Modified technique for the surgical treatment of congenital constriction bands of the arms and legs of infants and children

The combination of circumferential subcutaneous fat advancement flaps and Z-plasties allows for single-stage treatment of congenital constriction bands of the arms and legs of infants and children.

Endoscopic Release of Limb Constriction Rings in utero

Amniotic band syndrome is a sporadic condition that may result in constriction bands, amputation and multiple craniofacial, visceral and body wall defects. It occurs in 1/1,200 to 1/15,000 live births. Most cases present with multiple congenital anomalies that are incompatible with life. A small group of fetuses shows isolated limb constrictions that may cause severe limb dysfunction or limb amputation if left untreated. Successful in utero surgical lyses of constriction rings have been reported. We report a case of constriction amniotic bands involving both legs and compromising blood flow to the distal extremity. The constriction ring was successfully released by a minimally invasive endoscopic surgical technique avoiding severe limb dysfunction or foot amputation.

Fillet flap: a successful procedure to preserve the optimum length of below-the knee-amputation stump in congenital constriction band of the leg

The use of 'spare part' tissue from an amputated segment to cover a stump with soft tissue deficiency is a viable option for augmenting the shape of the stump and preserving functional length of the stump without additional donor morbidity. The procedure requires no microsurgical skill if the tissues are used as pedicle fillet flaps transfer. This concept of fillet flap makes the amputation distal to an unfavourable definitive amputation site such as in congenital constriction band possible. We report herein a case of amputation distal to constriction ring to illustrate the application of fillet flap in reconstruction surgery.

Bone lengthening for congenital differences of the hands and digits in children

PURPOSE

We investigated the growth of bones after lengthening to evaluate the effectiveness and usefulness of bone lengthening in congenital hand deficiencies.

METHODS

Bone lengthening was performed to treat congenital hand deficiencies including hypoplastic thumb, hypoplasia of the small finger, cleft hand, metacarpal synostosis, brachymetacarpia, symbrachydactyly, and amniotic band syndrome. A total of 15 patients (1-13 years old) underwent lengthening of 23 bones. The average of distraction was 10 mm. The mean follow-up period was 59 months. The length of the bones at follow-up evaluation was measured and then compared with the length of the bones immediately after lengthening. The bone growth after lengthening, the percentage of growth after lengthening, and the growth rate were compared among diagnostic groups.

RESULTS

In the cases involving older patients the bone length changed little and the growth plates of these patients closed naturally soon after lengthening. In contrast, in the cases in which the patients were younger than 7 years old the lengthened bones grew continuously. The amount of bone growth was different for each disease in the younger patients. In patients with amniotic band syndrome the lengthened bones grew at the same rate as the bones in the hand. Other diagnoses such as symbrachydactyly had a different growth pattern in the hand.

CONCLUSIONS

We conclude that bone lengthening is a reliable method for the correction of congenital differences of the hand. The indications for this procedure must be determined while considering the relationship between the specific disease and subsequent bone growth.

A case study of amnion rupture sequence with acalvaria, blindness, and clefting: clinical and psychological profiles

The purpose of this article is to report the case of a 10-year-old girl born with anophthalmia, bilateral oblique facial clefts, and missing scalp and bones over the temporal and parietal areas of the cranial vault bilaterally. Early amnion rupture seems to be the most probable cause of this rare combination of anomalies. Because no similar case has been reported in the literature so far, we describe here the clinical and psychosocial history of this unusual patient, who has been able to live the intellectually and socially normal life of a blind child in spite of the major craniofacial deformities. The already completed and possible future therapeutic strategies are discussed.

Favourable outcome of a tight constriction band secondary to amniotic band syndrome

Amniotic band syndrome or amniotic disruption complex is a well-known congenital limb abnormality, which occurs in 1 in 1200 to 1 in 15,000 live births. In cases of an isolated band constriction, it has been speculated that the bands lead to decreased blood flow in the constricted limb and subsequent natural amputation. Fetal surgery could be considered in these situations in order to release the constriction band in threatened limb amputation. We present a case of a tight constriction ring secondary to amniotic band syndrome with a favourable outcome, despite the failure of an attempted surgical procedure.

