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Syndactyly: Can web creep be avoided?
SYNDACTYLY:
CAN
WEB
CREEP
BE AVOIDED?
A. L. H. MOSS and G. FOUCHER From the Department of Plastic and Reconstructive Surgery, Frenchay Hospital, Bristol and S.O.S. Main, Strasbourg, France
Syndactyly is one of the most common congenital hand deformities but there still remains a high incidence of contractures and web creep after attempts at surgical corrlection using many assorted techniques. Little attention has been paid to the potential junctional scar in the aetiology of web creep. To remedy this, a technique is described which involves a dorsal flap and two palmar laterallybased flaps. This method not only breaks up the pahnar junctional scar but also completely reconstructs the web, not just the floor. The procedure can be used in all varieties of syndactyly and has reduced the incidence of creep in a series of 49 webs.
Journal of Hand Surgery (British Volume, 1990) 15B: 193-200
Operative technique
Under tourniquet, a traditional long quadrilateral flap is rais’ed on the dorsal aspect of the web. (This flap is now waisted to sit better in the base of the web). Zig-zag incisions, with acute angles, are made distally, to allow flaps to be raised (Fig. la). At the base of the digits on the palmar aspect, two laterally-based triangular flaps are raised, the length of each equal to the width of the web (Fig. lb, see also line illustration opposite). The proximal incision is transverse and should be at the level of the new web, assessed by normal adjacent webs and anatomy. These will be transposed to each side of the tip of the dorsal quadrilateral flap, in the reconstructed web, allowing complete closure in incomplete or partial syndactyly. Zig-zag incisions are then made distally, as on the dorsal aspect, arranged so that the flaps will interdigitate on each side of the fingers. All these flaps are radically thinned, as are the sides of the fingers, leaving intact the veins, arteries and nerves (Fig. lc). This will allow the flaps to be sutured without tension and will also result in more normal-looking digits. After the web has been adequately deepened and haemostasis thoroughly achieved, the flaps are inset (Fig. Id). 5/O or 6/O Ethilon or Dexon is used. The defects at the base of the digits are covered with thick split-skin grafts from the buttocks or full-thickness skin from the lateral inguinal region (Fig. le). The full-thickness skin grafts should include a thin layer of fat, which take perfectly in children, with no contraction and less pigmentation. Results 42 patients
with 49 webs have been treated by this technique: 19 males and 23 females. The age range was from 2-45 years, with a mean of 12 years. The right side was involved in 22 patients, the left in 20 and both in four cases. The webs affected by the congenital syndactyly were as expected, the most common being that between the ring and middle fingers. There were three patients VOL. 15B No. 2 MAY 1990
with bilateral and nine with unilateral first web syndactyly (Fig. 2). 15 webs had incomplete syndactyly (Fig. 3), eight complete simple syndactyly (Figs. 1 and 3), one complex syndactyly (Fig. 4) and 11 post-surgical web creep; eight were post-traumatic (Fig. 5) and seven followed burns (Fig. 6). There was an equal use of split and full-thickness skin grafts; three partly failed to heal primarily one splitskin and two full-thickness). These included one case which had maceration of a full-thickness skin graft at ten days requiring surgical revision after three years. During a follow-up period of between one and four years, no contractures were observed and no other secondary procedures were required.
Fig. 1
Line illustration
of transverse
proximal
incision.
Discussion
Zeller (1810) first described a single dorsal triangular flap, which was modified by Dieffenbach (1834) to a rectangular one. Norton (1881) wrote of the use of two triangular flaps for the correction of webbed fingers. He suggested that the flaps should be sutured end-to-end, but Felizet (1892) modified this to side-to-side. Pieri (1920) first advocated the use of zig-zag incisions to prevent flexion contractures, although grafts had been first suggested by Lennander (189 1). Many more modifications and techniques have been described which will not be discussed further. It is accepted that the web must be reconstructed using 193
A. L H. MOSS AND G. FOUCHER
Fig. 1
(a) Dorsal markings for release of a complete syndactyly of the third web. (b) Palmar markings of the same syndactyly, but the proximal incision should be transverse. (c) The flaps have been raised and thinned radically. (d) View showing the two palmar triangular flaps inset on each side of the tip of the dorsal quadrilateral flap. (e) The remaining flaps have been interdigitated and a thick split-skin graft applied to the base of the digit to complete the closure. (f) Palmar view of the same hand two years after operation.
