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Do babies require arm splints after cleft palate repair?
TIC
SURGERY
----
11
Do balbies require arm splints after cleft palate repair?
.Sl’.~l;Il.~I R 1.. Traditionally, arm restraints are used in children after cleft surgery to prevent traumatic disruption of the repair. A questionnaire amongst consultant plastic surgeons in the UK showed that restraints are in common use. However, a prospective randomised trial of 46 children having primary cleft palate repair showed that arm splints did not decrease the incidence of oronasal fistulae. Six of 21 children who had arm splints in the postoperative period and 5 of ;!S who did not have splints developed an oronasal fistula. We have therefore abandoned the use of arm splints after cleft palate repair. ~~
children having cleft lip repair lvhere arm restraints b’ere omitted. O’Riain found no cases where straving tingers caused a disruption of the suture line.’ W; are unaware of any study on the efficacy of arm restraints following cleft palate repair. Likewise. there have been no studies to determine the optimum time for IXhich the restraints should be applied. This paper describes two studies. The tirst V;IS ;I postal survey of consultant plastic surgeons in the UK to determine both the prevalence of the use of arm restraints following primary cleft surgery and also, the commonest recommended duration for their use. The second was a prospecticecontrolled trial of46children undergoing primary repairs of cleft palate. to study whether arm splints influenced the incidence of portoperative palatal breakdown leading tc,l oronasal fistulae.
In cleft lip and palate surgery. in order to prevent traumatic disruption of wounds in the early postoperative period. traditionally two precautions have been taken. One precaution has been to feed infants with a spoon or ;I syringe and to avoid bottle feeding.‘-” The other has been to splint the arms of infants to prevent them from sucking their thumb or fingers and Ao from pokiug ob.jects into the wound.’ ‘! For the pAst IS \‘L’aI-\. the senior author (BCS) has allowed bottle fe&ling of children immediately folloning both lip and palate surger). with no apparent adverse etfccts. IHowxer. the use of arm splints has been maintained and all children had splints applied for 3 weeks po5toper;ilively. We becsmc aware of the possible distress caused by splints to both the children and their parents and hence decided to wiew the need to continue this custom. We reasoned that the teat of the bottle was no more harmful than a child’s thumb and furthermore, it qeemed lunlikcl~ that a child would uilfully touch a painful site. In ;I prospective uncontrolled study of 24
Non-splinters
4 E z
36
; .;
20
-?z
16-
Palate only 1 1.7%
a3 EL E s $
-
l
**** .
.. ... 12. 84-
~-.“............ ..:.. ..
B
. . . . ...*.... median . . . . . .. . . . . . .... %-
--
0-l
46
.e...
After lip repalr
After palate reoalr
Do Babies Require Arm Splints After Cleft Palate Repair? Table 1
683
Summary of patient data Children with postoperative arm splints (n = 21)
Mean (standard deviation) age at operation in months Number with syndromic deformities (all Pierre Robin) Number with associated cleft lip defects Number of digit suckers Number with flap closure of palate Cleft length: 0/3 1/3 2/3 3/3 Number with preoperative orthodontic treatment % width of cleft (in sample) Number with postoperative oronasal fistulae
Children with no postoperative arm splints (n = 25)
P-values
5.1 (_+0.7)
5.1 (_+0.9)
0.925
3
4
1.0
9 8 9
13 8 15
0.57 0.76 0.37
3 5 4 9 16
7 3 3 12 16
12.3 median 11.2-29.4 range (n = 7) 6
23.4 median 22.~27.1 range (n - 6) 5
0.87 0.52 0.22 0.73
....%iiiiiiii ................ "
alate
late
A o%
i~ .... ~i
D /o..~
Width of cleft = BC/AD % Fig. 3
Fig. 4
Figure ~-Method for classification of the length of cleft palate. Figure 4~-Method used to calculate the cleft width. The illustration and method are based on those described by FishP 1. Length of palatal defect. 2. W i d t h of cleft. 3. W h e t h e r repair was by v o n L a n g e n b e c k flaps or by direct closure. 4. Associated c o n g e n i t a l syndrome. 5. Associated clefts o f the lip. 6. W h e t h e r children were f i n g e r / t h u m b suckers at the time of operation, since this m a y increase the risk of
disrupting the repair if their arms are n o t splinted (Table 1). The length of the palatal defect was j u d g e d at operation. Defects o f the h a r d palate from its posterior m a r g i n to the incisive f o r a m e n were described in thirds a n d 0 / 3 d e n o t e d a defect o f only the soft palate (Fig. 3). The width o f the palatal defect was calculated i n 13
British Journal of Plastic Surgery
684 of the 46 children in the trial (18?%) in whom preoperative stone plaster orthodontic models (Kaffird) were available. Using a variation of the method described by Fish.” the width of the cleft at the level of the most distal point on the second deciduous molar tooth segment was expressed as a percentage of the perimeter of the roof of the mouth at the same plane (Fig. 4). The measurements were taken using a Vernier calliper gauge reading to 0.1 mm. The frequency of variables in each group was compared statistically. The Mann-Whitney test was used for the palate width measurements since the data were a continuous variable and the Chi square test was used for the remaining variables. The Student’s f-test was used to compare the age of children in the two groups.
