surgery plus injection group. Complications, web quality, scar score and satisfaction were assessed and compared. In the surgery plus injection group, three patients (3/13) experienced recurrence and ten webs were good, whereas in the simple surgery group, seven patients (7/9) experienced recurrence and five webs were poor. The mean Vancouver Scar Scale score was significantly lower (4.3 versus 7.8) and the mean Faces Questionnaire satisfaction score was higher (4.2 versus 2.6) in the surgery plus injection group. Combining surgical excision with early and repeated intralesional injection can achieve better results with low recurrence rate and side effects.Level of evidence: IV.

Current Debates on Etiopathogenesis and Treatment Strategies for Vitiligo

Vitiligo is an acquired, chronic, and progressive depigmentation or hypopigmentation characterized by the destruction of melanocytes and the occurrence of white patches or macules in the skin, mucosal surface of eyes, and ears. Melanocytes are the melanin pigment-producing cells of the skin which are destroyed in pathological conditions called vitiligo. Approximately 0.5 - 2.0% of the population is suffering from vitiligo, and a higher prevalence rate of up to 8.8% has been reported in India. It is caused by various pathogenic factors like genetic predisposition, hyperimmune activation, increased oxidative stress, and alteration in neuropeptides level. Genetic research has revealed a multi- genetic inheritance that exhibits an overlap with other autoimmune disorders. However, melanocytes specific genes are also affected (such as DDR1, XBP1, NLRP1, PTPN22, COMT, FOXP3, ACE, APE, GSTP1, TLR, SOD, and CTLA-4). A number of therapeutic options are employed for the treatment of vitiligo. The topical corticosteroids and immunomodulators are currently in practice for the management of vitiligo. Phototherapies alone and in combinations with other approaches are used in those patients who do not respond to the topical treatment. The main focus of this review is on the etiopathological factors, pharmacological management (phototherapy, topical, systemic, and surgical therapy), and herbal drugs used to treat vitiligo.

Pediatric Forefoot Deformities

This article explores different pediatric forefoot deformities including syndactyly, polydactyly, macrodactyly, curly toe, and congenital hallux varus. The epidemiology and genetic background are reviewed for each condition. Preferred treatment options and recommended surgical techniques are discussed with review of the current literature.

Surgical treatment in child's congenital toe syndactyly: Risk factor of recurrence, complication and poor clinical outcomes

INTRODUCTION

Surgical treatment of toe syndactyly remains controversial. The strong demand from parents for a cosmetic release is increasing in our societies. But is it worth it? The objective was to assess medium-long term outcomes and to identify the risk factors of recurrence, complication and poor clinical outcomes.

METHODS

Sixty-eight toe syndactylies (38 patients) undergoing surgery between 2008 and 2017 with a follow-up higher than two years were included consecutively and retrospectively. Four children (four syndactylies) were lost to follow-up and excluded. The mean age of the first surgery was 3.9 years old (0.8-16.7) and cohort mean follow-up was 6.9 years (2.8-11.2). In all patients, web release with a commissural dorsal flap was performed and associated a cutaneous resurfacing (spontaneous epithelialization, full-thickness skin graft taken from the popliteal crease, or a hyaluronic acid ester matrix).

RESULTS

Eighteen syndactylies (28.1%) in 14 patients recurred and one syndactyly required revision surgery. An age of surgery above two years was the only risk factor for recurrence found in univariate (OD = 0.27[0.08;0.85];p = 0.02) and multivariate studies (IC 95% = 0.05-0.68;p = 0.02). Seven complications (11.7%) in seven syndactylies (6 patients) were reported with six keloids (9.4%) and one scar retraction (1.6%). Each complication underwent an additional procedure. African ethnicity (N = 15) represents a risk factor (N = 4/15; OD = 0.12[0.009;0.97];p = 0.02) for keloids formation. Withey's average score is 4.9 (1-11), mean OxAFQ-C score was 52/60 (30-60), 67% would repeat the surgery and 69% felt satisfied at last follow-up. The simple syndactyly would appear less satisfied than complex or complicated (p = 0.02).