flaps, but there are two main schools of thought regarding the type to be used. Some surgeons argue for the two triangular flap technique (Cronin, 1956; Ebskov and Zachariae, 1966; Boyes, 1970; Skoog, 1974; BuckGramcko, 1975; Smith, 1981) while others advocate a dorsal rectangular or quadrilateral flap (Bauer et al., 1956; Flatt, 1962 and 1977; Dobyns, 1982; Ketchum, 1982; Keret and Ger, 1987). The former argue that there is less chance of web creep but the latter maintain that the tips of the triangular flaps migrate distally, even though sutured side-to-side, resulting in an abnormallooking web with creep (Flatt, 1974) as shown in Figure 7. The normal web skin is dorsal in origin and inclined distally at about 40” in a dorso-palmar direction; therefore 194
the dorsal flap technique should give a more natural appearance (Kelikian, 1974; Skoog, 1974; Hentz and Littler, 1978). Colville (1989) has recently described a dorsal island flap with rectangular flaps to close one side of a digit. On the other finger, rectangular defects are covered with full-thickness skin grafts. However, in the post-operative views, web creep and a flexion contracture are shown, probably due to junctional scarring volar to the mid-lateral line. Similarly, there are two schools regarding the type of graft to be used at the base of the fingers. Those who argue for split skin (Boyes, 1970) maintain that there is better donor-site appearance, even if large areas are used, and that there is better colour match on the palm than with full-thickness skin. The opposite view is that fullTHE JOURNAL
OF HAND SURGERY
SYNDACTYLY:
,: ---k
CAN WEB CREEP BE AVOIDED?
:,.;.
.:“. . ..’ ,.. ;u:,,... ‘,
.,:,.:
. . . ,......,;
‘.‘.,
. . .,:..:.
:,.;:,
‘.‘:,..;
..
.‘..
.-.,;:;
.,:.:
d
Fig. 2
1
,,‘., 1.
(a) Dorsal markings for release of syndactyly of the first web. (b) Palmar markings of the same web. (c) The flaps inset and grafts applied. (d) Diagram of Figure 2c showing the various flaps. (e) Dorsal view 18 months after operation. A simultaneous release was done of an incomplete syndactyly of the second web on the other hand
thickness skin should result in less contraction (Bauer et al., 1956; Flatt, 1974; Buck-Gramcko, 1975; Smith, 1981; Ketchum, 1982). We support this latter view, especially if a thin layer of fat is left attached to the dermis, as this tends to reduce the pigmentation and contraction and appears to take satisfactorily. Creep is defined as distal migration of the web following surgery to correct syndactyly. However, there is no clear definition as to the normal position of the web. Some authors use needles to mark the new web using adjacent spaces as guides (Dobyns, 1982); others measure from the distal palmar crease (Toledo and Ger, 1979) or from the “normal palmar crease” (Brown, 1977). From prel.iminary findings of an on-going study of hand X-rays in normal children of varying ages, it appears that the normal web is approximately half-way between the VOL. 15B No. 2 MAY
1990
metacarpal head and the head of the proximal phalanx, confirming the opinion of Dobyns (1982). Many authors comment that web creep and contractures are common following correction of syndactyly (Cronin, 1956; Skoog, 1974; Brown, 1977), recurrence and re-operation rates ranging from 5-59x (Ebskov and Zachariae, 1966; Buck-Gramcko, 1975; Brown, 1977; Toledo and Ger, 1979; Percival and Sykes, 1989; Keret and Ger, 1987). It appears that the only significant factor is the use of full-thickness skin grafts which has better results. Other reasons why contractures and web creep may occur are the design of the incisions, the type of flaps used and delay in healing (due to haematoma, tension, flap necrosis or loss of graft). Other causes have been described: lack of splintage (MacCollum, 1940), type of 195
A. L. H. MOSS AND G. FOUCHER
Fig. 3
(a) Dorsal view showing an incomplete syndactyly of the third web on the left hand and a complete syndactyly aspect of the same patient. (c) Dorsal view 2%years after release. (d) Palmar view 2f years after release.
Fig. 4
196
on the right.
(b) Palmar
(a) Complex syndactyly of the third web of both hands. (b) X-ray of the same patient. (c) The right hand four years after a single procedure, showing maintenance of the release of the web.
THE JOURNAL
OF HAND SURGERY
SYNDACTYLY:
CAN WEB CREEP BE AVOIDED?
Fig. 5
(a) Traumatic syndactyly of the fourth web (part of the dorsal quadrilateral flap has been drawn on the skin). (b) Palmar aspect, with the two triangular flaps marked: note the more transverse proximal incision. (c) View into the web showing the three flaps inset with complete closure of the defects. (d) Diagram of Figure 5c, clarifying the flaps. (e) Dorsal view two years after operation.
Fig. 6
(a) Dorsal view of burn syndactyly of all webs of both hands. (b) Three years after release of all webs, where no skin grafts were used. Pressure garments were used for the hypertrophic scarring and this may have helped to prevent web creep.
VOL. 15B No. 2 MAY
1990
197
A. L. H. MOSS AND G. FOUCHER
Fig. 7
Dorsal view of a right hand showing creep of the second web after release with the two-triangular-flap technique and of the third web following the traditional dorsal quadrilateral flap method.
bandages (Toledo and Ger, 1979; Keret and Ger, 1987), the age of the patient at the time of operation (Flatt, 1962; Ebskov and Zachariae, 1966; Keret and Ger, 1987) and the experience of the surgeon (Ebskov and Zachariae, 1966; Buck-Gramcko, 1975).
