Graftless Syndactyly Release

Syndactyly release aims to address skin deficits by resurfacing web spaces and sides of digits to allow independent digital motion while minimizing the risk of web creep and scar contractures. Conventional methods include the use of a dorsal and interdigitating flaps with full-thickness skin grafts. More recently, there have been several descriptions of "graftless" syndactyly release without skin grafts, thus avoiding a further (usually distant) donor site. However, the indications of when and when not to use these techniques remain unclear. In addition, the inevitable scarring from extra recruitment of local adjacent skin is perhaps underemphasized. In this article, we revisit the trilobed flap technique which serves to balance the amount of skin needed for resurfacing digits while minimizing local donor site scarring. The geometry and nuances of the flap inset are illustrated in detail to guide those embarking on this technique. The trilobed syndactyly release technique is a reproducible, safe, and reliable method for the release of simple syndactyly.

Syndactyly Reconstruction Technique Utilizing Skin Substitute

Syndactyly reconstruction often times leaves areas of skin deficit that require coverage for healing. Numerous techniques have been reported to address the deficits, including graftless technique, which utilizes mobilization of adjacent skin for coverage, full-thickness skin grafting, and skin substitute grafts. The technique described here demonstrates the ease of the use of skin substitutes for coverage in syndactyly reconstruction and reports the expected outcomes.

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.

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.

Syndactylized glabrous flaps for multiple finger palmar defects

BACKGROUND

Palmar finger or pulp defects require coverage with glabrous tissue to achieve a good match with the lost tissue. The management of multiple finger palmar or pulp defects is challenging because these defects may not always be suitable for local or pedicled flaps. In such situations, syndactylizing free or pedicled flaps can be used.

PATIENTS AND METHODS

We evaluated the results of free glabrous flaps syndactylizing across multiple finger defects. The two flaps used were the superficial branch of the radial artery (SUPBRA) flap and hypothenar free flap. Seven syndactylized glabrous free flaps were used to cover the defects in 16 fingers. The functional results and complaints were also assessed.

RESULTS

Mean flap size was 14.35 cm2. Six flaps survived. Postoperative evaluation data were obtained for the 13 fingers. All the patients returned to their previous work. All patients had a diminished protective sensation of at least 4.31 according to the SWM test. The mean two-point discrimination score of the patients was 9.9 mm (7-14). One finger had a PIP joint flexion contracture of 30°, no donor-site complaints were observed.

CONCLUSION

The advantages of these flaps include single operation site, strong glabrous tissue coverage, low risk of flexion contracture, and adequate tissue size for large defects. Disadvantages include two-stage and complex microsurgical operations, prolonged treatment, and hospital stay.

Lower Extremity Polydactyly Does Not Disturb Finding One's Feet

Little is known about functional outcomes in children with treated lower extremity polydactyly (LEP). No classification system has been shown to be prognostically useful for functional outcomes. This study investigates whether children with treated LEP learn to walk at an age comparable to the population and whether the SAM (severity of syndactyly, axis deviation and metatarsal involvement) classification system is prognostically useful. In a retrospective cohort of 18 patients, we tested for associations between patient characteristics and SAM scores, age at learning to walk, and ability to fit off-the-shelf shoes. The proportion of children with treated LEP able to walk at 18 months of age was compared with the general population. We found no association between the age at which the 17 participants learned to walk and the severity of syndactyly (p = .214), axis deviation (p = .723) and metatarsal involvement (p = .781), nor between the proportion of patients able to wear off-the-shelf shoes compared to those requiring extra wide off-the-shelf shoes and the severity of syndactyly (p = 1.000), axis deviation (p = 1.000) and metatarsal involvement (p = 1.000). We found a trend between older age at surgery and the need for extra wide off-the-shelf shoes (OR = 1.008, p = .080). We found no significant difference in the proportion of children able to walk at 18 months between our patients (proportion = 1.00) and the general population (proportion = 0.95) (p = 1.000). We found no significant association between different SAM scores and functional outcomes, and none in the proportion of children able to walk at 18 months between treated LEP patients and the general population.

Plantar intermetatarsal perforator flap for first web skin-graftless syndactyly release: Anatomical study and clinical application

INTRODUCTION

Foot-syndactyly has long been managed through conventional surgical procedures, each having its own distinct advantages and drawbacks. While these methods, which do not require skin grafts, exhibit a lower incidence of long-term complications, they lead to undesirable scarring on the dorsal side of the foot and reduced patient satisfaction. In this study, we introduce an innovative technique involving an intermetatarsal plantar flap, supported by an anatomical investigation and clinical application.

METHODS

Eight freshly preserved lower limbs were injected with colored latex to examine the cutaneous vessels on the plantar surface, a skin-flap was designed in an elliptical shape to address first web conjoined toes. The flap was extended from the center of each affected ray measuring ~30% of the sole's length. Using the mentioned novel approach, a flap was created and dorsally extended with a straight incision to release bilateral simple foot-syndactyly in an 8-year-old child presented with Apert's Syndrome.

