Treatment of the hands and feet in Apert syndrome: an evolution in management

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.

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.

Two-stage surgical treatment for medially angulated great toes in Apert feet by wedged corrective osteotomy with distraction of the inter-metatarsal space: A case report

BACKGROUND

One of most severe clinical problems related to Apert foot anomalies is medial angulation deformities of the great toe as the foot grows.

CASE PRESENTATION

The patient was a 22-month-old Japanese child with Apert syndrome, who had broad bilateral great toe showing medially angulated deformity. We performed two-stage surgical treatment including distraction of the remarkable narrowing the first inter-metatarsal space using an external distractor device, and the corrective wedge-osteotomy of the first metatarsal with a graft of wedged bone in the reverse direction and inter-positioning of the resected local bone between the first and second metatarsal to preserve the space. At 3 years after surgery, the patient did not have any disturbance of gait and could wear normal shoes without weight-bearing pain, and was satisfied with the appearance of the great toes.

CONCLUSION

The two-stage surgical method could be an option for surgical treatment of Apert feet.

Thumb and first webspace reconstruction in nonsyndromic congenital mitten hand with symbrachydactyly

INTRODUCTION

Nonsyndromic congenital mitten hand with thumb and index finger syndactyly is rare. Reconstruction of this condition is challenging, requiring repositioning of the thumb and creation of a wide and deep first webspace. The aim of this paper is to describe the characteristics of patients with this condition and also to describe our surgical technique.

METHODS

We describe our technique in 16 consecutive children utilizing complete mobilization of the first metacarpal and thumb as an island flap on the neurovascular bundle, with a rotational osteotomy to reposition the thumb in pronation. In addition, a dorsal M flap was used to reconstruct the first webspace. Patients in this series also had varying degrees of symbrachydactyly with hypoplastic or aplastic phalanges of the central digits.

RESULTS

There were 9 male and 7 female patients, with a mean age of 24.4 ± 22.4 months at the time of surgery. Mean follow-up was 19.1 ± 18.3 months. All reconstructions healed well. The mean thumb web distance in the affected hands was 4.2 cm (range 3.5 to 5). All reconstructed thumbs had a good opposition. Two children initially had mild hypertrophic scarring, which resolved with pressure gloves. No other complications were observed.

CONCLUSION

One-stage reconstruction of the thumb and first webspace can be effectively achieved with our technique of complete mobilization of the thumb unit, rotational osteotomy, and a dorsal interdigitating M flap.

[Developments in the Diagnosis and Therapeutic Strategy of the Apert Hand]

The necessity for early surgical correction of Apert hands for the overall child development has been highlighted repeatedly in older literature. Nevertheless, uncertainties regarding the time and the scale of the initial surgical treatment still remain. While in former times there were no regular follow-ups after the syndactyly release, we now know that during growth bony changes will develop in the Apert hand requiring regular check-ups and, in some cases, revision surgeries. Affected parents need comprehensive clarification about a clear and time-efficient therapeutic concept. This review article describes our actual concept treating Apert hands.

[The Apert Foot: Anatomical Changes, Classification, Thoughts on surgical Treatment]

Diagnosis and therapy of the Apert foot are scarcely described in extant literature. This article describes anatomical changes observed in 30 Apert feet. By analysis of X-rays and computed scans 5 types of bony Apert foot malformations were identified. We developed therapeutic recommendations based on this classification.

Surgical Procedures Based on the Arthrographic Findings of the Fifth MTP Joint With Proximal Phalanx Duplication in Postaxial Polydactyly of the Foot