Cronin (1956) mentioned the possibility of the palmar junctional scar contributing to the recurrence of webbing (Fig. 8) and this has been alluded to by various authors since (Ebskov and Zachariae, 1966; Kelikian, 1974; Skoog, 1974; Buck-Gramcko, 1975). However, little has been suggested to prevent this, as one can see from immediate post-operative photographs and diagrams in many modern publications, the potential junctional scars being palmar to the mid-lateral line in the floor of the web (Figs. 7 and 9). Shaw et al. (1973) described the double Z-plasty (butterfly flaps) method for web release in minor syndactyly. This was modified by Flatt (1977) so that the previous two triangular flaps on the palmar aspect became rectangular (the dorsal-palmar flap combination procedure); these modified flaps also were twice the length of the triangular ones which were only half the width of the web. The operative technique which we have used, first described by Ostrowski et al. in 1985, is a modification of both these methods by using two laterally-based palmar triangular flaps each of which is as long as the width of the new web. The technique is advocated in complete syndactyly (Figs. 1 and 3) as well as traumatic (Fig. 5) and burn cases (Fig. 6) where the dorsal and palmar flaps can be raised on scar tissue as usually the subcutaneous fat and blood supply are unaffected by the burn. These flaps can be raised even if skin grafts have been used or with hypertrophic scars, although they are not as pliable as virgin tissue. In burn syndactyly, it may be difficult to wear pressure garments to control the
b Fig. 8
198
(a) Dorsal view of web creep following release using a quadrilateral flap and full-thickness skin graft without delay in healing. (b) Diagram of Figure 8a showing the outline of the dorsal quadrilateral flap and skin graft (hatched area). Note the junctional scar palmar to the midlateral line and the minimal increase in pigmentation after the use of full-thickness grafts with a thin layer of subdermal fat. THE JOURNAL OF HAND SURGERY
SYNDACTYLY:
Fig. 9
CAN WEB CREEP BE AVOIDED?
Diagram of the conventional design for releasing syndactyly by using a dorsal quadrilateral flap, as shown in many papers and textbooks. Note the potential junctional scar along the palmar aspect of the new web extending laterally from the tip of the dorsal flap.
scarring, as the fingers cannot abduct. This technique has allowed release of the webs and thus the application of pressure garments to produce a much improved result, both cosmetically and functionally (Fig. 6). A similar technique (the square flap procedure) has been described for burn contracture of the axilla and it was suggested that the method may be suitable for webbing of the fingers (Hyakusoku and Fumiiri, 1987). In our series, the results have been encouraging in all types of cases, and although the follow-up in some patients is only 12 months, web creep should have occurred by then (Mercer et al., 1989). However, of the
Fig. 10
(a) First web contracture
VOL. 15B No. 2 MAY 1990
with shortening
of thumb.
three cases where there was delay in healing, only one required secondary surgery. This must be as a result of the irregularly-shaped junctional scar on the palmar aspect comprising the dorsal flap with the two triangular flaps from the palmar side. With tissue expansion (Van Beek and Adson, 1987), one should be able to avoid the use of grafts as well as the volar junctional scar. In partial syndactyly and deepening procedures, the volar flaps are able to close the secondary defects (Fig. 5). When this method is used for the first web space, primarily (Fig. 2) or with thumb shortening (Fig. lo), or even following a Matev lengthening operation, an excellent contour is obtained which may allow for the fitting of a prosthesis, if necessary. Accurate records are important, as a critical review of the results of surgery for this common deformity may not be as perfect as we think (Flat& 1962). Many authors report on “partial recurrence not requiring further surgery” (Skoog, 1974; Brown, 1977; Toledo and Ger, 1979) but this must be unacceptable. With an atraumatic technique using magnification and bipolar coagulation, one should obtain primary healing with tension free closure of well designed and raised flaps. The primary aim in syndactyly surgery is to approach normality, both cosmetically and functionally. Acknowledgements We would like to thank the Consultant Reconstructive Plastic Surgeons at Frenchay Hospital, Bristol, for allowing us to include in this series patients under their care, and the Medical Illustrations Department at Frenchay Hospital, for the photographs and diagrams.
References BAUER, T. B., TONDRA, J. M. and TRUSLER, H. M. (1956). Technical modification in repair of syndactylysm. Plastic and Reconstructive Surgery, 11: 5: 385-392.
(b) Post-operative
result.