Results There was no statistical association between the 6 possible risk factors of poor outcome with either group of children, suggesting the two populations were matched (Table 1). Three months postoperatively. there was no statistical difference in the fistula rate between the two groups of children. Among the 21 children who had postoperative arm splints 6 had a fistula and, among the 25 children who did not have splints. 5 had a fistula. All fistulae were pin-hole or narrow slits and none required immediate closure.
Discussion The primary operation to repair a cleft palate is allimportant and it is appropriate that efforts be made to optimise results. In addition to arm restraints and the avoidance of bottle feeding.’ ” preoperative antibiotics are also routinely given in an attempt to reduce the incidence of wound breakdown. However. whereas the harm from oro-pharyngeal infections” and the subsequent benefit of perioperative antibiotics has been demonstrated,’ the benefit of arm restraints has not been critically evaluated. Our prospective randomised study showed no benefit from arm restraints. Nonetheless. the postal survey revealed that the majority of UK consultant plastic surgeons with a cleft practice advocate the use of arm restraints either after cleft lip or palate surgery, or both procedures. However. the observation that some surgeons either do not use arm restraints all the time. or not at all. suggests that some have already questioned their usefulness. Furthermore. the recommended duration for arm restraint application varied from 2 to 43 days. Such a wide disparity may reflect an element of uncertainty as to their benefit. The operative technique described here aims to optimise the quality of speech and normal maxillary growth. The success of this philosophy will of course not be evident for several years. However, the radical muscle retro-positioning leaves the anterior one third of the soft palate vulnerable to dehiscence, due to the absence of any muscle or aponeurotic reinforcement.
More aggressive use of mucoperiosteal hard palate flaps and less radical muscle dissection might have reduced the fistula rate but our overall fistula rate of 14% is similar to those reported from large studies (18-23 %I).” ‘I’ It may be suggested that the purpose of arm restraints is not to prevent the small pin-hole or slitlike fistulae we described, but a complete traumatic disruption of the repair. This issue can only be resolved by additional studies. One other criticism of this study is that palate width measurements were only possible in a small sample of children (28 ‘?A). In addition. the method of assessing palatal width assumes that the palatal defect has a strict geometric form.; Whereas this is possibly an over simplification and a technique of three-dimensional image analysis might have been more accurate, we considered the method suficient for our purpose of simply comparing the severity ol defects in each group ot children. Theories whych search for a benefit from arm restraints after cleft surgery must be balanced by considering the possible disadvantages of this time honoured custom. It has been suggested that restraints may contribute to a motor weakness in children with cleft lip and palate defects.’ There have been no studies to our knowledge that have assessed the psychological effects of arm splints. but during this study several parents expressed their dissatisfaction with the restriction of their children. Without evidence in their favour. at the very least arm restraints may be an unnecessary accessory to cleft surgery. As a conscquence of this study. we have abandoned arm restraints after cleft palate surgery and we are presently reviewing their role after cleft lip repair. Acknowledgements The authors are gtxb3’ul to: Sister P. Elc! and the ntming ,lalf 01 Burstead Ward for their enthusiasm and cooperation during the trial; Mr M. A. C. S. Cooper for help with the data collection: MI D. Di Bia.rc for hi:, advice and for providing the orthodontic model>: Miss J. Pearson for the statistical analysis: Miss L. Masters for the graphic artwork; and to a11 the consultant plastic surgeon5 who took part in the postal questionnaire.