RESULTS

We identified cutaneous branches originating either from the medial plantar vessels or the lateral proper artery of the hallux. On average, the mean number of cutaneous branches found over the first intermetatarsal web spaces was 5.8 (ranging from 5 to 8) most of them originating from medial plantar vessels with a mean of 5.1 branches (range 4-6) while proper lateral great-toe digital artery provided a mean of 0.6 branches (range 0-2). Intra-operatively, in our patient, advancing the plantar flap ensured complete coverage of the commissure, obviating the necessity for skin grafts. Incisions healed uneventfully and a wide first web was obtained. Over a 15 months follow-up, no complications were observed.

CONCLUSIONS

Our findings suggest that the skin-graftless first web release of syndactyly using a plantar intermetatarsal flap is a reliable and straightforward procedure with good cosmetic results, offering a promising alternative to conventional techniques.

LEVEL OF EVIDENCE

Therapeutic IV.

Utilization of the web index in the measurement of web creep after syndactyly surgery

The aim of this study was to explore the feasibility of using a web index to measure web creep after syndactyly surgery. A total of 19 hands in nine children (six preoperatively and 13 immediately postoperatively) underwent measurement of their web position. A preliminary study confirmed that the web index measured on the child's hand at the time of surgery was similar to that measured on photographs taken at the same time. Subsequently, an intra- and inter-observer error rate found excellent agreement among four observers measuring the web index using photographs. Of 13 postoperative webs using a winged central rectangular web flap without skin grafting, 12 were re-measured using photographs at an average of 88 months (range 78 to 96) after surgery. There was evidence of minor web creep in one web only. Our study demonstrates the efficacy of web index calculation on photographs to measure web position in children after syndactyly surgery. The study also demonstrates the effectiveness of the graftless winged central rectangular web flap technique in avoiding web creep.Level of evidence: IV.

Syndactyly release with the use of the Pelnac™ artificial dermal substitute without skin grafting

We present our results of one-stage resurfacing following syndactyly release with the Pelnac™ artificial dermal substitute. From 2016 to 2020, raw areas after digit release were restored with an artificial dermal substitute in 145 webs from 62 patients (average age, 33.1 months) including 65 simple incomplete web spaces, 29 simple complete web spaces, 20 complex complete web spaces, and 31 complex complicated web spaces. Fourteen patients were syndromic. The average follow-up period was 33.4 months (range, 7-55 months). Postoperative outcomes assessed as according to the Vancouver scar scale (0-14) averaged 1.8 (range, 0-11) and web creep score (0-5) averaged 0.7 (range, 0-4). Patient- and family-provided visual analog scale scores averaged 1.1 (range, 0-10) for appearance. In conclusion, the Pelnac™ artificial dermal substitute is a minimally invasive, simple, and effective option for one-stage resurfacing of defects in syndactyly release.

Omega Flap Technique: Revisiting Conventional Wisdom

Various surgical techniques have been described for the release of syndactylized fingers. In our experience, the omega flap technique, which includes a dorsal truncated flap and an anchor incision on the volar side, stands out as a good technique to release syndactyly. Incidentally, in symbrachydactyly also, the fused digits can be released using this technique. Despite this, we could find no reference in the recent years. We would like to stress the ease and importance of this technique, hoping many practicing hand surgeons will benefit from this. Our purpose was to revisit this technique and expose it to the younger generation of hand surgeons. We have operated on 20 cases of syndactyly of different types-simple, compound, and complex-and 5 cases of symbrachydactyly. In all cases, the omega flap on the dorsum and anchor incision on the volar aspect of the finger forming 2 lateral palmar flaps were used. The release of syndactyly was satisfactory in all patients. There was no flap necrosis. None of these cases have required secondary surgery because the primary releases were adequate. Release of syndactyly had been a problem for centuries. Awareness of the disability was insufficient in earlier days; currently, they seek early medical care. The release should be complete. These children must be able to achieve the form and function of the hand, and additionally precision to work. We believe that the use of omega flap and anchor flap is a good procedure for syndactyly release.

Triphalangeal thump, thumb duplication, and syndactyly: The first case report in the literature

RATIONALE

Triphalangeal thumb (TPT) is a rare congenital malformation where the thumb has three phalanges instead of two. Syndactyly is a condition in which children are born with fused or webbed fingers. The combination of TPT, Syndactyly, and thumb duplication is extremely rare, especially when these deformities are combined in one hand.

PATIENT CONCERNS

Hand abnormalities and polydactyl have been reported in a 1-year-old boy.

DIAGNOSIS

A clinical examination reveals two thumb duplications, finger fusion (Syndactyly), and a thumb with three phalanges (TPT). The diagnosis was based on clinical findings and an X-ray image of the hand.

INTERVENTIONS

The Z-plasty method was used to remove the adhesion between the thumb and forefinger, as well as the removal of the medial and distal phalanx of the thumb's medial tip.