Radiographic findings in several atypical cases of postaxial polydactyly of the foot do not provide sufficient information to assess the cartilaginous structures or duplicated digit connections at the MTP joint. The purpose of this study was to demonstrate the surgical procedures using arthrography for the cartilaginous structures of the MTP joint in postaxial polydactyly of the foot. We performed arthrography in 7 feet of 7 patients with postaxial polydactyly of the foot in which duplication of the proximal phalanx was observed at the fifth MTP joint on the basis of radiographic evaluation. The average age at surgery was 13.5 months and average duration of postsurgical follow-up was 36 months. Individual surgical procedures were confirmed or modified during the operation by reference to the arthrographic findings. Radiographic and arthrographic findings were assessed in relation to the findings from direct observation of the cartilaginous structures at surgery. Postoperative malalignment, functional disturbance and pain in the reconstructed toe were evaluated. The arthrographic findings provided different forms of cartilaginous structures that could be categorized in 4 types, and reflected the cartilaginous connection visualized at surgery that could not be detected on radiographs in each case. No cases revealed any deformities, functional disturbance, or pain in the reconstructed toe after surgery. The parents' evaluation in each case was "very satisfied" or "satisfied." The arthrographic findings provided additional information regarding variations in the cartilaginous structures of the fifth MTP joint and for determining individual surgical procedure for postaxial polydactyly of the foot.

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.

Helal Metatarsal Osteotomy in Apert Foot

BACKGROUND

Apert syndrome is a rare condition characterized by a craniosynostosis associated with complex bilateral malformations of the hands and feet. Although correction of syndactyly of the extremities is largely described, just a few authors have focused their attention on the gradual subluxation of the second metatarsal head during child growth, with hyper pressure, hyperkeratosis on the plantar surface and acute pain leading to walking impairment. The aim of this study is to describe our experience with the Helal metatarsal osteotomy technique on this group of patients. An oblique osteotomy performed dorsal to plantar, proximal to distal on the subluxed metatarsal bone is carried out. No internal bone fixation is needed, but a fundamental hypercorrective bandage is placed under the plantar surface. Immediate full weight-bearing, 24 hours after surgery, is highly recommended.

METHODS

Seventeen feet of 12 patients were treated between 2003 and 2018. Corrective osteotomy was performed on a single bone in 13 patients, on 2 bones in 3 patients, and on 3 bones on 1 patient. The mean follow-up was 5 years, with a physical examination once a year.

RESULTS

No complication such as infection or delayed wound healing was registered. X-rays taken 3 weeks after surgery showed complete bone consolidation and a correction of the previous plantarflexed position of the metatarsal with consistent reduction of pressure and pain for every patient who was able to wear normal shoes again after surgery.

CONCLUSION

The Helal metatarsal osteotomy is a safe, reproducible, and feasible technique that should be considered in cases of painful metatarsal head plantar subluxation in Apert feet.

LEVEL OF EVIDENCE

Level IV.

Three-dimensional CT angiography for surgical planning in congenital hand malformations: a case series presentation

Between January 2000 and December 2019, three-dimensional computer tomographic (CT) angiography was used in a total of 140 hands (116 patients, mean age 6.8 years) with congenital hand malformation to assess the vascular and bony structures. Analysis showed overall satisfactory three-dimensional CT images for operative planning, including detailed abnormal vascular patterns and bony malformations. Among the 116 patients, six patients with typical findings of a few malformations are reported in detail. Pitfalls in interpretation of the images and the use of three-dimensional CT angiography in surgical planning are discussed. We conclude that three-dimensional CT angiography is useful for preoperative planning of complex congenital hand malformations.Level of evidence: IV.

Is the Apert foot an overlooked aspect of this rare genetic disease? Clinical findings and treatment options for foot deformities in Apert syndrome

BACKGROUND

Apert syndrome is characterised by the presence of craniosynostosis, midface retrusion and syndactyly of hands and feet, thus, synonymously referred to as acrocephalosyndactyly type I. Considering these multidisciplinary issues, frequently requiring surgical interventions at an early age, deformities of the feet have often been neglected and seem to be underestimated in the management of Apert syndrome. Typical Apert foot features range from complete fusion of the toes and a central nail mass to syndactyly of the second to fifth toe with a medially deviated great toe; however, no clear treatment algorithms were presented so far. This article reviews the current existing literature regarding the treatment approach of foot deformities in Apert syndrome.