References I. Millard RD. Cleft craft: the aolutlon of its surgery. Vol. III. Boston : Little Brown and Company. lU80: Ii9 63. 2. Randall P. La Row 1). Cleft palate. In: McCarthy JG. ed. Plastic aurger). Philadelphia: WB Saunders Company. 1990. 2723-51. 3. Grabb WC. General aspect5 of cleft palate surgery. In: Grabb WC. Roaenstein SW. Brwh KR. eds. Cleft lip and palate. surgical. dental and speech aspects Boston: Little Broun and Compnny. 1971 : 373-Y?. 1. O’Riain S. Cleft lip burgerq without postoperati\c restraints. Br J Plast Surg 1977: 30: 140-l. 5. Fish J. Growth of palatal shelves of post-alveolar cleft palate infants: efl’ectb of atimulatlon apphances. Br Dent J lY72: I??: 492 501. 6. Jolleys A. Savage JP. Healing defect\ in cleft palate hurgcry: the role of infection. Br J Plast Surg 1963; 13: Ii4 9 7. Moore MD. Lnwrrnce WT. Ptak JJ. Trier WC. Compllcatlon 01 primaq palatoplasty: il twenty-one-year review. Cleft Palate J IYXX: 2.5: 15662. X. Ahyholm I-E. Borchgrevinh HHC, Eskrland G Palatal tistulac following cleft palate surgery. Stand J PIat Recunstr Surg 1070; 13: 2Y5-300.
Uo
Babio
Rquirc
,4rtn
Splint,
After
Cleft
Palate
Repair’!
hX5
SURGERY
----
11
Do balbies require arm splints after cleft palate repair?
.Sl’.~l;Il.~I R 1.. Traditionally, arm restraints are used in children after cleft surgery to prevent traumatic disruption of the repair. A questionnaire amongst consultant plastic surgeons in the UK showed that restraints are in common use. However, a prospective randomised trial of 46 children having primary cleft palate repair showed that arm splints did not decrease the incidence of oronasal fistulae. Six of 21 children who had arm splints in the postoperative period and 5 of ;!S who did not have splints developed an oronasal fistula. We have therefore abandoned the use of arm splints after cleft palate repair. ~~
children having cleft lip repair lvhere arm restraints b’ere omitted. O’Riain found no cases where straving tingers caused a disruption of the suture line.’ W; are unaware of any study on the efficacy of arm restraints following cleft palate repair. Likewise. there have been no studies to determine the optimum time for IXhich the restraints should be applied. This paper describes two studies. The tirst V;IS ;I postal survey of consultant plastic surgeons in the UK to determine both the prevalence of the use of arm restraints following primary cleft surgery and also, the commonest recommended duration for their use. The second was a prospecticecontrolled trial of46children undergoing primary repairs of cleft palate. to study whether arm splints influenced the incidence of portoperative palatal breakdown leading tc,l oronasal fistulae.
In cleft lip and palate surgery. in order to prevent traumatic disruption of wounds in the early postoperative period. traditionally two precautions have been taken. One precaution has been to feed infants with a spoon or ;I syringe and to avoid bottle feeding.‘-” The other has been to splint the arms of infants to prevent them from sucking their thumb or fingers and Ao from pokiug ob.jects into the wound.’ ‘! For the pAst IS \‘L’aI-\. the senior author (BCS) has allowed bottle fe&ling of children immediately folloning both lip and palate surger). with no apparent adverse etfccts. IHowxer. the use of arm splints has been maintained and all children had splints applied for 3 weeks po5toper;ilively. We becsmc aware of the possible distress caused by splints to both the children and their parents and hence decided to wiew the need to continue this custom. We reasoned that the teat of the bottle was no more harmful than a child’s thumb and furthermore, it qeemed lunlikcl~ that a child would uilfully touch a painful site. In ;I prospective uncontrolled study of 24
Non-splinters
4 E z
36
; .;
20
-?z
16-
Palate only 1 1.7%
a3 EL E s $
-
l
**** .
.. ... 12. 84-
~-.“............ ..:.. ..