OUTCOMES

The patient was followed for 2 months and found him in good health. To authors' knowledge, we described an unusual case from Syria, considered the first in medical history.

LESSONS LEARNED

General and plastic surgeons should be aware about this unusual mix of the three abnormalities. The family history must also be carefully investigated to explore the occurrence of hereditary illnesses.

Separation of congenital embryonic syndactylies in children: dorsal or volar flap? About a comparative retrospective series

Congenital syndactylies account for 1 to 2 out of 2000 birth defects. Although several types of syndactylies exist, we only studied embryonic syndactylies. The goal of our study was to compare 2 types of coverage flap for the reconstruction of the finger web spaces: a volar flap described by Blauth and a dorsal flap described by Gilbert. Between 1993 and 2015, children affected by simple and complex syndactylies (partial or complete) were treated in 2 french pediatric hospitals and were selected for our analytic, comparative, retrospective review. The 2 hospitals used different surgical techniques: one used a volar flap described by Blauth and the other a dorsal flap described by Gilbert. The children were followed up to look for signs according to the stages of the Classification of Withey and to evaluate a global result according to the score of Withey. Our secondary criteria of judgement were the aspect of the surgical scar according to the VSS (Vancouver Scar Scale) and the satisfaction of the parents and children. The age of the children, need for a surgical revision and time of last follow- up were also studied. We found statistically significant differences between group I (volar flap) and group II (dorsal flap) in favor of the volar flap: higher scores of Withey (even when the number of commissures was increasing) and better VSS (regardless of the number of web spaces treated). There was no statistically significant difference between the 2 groups in terms of age, follow-up, or rate of surgical revision. All in all, the volar flap presented less sequelae in terms of scar retraction. Regardless of the flap used, the cosmetic results of the full-thickness skin graft used impacted the result both on the receiving site (dyschromia, hairiness) and the donor site.

Recent Advances in Syndactyly: Basis, Current Status and Future Perspectives

A comprehensive summary of recent knowledge in syndactyly (SD) is important for understanding the genetic etiology of SD and disease management. Thus, this review article provides background information on SD, as well as insights into phenotypic and genetic heterogeneity, newly identified gene mutations in various SD types, the role of HOXD13 in limb deformities, and recently introduced modern surgical techniques for SD. This article also proposes a procedure for genetic analysis to obtain a clearer genotype-phenotype correlation for SD in the future. We briefly describe the classification of non-syndromic SD based on variable phenotypes to explain different phenotypic features and mutations in the various genes responsible for the pathogenesis of different types of SD. We describe how different types of mutation in HOXD13 cause various types of SD, and how a mutation in HOXD13 could affect its interaction with other genes, which may be one of the reasons behind the differential phenotypes and incomplete penetrance. Furthermore, we also discuss some recently introduced modern surgical techniques, such as free skin grafting, improved flap techniques, and dermal fat grafting in combination with the Z-method incision, which have been successfully practiced clinically with no post-operative complications.

Utilization of a Newly Designed Asymmetric Dorsal Gull Wing Flap for the Treatment of Postoperative Web Creep After Syndactyly Surgery

BACKGROUND

Web creep is the most common long-term complication requiring revision after syndactyly surgery; however, few methods have been reported. The aim of this study was to introduce a newly designed asymmetric dorsal gull wing flap to reconstruct web for the postoperative web creep.

METHODS

A retrospective analysis was performed for 20 patients from January 2016 to May 2019. Sex, age, original malformations, original surgical procedure, complications, time between the 2 operations, operation records, preoperative and postoperative photographs, and Withey score were reviewed.

RESULTS

Eleven boys and 9 girls with average age of 60.65 ± 44.76 months underwent revision. Twenty-nine web spaces were affected (web creep, 12 cases; web creep and scar contracture, 17 cases). The original surgical procedure consisted of syndactyly separation in 15 cases, syndactyly separation with a full-thickness skin graft in 5 cases. There was 1 case of postoperative infection. All patients received an asymmetric dorsal gull wing flap and a zigzag incision, 15 patients received an additional full-thickness skin graft. The average time interval between the 2 operations was 34.60 ± 35.94 months. The follow-up time was 34.30 ± 20.73 months. No complications were noted, none of the patients redeveloped web creep. The median values for web creep, flexion-extension deformity, total Withey scores in the postoperative period were significantly lower than the preoperative values. The appearance and function of all digits were good.

CONCLUSIONS

The asymmetric dorsal gull wing flap is a good choice for web reconstruction when web creep is caused by syndactyly surgery.

Comparing Results of Syndactyly Operated Children Younger and Older Than 1 Year

INTRODUCTION

Syndactyly has a cosmetic, functional, and psychosocial impact, and surgical treatment is indicated in most cases. This study aimed to retrospectively identify whether patients undergoing surgical release of syndactyly younger than 1 year presented different results compared with those operated older than 1 year.

