Keloid formation after syndactyly release in patients with associated macrodactyly: management with methotrexate therapy

What are the key risk factors of keloid formation after repair of syndactyly of the toe?

PURPOSE

Keloid formation in toes area is rare. However, occurrence of this phenomenon in toes after the surgery of syndactyly repair has been reported. Risk factors of keloid formation in toes after syndactyly reconstructions are currently unknown. This study aimed to investigate the risk factors of keloid formation after the surgery of syndactyly repair of the toes.

METHODS

We retrospectively reviewed our case series including patients who were treated surgically at our institution. We hypothesized some key factors of keloid formation and analyzed each of them statistically.

RESULTS

A total of 105 patients were treated surgically at our hospital, and 9 patients were involved keloid formations after operations. Among our hypothesized key factors, the results of multivariate logistic regression analysis revealed the number of affected web spaces (OR 0.031; 95%CI 0.001-0.684; p = 0.028) was significantly different. Digital enlargement was not a significant factor (OR 17.731; 95%CI 0.686-458.174; p = 0.091).

CONCLUSION

Involving multiple web space was associated with keloid formation after syndactyly release, on the other hand, toe enlargement did not show a significant difference. However, the digital enlargement showed high Odds ratio, we could not deny its high relativity for keloid formation. Further investigations are needed to clarify the key risk factors of keloid formation after the surgery of syndactyly repair of the toes.

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.

Novel, Blended Polymeric Microspheres for the Controlled Release of Methotrexate: Characterization and In Vivo Antifibrotic Studies

Low dose methotrexate (MTX) is known to effectively decrease type I collagen production in dermal fibroblasts, while increasing the matrix metalloproteinase-1 (MMP-1) production in vitro. For in vivo use as an antifibrotic agent on wounds, a linear and extended controlled release formulation of MTX is required. The objective of this study was to optimize the fabrication of MTX-loaded polymeric microspheres with such properties, and to test the efficacy for the prevention of fibrosis in vivo. Poly lactic-co-glycolic acid (PLGA), Poly (L-lactic acid) (PLLA) and the diblock copolymer, methoxypolyethylene glycol-block-poly (D, L-lactide) (MePEG-b-PDLLA), were used to fabricate microspheres, which were then characterized in terms of size, drug encapsulation efficiency, and in vitro release profiles. The optimized formulation (PLGA with diblock copolymer) showed high drug encapsulation efficiency (>80%), low burst release (~10%) and a gradual release of MTX. The amphipathic diblock copolymer is known to render the microsphere surface more biocompatible. In vivo, these microspheres were effective in reducing fibrotic tissue which was confirmed by quantitative measurement of type I collagen and α-smooth muscle actin expression, demonstrating that MTX can be efficiently encapsulated in PLGA microspheres to provide a delayed, gradual release in wound beds to reduce fibrosis in vivo.

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.

Predictive Factors of Keloid Formation in Congenital Foot Syndactyly

Keloid formation after syndactyly division is a stressful situation for patients. In our experience, digital enlargement may be involved in keloid formation following syndactyly divisions. Therefore, we aimed to identify predictive factors and reference values for keloid formation.

Isolated Acquired Macrodactyly of the Left Fourth Toe

Macrodactyly is a rare congenital disorder affecting the digits of hands and feet. It is often distressing for both parents and children. Surgical options range from soft tissue debulking with or without osteotomy and physeal arrest to simple or ray amputation. Although amputation is generally reserved for the severe progressive variant of macrodactyly and revision surgery, there is controversy regarding whether initial amputation or debulking is the best approach. We present a case of isolated macrodactyly of a minor toe, where debulking showed superior results.

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.