B
. . . . ...*.... median . . . . . .. . . . . . .... %-
--
0-l
46
.e...
After lip repalr
After palate reoalr
Do Babies Require Arm Splints After Cleft Palate Repair? Table 1
683
Summary of patient data Children with postoperative arm splints (n = 21)
Mean (standard deviation) age at operation in months Number with syndromic deformities (all Pierre Robin) Number with associated cleft lip defects Number of digit suckers Number with flap closure of palate Cleft length: 0/3 1/3 2/3 3/3 Number with preoperative orthodontic treatment % width of cleft (in sample) Number with postoperative oronasal fistulae
Children with no postoperative arm splints (n = 25)
P-values
5.1 (_+0.7)
5.1 (_+0.9)
0.925
3
4
1.0
9 8 9
13 8 15
0.57 0.76 0.37
3 5 4 9 16
7 3 3 12 16
12.3 median 11.2-29.4 range (n = 7) 6
23.4 median 22.~27.1 range (n - 6) 5
0.87 0.52 0.22 0.73
....%iiiiiiii ................ "
alate
late
A o%
i~ .... ~i
D /o..~
Width of cleft = BC/AD % Fig. 3
Fig. 4
Figure ~-Method for classification of the length of cleft palate. Figure 4~-Method used to calculate the cleft width. The illustration and method are based on those described by FishP 1. Length of palatal defect. 2. W i d t h of cleft. 3. W h e t h e r repair was by v o n L a n g e n b e c k flaps or by direct closure. 4. Associated c o n g e n i t a l syndrome. 5. Associated clefts o f the lip. 6. W h e t h e r children were f i n g e r / t h u m b suckers at the time of operation, since this m a y increase the risk of
disrupting the repair if their arms are n o t splinted (Table 1). The length of the palatal defect was j u d g e d at operation. Defects o f the h a r d palate from its posterior m a r g i n to the incisive f o r a m e n were described in thirds a n d 0 / 3 d e n o t e d a defect o f only the soft palate (Fig. 3). The width o f the palatal defect was calculated i n 13
British Journal of Plastic Surgery
684 of the 46 children in the trial (18?%) in whom preoperative stone plaster orthodontic models (Kaffird) were available. Using a variation of the method described by Fish.” the width of the cleft at the level of the most distal point on the second deciduous molar tooth segment was expressed as a percentage of the perimeter of the roof of the mouth at the same plane (Fig. 4). The measurements were taken using a Vernier calliper gauge reading to 0.1 mm. The frequency of variables in each group was compared statistically. The Mann-Whitney test was used for the palate width measurements since the data were a continuous variable and the Chi square test was used for the remaining variables. The Student’s f-test was used to compare the age of children in the two groups.
Results There was no statistical association between the 6 possible risk factors of poor outcome with either group of children, suggesting the two populations were matched (Table 1). Three months postoperatively. there was no statistical difference in the fistula rate between the two groups of children. Among the 21 children who had postoperative arm splints 6 had a fistula and, among the 25 children who did not have splints. 5 had a fistula. All fistulae were pin-hole or narrow slits and none required immediate closure.
