Sunday, March 29, 2020

Congenital Differences- Timing of Intervention in the era of COVID-19

March 28, 2020

We are in an unprecedented time.  COVID-19, the coronavirus which began in Wuhan Province in China in late 2019, has impacted our world in many ways.  Medical centers in the US and Europe are in a time of crisis as they prepare for or are in the midst of the pandemic.  In the US, in large part but curiously not at all sites, elective surgery has been halted, indefinitely.  Generally, most centers (perhaps unless the center is in a 'hot zone') have a similar approach in that, time- sensitive surgeries may proceed as needed.  That means that emergency surgery (typically trauma) can be treated surgically but other surgeries are carefully considered and most are being delayed.  The logic behind these decision are around social distancing, keeping patients and healthcare providers safe, and preserving PPE (personal protective equipment).

How will these restrictions affect upper extremity surgery for congenital differences?  What happens if your child's surgery for a congenital difference is delayed?  Thankfully, in large part congenital difference surgery is not time sensitive.  Waiting is, in all likelihood, ok.  We consider a few factors when recommending surgery:

1) We consider surgery at an age when safe for the child.  The risks of early surgery are debatable and there has been much discussion about the impact of surgery at a young age.  There are concerns that anesthesia exposure may increase the risk of behavioral issues or conditions like attention deficit disorder.  We believe that relatively short surgeries are safe.  And single surgeries are likely safer than a number of surgeries. However, delaying surgery, especially in these times, might make sense if the condition does not require intervention as noted below.

Certainly, we avoid surgery in the very young child due to specific anesthesia risks related to age and size.  While surgery is safe at even 3 months of age, we try to avoid intervention until at least 6 months of age for surgeries with some urgency.  For more elective surgery, often 12-24 months, is our preference.  Again, we can wait longer in most conditions.

2) There are few conditions that may have urgency.
     a) a newborn with an arm or finger with compromised blood supply.  These are very rare and may be related to neonatal compartment syndrome (if identified early and still in evolution) or amniotic constriction band, tight around a finger or extremity.  If a condition such as one of these is identified, urgent surgery is considered.
     b) Syndactyly on a border digit.  That means ring- little finger syndactyly and, more importantly, thumb- index finger syndactyly. The idea is that the longer digit will be tethered and likely deviated in some way by the shorter digit.  We often consider surgery at approximately 6 months of age for children with these conditions.
     c) Some syndactyly surgeries related to amniotic band may benefit if all the fingers are tethered.  If the digits are freed early, a remarkable improvement can be seen.  Here is one example of tethered digits.

Amniotic constriction band with tethered digits


3) The timing of surgery as relates to school is another condition.  We aim to have surgeries complete prior to kindergarten.  While this is not always possible, it is helpful.  That way, school is not interrupted and the child may be more comfortable with and 'used to' the condition.  Function is often improved after surgery and this can help with advanced, age related activities such as scissor, etc.  Therefore, a surgery planned at two years of age can often safely be delayed until three years of age.

4) Other surgeries.  The timing of more typical congenital difference surgery is often based on surgeon preference and hospital protocols.  For example, there is little to guide us on the timing of 'typical' syndactyly' surgery although at least one paper has suggested that later surgery is better.  Most of us believe that surgery at 18 months is a good time.

Another example is radial longitudinal deficiency.  Surgery can be considered almost anytime although surgery at or after 18 months is our preference.  But, if a series of surgeries are planned, an early start may be helpful.  For example, a child might have an external fixator placed at 18 months of age, a centralization procedure at 24 months of age, and a pollicization procedure at 30 months of age.  Sometimes the pollicization can be accomplished at the time of centralization but we often separate.  AND, if both sides are affected, bilateral surgery can be considered but may be too much for the patient and the family. Tough decisions.

I hope this is helpful.  Post questions on specific surgeries and I can share my personal protocols and also share our feelings on risks (or safety) for delay.

Charles A. Goldfarb, MD              
email: congenitalhand@wustl.edu

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