METHODS

Patients were assessed through photographic records by 3 independent specialist surgeons for the quality of scar, presence of web creep, rotational, flexion-extension, and lateral flexion deformities using the Withey score.

RESULTS

Thirty-four patients were included in the study, totaling 51 commissures operated. The score was higher in the group operated younger than 1 year (5.83 ± 2.39) compared with the group older than 1 year (3.94 ± 1.93), being statistically significant, with a P value of 0.011.

CONCLUSIONS

Children with syndactyly operated younger than 1 year have worse postoperative outcomes measured by the Withey score than those operated older than 1 year.

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.

Novel Use of Pennig External Fixation for the Treatment of Pediatric Syndactyly

Syndactyly is one of the most common congenital limb malformations, second only to polydactyly. Syndactyly is treated with surgical intervention. During separation, free skin grafting or skin flap transplantation is required to allow for adequate skin closure. We introduce a novel application method of the Pennig external fixation device for the management of pediatric syndactyly without skin grafting. The Pennig minifixator was used in syndactyly to expand the web space soft tissue in order to allow a Z-plasty to be performed in a second operation. All patients had developed sufficient skin tissue from the external fixation. No infection, cutaneous necrosis or nonunion was noted in any of the patients. All patients had a satisfactory outcome in terms of final appearance and digit function. On the basis of the principle of strain-stress, use of the Penning external minifixator allows development of sufficient tissue in the web space for a second phase of reconstruction in syndactyly. The need for skin grafting and risk of blood vessel damage were avoided in this study, and, the incidence of skin necrosis and scar formation was reduced. Both the patients' families and our research members expressed high satisfaction with the postoperative function and appearance. Overall, application of the Pennig external fixation frame in our novel method is effective for the management of syndactyly and should be studied further. Level of Evidence: Level IV, case series.

Routine circumcision? The role of prepuce in syndactyly repair

Circumcisions are among the most commonly performed procedures in the pediatric population, but the value of the preputial skin often goes unrecognized as a potential graft (Ehrlichman et al., 2018). We highlight three patients who underwent coordinated circumcision and use of the excised preputial skin as a graft for syndactyly repair. Syndactyly, a condition where fingers are fused together, is often repaired utilizing skin from the groin region, which can result in unwanted hair growth and subcutaneous fat growth. The utilization of the prepuce is a convenient alternative that may have fewer undesirable qualities.

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.

Gastrointestinal disorders in Curry-Jones syndrome: Clinical and molecular insights from an affected newborn

Curry-Jones syndrome (CJS) is a pattern of malformation that includes craniosynostosis, pre-axial polysyndactyly, agenesis of the corpus callosum, cutaneous and gastrointestinal abnormalities. A recurrent, mosaic mutation of SMO (c.1234 C>T; p.Leu412Phe) causes CJS. This report describes the gastrointestinal and surgical findings in a baby with CJS who presented with abdominal obstruction and reviews the spectrum of gastrointestinal malformations in this rare disorder. A 41-week, 4,165 g, female presented with craniosynostosis, pre-axial polysyndactyly, and cutaneous findings consistent with a clinical diagnosis of CJS. The infant developed abdominal distension beginning on the second day of life. Surgical exploration revealed an intestinal malrotation for which she underwent a Ladd procedure. Multiple small nodules were found on the surface of the small and large bowel in addition to an apparent intestinal duplication that seemed to originate posterior to the pancreas. Histopathology of serosal nodules revealed bundles of smooth muscle with associated ganglion cells. Molecular analysis demonstrated the SMO c.1234 C>T mutation in varying amounts in affected skin (up to 35%) and intestinal hamartoma (26%). Gastrointestinal features including structural malformations, motility disorders, and upper GI bleeding are major causes of morbidity in CJS. Smooth muscle hamartomas are a recognized feature of children with CJS typically presenting with abdominal obstruction requiring surgical intervention. A somatic mutation in SMO likely accounts for the structural malformations and predisposition to form bowel hamartomas and myofibromas. The mutation burden in the involved tissues likely accounts for the variable manifestations.

Full Thickness Grafts Taken from the Plantar Instep for Syndactyly Release

Thirteen digital clefts (eight patients) were reviewed in which full-thickness plantar instep skin was used in syndactyly release. The results are presented, emphasising the good colour match of plantar instep skin with digital skin. There was a surprising lack of morbidity in the thirteen donor sites.

Modified Dorsal Rotation Advancement Flap for Release of the Thumb Web Space

The dorsal rotational advancement flap described by Buck-Gramcko in 1998 is a good local flap for release of the thumb index web space. This paper describes a modification which broadens the apex of the flap and increases its length. This modification provides a long wide flap which releases the thumb index web space with suture lines far beyond the web. In addition, it provides a release of the palmar skin even when very tight in severe narrowing of the web. It is suitable for release of thumb–index syndactyly, severe narrowing of the web in thumb hypoplasia and congenital clasped thumb.