CONCLUSIONS

Surgical treatment of child's congenital syndactyly involves a risk of recurrence (28%) and potential complications (11,7%). Performed surgical procedure over two years old increase the risk of recurrence. African ethnicity is a risk factor in scarring complication. Only half of simple syndactylies are satisfied and prone to repeat the surgery.

Aesthetic and Anatomic Reconstruction of Polysyndactyly of the Fifth Toe Fused With the Fourth Toe

BACKGROUND

The aim of the study was to present a new operative technique for aesthetic and anatomic reconstruction of polysyndactyly of the fifth toe fused with the fourth toe.

METHODS

Surgery was performed in 86 feet in 73 patients with polysyndactyly of the fifth toe fused with the fourth toe. The operation involved polydactyly excision, syndactyly release using an improved dorsal asymmetric gullwing flap for web space reconstruction without skin grafting, and simultaneous correction of valgus deformity and brachydactyly of the toes. The web shape (height and width),scar contracture, and aesthetic outcomes (foot contour and morphology of the reconstructed fifth toe) were assessed using the criterion of D'Arcangelo, Vancouver Scar Scale score, and older children and parent-based satisfactory questionnaire, respectively.

RESULTS

The patients were followed up for 12 to 36 months. The reconstructed web spaces were slightly deeper than normal, with an hourglass shape and a physiological slope. Valgus deformity was completely corrected without recurrence. The reconstructed fifth toes appeared to be visually lengthened. On the basis of the criterion of D'Arcangelo, the height and width of the webs were good in 76, fair in 10, and poor in none of the feet. The mean Vancouver Scar Scale score was 1.5. All parents and patients were satisfied with the appearance and function.

CONCLUSIONS

Our new operative procedure could achieve aesthetic and anatomic reconstruction of polysyndactyly of the fifth toe fused with the fourth toe with good shape of the reconstructed web space without skin grafting, favorable appearance and axis alignment of the reconstructed fifth toes, and good foot contour.

[Application of dorsal foot hexagonal flap for reconstruction of web space in fourth and fifth toe syndactyly combined with polydactyly]

Objective

To explore the application of the dorsal foot hexagonal flap for reconstruction of the web space in the fourth and fifth toe syndactyly combined with polydactyly.

Methods

Between May 2016 and October 2019, 27 patients (34 feet) with the fourth and fifth toe syndactyly combined with polydactyly were treated, including 12 males and 15 females with an average age of 22.8 months (range, 10 months to 8 years). There were 7 bilateral feet and 20 unilateral foot. Twenty-four of which were incomplete and 10 were complete syndactyly of the fourth and fifth toes, and the fifth toes showed various degrees of fibular deflection. All the 34 feet were treated with one-stage reconstruction of the toe web with the dorsal foot hexagonal flap, and the correction of the fibular deviation of the fifth toe was made by removing the tibial polydactyly and using the articular surface dressing or wedge osteotomy.

Results

All wounds healed by first intention without skin-frafting. All patients were followed up 6-36 months (mean, 18 months). There was no flexion contracture and obvious scar hyperplasia in all the patients, and the width and slope of the toe webs were normal. Three of the 34 webs developed web creep, and the rest of the toe webs were normal in depth. All 34 feet were corrected with peroneal fibular deviation, and the function of toe flexion was good. All parents of the children were satisfied with the outcome.

Conclusion

The reconstruction of toe webs with dorsal foot hexagonal flaps for the treatment of the fourth and fifth toes syndactyly combined with polydactyly requires no skin graft. The operation is simple with high survival rate of the flap, the appearance and function of the toes are good, and the effectiveness is satisfactory.

Toe Keloids Treated with Core Excision, Postoperative Radiotherapy, and Steroid Plaster

Although keloids are common on the joints, precordial areas, and abdomen, toe keloids are rare. The limited literature to date also suggests that they can be difficult to treat. We experienced the case of a 21-year-old woman with toe keloids on the first, second, and third toes that arose after ingrown-nail operations at another hospital. The second toe keloid was resected but recurred. Since subsequent conservative treatments were ineffective, the patient was referred to our hospital. The first visit revealed three large keloids: in particular, the keloid on the second toe had engulfed the entire circumference of the toe. Surgery with the core-excision method and postoperative radiotherapy were performed. After the sutures were removed, the scars were treated for 24 hours/day with steroid plaster until the induration disappeared. One and a half years after the operation, recurrence was not observed and the appearance of the toes had improved greatly. Thus, combination therapy composed of core excision, radiotherapy, and steroid plaster therapy is highly effective for toe keloids.

