Wednesday, September 23, 2015

Syndactyly Treatment: What's Next?

The basic treatment of syndactyly has not changed in many years.  The essential surgical care includes the creation of a web space (the 'commissure') with a flap and zig- zag incisions to the tips of the fingers to allow separation without straight- line scars (which can contract).  There is no doubt that our understanding of syndactyly has improved over the years and there have been many technical advances including variations on the commissural flap and modifications based on the exact type of syndactyly. Reports on reconstructing syndactyly without skin grafts have offered exciting new potential although many congenital hand surgeons continue to use grafts suggesting that results are not universally ideal.    I have written many times on syndactyly- check for those posts HERE.

Recently, Dr Landi reported outcomes using a new concept in the treatment of syndactyly.

This article describes the use of a hyalruonic acid scaffold to fill in the defects instead of skin grafting for syndactyly reconstruction.  The results are very good.  Article link  This material has become available in the United States and I wanted to share a recent case of ours.

This one year old child has bilateral cleft hands and cleft feet. He has a complete, cutaneous (skin only) syndactyly of the ring and small fingers bilaterally.  

Cleft hand with ring/ small finger syndactyly

Cleft hand with ring/ small finger syndactyly, palm view

In an effort to improve function and independence of the two fingers, he was brought to the operating room for bilateral syndactyly reconstruction.  We discussed using skin grafts but elected to proceed with the hyaluronic acid scaffold.  The 'hyalomatrix' works as a hydrophilic gel which allows cellular migration onto its 3D scaffold.    Skin cells can then migrate to allow healing.  


Hyaluronic acid scaffold
Hyaluronic acid scaffold- shiny side later peels off.

Here are a few pictures after the surgery.

Syndactyly reconstruction with hyaluronic acid scaffold, palm view
Syndactyly reconstruction with hyaluronic acid scaffold, dorsal view
It is too soon to know if this material will dramatically change the treatment of syndactyly.  But it does seem to be an important step forward to minimize or eliminate the need for skin grafts (with the accompanying scar).  More to come on this treatment.

Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu

Saturday, September 5, 2015

Amniotic Constriction Band

Amniotic Constriction Band commonly affects the hand and feet.  I have previously posted on the topic on several occasions as can be viewed HERE.  I wanted to share a few recent cases to demonstrate the different types of Amniotic Constriction Band.

This young child has Amniotic Constriction Band affecting one foot and one hand as depicted below.  The toes are characteristically short and there is a syndactyly (joining of the digits) as well.  As classically noted, the syndactyly is fenestrated such that the tip of the digits are joined but there is an opening closer to the foot.  The hand has a great thumb and a reasonable index finger but the finger is tethered to the remnants of the other digits.

Amniotic Constriction Band of the foot

Amniotic Constriction Band of the hand

Amniotic Constriction Band of the hand, view of the palm

Here is another case of Amniotic Constriction Band demonstrating a slightly different appearance. First, here is the hand prior to surgery.  The thumb is somewhat short, the index finger short and the first webspace (between the thumb and index finger) is tight.  The index finger is bulbous as may be seen in this condition.
Amniotic Constriction Band of the hand, view of the palm.  The pinky is normal but the other digits are short.

Amniotic Constriction Band of the hand.  Note the abnormal index finger with bulbous index finger.

Amniotic Constriction Band of the hand, view of abnormal index finger

Tight first web space with 2 bands of contracture.  Amniotic Constriction Band.
The decision for surgery is based primarily on function but also should consider appearance.  Mom and family were concerned about the length of the thumb and the appearance of the hand.  Certainly, I agreed with the concerns about the thumb because the short thumb and tight webspace limit large object grasp.  And, the bulbous nature of the index finger also limits both function and appearance.  We therefore offered reconstructive surgery.  The webspace was limited in two planes and therefore we used a more complex flap than typical.
Flap raised to reconstruct the first webspace in Amniotic Constriction Band
Flap raised to reconstruct the first webspace in Amniotic Constriction Band. The flap has been laid across the tight web.
Reconstructed hand with deeper webspace and contoured index finger Amniotic Constriction Band

Reconstructed hand with deeper webspace and contoured index finger Amniotic Constriction Band.  The pinky finger is held by the instrument.
Reconstructed hand in Amniotic Constriction Band

Charles A. Goldfarb, MD
My Bio at Washington University
congenitalhand@wudosis.wustl.edu