Ultrasound-guided axillary brachial plexus blocks for pseudo- syndactyly surgeries in a patient with epidermolysis bullosa: a case report

Epidermolysis bullosa (EB) is a rare genetic disease characterized by recurrent blister formation following injuries or traumas. In patients with EB, general anaesthesia may result in potential airway obstruction, aspiration and prolonged hospital stay due to airway instrumentation-associated new bullae formation and scarring. On the other hand, regional anaesthesia has been shown to be efficient and safe. Ultrasound (US)- guidance particularly provides additional benefits to this clinical situation by minimizing skin contacts, improving block success and preventing complications. We describe a patient with EB, whose bilateral pseudo-syndactyly surgical treatment was successfully managed by the use of US-guided axillary brachial plexus blocks.

[EFFECTIVENESS OF DORSAL PENTAGONAL FLAP FOR RECONSTRUCTION OF THE WEB SPACE IN CONGENITAL TOE SYNDACTYLY]

OBJECTIVE

To investigate the effectiveness of dorsal pentagonal flap for reconstruction of the web space in congenital toe syndactyly.

METHODS

Between January 2009 and June 2014, 10 patients with congenital toe syndactyly were treated for web space reconstruction with dorsal pentagonal flap. There were 6 boys and 4 girls with the average age of 42 months (range, 8 months to 9 years). The congenital toe syndactyly located at the left foot in 5 cases, the right foot in 4 cases, and both feet in 1 case; 7 patients had polydactyly and 1 patient had brachydactylia. During follow-up, the toe function and web space appearance, web space depth, and web space gradient were observed to evaluate the effectiveness.

RESULTS

All 13 flaps survived and incisions healed by first intention. Ten patients were followed up 6-50 months (mean, 26 months). The skin color and texture in 13 reconstructed web spaces were close to normal web space. in 9 patients undergoing web spaces reconstruction of single foot, the abduction angle of toes was (42.879±3.703) at the injured side, showing no significant difference when compared with the normal side [(45.922±2.657)°] (t= -2.004, P=0.062); the web space depth was (1.881±0.266) cm at the injured side and was (1.631±0.202) cm at the normal side, showing significant difference (t=2.248, P=0.039); and the web space gradient was (42.733±3.421)° at the injured side and was (41.189±5.593)° at the normal side, showing no significant difference (t=0.707, P=0.490). The web space appearance, web space depth, and web space gradient were close to those of the normal web space in 1 patient undergoing bilateral web spaces reconstruction.

CONCLUSION

Web space reconstruction with dorsal pentagonal flap is easy to perform with reliable blood supply and low re-operated rate. The cosmetic and functional results are satisfactory.

[The application of the dorsal metacarpal perforator sliding flap for web-space reconstruction in congenital syndactyly]

OBJECTIVE

To investigate the application of the dorsal metacarpal perforator sliding flap for web-space reconstruction in congenital syndactyly.

METHODS

According to the size and shape of skin defect at the web space after division operation of syndactyly, the corresponding intermetacarpal perforator sliding flap was designed. The edge of the flap was cut off, but its underlying tissue was not dissected. From May 2007 to November 2012, 28 web-spaces in 15 patients with syndactyly (10 male and 5 female) were reconstructed.

RESULTS

All the 28 flaps survived completely. The flap size ranged from 3 cm x 2 cm to 1.5 cm x 1.0 cm. 14 cases with 26 flaps were followed up for 10-22 months (average, 14.5 month). The reconstructed web spaces had normal appearance and movement range. The 2-point discrimination distance was 9-13 mm (average, 11 mm). According to the Swanson Standard, 18 fingers were graded as excellent, 8 as good and 2 as fair (excellent and good, 92.6%, 26/28).

CONCLUSIONS

Reconstruction of web-space in syndactyly with the dorsal metacarpal perforator flap has the advantages of easy handling, good cosmetic and functional results.

[Interest of dermal substitute (Matriderm ©) to cover long fingers after congenital syndactyly: About 20 commissures]

INTRODUCTION

Surgical treatment of congenital syndactylies is based on the creation of a new commissure - with a commissural flap - and on the management of fingers lateral faces - with mirror zigzag incisions. Lateral skin defects are covered by full-thickness skin graft. Since their discover 30 years ago, dermal substitutes applications have been enlarged. We have wandered if these technique could be interesting for the treatment of these lateral skin defects.

MATERIALS AND METHOD

We have launched a monocentric and retrospective study with only one surgeon. The assessor and the operator were different. Included patients have a simple or complex congenital syndactyly, complete or not, associated with a syndrome or not. Children with a first web space syndactyly were excluded. Surgical treatment was performed with a dorsal commissural flap, with mirror incisions and with a lateral skin defects coverage by dermal substitute (Matriderm(©)) and split-thickness skin graft taken from the scalp. The initial assessment criterion was the quality of the scare measured by the OSAS score. Web creep (Whitney's scale) and time of surgery were two minor criteria.