Toe keloid after nail extraction treated with surgical excision: A case report

RATIONALE

In this study, a case of toe keloid after nail extraction is presented, in which the keloids on both toes were resected by surgical excision. Keloids (from the Greek word meaning "crab's claw") are fibrous growths that extend beyond the original area of injury to involve the adjacent normal skin. In general, keloid tendencies appear to be regionally isolated to keloid-prone areas, such as the chest, ears, and deltoid regions, whereas the hands and feet are usually spared, which is why this case is meaningful.

PATIENT CONCERNS

A 20-year-old Chinese man had paronychia on both halluxes when he was 16 years old. He underwent a nail extraction at the age of 17. The nails of both halluxes were removed by nail extraction. This operation was successful, and the postoperative course was uneventful. After 6 months, the scars of the nail extraction on both sides began to exhibit hyperplasia and became red and swollen with itching. Later, the scar expanded and eroded the tissue beyond the matrix unguis. The whole matrix unguis was destroyed, and the nails were distorted. The scars began to ulcerate after 2 years. The patient used potassium permanganate to clean his wounds, but the keloid scars did not improve.

DIAGNOSES

The patient was diagnosed as toe keloid based on his history and symptoms. The biopsy result supported our diagnoses.

INTERVENTIONS

The toe keloids were effectively cured by surgical excision and skin flap transplantation combined with postoperative irradiation and hyperbaric oxygen (HBO) treatment.

OUTCOMES

No recurrence was detected during the period from 6 to 24 months of follow-up after the surgery.

LESSONS

In this case, the trauma of the nail extraction was likely the key cause of the keloid. However, the patient was also predisposed to keloids, as we observed keloids on his chest. In general, keloid tendencies appear to be regionally isolated to keloid-prone areas such as the chest, ears, and deltoid regions, whereas the hands and feet are usually spared, which is why this case is meaningful.

The Double Volar Flap Technique for Aesthetic Repair of Syndactyly and Polysyndactyly of Toe without Skin Grafting

BACKGROUND

Aesthetic repair of syndactyly of the toes is desirable because patients may have psychological concerns about its appearance. There are 2 important factors for the aesthetic repair of syndactyly of the toe. One is to hide the operative scar from the visual site (dorsal site), whereas the other is to create an interdigital space close to the normal anatomical skin characteristics (2 general types of skin: glabrous and hairy).

METHODS

In total, 12 patients (4 males and 8 females) with 15 syndactylous webs were operated on by using the double volar flap technique. The following 3 local flaps were designed with this technique: an M-shaped flap designed on the dorsal side of the interdigital region (flap A) and double volar flaps (flaps B and C) designed on the volar side of the interdigital region. Flap A was used for reconstruction of the web slope, whereas flaps B and C were used for reconstruction of the proximal sidewall of toes.

RESULTS

The corrected toes showed a deep and natural interdigital commissure with no exposure of skin grafts or conspicuous scars on the dorsal visible side. The scars on the volar side were also inconspicuous.

CONCLUSIONS

The double volar flap method for repair of syndactyly and polysyndactyly of the toes has the same advantages as those of the local flap method, in addition to an optimum aesthetic result through matching with the normal anatomical skin characteristic of the interdigital space and hiding of the operative scar from the visual site.

Foot Syndactyly: A Clinical and Demographic Analysis

BACKGROUND

Syndactyly of the foot is the second most common congenital foot anomaly. In East Asia, however, no large case study has been reported regarding the clinical features of isolated foot syndactyly. In this study, we report a review of 118 patients during the last 25 years.

METHODS

We conducted a chart review of patients who underwent surgical correction for foot syndactyly between January 1990 and December 2014. Operations were performed with a dorsal triangular flap and a full-thickness skin graft. The demographics of included patients and their clinical features were evaluated. Surgical outcomes and complications were analyzed.