199
A. L. H. MOSS AND BOYES, .I. H. Bunnell’s Surgery of the Hand, 5th edn. Philadelphia, J.B. Lippincott, 1970: 59-107. BROWN, P. M. (1977). Syndactyly--a review and long term results. The Hand, 9: 1: 16-27. BUCK-GRAMCKO, D. (1975). Congenital malformations of the hand: indications, operative treatment and results. Scandinavian Journal of Plastic and Reconstructive Surgery. 9: 190-198. COLVILLE, J. (1989). Syndactyly correction. British Journal of Plastic Surgery, 42: 1: 12-16. CRONIN, T. D. (1956). Syndactylism: Results of zig-zag inclusion to prevent postoperative contractwe. Plastic and Reconstructive Surgery, 18: 6: 460468. DIEFFENBACH, J. F. Chirurgische Erfahrungen, besanders iiber die Wiederher,steNun~ Zerstiirter Theile des menschlichen Kbnxrs nach neuen Methoden BerlinTEnslin 1829. DOBYNS, J. H. Syndactyly. In: Green, D. P. (Ed) Operative Hand Surgery, New York, Churchill Livingstone, 1982: Vol 1: 281-293. EBSKOV, B. and ZACHARIAE, L. (1966). Surgical Methods in Syndactylism. Evaluation of 208 operations. Acta Chirurgica Scandinavia. 13 1: 258-268. Fl?LIZET, G. (1892). Op.&ration de la syndactylie congenitale (pro&d& autoplastique). Revue d’orthopedie, 3: 49-61. FLATT, A. E. (1962). Treatment of syndactylism. Plastic and Reconstructive Surgery, 29: 4: 336-341. FLATT, A. E. Practical factors in the treatment of syndactyly. In: Littler J. W., Cramer L. M. and Smith J. W. (Eds) Symposium in Reconstructive Hand Surgery. St Louis, C.V. Mosby, 1974: 144-156. FLATT, A. E. The Care of Congenital Hand Anomalies. St. Louis, CV Mosby Co, 1977: 186-189. HENTZ, V. R. and LITTLER, J. W. The Surgical Management of Congenital Hand Anomalies. In: Converse, J. M. (Ed.) R econstructive Plastic Surgery. Philadelphia, W.B. Saunders, 1978: 3306-3349. HYAKUSOKU, H. and FUMIIRI, M. (1987). The square flap method. British Journal of Plastic Surgery, 40: 1: 40-46. KELIKIAN, H. Congenital deformities of the hand and forearm. Philadelphia, W.B. Saunders, 1974: 331407. KERET, D. and GER, E. (1987). Evaluation of a uniform operative technique to treat syndactyly. Journal of Hand Surgery, 12A: 5(l): 727-729. KETCHUM, L. D. Skin Flaps. In: Green, D. P. (Ed) Operative Hand Surgery, NewYork, ChurchillLivingstone, 1982: Vol 1: 1327-1331. LENNANDER, K. G. (1891). Fall af kongenital syndaktyli, opereradt, med hjelp af Thiersch’s hudtransplantationmetod. Upsala hgkareforenings Forhandlingar, 26: 151-152.
200
G. FOUCHER MacCOLLUM, D. W. (1940). Webbed fingers. Surgery, Gynecology and Obstetrics, 71 : 782-789. MERCER, N. S. G., TAN, K. and MOSS, A. L. H. Paper presented at the British Society for Surgery of the Hand Spring Meeting, Nottingham, 18-19 May, 1989. NORTON, A. T. (1881). A new and reliable operation for the cure of webbed fingers. British Medical Journal. 2: 931-932. OSTROWSKI, D. M., GOULD, J. S. and FEAGIN, C. A. Three flap web-plasty for short incomplete syndactyly. Presented at the American Society for Surgeryofthe Hand at Las Vegas January 21-23rd, 1985. PERCIVAL, N. J. and SYKES, P. J. (1989). Syndactyly. A review of the factors which influence surgical treatment. Journal of Hand Surgery, 14B: 2: 196200. PIERI, G. (1920). Plastica cutanea per le retrazioni cicatriziali delle dita. Chir. Organi. Mov, 4: 303-306. SHAW, D. T., LI, C. S., RICHEY, D. G. and NAHIGIAN, S. H. (1973). Interdigital Butterfly Flap in the Hand (The Double-Opposing Z-plasty). Journal of Bone and Joint Surgery, 55A: 8 : 1677-1679. SKOOG, T. Plastic Surgery. New methods and refinements. Stockholm. Almqvist and Wiksell International, 1974: 412-427. SMITH, R. J., Syndactyly. In: Lamb, D. W. and Kuczynski, K. (Eds.) The PracticeofHandSurgery. (1st edn). Oxford, Blackwell Scientific Publications. 1981: 313-329. TOLEDO, L. C. and GER, E. (1979). Evaluation of the operative treatment of syndactyly. Journal of Hand Surgery, 4: 6: 556564. VAN BEEK, A. L. and ADSON, M. H. (1987). Tissue Expansion in the Upper Extremity. Clinics in Plastic Surgery, 14: 3: 535-542. ZELLER, S. Ubhandlung uber die enten Erscheinungen venerischer LokalKnmkheits-Formen, und deren Behandlung, sammt einer kurzen Anzeige zwener neuen Operazion+Methoden, nahmlich: die nngebornen uerwachsenen Finger, unddie Kastrazion bare-end. Vienna, Binz, 1810: 107-l 11.
Accepted: 14 February
1989 Mr. A. L. H. Moss, Department
0
1989 The British Society
of Plastic Surgery,
for Surgery
Frenchay
Hospital,
Bristol,
BS16 ILE
of the Hand
0266-7681/90/00154193/%10.00
THE
JOURNAL
OF HAND
SURGERY
CAN
WEB
CREEP
BE AVOIDED?
