Unusual complication of ligation of rudimentary ulnar digit

Surgical Excision of Postaxial Polydactyly Type B in the Office Setting

BACKGROUND

Simple postaxial polydactyly (type B) is a common congenital hand malformation often treated by suture or clip ligation.

METHODS

We present a case series of patients with simple postaxial polydactyly treated by surgical excision using local anesthesia in an office setting.

RESULTS

The procedure was performed on 78 digits in 48 children with a mean age of 10.2 weeks. There were no intraoperative or early postoperative complications. A follow-up by phone interview was performed at an average of 3.2 years postoperatively. All patients were reported to be pain-free and have normal function without a perceived range of motion deficits. All parents selected the highest level of satisfaction regarding cosmetic outcomes and overall experience with the procedure.

CONCLUSIONS

These results demonstrate that an office-based surgical excision is a safe, effective, and economical treatment option and has developed into our standard of care for this common condition.

Local Anesthesia Alone for Postaxial Polydactyly Surgery in Infants

BACKGROUND

Surgical excision for postaxial polydactyly type B is advocated to avoid long-term complications. Excision with local anesthesia (LA) in infancy represents a safe and effective treatment for this condition, although general anesthesia (GA) is employed by many surgeons. We present a comparison of surgical outcomes, cost, and time between LA and GA to support widespread change in management.

METHODS

A retrospective review of patients under 12 months of age undergoing surgical polydactyly excision by a single surgeon was performed. Anesthesia type, patient demographics, and complications were recorded. Comparisons were made between LA and GA groups on procedure cost, operating time, length of stay (LOS), and time from procedure end to discharge. Stepwise forward regression was used to identify the best model for predicting total costs.

RESULTS

Ninety-one infants with a mean age of 3 months (±1.9) were examined; 51 (56%) underwent LA alone, 40 (44%) underwent GA. Mean operating time was 11.53 ± 4.36 minutes, with no difference observed between anesthesia groups (P = .39). LA infants had a significantly shorter LOS (2.5 vs 3.5 hours; P < .05), quicker postoperative discharge (32 vs 65 minutes, P < .05), and fewer overall expenses, 2803 vs 6067 U.S. dollars (USD), P < .05. Two minor surgical complications (1 in each group) were reported.

CONCLUSIONS

This study demonstrates significantly decreased cost, LOS, and time to discharge using LA alone for surgical excision of postaxial polydactyly type B. Results suggest the approach is quick, economical, and avoids the risks of GA in early infancy.

Excision of Rudimentary Preaxial Polydactyly of the Hand with Use of Electrocautery

Background

Suture ligation has been used widely for the treatment of rudimentary type extra digits, but several complications related to this treatment have been reported. The purpose of this study was to describe a new technique for excision of rudimentary preaxial polydactyly of the hand using electrocautery and assess its clinical outcomes.

Methods

The authors performed a retrospective study of 34 thumbs (32 patients) that had undergone excision of rudimentary preaxial polydactyly using electrocautery under local anesthesia. The mean follow-up period was 16.5 months.

Results

All children had full range of thumb motion without angular deformity at the most recent follow-up. There were no postoperative complications such as bleeding or infection. In 33 thumbs (97.1% of 34 thumbs), there were no signs of residual digit prominence. One thumb had a residual digit prominence at the extra digit removal site. In two thumbs, scar hypertrophy was evident at the operation site. All parents of the patients except two were very satisfied with this technique and the mean visual analog scale score for satisfaction was 9.5 ± 2.0 (range, 0–10).

Conclusions

Excision of rudimentary preaxial polydactyly of the hand with the use of electrocautery could remove an extra digit completely in 97.1% of the cases. This technique would be a useful alternative to suture ligation, surgical clip application, or surgical excision for the treatment of rudimentary preaxial polydactyly of the hand.