RESULTS

Among 118 patients with 194 webs (155 feet), 111 patients showed nonsyndromic cases and 7 patients showed syndromic cases. In 80 unilateral cases (72.1%), the second web was the most frequently involved (37.5%), followed by the fourth (30%), the first (15%), the third (15%), the first and second in combination (1.3%), and the second and third in combination (1.3%). Among 31 bilateral cases, 2 cases were asymmetric. Among the remaining 29 symmetric bilateral cases, the second web was the most frequently involved (45.2%), followed by the first (22.6%), and the fourth (6.5%). No specific postoperative complications were observed, except in the case of 1 patient (0.51%) who required a secondary operation to correct web creep.

CONCLUSIONS

This retrospective clinical study of 118 patients with both unilateral and bilateral foot syndactyly revealed that the second web was the most frequently involved. In addition, complete division and tension-free wound closure with a full-thickness skin graft of sufficient size showed good postoperative results.

Technique of Dorsal Transversely Oriented Transposition Flap for Web Reconstruction in Toe Syndactyly Surgery

In toe desyndactyly, a dorsal or plantar commissural flap, combined with skin grafts, will ensure an acceptable result. However, the parallel unsightly scars in the longitudinal direction on the dorsum of the toes will sometimes fail to satisfy the patient's and/or the parents' aesthetic expectations. To address this issue, we developed a technique using a transversely oriented transposition flap for web reconstruction, which can spare the dorsal interdigital skin maximally to shift the dorsal scars plantarly such that they become inconspicuous. The design of the flap is simple and uncomplicated surgically. Moreover, the donor site morbidity is minimal, owing to the good healing potential of the transverse scars. This technique could be an alternative in web reconstruction of toe desyndactyly, especially in cases with high cosmetic priority.

A toe keloid after syndactyly release treated with surgical excision and intralesional steroid injection

Summary:

A keloid is a benign fibroproliferative disease of unknown etiology. Although it is common among Asians, the development of keloid on the foot is rare. We experienced a case of a keloid which arose on the foot of a 4-year-old boy after the surgical release of syndactyly. He had congenital cutaneous syndactyly of the third and fourth toes. After the reconstructive operation was performed when the patient was 2 years old, the wound became hypertrophic and grew to 37 × 37 × 8 mm. After the diagnosis of keloid based on a pathological examination, the keloid was resected completely. The web was reconstructed with a planter rectangular flap, and the skin defects were covered with a full-thickness skin graft. After the operation, we administered 5 intralesional steroid injections. Finally, the keloid was diminished 2 years after the operation.

Metatarsal transfer for the treatment of post-axial metatarsal-type foot synpolydactyly: a new technique that allows for comfortable shoe wearing

We analysed the clinical and radiological outcomes of a new surgical technique for the treatment of heterozygote post-axial metatarsal-type foot synpolydactyly with HOX-D13 genetic mutations with a mean follow-up of 30.9 months (24 to 42). A total of 57 feet in 36 patients (mean age 6.8 years (2 to 16)) were treated with this new technique, which transfers the distal part of the duplicated fourth metatarsal to the proximal part of the fifth metatarsal. Clinical and radiological assessments were undertaken pre- and post-operatively and any complications were recorded. Final outcomes were evaluated according to the methods described by Phelps and Grogan. Forefoot width was reduced and the lengths of the all reconstructed toes were maintained after surgery. Union was achieved for all the metatarsal osteotomies without any angular deformities. Outcomes at the final assessment were excellent in 51 feet (89%) and good in six (11%). This newly described surgical technique provides for painless, comfortable shoe-wearing after a single, easy-to-perform operation with good clinical, radiological and functional outcomes.

Correction of postaxial metatarsal polydactyly of the foot by percutaneous ray amputation and osteotomy

Polydactyly of the foot is a congenital anomaly characterized by the appearance of all or part of 1 or more additional rays. The patient with this condition might complain of an abnormal cosmetic appearance or difficulty with footwear. A minimally invasive technique for correction of postaxial metatarsal polydactyly of the foot is presented in this techniques report.