Hand Function in Apert Syndrome

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.

Apert Syndrome Type III Hand: Prevalence and Outcomes

BACKGROUND

The Upton type III hand, which represents the most severe hand type among Apert syndrome patients, has been considered the least prevalent hand type. The objective of this study is to address type III Apert hand prevalence and describe treatment strategies that will result in a 5 digit hand.

METHODS

The authors retrospectively reviewed 15 years of Apert syndrome hand practice at our hospital. Demographic (patient sex and age at the time of the operation), surgical (eg, techniques used for webspace release, osteotomy, and various aspects of soft-tissue reconstruction), and outcome (perioperative and long-term complication and need for revision operation) data was verified through medical records, clinical photographs, radiographic images, and interviews with patients' families. Patients who had incomplete medical records and/or postoperative follow up <6 months in length were excluded from this study.

RESULTS

A total of 93 Apert patients [50 male (56.1%) and 43 female (43.9%)] were treated at our hospital from 2007 to 2021. Stratification of Apert hand severity using Upton's classification system identified 34 patients with type I hands (36.4%), 19 patients with type II hands (20.6%), and 40 patients with type III hands (43%). Of the 40 patients with type III hands a 5 digit hand was achieved for 35 patients (87%), with an average of 3.37 operations per patient.

CONCLUSIONS

The Upton type III hand is the most prevalent hand type among Apert syndrome patients. Following a three stage protocol, a surgical team can consistently achieve a 5 digit hand for the majority of Apert syndrome patients with type III hands.

Apert Syndrome: Selection Rationale for Midface Advancement Technique

Apert syndrome is characterized by a wide spectrum of craniofacial clinical features that have been successfully addressed via a variety of midface advancement techniques. Although surgeons have individual preferences as to which specific procedures should be performed to best treat Apert patients, craniofacial plastic surgeons, working in tandem with pediatric neurosurgeons, can identify and evaluate functional limitations and facial morphologic disproportions, and establish appropriate criteria for effective midface advancement technique indication and selection. The purpose of this review article is to present and discuss our rationale for midface advancement technique selection based upon the most common craniofacial characteristics presented by Apert syndrome patients. The present article also provides a grading system that stratifies as major, moderate, and mild, the effect of each midface advancement technique on the different types of Apert syndrome facial features. Surgeons should take into consideration the maximum effect and benefit of each craniofacial osteotomy and how these procedures will alter the craniofacial skeleton. By understanding the long-term effect of each osteotomy on the most common craniofacial characteristics of Apert syndrome patients, craniofacial plastic surgeons and neurosurgeons will be able to customize the surgical procedures they perform in order to achieve the best possible outcomes.

Apert Hand Reconstruction: Do Partial-Thickness Skin Grafts Result in Flexion Scar Contracture?

BACKGROUND

Hand reconstruction for patients with Apert syndrome is a critical step in comprehensive care and enables this population to gain significant hand function. Digit separation for Apert syndrome, as described in most algorithms, is finalized using local flaps and full-thickness skin grafts. The objective of this study is to report our experience using local flaps and partial-thickness skin grafts after digit separation for Apert hand reconstruction.

METHODS

An observational retrospective study was performed with Apert patients whose hands were reconstructed between January 2007 and July 2019 using local flaps and partial-thickness skin grafts after digit separation. Demographic data and outcome data were verified and recorded.

RESULTS

Out of a total of 75 Apert patients who underwent hand reconstruction, 12 underwent hand reconstruction utilizing local flaps and partial-thickness skin grafts. The average patient age at the time of the first procedure was 1.9 years. These 12 patients were stratified according to Upton hand severity, 3 being type I (25%), 3 being type II (25%) and 6 being type III (50%). Mean follow up provided to all patients in this study was 1.8 years and donor site-related complications were seen in 2 patients (16.6%). No flexion scar contracture was observed in any of the patients who received partial-thickness skin grafts.

CONCLUSIONS

The use of local flaps along with partial-thickness skin grafts to finalize digit separation for patients with Apert syndrome is an effective technique that reduces donor site morbidity and does not result in flexion scar contracture.

Syndrome-related outcomes following posterior vault distraction osteogenesis

PURPOSE

The most commonly occurring syndromic craniosynostoses are Apert syndrome, Crouzon syndrome, Pfeiffer syndrome, and Saethre-Chotzen syndrome. There is insufficient data regarding postoperative syndrome-related outcomes following the posterior vault distraction osteogenesis (PVDO) procedure, as well as data addressing whether or not additional procedures will be subsequently necessary to comprehensively treat children who undergo PVDO. Thus, the objective of this study is to describe and compare syndrome-related potential complications and outcomes associated with the PVDO procedure.

METHODS

An observational retrospective study was performed on consecutive patients (n=24) with Apert syndrome, Crouzon syndrome, Pfeiffer syndrome, or Saethre-Chotzen syndrome, respectively, who underwent PVDO between 2012 and 2019. Demographic data (patient gender and age when the PVDO procedure was performed), diagnosis, surgery-related data, and outcome data (perioperative and midterm complications and need for additional surgery) were verified.

RESULTS

Total relative blood transfusion volumes per kilogram for the patients were as follows: 22.75 ± 9.30 ml for Apert syndrome, 10.73 ± 2.28 ml for Crouzon syndrome (Apert versus Crouzon, p<0.05), 18.53 ± 8.08 ml for Pfeiffer syndrome, and 19.74 ± 9.12 ml for Saethre-Chotzen syndrome. None of the patients required a secondary procedure to alleviate intracranial pressure except for a Saethre-Chotzen patient.

CONCLUSION

PVDO is an effective technique to address elevated intracranial pressure in SC patients that alleviates the need for secondary procedures at midterm follow-up. Apert syndrome patients presented relatively higher total blood transfusion rates than Crouzon syndrome patients who were operated on at a later age and weighed more.

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.

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.

Pfeiffer Syndrome: A Therapeutic Algorithm Based on a Modified Grading Scale

Background:

Pfeiffer syndrome (PS) is a very rare condition with a wide clinical spectrum. There are only a few studies that address the classification and treatment of PS and take into account the most commonly presented clinical features. Thus, the objectives of this study are to propose an algorithm for PS management based on a modified severity scale and correlate PS severity with tracheostomy placement.

Methods:

An observational retrospective study was performed on consecutive patients with PS (n = 12), who underwent surgery between 2008 and 2018. Clinical features and findings of all included patients with PS were classified as types A, B, and C, which guided treatment workflow. The Fisher test was used to correlate the severity of patients with PS with tracheostomy placement.

Results:

There were 12 patients, classified as type A (n = 3), type B (n = 6), and type C (n = 3). All patients who received tracheostomies (n = 6) were stratified into the severe category (n = 9; types B and C) (P < 0.05). There were 4 minor complications, and 1 major complication according to a modified Clavien–Dindo surgical complication scale.

Conclusion:

A treatment algorithm based on the 3 different Pfeiffer types was proposed. Severity of PS statistically correlates to tracheostomy placement.