RESULTS

Twenty commissures (11 children) have been included between 2008 and 2013. Fourteen complex syndactylies were noted. The average aftercare was equal to 2.7 years (0.5-5.5 years). Interventions were performed at the age of 1.8 years (0.5-4 years). Surgical time was equal to 44.6 min (22-95 min). Patients OSAS score was 11.9 (6-18). It was 12.2 (60-20) for complex forms and 11.9 (10-16) for simple forms. Graft weren't hairy. There was no complication on the donor site. Whitney's score was 1.2 (0-3) and three web spaces were reoperated.

CONCLUSION

We think that the use of dermal substitute Matriderm(©) is a new and serious alternative to treat congenital syndactylies. Results have to be confirmed by a new study which would compare this material to full-thickness skin graft, gold standard technique for these skin defects.

[Reconstruction finger web with dorsal two wing-shaped flap for the treatment of congenital syndactyly]

OBJECTIVE

To explore the clinical effect of using dorsal two wing-shaped flap to reconstruct finger web for treatment of congenital syndactyly.

METHODS

This technique has been used in 19 children with congenital syndactyly. At the dorsum, a flap with V-shaped tip and two wing-shaped pedicle were designed and was just sewed up with an anchor-shaped incision at the palm. The web was primarily reconstructed without skin graft at base of fingers. Distal end of fingers were separated by using serrated flap and were closed after removal of fatty tissue. At some cases with tight skin connection. The defect area at lateral and distal end of fingers was closed by small pieces of skin graft.

RESULTS

All the webs were reconstructed primarily without skin graft at the base of fingers. 7 cases with tight skin connection had small pieces of skin graft at lateral and distal end of fingers. Primary healing was achieved in all cases. After 1 to 6 months of follow-up, both the appearance and function were satisfactory without conspicuous scar. The reconstructed finger webs were in normal depth and width.

CONCLUSIONS

Primary web space can be achieved by dorsal two wing-shaped flap without skin graft at base of fingers. It is one of the best choices for treatment of congenital syndactyly.

Sudden cardiac arrest during anesthesia in a 30-month-old boy with syndactyly: a case of genetically proven Timothy syndrome

Timothy syndrome, long QT syndrome type 8, is highly malignant with ventricular tachyarrhythmia. A 30-month-old boy had sudden cardiac arrest during anesthesia induction before plastic surgery for bilateral cutaneous syndactyly. After successful resuscitation, prolonged QT interval (QTc, 0.58-0.60 sec) and T-wave alternans were found in his electrocardiogram. Starting β-blocker to prevent further tachycardia and collapse event, then there were no more arrhythmic events. The genes KCNQ1, KCNH2, KCNE1 and 2, and SCN5A were negative for long QT syndrome. The mutation p.Gly406Arg was confirmed in CACNA1C, which maintains L-type calcium channel depolarization in the heart and other systems.

Congenital symbrachydactyly: outcomes of surgical treatment in 120 webs

BACKGROUND

Symbrachydactyly is defined as a combination of short fingers with syndactyly. There are few published reports estimating the incidence of symbrachydactyly. The aim of this study was to investigate the clinical features and the outcome of surgical treatment for congenital symbrachydactyly.

METHODS

One hundred and twenty webs of thirty-four patients of symbrachydactyly were involved in the study. The sex ratio was 21 males/13 females. The age ranged from 1 year to 8 years, average 2.6 years. Four cases had both hands involved and 30 patients had one hand involvement. Release of the syndactylous digits webs were completed by one surgical procedure in 14 cases and more than one surgical procedure in 20 cases; 3 to 6 months between the procedures. In the meantime, some of the associated hand deformities were treated.

RESULTS

Postoperative follow-up time was 10 to 18 months, average 12 months. All the fingers involved in this study were separated successfully. However, 6 fingers had scar tissue contracture and 8 had web scar adhesion. All complications needed further surgical treatment. Parents of 94.1% of the patients were satisfied with the overall function of the hand, and 76.5% were satisfied with the cosmetic appearance of hand.

CONCLUSIONS

The combination of syndactyly and brachydactyly is the main clinical feature in symbrachydactyly. Separation of the digital webs can greatly improve the function of the hand. However, more work needs to be done to improve the cosmetic appearance of the hand.

[Soft tissue reconstruction for secondary deformity after correction of Wassel type IV-D thumb duplication]

OBJECTIVE

To investigate an effective therapeutic method for the secondary deformity after the correction of the Wassel type IV thumb duplication.

METHODS

9 cases of Wassel W-D Complex thumb deformities in children with postoperative secondary deformity, including 6 males and 3 female, were treated. The age ranged from 2.0 to 14 years old with an average of 5.3 years old. During the operation, the anatomical structure was dissected to observe the structure and alignment of the flexor tendon as well as anatomical structure of the joint. In the meantime, the flexor pollicis longus tendon was shifted, A2 pulley was reconstructed, joint capsule was released and contracted, the end point of thenar was shifted. Kirschner wires fixation were used for about 4-5 weeks, the brace fixation for about 3 months.