To Tie or Not to Tie: A Systematic Review of Postaxial Polydactyly and Outcomes of Suture Ligation Versus Surgical Excision

Background: Ulnar polydactyly is frequently encountered in the newborn nursery and is commonly treated with bedside suture ligation. However, growing concern about the complications associated with suture ligation has led some practitioners to advocate for primary surgical excision instead. Thus, we set out to compare outcomes of suture ligation and surgical excision by systematic appraisal of the literature. Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review was performed to identify studies published between 1950 and 2017 that described outcomes of suture ligation, surgical excision, or both. Baseline characteristics, complications, and study quality were extracted for each included article. Results: A total of 900 articles were reviewed, of which 10 studies (8 case series, 2 comparative analyses) met the inclusion criteria. There was considerable heterogeneity among the studies with respect to patient characteristics and reported outcomes. There were 2 retrospective case series of suture ligation that reported no acute complications and a variable proportion of patients with residual remnants or neuromas. Studies evaluating surgical ligation reported no acute or long-term complications, with only 1 case series reporting a small percentage of residual remnants. However, in the largest cohort analysis, the difference in complication rate was reported to be as high as 23.5% for suture ligation compared with 3% for surgical excision. Conclusions: There is a paucity of literature limiting the comparison of suture ligation and surgical excision for ulnar polydactyly. Further studies are required to determine the optimal treatment.

Polydactyly of the Hand

Polydactyly is one of the most common congenital hand deformities managed by orthopaedic surgeons. It is most often found in isolation; however, rarely, it may be associated with genetic syndromes. Polydactyly is classified as postaxial, preaxial, or central depending on the radioulnar location of the duplicated digits. Postaxial polydactyly, which affects the ulnar side of the hand, is most common and is typically managed with excision or suture ligation of the supernumerary digit. Preaxial polydactyly, which affects the thumb or radial side of the hand, often requires reconstructive techniques to ensure a functional, stable thumb. Central polydactyly is much less common, and reconstruction can be challenging.

Management of complications of congenital hand disorders

This article reviews treatment and presents complications seen in the treatment of 7 common congenital hand differences, including syndactyly, camptodactyly, ulnar and radial polydactyly, thumb hypoplasia, radial longitudinal deficiency, and epidermolysis bullosa. The management of these conditions is challenging but has evolved over the last several decades with refined understanding of the disease processes and treatments. The goal of this article is to synthesize prior knowledge and provide further insights into these conditions that will help the surgeon avoid treatment complications.

Complications of suture ligation ablation for ulnar polydactyly: a report of two cases

We report two cases resulting in complications following suture ligation treatment for ulnar polydactyly. One case consisted of bilateral, retained gangrene and cellulitis, and a second case consisted of a residual, sensitive skin tag. The case involving gangrene and cellulitis developed after an unsuccessful suture ligation of bilateral pedunculated duplicated digits. The second case developed after suture ligature ablation of a rudimentary digit in the nursery but presented 3 years later with a residual symptomatic nubbin. Both cases were treated by surgical excision of the residual tissue in the operating room. The first case illustrates a morbid complication following unsuccessful ligature while the second case demonstrates the inevitable suboptimal long-term outcome associated with what has traditionally been considered "successful" suture ligation.

Rudimentary polydactyly in an adult: an unusual presentation to a dermatological surgery unit

Accessory digits or polydactyly present uncommonly to dermatologists. Usually they are treated by ligature in the neonatal period or by surgery in childhood. We report a 38-year-old man who presented to a dermatological surgery unit for treatment of a lifelong lesion on the ulnar aspect of his right fifth finger. Clinically this appeared to be a miniature accessory digit and this was discussed with the patient. Subsequent histological examination of the excision specimen confirmed the clinical diagnosis. Further questioning of the patient revealed a strong family history of polydactyly.

Surgical excision of pedunculated supernumerary digits prevents traumatic amputation neuromas

Nine patients divided into two groups were treated for pedunculated supernumerary digits or their sequelae. The first group consisted of three patients who had among them five traumatic amputation neuromas. In each case these lesions resulted from primary suture ligation of accessory digits in infancy. Secondary surgical excision of the vestigial digit with high ligation and retraction of the accompanying nerve tissue was required in all cases. The second group consisted of six patients who had 12 pedunculated supernumerary digits. Primary surgical excision of these digits was performed with high transection and retraction of the accompanying accessory digital nerve. All patients in this group had excellent cosmetic results with no postoperative neuroma formation. Adult family members who had undergone suture ligation of similar supernumerary digits in infancy accompanied seven of the nine patients in this series. On careful examination, each of these family members had signs and symptoms attributable to traumatic amputation neuromas. We feel identification and high transection of the accessory digital nerve is essential in the treatment of pedunculated supernumerary digits. This treatment prevents traumatic amputation neuromas and yields a better cosmetic result than the traditional method of suture ligation in infancy.