Surgery Spotlight: Bilateral Syndactyly Reconstruction-Surgery Spotlight: Bilateral Syndactyly Reconstruction

Surgery Spotlight: Bilateral Syndactyly Reconstruction

Video Transcription

I'm Kevin Chung from the University of Michigan. Today we're going to introduce you to congenital hand reconstruction.  This case is going to be a child who has bilateral syndactyly between the long and little finger.  On the right side is a complex complete syndactyly and a complex because there's some bony components that involve the distal phalanx with distal phalanx being stuck together.  So we'll demonstrate the incision and the drawing of the incision and different flaps. The key components that one needs to remember during a syndactyly release is to draw out  a long dorsal skin flap that can resurface your web space. And that will prevent the scarring between the web space and can create adhesions or  attachment of the operated fingers over time. So that dorsal flap is the most important flap in this operation to prevent recurrent contracture between the fingers.  And of course, one needs to use zigzag incisions distally so the flaps can resurface both sides of the fingers.  In this particular case, because the skin is so short, the skin graft is necessary. So I would design zigzag incisions to demonstrate the flap technique.  However, the precision of the flap design is not necessary because it's not necessarily tight because we will need to use skin graft.  And the skin graft will harvest, it's always in the groin area. One needs to be cognizant of scarring for these children with skin graft harvested from the upper extremity.  I've seen intruditious skin graft harvested from the wrist, which is very unsightly for the child. So the skin graft is always going to be in the groin area.  So this is a two and a half year old, maybe two year old kid. On the right side, what I'm doing is a complete, complex, maybe even complicated syndactyly  because there are bones intervening between the middle and ring metacarpals. And this can be a bit tricky.  So my goal is to separate the fingers and those extra bones, we need to worry about that later. So this is a complete syndactyly because it goes all the way to the tip and it's also  a complicated syndactyly because there are bones in between. And then furthermore, so what I'm going to do is I'm going to separate the fingers, really.  So the technique we use, there are several techniques, but this is pretty standard. The most important criteria for you to do a syndactyly is to make sure that you have  an ample dorsal flap that can surface the web space. You've got to have web space. I mean, if you have web space contracture, the fingers cannot open.  And the web space needs to go to about two, I mean, look at this. Your web space starts about two thirds, maybe one half of your proximal phalanx.  It doesn't start all the way at the MCP joint. But in this particular case, we're going to overcome, we're going to compensate just a  little bit more just in case the child grows and it's going to be a bit, it's going to creep more distally.  So we're going to start at the MCP joint and we're going to go two third, two third of the proximal phalanx. And this flap is going to look like this.  It's going to go straight into the volus side. And then we're going to go zigzag incision, zigzag incision from one corner, the MCP joint.  The big flaps, the MCP joint, and then we're going to come across and separate between the fingers.  And then, of course, the opposite side needs to match, except that there's going to be skin shortage in this case.  So for me to match it, it's not as critical because the skin is going to be short. See how tight it is? The skin is going to be short.  But if you go to volus side, I'm going to go right at the level. I'm going to make an incision right at the level of the base.  This is going to correspond to the other fingers with the web space. And then you're going to go big times, flaps that go zigzag, and hopefully it will match.  So typically, sometimes when I do this, I put a needle right through the base of here. In this case, because we're short of skin, it probably doesn't matter.  The needle is going to come up here. And that needle is going to correspond to the tip of the thing. So if I put a needle, it's going to be right here.  So essentially, I'm going to make a flap across, I'm going to make a flap across, and I'm going to come across right here and separate the fingers.  So hopefully this flap will match. But regardless, in this case, it's going to need skin graft anyway.  The key thing about this volus flap, do not cross more than the midline. It's unnecessary to make the flap so distal, so much across the midline, because this is  going to come across pretty nicely. Let's make it easier. All right, we're going to get started. I use tourniquet, ace bandage.  Use tourniquet, we're going to blow it up to typically 250. You go, with children, you go about twice as much as the systolic pressure, hold this.  So we usually go 250, it shouldn't be a problem. I want to extend it pretty well. It's very important that your tourniquet is snug.  If you have bleeding in your wound, stop and redress your tourniquet, because you've got to see all the fine details of the surgical procedures in children. Tourniquet out, please.  So you've got to, having good tourniquet control is important.  Okay, good? Okay, good. Okay, so we're going to do this.  We're going to do this. As you can see that the fingers are all pale. Very good. And Nas is going to help me by holding the thing.  