Amniotic Band Sequence: The Use of Bone Grafting and Distraction Osteogenesis

Distraction has proven to be a useful technique in cases of severe bone deficiency in the craniofacial skeleton. This is a report of its use in the treatment of a child affected by amniotic band sequence. This 5 year old Hispanic female presented with transverse deficiences of one lower extremity and both upper extremities. Additionally, she was missing the mandible and overlying soft tissue from ramus to ramus. Although free fibula transfer was a possibility, due to the presence of only one lower extremity, it was elected to utilize the technique of distraction. After preliminary bone grafting to unite these two hemimanibles, the bone graft was distracted bilaterally to create a neomandible. Following consolidation and removal of the distraction devices, the child was markedly improved despite what appeared to be a pathologic fracture in the region of the mandibular angle. Repeat distraction was planned.

[Amniotic band syndrome: pathogenesis, prenatal diagnosis and neonatal management]

Amniotic band syndrome is a collection of fetal congenital malformations, affecting mainly the limbs, but also the craniofacial area and internal organs. Two mains pathogenic mechanisms are proposed: early amnion rupture (exogenous theory) leading to fibrous bands, which entrap the fetal body; the endogenous theory privileges vascular compromise, mesoblastic strings not being a causal agent. The outcome of the disease depends on the gravity of the malformation. Termination of the pregnancy is usually proposed at the time of the diagnostic of severe craniofacial and visceral abnormalities, whereas minor limb defects can be repaired with postnatal surgery. In case of an isolated amniotic band with a constricted limb, in utero lysis of the band can be considered to avoid a natural amputation. However, as the exact etiology of amniotic band syndrome remains unknown and its natural course unpredictable, prenatal surgery continues to be controversial. Doppler studies of the constricted limb could be of useful predictive value of in utero amputation, and therefore could be helpful to determine when in utero treatment should be considered.

In utero limb salvage: fetoscopic release of amniotic bands for threatened limb amputation

The natural history of extremity amniotic band syndrome (ABS) is a progression to deformity or amputation. Fetoscopic laser release of amniotic bands in extremity ABS offers the potential to prevent limb amputation. The authors report on 2 patients with isolated extremity ABS who underwent fetoscopic release. Both patients had isolated extremity ABS with compromised extremity perfusion and no other significant structural abnormality diagnosed sonographically. The first patient underwent fetoscopic release of bands of the left wrist, and the second patient underwent lysis of bands around the right wrist and an unsuspected band around the right lower extremity. Both patients had restoration of blood flow by color Doppler to the affected extremity. There were no perioperative complications. In select patients with isolated extremity ABS, early fetoscopic release may prevent amputation and allow improved limb development.

Minimal access techniques for fetal surgery

The impetus for the development of minimal access techniques for fetal surgery was the unusual occurrence with open hysterotomy of preterm labor, premature rupture of membranes, and the maternal complications resulting from tocolytic therapy. This strategy involves a constellation of techniques that allow surgical procedures to be performed inside the uterus without a hysterotomy. The unique requirements of this approach necessitated modifications of existing endoscopic techniques, development of novel fetoscopic instruments, and utilization of the expertise of a wide variety of specialists. Technical expertise in the field and a natural evolution of techniques have given rise to innovative repairs previously not envisioned. Severe congenital diaphragmatic hernia, diseases of monochorionic twins, and obstructive uropathy have already been successfully treated using fetoscopic surgical techniques. Fetoscopic correction of many other non-life-threatening anomalies continues to evolve. The future of fetoscopic surgical intervention depends on the continual evolution of novel techniques, the elucidation of the pathophysiology and treatment of other fetal disorders, and a better understanding of treatment of complications of intervention.