A. L. H. MOSS and G. FOUCHER From the Department of Plastic and Reconstructive Surgery, Frenchay Hospital, Bristol and S.O.S. Main, Strasbourg, France
Syndactyly is one of the most common congenital hand deformities but there still remains a high incidence of contractures and web creep after attempts at surgical corrlection using many assorted techniques. Little attention has been paid to the potential junctional scar in the aetiology of web creep. To remedy this, a technique is described which involves a dorsal flap and two palmar laterallybased flaps. This method not only breaks up the pahnar junctional scar but also completely reconstructs the web, not just the floor. The procedure can be used in all varieties of syndactyly and has reduced the incidence of creep in a series of 49 webs.
Journal of Hand Surgery (British Volume, 1990) 15B: 193-200
Operative technique
Under tourniquet, a traditional long quadrilateral flap is rais’ed on the dorsal aspect of the web. (This flap is now waisted to sit better in the base of the web). Zig-zag incisions, with acute angles, are made distally, to allow flaps to be raised (Fig. la). At the base of the digits on the palmar aspect, two laterally-based triangular flaps are raised, the length of each equal to the width of the web (Fig. lb, see also line illustration opposite). The proximal incision is transverse and should be at the level of the new web, assessed by normal adjacent webs and anatomy. These will be transposed to each side of the tip of the dorsal quadrilateral flap, in the reconstructed web, allowing complete closure in incomplete or partial syndactyly. Zig-zag incisions are then made distally, as on the dorsal aspect, arranged so that the flaps will interdigitate on each side of the fingers. All these flaps are radically thinned, as are the sides of the fingers, leaving intact the veins, arteries and nerves (Fig. lc). This will allow the flaps to be sutured without tension and will also result in more normal-looking digits. After the web has been adequately deepened and haemostasis thoroughly achieved, the flaps are inset (Fig. Id). 5/O or 6/O Ethilon or Dexon is used. The defects at the base of the digits are covered with thick split-skin grafts from the buttocks or full-thickness skin from the lateral inguinal region (Fig. le). The full-thickness skin grafts should include a thin layer of fat, which take perfectly in children, with no contraction and less pigmentation. Results 42 patients
with 49 webs have been treated by this technique: 19 males and 23 females. The age range was from 2-45 years, with a mean of 12 years. The right side was involved in 22 patients, the left in 20 and both in four cases. The webs affected by the congenital syndactyly were as expected, the most common being that between the ring and middle fingers. There were three patients VOL. 15B No. 2 MAY 1990
with bilateral and nine with unilateral first web syndactyly (Fig. 2). 15 webs had incomplete syndactyly (Fig. 3), eight complete simple syndactyly (Figs. 1 and 3), one complex syndactyly (Fig. 4) and 11 post-surgical web creep; eight were post-traumatic (Fig. 5) and seven followed burns (Fig. 6). There was an equal use of split and full-thickness skin grafts; three partly failed to heal primarily one splitskin and two full-thickness). These included one case which had maceration of a full-thickness skin graft at ten days requiring surgical revision after three years. During a follow-up period of between one and four years, no contractures were observed and no other secondary procedures were required.
Fig. 1
Line illustration
of transverse
proximal
incision.
Discussion
Zeller (1810) first described a single dorsal triangular flap, which was modified by Dieffenbach (1834) to a rectangular one. Norton (1881) wrote of the use of two triangular flaps for the correction of webbed fingers. He suggested that the flaps should be sutured end-to-end, but Felizet (1892) modified this to side-to-side. Pieri (1920) first advocated the use of zig-zag incisions to prevent flexion contractures, although grafts had been first suggested by Lennander (189 1). Many more modifications and techniques have been described which will not be discussed further. It is accepted that the web must be reconstructed using 193
A. L H. MOSS AND G. FOUCHER
Fig. 1
(a) Dorsal markings for release of a complete syndactyly of the third web. (b) Palmar markings of the same syndactyly, but the proximal incision should be transverse. (c) The flaps have been raised and thinned radically. (d) View showing the two palmar triangular flaps inset on each side of the tip of the dorsal quadrilateral flap. (e) The remaining flaps have been interdigitated and a thick split-skin graft applied to the base of the digit to complete the closure. (f) Palmar view of the same hand two years after operation.