Why don't you use Nancy to help hold the fingers, okay? You kind of use the assistance nicely, okay? Hold this. All right, Nas, hold this, please. Number 15, please.  Let me tell you, the intricate nature of surgery is that you don't have to rush. You don't have to, but the thing is that every motion needs to be precise, okay?  I mean, you shouldn't, when you do surgery, one of the things I teach everybody is don't have this kind of jerky motion, okay?  I know that people are nervous and start shaking a little bit. That's okay, but the thing is the key part of the operation is, you know, you can accomplish  as much as you can, as well as you can, by doing precise surgery, okay?  So, smooth execution of incision, no problem, this one cuts, very interesting, how the variations of the blades.  So what I do is I make an incision dorsally, dorsally, and this part can be pretty rapid because when you go across here, you're going to lift a healthy flap right over the extensor  mechanism. I'm sorry, shine the light down here, please, okay, pick up, please, I'm sorry. So look at this, I'm operating, I'm elevating the skin flap, the skin flap needs to be  not too thick, but enough subcutaneous fat that it can reach nicely and well vascularized, you can go pretty quickly, I like to use a knife, go quickly, and you want to elevate  beyond the midline because then the skin can stretch, see that? And gently, don't pinch the skin too much, and then gently, and get this thing, see once  you get beyond the midline, it'll be easy to come across, see that, it'll be straight either side of this, and then hold the finger down like this, nice, use the other hand,  get your finger out of the way, so I'm going to elevate the skin flap.  Okay so this is very quick. Skin flap, skin flap, skin flap. Let's turn over to the palmar side. I'm sorry, 15 please. That's okay. That's like the other one is fine.  The other blade is good. The same blade is good. Just you have to be careful on the volus side. You don't have to get very far but you want to make  sure that you don't go too deep because a little bit deeper is your neurovascular bundle. You're going to be careful. That's why in syndactyly  surgery we only do adjacent sides for one finger first. We don't do, if we have three fingers stuck, we only do one side and not do on either side of the finger  so that we can avoid devascularizing the finger. And now you see I've separated, I've opened up the thing and the next phase is that, okay Dr. Chang, how are you  going to separate the fingers now you have done this? And the fingers stuck. So this is not as easy as complete ones because the bone involvement. So let's  see how it goes. So what I'm going to do is that I'm going to have a skin hook please. Thank you. So now I'm just going to hold the finger apart and typically what  we do is that we start separating the fingertip. Okay and 15 please. But the thing is that bones are fused and the nails are fused so it can be kind of  difficult to get through the fingertip. So let's see how we're going to get through the fingertips. I'm sorry. Come down right here. So what I'm going to do  is that let's cut the pulp. Let's go straight down to the pulp and then the next question is how am I going to get the bones together? And I'm going to show you  how to separate the bones. Okay I'm sorry take this. Give me scissors please. I want a heavy, heavy scissors as well. So what I'm doing is that I'm separating in  between. I'm separating the soft tissue in between and then what I'm going to do is that I'm going to take a big pair of scissors and cut between them. That's really the only way to do things. So this is kind of the slow action mode. Slow action mode to see how this is done. I'm taking this pair of scissors and I'm going to be chomping through this thing.  Slow action. See how precise the cut is?  Okay so I'm using the scissors and cut the bone, separating it. I found that's probably the only way to do things. Be careful not to cut the skin on either side.  Give me the skin hook. And now the thing is separated and what I'm going to do now, scissors, is that I'm going to gently dissect in between them. I'm going to separate the fingers and anything that goes side by side, I mean transverse, I can cut because that's not important. Anything that goes up and down, do not cut because that's neurovascular bundle.  I mean there's a lot of anomalies in this kind of cases. So what you do is gently tease things apart. Can I have a skin hook please? Skin hook to my side.  Thank you. So I have a skin hook on either side and what I'm going to do is that I'm going to gently cut through them and very soon I'm going to find some extra bone in here. You can see that stuff that goes side by side, transverse, I'm going to take that.  Okay, the fingers are coming. And the limiting factor, most likely you're going to see a neurovascular bundle at the base. Let's separate them. Let's separate these.  Okay. Sorry. Can you hold this one second? I'm going to dry it up a little bit.  Okay. Alright, we're almost there. I'm sorry, scissors. We're almost there. I'm separating the fingers.  There's some fibrous bands here. I'm sorry. Can I hold this up like this so you can see in between? Okay.  You can see vessels coming down here. You probably cannot see too well, but there are vessels on either side. I'm going to gently stay away.  Typically this maneuver is much faster than what I'm doing now, but because of the so-called intervening bone, it's a bit more difficult.  