STATE-OF-THE-ART TOPIC REVIEW

Overall, the main focus in the literature seems to be on the surgical approach to syndactyly separation of the toes and the management of the great toe deformity (hallux varus). Although the functional benefit of syndactyly separation in the foot has yet to be determined, some authors perform syndactyly separation usually in a staged procedure. Realignment of the great toe and first ray can be performed by multiple means including but not limited to second ray deletion, resection of the proximal phalanx delta bone on one side, corrective open wedge osteotomy, osteotomy of the osseous fusion between metatarsals I and II, and metatarsal I lengthening using gradual osteodistraction. Tarsal fusions and other anatomical variants may be present and have to be corrected on an individual basis. Shoe fitting problems are frequently mentioned as indication for surgery while insole support may be helpful to alleviate abnormal plantar pressures.

CONCLUSION

There is a particular need for multicenter studies to better elaborate surgical indications and treatment plans for this rare entity. Plantar pressure measurements using pedobarography should be enforced in order to document the biomechanical foot development and abnormalities during growth, and to help with indication setting. Treatment options may include conservative means (i.e. insoles, orthopedic shoes) or surgery to improve biomechanics and normalize plantar pressures.

LEVEL OF EVIDENCE

Level V.

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?

Management of Paronychia in Patients With Apert Syndrome

Apert syndrome is a complex congenital syndrome that includes bicoronal craniosynostosis, craniofacial dysmorphologies, cleft palate, hearing loss, spina bifida occulta, cardiac anomalies, and affects the upper and lower extremities-producing complex syndactyly in these patients. Management of the hands yields several challenges and mandates close follow-up to balance repair of complex polysyndactyly with other pressing interventions, such as posterior cranial vault distraction and surgical management of the airway. Our goals of therapy for the hands are to preserve 10 digits, provide sufficient soft tissue coverage, optimize hand function, and minimize the number of surgical interventions. Ideally, surgical management of the hand differences occurs between the ages of 9 months and 2 years, to optimize neurocognitive development. In complex syndactyly observed in patients with Apert syndrome, there are broad, conjoined nail plates that overlie the fused digits, and paronychia occurs frequently. Suppurative infections can delay definitive surgical intervention for the patient's complex syndactyly, and resolution of paronychia is critical. This study aims to propose an effective and safe technique to manage paronychia when it occurs in patients with Apert complex syndactyly and to mitigate the length of delay to definitive polysyndactyly reconstruction. In the context of these patients' need for multiple surgical interventions within the first few years of life, this strategy for preventing or mitigating paronychia can play an important role in streamlining their complex surgical management while avoiding multiple cancellations.

Hand Function in Apert Syndrome

Background:

The Michigan Hand Questionnaire is widely used to assess hand outcomes in congenital hand deformities. The purpose of the present study is to compare Apert syndrome hand outcomes according to Upton hand type and age stratification with age-matched unaffected controls.

Methods:

The Brief Michigan Hand Questionnaire was administered to 39 Apert patients after completion of the digit separation surgical regimen, and 140 age-matched unaffected controls. Patients were divided into 3 groups according to age. In group 1 (from 4 months to 7 years of age), responses were provided by parents of Apert patients, and in group 2 (from 8 to 17 years of age), patients responded with assistance from their parents, and in group 3 (18 years of age or older), responses were provided by the patients themselves. Groups were substratified according to Upton hand type (type I, II, and III). Comparisons were made among groups, subgroups, and controls.

Results:

Comparisons of hand types for intragroups 1, 2, and 3, did not demonstrate any statistically significant differences (P > 0.05) between hand outcomes according to Upton hand type, regardless of patient age. Comparisons between Apert patients and their age-matched controls demonstrated statistically significant differences (P < 0.05), as the control group had higher outcome scores.

Conclusions:

Similar hand outcomes scores were achieved by all Apert patients regardless of hand type. Following completion of the digit separation regimen, Apert patients presented hand outcome scores that were lower than those of the patients in the normative control group.

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.