flaps, but there are two main schools of thought regarding the type to be used. Some surgeons argue for the two triangular flap technique (Cronin, 1956; Ebskov and Zachariae, 1966; Boyes, 1970; Skoog, 1974; BuckGramcko, 1975; Smith, 1981) while others advocate a dorsal rectangular or quadrilateral flap (Bauer et al., 1956; Flatt, 1962 and 1977; Dobyns, 1982; Ketchum, 1982; Keret and Ger, 1987). The former argue that there is less chance of web creep but the latter maintain that the tips of the triangular flaps migrate distally, even though sutured side-to-side, resulting in an abnormallooking web with creep (Flatt, 1974) as shown in Figure 7. The normal web skin is dorsal in origin and inclined distally at about 40” in a dorso-palmar direction; therefore 194
the dorsal flap technique should give a more natural appearance (Kelikian, 1974; Skoog, 1974; Hentz and Littler, 1978). Colville (1989) has recently described a dorsal island flap with rectangular flaps to close one side of a digit. On the other finger, rectangular defects are covered with full-thickness skin grafts. However, in the post-operative views, web creep and a flexion contracture are shown, probably due to junctional scarring volar to the mid-lateral line. Similarly, there are two schools regarding the type of graft to be used at the base of the fingers. Those who argue for split skin (Boyes, 1970) maintain that there is better donor-site appearance, even if large areas are used, and that there is better colour match on the palm than with full-thickness skin. The opposite view is that fullTHE JOURNAL
OF HAND SURGERY
SYNDACTYLY:
,: ---k
CAN WEB CREEP BE AVOIDED?
:,.;.
.:“. . ..’ ,.. ;u:,,... ‘,
.,:,.:
. . . ,......,;
‘.‘.,
. . .,:..:.
:,.;:,
‘.‘:,..;
..
.‘..
.-.,;:;
.,:.:
d
Fig. 2
1
,,‘., 1.
(a) Dorsal markings for release of syndactyly of the first web. (b) Palmar markings of the same web. (c) The flaps inset and grafts applied. (d) Diagram of Figure 2c showing the various flaps. (e) Dorsal view 18 months after operation. A simultaneous release was done of an incomplete syndactyly of the second web on the other hand
thickness skin should result in less contraction (Bauer et al., 1956; Flatt, 1974; Buck-Gramcko, 1975; Smith, 1981; Ketchum, 1982). We support this latter view, especially if a thin layer of fat is left attached to the dermis, as this tends to reduce the pigmentation and contraction and appears to take satisfactorily. Creep is defined as distal migration of the web following surgery to correct syndactyly. However, there is no clear definition as to the normal position of the web. Some authors use needles to mark the new web using adjacent spaces as guides (Dobyns, 1982); others measure from the distal palmar crease (Toledo and Ger, 1979) or from the “normal palmar crease” (Brown, 1977). From prel.iminary findings of an on-going study of hand X-rays in normal children of varying ages, it appears that the normal web is approximately half-way between the VOL. 15B No. 2 MAY
1990
metacarpal head and the head of the proximal phalanx, confirming the opinion of Dobyns (1982). Many authors comment that web creep and contractures are common following correction of syndactyly (Cronin, 1956; Skoog, 1974; Brown, 1977), recurrence and re-operation rates ranging from 5-59x (Ebskov and Zachariae, 1966; Buck-Gramcko, 1975; Brown, 1977; Toledo and Ger, 1979; Percival and Sykes, 1989; Keret and Ger, 1987). It appears that the only significant factor is the use of full-thickness skin grafts which has better results. Other reasons why contractures and web creep may occur are the design of the incisions, the type of flaps used and delay in healing (due to haematoma, tension, flap necrosis or loss of graft). Other causes have been described: lack of splintage (MacCollum, 1940), type of 195
A. L. H. MOSS AND G. FOUCHER
Fig. 3
(a) Dorsal view showing an incomplete syndactyly of the third web on the left hand and a complete syndactyly aspect of the same patient. (c) Dorsal view 2%years after release. (d) Palmar view 2f years after release.
Fig. 4
196
on the right.
(b) Palmar
(a) Complex syndactyly of the third web of both hands. (b) X-ray of the same patient. (c) The right hand four years after a single procedure, showing maintenance of the release of the web.
THE JOURNAL
OF HAND SURGERY
SYNDACTYLY:
CAN WEB CREEP BE AVOIDED?
Fig. 5
(a) Traumatic syndactyly of the fourth web (part of the dorsal quadrilateral flap has been drawn on the skin). (b) Palmar aspect, with the two triangular flaps marked: note the more transverse proximal incision. (c) View into the web showing the three flaps inset with complete closure of the defects. (d) Diagram of Figure 5c, clarifying the flaps. (e) Dorsal view two years after operation.
Fig. 6
(a) Dorsal view of burn syndactyly of all webs of both hands. (b) Three years after release of all webs, where no skin grafts were used. Pressure garments were used for the hypertrophic scarring and this may have helped to prevent web creep.
VOL. 15B No. 2 MAY
1990
197
A. L. H. MOSS AND G. FOUCHER
Fig. 7
Dorsal view of a right hand showing creep of the second web after release with the two-triangular-flap technique and of the third web following the traditional dorsal quadrilateral flap method.
bandages (Toledo and Ger, 1979; Keret and Ger, 1987), the age of the patient at the time of operation (Flatt, 1962; Ebskov and Zachariae, 1966; Keret and Ger, 1987) and the experience of the surgeon (Ebskov and Zachariae, 1966; Buck-Gramcko, 1975).