Treatment of congenital syndactyly

Defined as the union of two adjacent digits, syndactyly is one of the most common congenital deformities. The severity of the malformation depends on the fusion level, the tissues involved in the union, and whether it is isolated or syndromic. In order to improve the hand's appearance and function, surgery is recommended in the great majority of cases, ideally during early childhood (i.e., before entering school). Web space reconstruction is done using local flaps. Depending on the flap design, digital resurfacing can be done with or without skin grafts. While graftless techniques have shorter operating times and no morbidity associated with skin harvesting, their cosmetic outcomes seem to be worse than those of traditional grafting techniques, with more postoperative complications; furthermore, such techniques cannot be used in all cases, especially those with osteoarticular fusions. When the fingertip is involved, paronychial reconstruction is carried out with pulp flaps. The prognosis for these deformities directly depends on their severity, with excellent outcomes in cases of cutaneous fusion, and much less predictable ones when osteoarticular and/or tendinous tissues are involved.

Macrodactyly: decision-making and surgery timing

Macrodactyly is a rare condition in which fingers, hands or limb growth is unregulated, resulting in overgrowth of tissues in the affected extremities. It is critical to properly assess these extremities for signalling pathway, psychological impact and potential surgical intervention, to achieve the best possible outcome for each patient. Treatment approaches can vary, and patient and family expectations weigh heavily on care complexity. Common surgical procedures may include epiphysiodeses, osteotomies, debulking procedures, carpal tunnel releases, toe transfers and amputations. The selection and timing of these surgeries is a vital component of the approach, as delayed healing and excessive scarring may occur. The purpose of this review is to assist in the navigation of decision-making and surgical timing for patients presenting with overgrowth manifesting itself as macrodactyly.

Scar management in burn injuries using drug delivery and molecular signaling: Current treatments and future directions

In recent decades, there have been tremendous improvements in burn care that have allowed patients to survive severe burn injuries that were once fatal. However, a major limitation of burn care currently is the development of hypertrophic scars in approximately 70% of patients. This significantly decreases the quality of life for patients due to the physical and psychosocial symptoms associated with scarring. Current approaches to manage scarring include surgical techniques and non-surgical methods such as laser therapy, steroid injections, and compression therapy. These treatments are limited in their effectiveness and regularly fail to manage symptoms. As a result, the development of novel treatments that aim to improve outcomes and quality of life is imperative. Drug delivery that targets the molecular cascades of wound healing to attenuate or prevent hypertrophic scarring is a promising approach that has therapeutic potential. In this review, we discuss current treatments for scar management after burn injury, and how drug delivery targeting molecular signaling can lead to new therapeutic strategies.

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.

Surgical Treatment of Macrodactyly

Macrodactyly, enlargement of one or multiple digits, was described in the literature nearly 200 years ago. This is an exceptionally uncommon diagnosis that has led to a paucity of descriptive literature on the treatment options. Because the literature is scarce, and the frequency with which hand surgeons encounter macrodactyly is even scarcer, treatment can be a formidable task often left exclusively to those trained in congenital hand deformity. This article presents our algorithm and surgical techniques for dealing with children with macrodactyly in such a way that should make a complex problem more easily approachable.

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.

Clinical features and outcomes of foot keloids treated using complete surgical excision and full thickness skin grafting followed by corticosteroid injections

Background

Keloids are often resistant to treatment and have high recurrence rates. To the best of the authors’ knowledge, however, there have been very few case reports related to foot keloids. The purpose of this retrospective case-series was to summarize the baseline characteristics of a cohort of patients, introduce our treatment regimen for the successful treatment of foot keloids.

Methods

Patients were treated with surgical excision followed by full thickness skin grafting combined with postoperative steroid injections combined with silicone gel sheeting over a period of eight years from December 2004 to November 2012 at our institution. Subjective outcome was evaluated using Patient Scar Assessment Scales. The final objective outcome was judged by two independent physicians at the time of 12 months after treatment as recurrence or non-recurrence.