Breast asymmetry as a result of congenital amniotic folds in the thoracoabdominal area

Breast asymmetry is a relatively common condition. Mild breast asymmetry usually does not require correction. A rare case of breast asymmetry associated with congenital amniotic bands in the thoracoabdominal area was surgically corrected by transposition of the ectopic right breast and nipple-areola complex with Z-plasty and thick split-skin grafting. The Ribeiro technique was used to treat the tuberous left breast.

[Surgical treatment of congenital clubfoot with constriction band syndrome]

Twelve feet in 11 patients with constriction band syndrome age ranging from 3 to 18 months (mean age 11 months) were evaluated in this study. The constriction band was located at the in the calf, at distal, media and proximal third levels. All these patients were treated surgically by a wide peritalar release using the Cincinnati incision, followed by a two-stage Z-skin plasty. Both clinical and radiological results were evaluated. In our material an excellent result was achieved in 1 case, good results in 3 cases, satisfactory in 4 cases and poor in the remaining four cases. Very good and good results were achieved in feet with shallow bands type II and III, while poor results were found in feet with deep constriction band type I. Early surgical treatment followed by serial casting leads to better functional results.

[Amniotic band syndrome. Case report]

Amniotic band syndrome is a rare fetal malformation involving limb ring strictions, cranio-facial and trunck abnormalities. The authors report a case of 5 months old infant with also facial cleft. The plastic reconstructive surgery leads to a better functional result. This affection represents a sporadic disease without genetic causes. The pregnancy ultrasonography visualise fetal abnormalities.

A malformed fetus in a rudimentary uterine horn pregnancy

We present a case of a 13-week pregnancy with a malformed fetus in a ruptured, non-communicating rudimentary horn. The patient, a 21-year-old woman with pelvic and right-sided abdominal pain, was admitted to the gynecology clinic of our institution. A ruptured rudimentary horn pregnancy was diagnosed by ultrasonography. The fetus in the gestation sac showed evisceration of the liver and intestines and an absent left femur. There was an amniotic band extending across the body of the fetus. The ruptured horn was excised by laparotomy. The factors associated with rudimentary horn pregnancy and related fetal abnormalities are discussed.

Severe constricting ring syndrome: case report

This report presents a case of a male newborn with a severe circumferential amniotic band, treated by single-stage excision of the ring, and microvascular venous anastomosis between the proximal and distal parts of the affected site. No complications were encountered. A microsurgical approach to improve the circulation may be useful in some cases.

Spinal cord tethering associated with amniotic band syndrome

Amniotic band syndrome (ABS) comprises fetal morphological abnormalities that may be associated with fibrous amniotic bands that damage developing fetal parts resulting in cutaneous scars, erosions and ulcerations, digital constricting bands, craniofacial and visceral anomalies. Multiple asymmetric encephaloceles and anencephaly are neural-tube-like defects previously reported with ABS. This is the first report of spinal dysraphism with dorsal spinal cord tethering associated with ABS. We examine the pathogenetic theories of ABS in light of this report.

Double second toe transfer in congenital hand anomalies

A series of 14 patients with congenital hand anomalies who received staged double second toe transfers to the same hand for restoration of function or form were reviewed retrospectively. There were three children with constriction ring syndrome, two with symbrachydactyly and nine with transverse absence (failure of formation). There were different indications, technical difficulties and results with the various anomalies. All transferred toes were mobile and sensate, and were reported to be of benefit in both function and appearance. However, secondary surgical procedures were required in all patients.

An unusual presentation of constriction band syndrome

Congenital constriction band syndrome is a rare entity with a wide spectrum of associated congenital anomalies. Review of the pathogenesis and an unusual case of constriction band syndrome in a newborn are presented. Surgical excision of the deformity and the band was performed within the first week of life. There were no vascular or neural structures within the excised tissue, and there were no other associated anomalies other than dextrocardia and an equinovarus deformity of the foot. The wound was closed primarily without the need for Z-plasties. This alternative method of treatment can be considered in such unusual locations of constriction band syndromes.