Okay, vessels. You can see that? That's vessels. That tiny vessel coming up and down. I'm going to try to save that.  Okay, I'm going to look at the backside to be sure that, okay, I'm going to separate the back side. Good. Okay. So gently. Gently. I'm just looking under magnification to be  sure that I can preserve the nerve, see that tiny nerve in between. Gently spreading. Gently spreading. Good. And now I'm encountering something very unusual. I got a piece of bone  in here that I probably need to take off, a piece of bone that I see on x-ray, but let's see. Okay. I'm sorry. Let's turn it over. Let's turn the hand over. Let's see the other  way. Turn the hand over. That's okay. I'm going to take this off. Okay. You can use this. Now let's just separate the fingers. Let's grab each finger and separate them.  I'm sorry, let's separate them.  Okay, now I'm feeling a little bit of bone, which is a transverse bone that I see earlier.  The question is, is that going to interfere with my separation, or do I need to do something with that?  Let's see, it may not affect me.  Okay, let me think thing is that I got to be able to, I'm sorry, turn over, I got to be able to move that skin flap all the way down to volatilly, except for the fingers.  Let's see here. It seems like it can reach pretty good, volatilly. Okay, so what I'm going to do is that, give me a stitch please, 3-O chromic please.  Can I have a 3-O chromic please?  It should be in the cart there.  Can you hold the finger? Hold it like this. I'm going to separate the skin flap just a little bit so it can reach, so it can reach volatilly.  I want to be able to reach volatilly. And it looks like it may be kind of a long reach, but let's see how it goes.  And then, what we're going to do is that, I'm going to sew the dorsal flap to the volatile skin to recreate that web space. And let's see whether it's going to reach or not.  And then after that, I'm going to sew this skin down to that. It's going to be a bit tight. I'm going to sew it down to that.  For congenital hand reconstruction, age for surgery is actually a reasonable consideration. And I have two ages, just to make it simple.  Typically, I do reconstruction when the baby is two years old. The reason for that is the structures are much larger, and it's a much simpler operation.  And furthermore, for anesthetic consideration, there's very little risk. The only time I would do the operation much earlier is when there are potential vascular compromise,  such as constriction band syndrome, when the bands are so tight that as the child grows, then the circulation can be cut off.  And when I say early, typically I do this operation at the age of six months.  Another consideration is that when you have syndactyly, in which there is different show growth of the finger, such as the little and ring finger.  If you wait too long, the ring finger will be drawn towards the little finger, causing joint deformity.  In those cases, I would want to do the operation much earlier, such as in six months, when the six-month-old or nine-month-old,  so that the fingers can be separated before irreversible changes of the joint can occur. But other than that, most congenital hand reconstruction are done,  in my feeling, my concept, is at two years of age.  I just want to see where my dorsal flap is. I'll lift this up some. My dorsal flap is all the way here.  Let's see. Separate the fingers.  I'll be able to get it. It's okay? I'll get it to this corner.  Okay, let's see.  Let's see how the skin flap is going to reach. Many times, it seems like it doesn't reach, but it will always reach, because the skin really stretches.  Sometimes, you may have to remove a little bit of the fat. Let's get the skin hooked up, please.  Sometimes, you may have to remove a little bit of the fatty tissue, so that the skin flap will reach, but in this case, I think it's going to reach pretty good.  This kid is quite chunky. This baby is quite chunky. There's a lot of fatty tissue in there. What I'm going to do is I'm just going to sew this dorsal flap in place.  The skin graft is going to sit in there.  Scissors for me please. Switch of scissors.  If the baby is not too cool, can you put the room temperature down some?  So I'm suturing, suturing to each corner of this flap. Each corner of this.  Okay, I want to see the dorsal flap here.  Yeah, so this flap is going to sit in between the web spaces. So that can accommodate. See that? It does touch. It does touch. It may contract a little bit,  but you want it to sit nicely to resurface the web space. And with chromic suture, you've got to put a lot of knots because once it gets wet,  once it gets wet, it's going to unravel. So you want to make sure they put a lot of knots in there. I put about seven or eight knots. Okay?  Alright, so.  So now you can see that the web space, the skin is in there. It resurfaced the web space. And now what I'm going to do is the next thing. I'm going to fold chromics please.  The next thing is I want to close this nail fold. So let's close the nail fold.  So let's close this nail fold. What I'm going to do is I'm going to sew it to the nail.  See that? Close the nail fold. In textbooks, even in my first edition of my textbook on hand and wrist, we use this kind of funky flap design.  So you can use the flap from the tip of the finger and flap on either side. I find that to be unnecessary now because when you close the fold, it should be fine.  It's most unnecessary to make that long flap that most times may not be well vascularized. So what I'm going to do is I'll close this.  