RESULTS

All the patients had radial side skin contracture of the interphalangeal joint, radial deviation of the thumb tip, radial side contracture and ulnar relaxation of the joint capsule. Flexor hallucis longus tendon was located in front of the radial side of the proximal phalanx, with no wrapped sheath or A2 pulley. Flexor hallucis longus tendon was attached to the thumb tip substrate, of which 1/3 was located in the center and 2/3 in the radial side. The thumb tip rotated about 10 degrees-15 degrees to the radial side. The patients were followed up for 6-38 months, with an average of 24 months. We adopted Tada standard to evaluate the follow-up results as excellent in 7 cases, good in 1 case, poor in 1 case.

CONCLUSIONS

Soft tissue reconstruction for the secondary deformity after the correction of the Wassel type IV-D thumb duplication is an effective method. Application of the brace after removal of Kirschner wires has an important role in preventing the secondary deformity.

Free fat graft for congenital hand differences

BACKGROUND

Free fat graft has been used for the treatment of congenital hand differences. However, there have been a few reports about the outcome of that treatment. In this study, the outcome of free fat grafts for congenital hand and foot differences was investigated.

METHODS

Fourteen bones with longitudinal epiphyseal bracket, 3 wrists with Madelung deformity, and 5 cases of osseous syndactyly were treated with free fat graft with osteotomy, physiolysis, or separation of osseous syndactyly. Of the fourteen bones with longitudinal epiphyseal bracket, 9 were treated with open wedge osteotomy with free fat graft and 5 with physiolysis and free fat graft. The Madelung deformity was treated with physiolysis with free fat graft. For osseous syndactyly, syndactyly release with free fat graft was performed five times on four hands.

RESULTS

In the fourteen cases with longitudinal epiphyseal bracket, lateral deviation improved in all except two cases after surgery. The average lateral deviation angle changed from 32.5 degrees before surgery to 15.2 degrees after surgery. The average improvement of the lateral deviation angle was 12.2 degrees in the osteotomy group and 20.6 degrees in the physiolysis group. The mean ratio of improvement of the lateral deviation angle to the lateral deviation angle before surgery was 39.4% in the osteotomy group and 51.2% in the physiolysis group. The Madelung deformity improved after surgery in two cases but there was no improvement in one case. For these conditions, the results were not good enough when surgery was done after age 13 or at age four for severely hypoplastic brachymesophalangy. Of the 5 cases of osseous syndactyly, reunion of the separated bones occurred in one case. The grafted free fat should be deep enough to cover the osteotomy site of the bones to prevent reunion of the separated bones.

CONCLUSIONS

Physiolysis and free fat graft performed during the growth period can correct the deviation due to longitudinal epiphyseal bracket and Madelung deformity. Free fat graft is also useful to prevent reunion of the bones after separation of osseous syndcatyly, if the grafted fat is securely filled into the space between the separated bones.

DORSAL PENTAGONAL ISLAND FLAP: A TECHNIQUE OF WEB RECONSTRUCTION FOR SYNDACTYLY THAT FACILITATES DIRECT CLOSURE

Though many techniques have been described for the correction of syndactyly, current methods result in skin deficiency that requires skin grafting, especially at the finger bases. We discuss the technical aspects and document our experience with the dorsal pentagonal metacarpal island flap for reconstruction of the web commissure in a series of 12 patients (22 webs) with syndactyly of varying complexity.

In appropriately selected cases, this technique can improve reconstruction of the web commissure, facilitating direct closure, minimising the need for skin grafts and offers the potential for continued growth. This reduces operative time significantly and simplifies post-operative wound care. In this series, all our cases healed primarily in two to three weeks with minimal donor site morbidity. There were no post-operative complications, although the prominent dorsal scar remains a concern. At an average follow-up of 33.7 months, no cases of contracture or web creep after correction were noted.

[Anesthetic considerations for a boy with non-bullous ichthyosiform erythroderma]

We administered anesthesia for a 20-month-old boy with non-bullous ichthyosiform erythroderma who underwent orthopedic syndactyly repair on two occasions. Anesthetic considerations include the difficult fixation of the tracheal tube and iv cannulas and the risk of hypothermia. Intravenous access placement was also difficult due to the hyperkeratosis and the deformity of extremities. In the first surgery, pharyngeal temperature fell to 34.4 degrees C despite the use of the 37 degrees C circulating water mattress and room temperature set to 26 degrees C. It gradually returned to 36 degrees C during the surgery. We applied Steri-Strip compound benzoin tincture to the skin to increase adhesiveness before taping the tracheal tube. It resulted in a good fixation but difficult removal. In the second surgery, we fixed the tracheal tube with a tube holder which enabled the fixation without the use of adhesive tapes to the skin. To maintain body temperature we used forced air warming device Bair Huggar, which was very useful to avoid hypothermia but resulting in a rather high body temperature. In conclusion, a tube holder was an effective device to fix the tracheal tube in this patient. Forced air warming device was useful to prevent hypothermia.