The in utero repair of Tessier number 7 lateral facial clefts created by amniotic band-like compression

The purpose of this study was to determine the effectiveness of intrauterine reconstruction of lateral facial clefts caused by surgically simulated amniotic band compression. The authors hypothesized that intrauterine lysis of these bands could: 1) prevent the progression of cleft formation; 2) normalize facial development; and 3) allow for the scarless repair of these lateral atypical facial clefts. In a prospective randomized trial, eight 65-day gestational fetal lambs (term, 140 days) were exposed via a maternal hysterotomy. A Tessier 7 facial cleft was made by applying a 2.0 nylon suture as a constriction band to the growing face. The sutures were attached to the zygomatic arch and looped circumferentially into the oral commissure. Two weeks after surgery, four of eight animals were re-exposed. All four animals developed phenotypic changes consistent with Tessier 7 lateral facial clefts. These animals were treated in utero by 1) excising the synthetic constricting band, and 2) opening the epithelialized edges of the lateral facial clefts and performing a primary repair. At birth, the bands on the four untreated animals were cut. The lambs developed to 3 months of age, at which time they were evaluated anthropomorphically for changes in soft tissue measurements, and histologically using hematoxylin and eosin and Mason trichrome stain for the degree of scar at the repair site. Tessier 7 lateral facial clefts were produced in all the untreated animals. Each developed macrostomia with an average 2.3-cm lateral displacement of the oral commissure and partial maxillary clefting induced by the pressure of the restriction band. No evidence of tissue necrosis, maceration, or ulceration was noted. In contrast, animals treated in utero were phenotypically normal. There was no evidence of macrostomia and all anthropomorphic measurements were symmetrical. No bony clefts were seen on gross examination. Histologically, there was no evidence of scar formation at the site of the cleft repair. These findings suggest that like the standard cleft lip, atypical lateral facial clefts can be repaired successfully in utero without scarring. Furthermore, lysis of a restriction band in utero can prevent the progression of this facial deformity, leading to normal development of the face.

Amniotic band syndrome

Amniotic band syndrome is an uncommon, congenital fetal abnormality with multiple disfiguring and disabling manifestations. A wide spectrum of clinical deformities are encountered and range from simple ring constrictions to major craniofacial and visceral defects. Lower extremity limb malformations are extremely common and consist of asymmetric digital ring constrictions, distal atrophy, congenital intrauterine amputations, acrosyndactyly, lymphedema and clubfoot. Although debated, early amnion rupture with subsequent entanglement of fetal parts (mostly limbs and appendages) by amniotic strands is the primary theory of pathogenesis. The sporadic nature of this congenital anomaly is discussed, as well as a case study involving the surgical correction of an associated rigid clubfoot deformity.

Congenital constriction band syndrome

Constriction band syndrome is a fairly common congenital hand disorder. Proposed etiologies for the formation of the anomalies are reviewed in this article and demographics for the syndrome are presented. Varied clinical presentations are addressed and potential treatment options are reviewed.

In utero lysis of amniotic bands

Amniotic band syndrome is a sporadic condition that occurs in approximately 1:1200 to 1:15,000 live births and that may result in amputations, constrictions and other deformities of the fetus. Although some cases present with congenital anomalies that are beyond surgical repair, a selected group of fetuses may show isolated limb constriction. It has been speculated that, without treatment, amputation or severe dysfunction of the limb may occur. Despite these potential complications, surgical treatment for this selected group of fetuses has not been previously performed. We report two cases that were successfully treated using novel minimally invasive surgical techniques. The cases involved fetuses with amniotic band syndrome with associated limb constriction in which the amniotic band was surgically interrupted to avoid spontaneous amputation of the extremity. Adequate blood flow distal to the obstruction was preserved and significant functional improvement of the extremity occurred in both cases, preserving the limbs. These cases represent the first prenatal surgical intervention successfully used to treat constricting amniotic bands in humans. In addition, these cases represent the first time that a non-lethal fetal entity has been surgically treated in utero. The results of this innovative therapy will encourage the efforts to continue developing minimally invasive techniques for the correction of birth defects.