Because you wonder, why am I able to suture this? Because this is not ossified bone yet. This is still cartilage, so it's easy to use a suture and just sew it right into the nail.  You can see that? It comes together quite nicely. I'm going to do that. The key thing, the next step, the key thing is don't make things constrictive.  The fingers need to be nice and pink when the baby leaves the operating room. It cannot be pale. If it's pale, then you have to remove some of the sutures  to be sure that it's not constrictive. So now I'm closing the nail fold on either side. The next step I'm going to do is I'm going to suture the flaps in place.  Let's just suture the nail folds.  Okay, now, what do we do next? What we do next is to see whether one of the big flaps is able to come across without too much difficulty.  Let's see, let's see what flaps we're gonna use. You want to be able to move the skin around so that you have one big piece of skin to put on.  You don't want to have multiple postage skins because that would really delay the operation. You want to be able to move the flaps to either side  so you can come together quite nicely. Okay, so let's see.  So, this one doesn't seem to come across easily, though.  I may have to bring this to that and put a piece of skin graft right in there. Okay, give me a stitch, please. Can I have a skin hook, please?  Now I'm closing the flap on either side, and then what I'm going to do is that, see, huge amount of skin shortage. We know that. Huge amount of skin shortage.  I try not to hog the skin together, so you can actually put skin grafts, so there'd be no constriction. I'm going to stitch, please.  So what I'm going to do is I'm going to see whether this skin can reach a little bit on either side so that it's not going to be too tight. Can I have another 4-0 chromic, please?  I want to close this wound over here. Can you separate the finger just a little bit? Yeah. I'm going to close the wound over here so I have one big skin graft, so that it'd be  much easier. So let's advance the skin flap just a tiny bit, okay? Let's advance just a tiny bit. How are you doing over there, Katie? You good?  Now you can see that it's a far reach because this kid has a lot of soft tissue, a lot of fatty tissue, so that little advancement, that little extra will allow you to reach  all the way to the volus side. So I'm just moving this a little bit over. I'm sorry, let me see.  So this is the tedious part of the operation, which we're trying to kind of figure out how to inset the skin flaps so that we can make this a bit easier.  Well, it may have to be two flaps then. Okay, that's okay. Okay, so what I'm going to do is that we are the big flap over here, so we may be able to match that with this tiny flap.  Let me just put some skin graft in between.  Okay, so we need several pieces of skin. You have more sutures, right? Yes, I have. Okay, so it's not too tight.  After I do this, I'm going to turn the kid down in a few minutes to make sure the fingers are well perfused. I'm going to go and harvest my skin graft.  You want to do as much as you can in one operation, so having two teams is very important so that this child doesn't have to come to operating room multiple times for various  surgical procedures. So I can do almost everything in one operation today. Can I cut this, please? A little bit of redundancy.  As the kid grows, as the baby grows, it will always fit nicely, so I'm not so worried about that either.  The key teaching point is that don't close the skin flap tight. Make sure the fingers are nice and pink.  Once the tourniquet is down, if it's pale, then take off the constrictive areas and then lay your skin graft in nicely and stretch the skin graft.  So this is actually based on what the kid has. It looks pretty nice. And it's the right size. So see if the fingers are pink right away, and it's good. There's no issues.  Fingers are pink. Okay? So what I'm going to do is that, give me the ace and the little gauze.  What I'm going to do is I'm going to wrap this hand while I venture to harvest my skin graft.  See that? There's virtually no bleeding in the wound. Exactly what you want.  You can see white, that's dermis. This is fat. You go at a level without button holding it, and you can just go very quickly.  So you don't have to deflate very much when you do this because everything comes out. This is my gauze.  Good. Nice piece of skin graft. Pop it.  Loosen this, pop it so that the knot can be hidden. Maybe we should use surgeon's knot. Let's see. Under just a bit of tension.  So what you do is that, what I do is that I just put a corner. Give me a stitch please. I suture a corner and I stretch it out.  Okay, so just put a corner in there, and then the rest you can really stretch.  Mm-hmm. Mm.  Stitch, please.  Okay, let's hold this finger. I'm going to stretch the skin graph all the way across here. How much do I need?  For syndactyly cases, I usually cast a child for two and a half weeks so the skin graft can be adherent and the child will not pick on the skin graft that can cause problems  after during the healing period. If I were to put a pin into a reconstructed thumb, then I would put a cast on again for  about two and a half weeks, maybe three weeks, so that the ligament reconstruction can heal and when they come back to clinic, we just put a pin and allow the child some activities,  cautioning the parents not to have the child play in the sand or go outside the playground for at least, I would say, six weeks after surgery.