Cronin (1956) mentioned the possibility of the palmar junctional scar contributing to the recurrence of webbing (Fig. 8) and this has been alluded to by various authors since (Ebskov and Zachariae, 1966; Kelikian, 1974; Skoog, 1974; Buck-Gramcko, 1975). However, little has been suggested to prevent this, as one can see from immediate post-operative photographs and diagrams in many modern publications, the potential junctional scars being palmar to the mid-lateral line in the floor of the web (Figs. 7 and 9). Shaw et al. (1973) described the double Z-plasty (butterfly flaps) method for web release in minor syndactyly. This was modified by Flatt (1977) so that the previous two triangular flaps on the palmar aspect became rectangular (the dorsal-palmar flap combination procedure); these modified flaps also were twice the length of the triangular ones which were only half the width of the web. The operative technique which we have used, first described by Ostrowski et al. in 1985, is a modification of both these methods by using two laterally-based palmar triangular flaps each of which is as long as the width of the new web. The technique is advocated in complete syndactyly (Figs. 1 and 3) as well as traumatic (Fig. 5) and burn cases (Fig. 6) where the dorsal and palmar flaps can be raised on scar tissue as usually the subcutaneous fat and blood supply are unaffected by the burn. These flaps can be raised even if skin grafts have been used or with hypertrophic scars, although they are not as pliable as virgin tissue. In burn syndactyly, it may be difficult to wear pressure garments to control the
b Fig. 8
198
(a) Dorsal view of web creep following release using a quadrilateral flap and full-thickness skin graft without delay in healing. (b) Diagram of Figure 8a showing the outline of the dorsal quadrilateral flap and skin graft (hatched area). Note the junctional scar palmar to the midlateral line and the minimal increase in pigmentation after the use of full-thickness grafts with a thin layer of subdermal fat. THE JOURNAL OF HAND SURGERY
SYNDACTYLY:
Fig. 9
CAN WEB CREEP BE AVOIDED?
Diagram of the conventional design for releasing syndactyly by using a dorsal quadrilateral flap, as shown in many papers and textbooks. Note the potential junctional scar along the palmar aspect of the new web extending laterally from the tip of the dorsal flap.
scarring, as the fingers cannot abduct. This technique has allowed release of the webs and thus the application of pressure garments to produce a much improved result, both cosmetically and functionally (Fig. 6). A similar technique (the square flap procedure) has been described for burn contracture of the axilla and it was suggested that the method may be suitable for webbing of the fingers (Hyakusoku and Fumiiri, 1987). In our series, the results have been encouraging in all types of cases, and although the follow-up in some patients is only 12 months, web creep should have occurred by then (Mercer et al., 1989). However, of the
Fig. 10
(a) First web contracture
VOL. 15B No. 2 MAY 1990
with shortening
of thumb.
three cases where there was delay in healing, only one required secondary surgery. This must be as a result of the irregularly-shaped junctional scar on the palmar aspect comprising the dorsal flap with the two triangular flaps from the palmar side. With tissue expansion (Van Beek and Adson, 1987), one should be able to avoid the use of grafts as well as the volar junctional scar. In partial syndactyly and deepening procedures, the volar flaps are able to close the secondary defects (Fig. 5). When this method is used for the first web space, primarily (Fig. 2) or with thumb shortening (Fig. lo), or even following a Matev lengthening operation, an excellent contour is obtained which may allow for the fitting of a prosthesis, if necessary. Accurate records are important, as a critical review of the results of surgery for this common deformity may not be as perfect as we think (Flat& 1962). Many authors report on “partial recurrence not requiring further surgery” (Skoog, 1974; Brown, 1977; Toledo and Ger, 1979) but this must be unacceptable. With an atraumatic technique using magnification and bipolar coagulation, one should obtain primary healing with tension free closure of well designed and raised flaps. The primary aim in syndactyly surgery is to approach normality, both cosmetically and functionally. Acknowledgements We would like to thank the Consultant Reconstructive Plastic Surgeons at Frenchay Hospital, Bristol, for allowing us to include in this series patients under their care, and the Medical Illustrations Department at Frenchay Hospital, for the photographs and diagrams.
References BAUER, T. B., TONDRA, J. M. and TRUSLER, H. M. (1956). Technical modification in repair of syndactylysm. Plastic and Reconstructive Surgery, 11: 5: 385-392.
(b) Post-operative
result.