The use of a dorsal double-wing flap without skin grafts for congenital syndactyly treatment: A STROBE compliant study

Numerous techniques have been developed that use various flaps to treat syndactyly. Skin grafts have often been used to cover remaining surgical defects. The long-term aim of surgery is to find new methods of separating the digits without using skin grafts. This paper describes a new surgical technique for the correction of simple, incomplete, and complete syndactyly. The technique consists of a dorsal double-wing flap to cover the newly created web space and zigzag incisions in the fingers, thus avoiding the use of skin grafts in this space. Overall, 35 web spaces in 24 patients were treated using this technique. Patient follow-up ranged from 6 months to nearly 5 years. There were no complications such as hematoma, infection or flap necrosis, and no fingers needed skin grafts after separation. The average operative time for each web space was approximately 45 minutes. Ninety-seven percent of patients treated with the dorsal double-wing flap procedure achieved good function, and superior cosmetic results following a single surgery. The technique is simple, rapid, safe, and easily performed and does not require the use of skin grafts.

Single-Stage Separation of 3- and 4-Finger Incomplete Simple Syndactyly With Contiguous Gull Wing Flaps: A Technique to Minimize or Avoid Skin Grafting

PURPOSE

Staged separation of 3- and 4-finger syndactyly is commonly performed owing to concerns about vascular supply to the central digit and availability of flap skin. We performed single-stage separation of patients with incomplete syndactyly of multiple digits with adjacent contiguous dorsal gullwing flaps and avoided skin grafts in the majority of cases.

METHODS

Seventy-four webs of 31 patients with more than 2-finger incomplete syndactyly were included. Median age at surgical separation was 12 months (range, 5-123 months). All cases were incomplete syndactyly that did not extend to the fingernail level, with no bony involvement. A dorsal gullwing flap was used for all cases, which reconstructed the interdigital webs and partly covered the lateral side of the proximal phalanx. The technique relies on perfusion of the flap through the dorsal metacarpal artery perforator to aid flap mobility and double radial and ulnar z-plasties on each side of the flap to aid flap advancement. Skin grafts were needed if there were any remaining skin defects.

RESULTS

In 30 of 31 cases, a single-stage procedure was accomplished. One case was staged owing to abnormal digital arterial anatomy found on exploration. No skin graft was required in 21 out of 31 patients (67.7%). Median postoperative follow-up was 12 months (range, 6-36 months). All finger web depths were normal or slightly deepened.

CONCLUSIONS

One-stage separation for 3- and 4-finger syndactyly with a dorsal gullwing flap is feasible and safe as long as at least 1 proper digital artery is preserved in each finger. The need for skin grafting is minimized.

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.

Correction of Brachymetatarsia and Medial Angulation of the Great Toe of Apert Foot By Distraction Osteogenesis: A Review of 7 Years of Experience

BACKGROUND

Apert foot anomalies may cause severe problems such as pain and development of callus formation related to weight redistribution, problems with footwear, and gait disturbances that may limit their daily activities. The main purpose of this study was to review our experience with distraction osteogenesis for the correction of brachymetatarsia and the great toe angulation of the patients with Apert syndrome.

METHODS

This study retrospectively reviewed 7 patients (14 extremities) followed up for Apert syndrome who underwent distraction for the correction of bilateral congenital brachymetatarsia and angulation of the great toe between 2004 and 2008. Correction of the metatarsal inclination angle, the medial angulation of the great toe, the percentage of lengthening, and lengthening rates of distracted bones were evaluated.

RESULTS

Patients ranged in age from 4 to 8 years at the distraction operation, with a mean age of 5.4±1.3 years, and the average length of follow-up was 86.6±21.0 months. The length of the first metatarsal bone increased significantly from the average length of 32.6±5.7 mm to an average of 46.7±6.5 mm (P<0.001). The mean lengthening rate and lengthening percentages of distracted bones were 0.4%±0.1%/month and 30.2%±6.4%/month, respectively. Preoperative and postoperative metatarsal inclination angles were at a mean of 43.8±5.12 and 32.6±3.8, respectively, and the correction of metatarsal inclination was considered as statistically significant (P<0.001). The mean angulation of the great toe reduced significantly from 49.8±11.76 to 13.2±8.5 degrees after distraction (P<0.001). Minor complications such as pin loosening, pin-tract infection, and early union that required reoperation were observed in 5 extremities (35.7%).