Video Summary

In a video lecture by Kevin Chung from the University of Michigan, the focus is on congenital hand reconstruction for a child with complex bilateral syndactyly. This intricate surgical procedure involves separating conjoined fingers, specifically a complete syndactyly on one hand, where bony components in the distal phalanx are fused. Dr. Chung emphasizes the importance of creating a long dorsal skin flap to prevent web space scarring and subsequent finger adhesions. The technique includes the use of zigzag incisions to create flaps that resurface the fingers' sides. In cases where skin is short, a skin graft, typically harvested from the groin area to minimize visible scarring, is necessary. The goal is to ensure the web space is properly reconstructed and prevent contractures. Dr. Chung details the meticulous steps, including managing skin flaps, ensuring proper vascular supply, and sewing techniques, to ensure successful separation of the fingers and reconstruction. Post-operative care involves immobilizing the hand with a cast for several weeks to ensure proper healing and graft adherence, minimizing complications and allowing for future functional use of the hand.

Asset Caption

In this video, Kevin Chung, MD performs a release on a two-year-old child born with complex bilateral syndactyly between the long and middle finger. It is a complex syndactyly because it involves the bony components of the distal phalanx being stuck together. In this video, Dr. Chung demonstrates the proper marking technique for planning the surgery, as well as how to utilize zigzag incisions to create the appropriate flap design. He discusses the most appropriate skin graft donor site and why the most important element of the surgery is the long dorsal skin flap to resurface the web space. He also describes a refinement on the closure technique that he has previously documented in textbooks.

Surgeon Kevin Chung, MD

Disclosure Dr. Chung has nothing to disclose. Dr. Neumeister has a Board of Trustee relationship with MTF Musculoskeletal Transplant Foundation. Dr. Aly is a consultant, speaker and advisor for Ethicon/J&J; receives research support from Ethicon/J&J; is an advisor for Angiotech Pharamceuticals; is an advisor for and a shareholder with Incisive Surgical Inc.; and receives royalties from QMP. All ASPS staff members managing this activity have no relevant financial relationships or affiliations to disclose. All identified conflicts of interest have been resolved and the educational content thoroughly vetted by ASPS for fair balance, scientific objectivity, and appropriateness of patient care recommendations. The ASPS also requires faculty/authors to disclose when off-label/unapproved uses of a product are discussed in a CME activity or included in related materials. This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Hand

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Kevin Chung MD; Memben

congenital hand reconstruction

bilateral syndactyly

dorsal skin flap

zigzag incisions

skin graft

web space reconstruction

post-operative care