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A. L. H. MOSS AND BOYES, .I. H. Bunnell’s Surgery of the Hand, 5th edn. Philadelphia, J.B. Lippincott, 1970: 59-107. BROWN, P. M. (1977). Syndactyly--a review and long term results. The Hand, 9: 1: 16-27. BUCK-GRAMCKO, D. (1975). Congenital malformations of the hand: indications, operative treatment and results. Scandinavian Journal of Plastic and Reconstructive Surgery. 9: 190-198. COLVILLE, J. (1989). Syndactyly correction. British Journal of Plastic Surgery, 42: 1: 12-16. CRONIN, T. D. (1956). Syndactylism: Results of zig-zag inclusion to prevent postoperative contractwe. Plastic and Reconstructive Surgery, 18: 6: 460468. DIEFFENBACH, J. F. Chirurgische Erfahrungen, besanders iiber die Wiederher,steNun~ Zerstiirter Theile des menschlichen Kbnxrs nach neuen Methoden BerlinTEnslin 1829. DOBYNS, J. H. Syndactyly. In: Green, D. P. (Ed) Operative Hand Surgery, New York, Churchill Livingstone, 1982: Vol 1: 281-293. EBSKOV, B. and ZACHARIAE, L. (1966). Surgical Methods in Syndactylism. Evaluation of 208 operations. Acta Chirurgica Scandinavia. 13 1: 258-268. Fl?LIZET, G. (1892). Op.&ration de la syndactylie congenitale (pro&d& autoplastique). Revue d’orthopedie, 3: 49-61. FLATT, A. E. (1962). Treatment of syndactylism. Plastic and Reconstructive Surgery, 29: 4: 336-341. FLATT, A. E. Practical factors in the treatment of syndactyly. In: Littler J. W., Cramer L. M. and Smith J. W. (Eds) Symposium in Reconstructive Hand Surgery. St Louis, C.V. Mosby, 1974: 144-156. FLATT, A. E. The Care of Congenital Hand Anomalies. St. Louis, CV Mosby Co, 1977: 186-189. HENTZ, V. R. and LITTLER, J. W. The Surgical Management of Congenital Hand Anomalies. In: Converse, J. M. (Ed.) R econstructive Plastic Surgery. Philadelphia, W.B. Saunders, 1978: 3306-3349. HYAKUSOKU, H. and FUMIIRI, M. (1987). The square flap method. British Journal of Plastic Surgery, 40: 1: 40-46. KELIKIAN, H. Congenital deformities of the hand and forearm. Philadelphia, W.B. Saunders, 1974: 331407. KERET, D. and GER, E. (1987). Evaluation of a uniform operative technique to treat syndactyly. Journal of Hand Surgery, 12A: 5(l): 727-729. KETCHUM, L. D. Skin Flaps. In: Green, D. P. (Ed) Operative Hand Surgery, NewYork, ChurchillLivingstone, 1982: Vol 1: 1327-1331. LENNANDER, K. G. (1891). Fall af kongenital syndaktyli, opereradt, med hjelp af Thiersch’s hudtransplantationmetod. Upsala hgkareforenings Forhandlingar, 26: 151-152.
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G. FOUCHER MacCOLLUM, D. W. (1940). Webbed fingers. Surgery, Gynecology and Obstetrics, 71 : 782-789. MERCER, N. S. G., TAN, K. and MOSS, A. L. H. Paper presented at the British Society for Surgery of the Hand Spring Meeting, Nottingham, 18-19 May, 1989. NORTON, A. T. (1881). A new and reliable operation for the cure of webbed fingers. British Medical Journal. 2: 931-932. OSTROWSKI, D. M., GOULD, J. S. and FEAGIN, C. A. Three flap web-plasty for short incomplete syndactyly. Presented at the American Society for Surgeryofthe Hand at Las Vegas January 21-23rd, 1985. PERCIVAL, N. J. and SYKES, P. J. (1989). Syndactyly. A review of the factors which influence surgical treatment. Journal of Hand Surgery, 14B: 2: 196200. PIERI, G. (1920). Plastica cutanea per le retrazioni cicatriziali delle dita. Chir. Organi. Mov, 4: 303-306. SHAW, D. T., LI, C. S., RICHEY, D. G. and NAHIGIAN, S. H. (1973). Interdigital Butterfly Flap in the Hand (The Double-Opposing Z-plasty). Journal of Bone and Joint Surgery, 55A: 8 : 1677-1679. SKOOG, T. Plastic Surgery. New methods and refinements. Stockholm. Almqvist and Wiksell International, 1974: 412-427. SMITH, R. J., Syndactyly. In: Lamb, D. W. and Kuczynski, K. (Eds.) The PracticeofHandSurgery. (1st edn). Oxford, Blackwell Scientific Publications. 1981: 313-329. TOLEDO, L. C. and GER, E. (1979). Evaluation of the operative treatment of syndactyly. Journal of Hand Surgery, 4: 6: 556564. VAN BEEK, A. L. and ADSON, M. H. (1987). Tissue Expansion in the Upper Extremity. Clinics in Plastic Surgery, 14: 3: 535-542. ZELLER, S. Ubhandlung uber die enten Erscheinungen venerischer LokalKnmkheits-Formen, und deren Behandlung, sammt einer kurzen Anzeige zwener neuen Operazion+Methoden, nahmlich: die nngebornen uerwachsenen Finger, unddie Kastrazion bare-end. Vienna, Binz, 1810: 107-l 11.
Accepted: 14 February
1989 Mr. A. L. H. Moss, Department
0
1989 The British Society
of Plastic Surgery,
for Surgery
Frenchay
Hospital,
Bristol,
BS16 ILE
of the Hand
0266-7681/90/00154193/%10.00
THE
JOURNAL
OF HAND
SURGERY