CONCLUSIONS

Anatomic features of Apert foot may lead to complaints that may limit patients' daily activities and require as much attention as associated hand and craniofacial anomalies. Distraction appears to be an effective and safe approach for the simultaneous correction of the shortness of the first ray and medial angulation of the great toe.

LEVEL OF EVIDENCE

Level IV.

Perifascial areolar tissue grafting for treating syndactyly with bone fusion in patients with Apert syndrome

Complete syndactyly with bone fusion in patients with Apert syndrome was treated using perifascial areolar tissue (PAT) grafts via a two-stage surgery (i.e. bone separation using inter-bone PAT graft insertion followed by web separation and reconstruction with full-thickness skin grafts). This technique is easy and created nail folds for fingertips.

CT angiography-guided single-stage release of adjacent webspaces in non-Apert syndactyly

We describe the CT angiography protocol and surgical technique utilized at our institution for single-stage release of adjacent web-spaces in non-Apert syndactyly. In a series of seven consecutive hands we analyse syndactyly anatomy, CT angiographic findings, operative details, and complications. Outcomes were assessed with a functional activity evaluation, range of motion, and a parental visual analogue scale. Seven affected hands in four patients underwent single-stage release of adjacent webspaces. In all cases, the CT angiogram correctly predicted the presence of at least one artery supplying each digit. There were no cases of digital ischemia or loss. Angiographically guided, single-stage release of adjacent webspaces is technically feasible and benefits patients by reducing the number of surgical stages and allowing complete release to be achieved at an earlier age compared with the standard multi-stage approach.

LEVEL OF EVIDENCE

IV.

Anesthesia for craniofacial surgery in infancy

Anesthetic management of infants undergoing craniofacial surgery can be challenging. Primary concerns for the anesthesiologist include blood loss and its management. The evolution of procedures to treat craniosynostosis has resulted in improvements in perioperative morbidity, including decreased blood loss and transfusion, shorter operations, and shorter hospital stays. An understanding of the procedures performed to treat craniosynostosis is necessary to provide optimal anesthetic management. Descriptions of current surgical techniques and approaches to anesthetic care are presented in this review.

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.

Eugène Apert and his contributions to plastic surgery

French pediatrician Eugène Apert is best known for his 1906 description of the eponymous Apert Syndrome: the widely recognized congenital condition that is known as acrocephalosyndactyly, which is characterized by distinct craniofacial deformities and bilateral syndactyly of the hands and feet. Subsequent efforts to study and treat this condition have led to contributions from numerous medical and surgical specialties under the guidance of plastic surgery. Apert's influence on medicine, however, extends far beyond what can be appreciated by the impact of his eponymous syndrome. Considered one of France's eminent pediatricians, Apert additionally made important contributions to the study of adult diseases. He was also a founding member of the French Eugenics Society, serving as its secretary general and president in a tenure that lasted for most of his career. Apert's medical contributions within the context of this scientific ideology make him an important and potentially controversial figure in medicine.

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.

Treatment of congenital upper extremity problems

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the terminology and classification of congenital hand anomalies. 2. Describe the incidence and embryogenesis of some common congenital hand anomalies. 3. Discuss the general principles and goals for treatment of congenital hand anomalies. 4. Describe the management of five of the more common congenital hand anomalies (syndactyly, short digits, thumb duplication, hypoplastic thumb, and radial dysplasia).

SUMMARY

Congenital hand anomalies can cause substantial emotional and functional problems. This article reviews the etiology, classification, and management of some of the more common hand anomalies. A general approach to the patient and the goals of treatment are reviewed, as is the approach to five specific congenital hand anomalies: syndactyly, short digits, thumb duplication, hypoplastic thumb, and radial dysplasia.