Discussion The primary operation to repair a cleft palate is allimportant and it is appropriate that efforts be made to optimise results. In addition to arm restraints and the avoidance of bottle feeding.’ ” preoperative antibiotics are also routinely given in an attempt to reduce the incidence of wound breakdown. However. whereas the harm from oro-pharyngeal infections” and the subsequent benefit of perioperative antibiotics has been demonstrated,’ the benefit of arm restraints has not been critically evaluated. Our prospective randomised study showed no benefit from arm restraints. Nonetheless. the postal survey revealed that the majority of UK consultant plastic surgeons with a cleft practice advocate the use of arm restraints either after cleft lip or palate surgery, or both procedures. However. the observation that some surgeons either do not use arm restraints all the time. or not at all. suggests that some have already questioned their usefulness. Furthermore. the recommended duration for arm restraint application varied from 2 to 43 days. Such a wide disparity may reflect an element of uncertainty as to their benefit. The operative technique described here aims to optimise the quality of speech and normal maxillary growth. The success of this philosophy will of course not be evident for several years. However, the radical muscle retro-positioning leaves the anterior one third of the soft palate vulnerable to dehiscence, due to the absence of any muscle or aponeurotic reinforcement.
More aggressive use of mucoperiosteal hard palate flaps and less radical muscle dissection might have reduced the fistula rate but our overall fistula rate of 14% is similar to those reported from large studies (18-23 %I).” ‘I’ It may be suggested that the purpose of arm restraints is not to prevent the small pin-hole or slitlike fistulae we described, but a complete traumatic disruption of the repair. This issue can only be resolved by additional studies. One other criticism of this study is that palate width measurements were only possible in a small sample of children (28 ‘?A). In addition. the method of assessing palatal width assumes that the palatal defect has a strict geometric form.; Whereas this is possibly an over simplification and a technique of three-dimensional image analysis might have been more accurate, we considered the method suficient for our purpose of simply comparing the severity ol defects in each group ot children. Theories whych search for a benefit from arm restraints after cleft surgery must be balanced by considering the possible disadvantages of this time honoured custom. It has been suggested that restraints may contribute to a motor weakness in children with cleft lip and palate defects.’ There have been no studies to our knowledge that have assessed the psychological effects of arm splints. but during this study several parents expressed their dissatisfaction with the restriction of their children. Without evidence in their favour. at the very least arm restraints may be an unnecessary accessory to cleft surgery. As a conscquence of this study. we have abandoned arm restraints after cleft palate surgery and we are presently reviewing their role after cleft lip repair. Acknowledgements The authors are gtxb3’ul to: Sister P. Elc! and the ntming ,lalf 01 Burstead Ward for their enthusiasm and cooperation during the trial; Mr M. A. C. S. Cooper for help with the data collection: MI D. Di Bia.rc for hi:, advice and for providing the orthodontic model>: Miss J. Pearson for the statistical analysis: Miss L. Masters for the graphic artwork; and to a11 the consultant plastic surgeon5 who took part in the postal questionnaire.
References I. Millard RD. Cleft craft: the aolutlon of its surgery. Vol. III. Boston : Little Brown and Company. lU80: Ii9 63. 2. Randall P. La Row 1). Cleft palate. In: McCarthy JG. ed. Plastic aurger). Philadelphia: WB Saunders Company. 1990. 2723-51. 3. Grabb WC. General aspect5 of cleft palate surgery. In: Grabb WC. Roaenstein SW. Brwh KR. eds. Cleft lip and palate. surgical. dental and speech aspects Boston: Little Broun and Compnny. 1971 : 373-Y?. 1. O’Riain S. Cleft lip burgerq without postoperati\c restraints. Br J Plast Surg 1977: 30: 140-l. 5. Fish J. Growth of palatal shelves of post-alveolar cleft palate infants: efl’ectb of atimulatlon apphances. Br Dent J lY72: I??: 492 501. 6. Jolleys A. Savage JP. Healing defect\ in cleft palate hurgcry: the role of infection. Br J Plast Surg 1963; 13: Ii4 9 7. Moore MD. Lnwrrnce WT. Ptak JJ. Trier WC. Compllcatlon 01 primaq palatoplasty: il twenty-one-year review. Cleft Palate J IYXX: 2.5: 15662. X. Ahyholm I-E. Borchgrevinh HHC, Eskrland G Palatal tistulac following cleft palate surgery. Stand J PIat Recunstr Surg 1070; 13: 2Y5-300.
Uo
Babio
Rquirc
,4rtn
Splint,
After
Cleft
Palate
Repair’!
hX5