Results

Of 79 patients, 75 (94.9%) were women and 4 (5.1%) were men. The average age was 18 (range 7-43) years. The average pretreatment total size of the lesions was 50 (range 18-150) cm. The number of patients treated for a primary foot keloid was 29 (36.7%), and 70 patients (63.3%) were treated for a recurrent keloid that failed to respond to prior treatments. Prior treatments included single therapies such as surgical excision alone (4 patients, 5.1%), prior steroid injection alone (33 patients, 41.8%), and laser therapy (2 patients, 2.5%). Other therapies included combination treatments (11 patients, 13.9%). Most patients reported improved Patient Scar Assessment Scale by lapse of time. All patients completed the treatment regimen and follow-up of 12 months. Of these patients, 62 patients (78.5%) achieved successful treatment, while the remaining 17 (21.5%) experienced recurrence.

Conclusions

We successfully treated foot keloids using complete surgical excision and full thickness skin grafting followed by four corticosteroid injections (at one month intervals).

Fibroproliferative Neuromas May Occur After Iatrogenic Injury for Lipomatosis of Nerve

BACKGROUND:

Lipomatosis of nerve (LN) is a condition associated with nerve-territory overgrowth. We have noted a unique type of neuroma at sites of LN injury; the neuroma extends beyond the epineurium, enhances, and appears to enlarge over time.

OBJECTIVE:

We sought to understand the relationship between fibroproliferative scarring and surgery performed on the nerve.

METHODS:

A review of the searchable records for LN at our institution found 52 cases, confirmed by pathology or pathognomonic appearance on magnetic resonance imaging (MRI). Clinical histories were reviewed to categorize the surgeries performed by the degree of iatrogenic injury to the nerve. Postoperative MRI was performed in 22 of the 46 patients who had surgery, which was then retrospectively reviewed for fibroproliferative neuromas.

RESULTS:

Complex and masslike neuromas were found on MRI, correlating with the degree of iatrogenic injury to the nerve. These fibrous neuromas proliferated beyond the epineurium, disrupted fascicular architecture, were contrast enhancing when contrast was administered, indicative they were unique and unlike stump or traction neuromas. Of the 8 patients who underwent surgery involving nerve decompression alone, none developed fibroproliferative neuromas. Of the 7 patients who underwent surgery involving nerve debulking, fibroproliferative neuromas developed in 4. Of the 11 patients who underwent surgery involving nerve transection, all developed fibroproliferative neuromas (P < .001). There was also a high incidence of hypertrophic scarring of the skin incision (21.3%).

CONCLUSION:

Surgical injury of LN appears to be strongly associated with the development of fibroproliferative neuromas. It is possible that the pathological overgrowth stimulus associated with LN promotes exuberant scar formation.

Long-term aesthetic outcome of fingertip reconstruction in complete syndactyly release

An aesthetically pleasing fingertip is an important but often under evaluated goal in syndactyly release. We assessed the aesthetic fingertip outcome in 26 patients with complete syndactylies, with a total of 84 separated digits, using a four-grade scale based on the quality of the lateral nail fold, nail plate definition, symmetry and pulp fullness. Fingertips with complete simple syndactylies released with the use of full-thickness skin grafts achieved a significantly better aesthetic result then fingertips with complete complex syndactylies released with the use of Buck-Gramcko pulp flaps. Fingertips involved in complex syndactylies achieved significantly better aesthetic results when reconstructed using Buck-Gramcko flaps in comparison with those reconstructed with full-thickness skin grafts. We recommend the use of Buck-Gramcko flaps in complete complex syndactylies, while reserve the traditional zig-zag and full-thickness skin graft closure for cases of complete simple syndactylies. We also propose a grading system for the aesthetic outcome of the fingertip following syndactyly release.

Treatment of keloid formation following syndactyly division: surgical technique

A strong association has been reported between keloid formation after syndactyly reconstruction and primary digital enlargement, and methotrexate (MTX) treatment has been shown to produce promising results in a few reported cases. However, detailed surgical technique for revision of keloid formation after syndactyly division has not been well described, and there is still no standard treatment protocol regarding use of MTX in such cases. In this paper, we describe the technical details of keloid excision and full thickness skin grafting followed by MTX medication for the treatment of massive keloid formation after syndactyly division. We also describe a case of unsuccessful use of MTX, and our experience of its prophylactic use for a patient with syndactyly with primary digital enlargement.