[Application of dorsal pentagonal flap for reconstruction of the web space in congenital syndactyly]

OBJECTIVE

To investigate the therapeutic effect of dorsal pentagonal flap for reconstruction of the web space in congenital syndactyly.

METHODS

From October 2007 to August 2009, 10 patients with congenital syndactyly were treated with dorsal pentagonal flap for web space reconstruction. During the follow-up period, the patients underwent finger functional assessment and web space appearance examination. The satisfactory rate of patients was also investigated.

RESULTS

10 patients with 17 reconstructed web spaces were followed up for 4-25 months (median, 15 months). Normal passive flexion and extension of fingers were achieved with good cosmetic result at web space. The abduction angle of fingers ranged from 30 degrees to 45 degrees. No web creep occurred and no secondary procedures were required. All the parents of the patients were satisfied with the results.

CONCLUSIONS

Web space reconstruction with dorsal pentagonal flap is easily performed with reliable blood supply and low re-operated rate. The cosmetic and functional result is satisfactory.

Nonvascularized toe phalangeal transfer and distraction lengthening for symbrachydactyly

Symbrachydactyly describes a spectrum of congenital hand differences consisting of digital loss resulting in fused short fingers. As the principles for distraction lengthening have evolved, the technique of nonvascularized toe phalangeal transfer to the hand with shortened digits has provided patients with improved outcomes. Nonvascularized toe phalanx to hand transplant with distraction lengthening restores functional length to a skeletally deficient, poorly functioning hand while maintaining an overlying layer of vascular and sensate tissue. The primary goal is improvement of digital length to enhance mechanical advantage and prehension. We describe the technique of nonvascularized toe phalangeal transfer and distraction lengthening for symbrachydactyly, including the following steps: nonvascularized proximal toe phalanx harvest, toe phalanx transfer to hand, pin placement, osteotomy, and closure.

Congenital syndactyly: outcome of surgical treatment in 131 webs

Congenital syndactyly is one of the most common congenital hand differences and various methods of surgical treatment have been described since the 19th century. Nevertheless, unsatisfactory results including web creep, flexion contractures, and rotational deformities of the fingers are still reported. This study presents the outcome of syndactyly release in 131 webs in 78 patients. The sex ratio was 40 males/38 females. The age ranged from 4 months to 22 years (average: 4 y). In the majority of the webs the result was good or excellent. The type of flaps used for the reconstruction of the web was important as the combination of a dorsal rectangular and 2 volar triangular flaps gave superior results than the use of 2 triangular flaps. The less rewarding overall outcome was obtained in the presence of associated differences of the involved fingers, that is, complex complicated syndactyly and in the cases of delayed correction. Use of a dorsal rectangular flap in combination with 2 volar triangular flaps and use of full thickness skin grafts, ensure a satisfactory outcome and minimize the number of operations per web.

[Syndactyly]

Syndactyly is one of the most common congenital anomalies of the hand. It can be isolated or associated with systemic syndromes. Surgical treatment is performed between the ages of six and 18 months depending on the type and extent of the malformation. Commissure construction is achieved using local flaps. Direct closure of the lateral sides of the digits is possible in many cases. In complex cases, and/or when adjacent web spaces are involved, full-thickness skin grafts remain useful. Functional and cosmetic results are usually excellent in simple cases. In complex cases, postoperative prognosis depends on the severity of bone, joint and tendons abnormalities.

A persisting median artery in a patient with symbrachydactyly and carpal tunnel syndrome

A persisting median artery associated with carpal tunnel syndrome in a patient with symbrachydactyly has not been previously described in the literature. It is unclear whether there may be a developmental association between persistence of a median artery and Symbrachydactyly.

Hourglass dorsal metacarpal island flap: a new design for syndactylized web reconstruction

Web space reconstruction is the key point and an important component of syndactyly treatment. A design of the dorsal metacarpal artery flap was used as an island flap based on the direct cutaneous branch arising from the dorsal metacarpal artery at the distal end of the flap to reconstruct congenital web syndactyly. The flap rotated from 0 degrees to 180 degrees and passed under a skin bridge at the distal end of the flap to reach the web defect. Such design enables a better use of the skin territory from the intermetacarpal space proximal to the pedicle, with a short donor site scar and a more supple reconstruction of the web space.

Technique of nonvascularized toe phalangeal transfer and distraction lengthening in the treatment of multiple digit symbrachydactyly

A combination of nonvascularized multiple toe phalangeal transfers, web space deepening, and distraction lengthening may provide excellent function in the child born with the oligodactylous type of symbrachydactyly. These techniques may reconstruct multiple digits, maintaining a wide and stable grip span with good prehension to the thumb. We detail the techniques of each of these 3 stages in reconstruction and describe appropriate patient selection. Potential complications are discussed. However, with strict attention to technical details, these complications can be minimized.