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Singh K, Aggarwal K, Beniwal M. Cleft Hand—Our Experience of Five Cases. Indian J Plast Surg 2022; 55:302-306. [PMID: 36325090 PMCID: PMC9622323 DOI: 10.1055/s-0042-1750373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction
Hand helps us perform our work and express ourselves. Cleft hand is an aesthetic deformity rather than functional. We document our experience in five such cases from the ages of 3 to 5 years who underwent reconstruction under general anesthesia.
Materials and Methods
Three patients underwent Snow–Littler procedure, one underwent osteotomy for angled metacarpal and transverse metacarpal ligament reconstruction, and one underwent removal of transverse bone and transverse metacarpal ligament reconstruction. Splintage was done for 6 to 8 weeks and physiotherapy started. Function was assessed at 6 months.
Results
The operating time ranged from 2 to 3 hours. No major postoperative complications were noted. The parents' satisfaction was excellent at 6 months. None of the patients needed revision surgery for recurrence or first web space widening.
Conclusion
Cleft hand needs to be analyzed for the adequacy of first web space. The reconstruction is aimed at functional first web space and cleft closure for providing better aesthetic results.
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Affiliation(s)
- Kuldeep Singh
- Department of Burns and Plastic Surgery, Pt. Bhagwat Dayal Sharma PGIMS, Rohtak, Haryana, India
| | - Krittika Aggarwal
- Department of Burns and Plastic Surgery, Pt. Bhagwat Dayal Sharma PGIMS, Rohtak, Haryana, India
| | - Meenu Beniwal
- Department of Burns and Plastic Surgery, Pt. Bhagwat Dayal Sharma PGIMS, Rohtak, Haryana, India
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Yasin E, Amin H, Mahmoud M, Abdel-Ghani H. Using Skin of the Cleft as Bipedicle flap for Release of the First Web Space in Congenital Central Deficiency. J Hand Surg Am 2020; 45:665.e1-665.e7. [PMID: 32327341 DOI: 10.1016/j.jhsa.2020.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 10/27/2019] [Accepted: 03/07/2020] [Indexed: 02/02/2023]
Abstract
We are describing a new technique to utilize the skin of the cleft as a bipedicle flap to reconstruct and to widen the narrow first web space in congenital central deficiency. The skin of the cleft maintains its attachments on the dorsal and palmar aspects of the hand and the index finger is passed (tunneled) underneath it so that the skin of the cleft comes to occupy the first web space. This technique ensures maintenance of good blood supply of the skin of the cleft and a rounded edge of the first web without scars across it.
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Affiliation(s)
- Ebeed Yasin
- Department of Orthopedics, Aswan University, Aswan, Egypt
| | - Hosam Amin
- Department of Orthopedics, Al Haram Hospital, Giza, Egypt
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Leonchuk SS, Neretin AS, Blanchard AJ. Cleft foot: A case report and review of literature. World J Orthop 2020; 11:129-136. [PMID: 32190557 PMCID: PMC7063450 DOI: 10.5312/wjo.v11.i2.129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/13/2019] [Accepted: 11/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cleft foot is a very rare congenital anomaly, which is characterized by central rays deficiency of the foot. It is also known as split foot or ectrodactyly of the foot, and it is very often combined with splitting of the hands. The defect develops due to insufficient activity of the median apical ectodermal ridge, which leads to an increase in cell death or a decrease in cell proliferation. Due to the rarity of the pathology, there are few papers on the surgical treatment of this congenital foot disease, and publications to date concern the treatment of children.
CASE SUMMARY We present a clinical case of congenital splitting of the feet and hands in a 31-year-old woman and a long-term result of foot treatment using the minimal arrangement of the Ilizarov apparatus. The patient had paternal inheritance of the trait. After the surgical treatment, cosmetic view and functional condition of the foot were improved and persisted two years after intervention. There were no complications in the treatment process.
CONCLUSION The possibility of dosed control and stable fixation of the foot rays made it possible to create favorable conditions for the healing of the central wound and the closure of the segment splitting without complications. The long-term outcome of the treatment of foot congenital splitting using the proposed Ilizarov apparatus arrangement has shown its effectiveness. Our approach should be considered as an option of treatment in similar cases.
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Affiliation(s)
- Sergey S Leonchuk
- 6th and 5th Orthopedic Departments, Russian Ilizarov Scientific Center for Restorative Traumatology and Orthopedics 6, Kurgan 640014, Russia
| | - Andrey S Neretin
- 6th and 5th Orthopedic Departments, Russian Ilizarov Scientific Center for Restorative Traumatology and Orthopedics 6, Kurgan 640014, Russia
| | - Anthony J Blanchard
- Department of Surgery, University of Cincinnati, College of Medicine, Cincinnati, OH 45219, United States
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Guero S, Holder-Espinasse M. Insights into the pathogenesis and treatment of split/hand foot malformation (cleft hand/foot). J Hand Surg Eur Vol 2019; 44:80-87. [PMID: 30380990 DOI: 10.1177/1753193418807375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Cleft hand or split hand foot malformation is a sequence of phenotypes, from a minor shortening of the central digit to a complete absence of the third ray and in the most severe cases, absence of two, three or four rays. It is a rare but spectacular presentation usually involving both hands and feet. Inheritance is mostly autosomal dominant but sporadic cases without family history are also reported, resulting from a de novo mutation/deletion/duplication. Intra-familial clinical variability is the rule, with incomplete penetrance. X-linked or autosomal recessive inheritance has also been described. To date, seven subgroups of split hand foot malformation have been identified and seven loci are currently known. Anatomical records have enhanced our knowledge of this group of disorders of the hands and feet and allowed us to improve surgical procedures and long-term outcome.
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Abstract
Several techniques have been described for cleft hand closure and web space reconstruction in patients with central deficiency; however, long-term documentation of results is rare. We present a 23-year follow-up of a patient who underwent the Miura procedure for a Manske type IIb cleft hand exhibiting long-term aesthetic and functional success. In addition, early skin flap necrosis and late web space contracture, which have been seen after the Snow-Littler procedure, did not occur in this case.
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Affiliation(s)
- John D. Beck
- />Department of Orthopaedic Surgery, University of California Irvine, 101 The City Drive South, Orange, CA 92868 USA
- />12911 120th Ave NE, H-10, Kirkland, WA 98034 USA
| | - Benjamin Chang
- />Hospital of the University of Pennsylvania, 3400 Spruce Street, 10 Penn Tower, Philadelphia, PA 19104 USA
| | - Neil F. Jones
- />Department of Orthopaedic Surgery, University of California Irvine, 101 The City Drive South, Orange, CA 92868 USA
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Aleem AW, Wall LB, Manske MC, Calhoun V, Goldfarb CA. The transverse bone in cleft hand: a case cohort analysis of outcome after surgical reconstruction. J Hand Surg Am 2014; 39:226-36. [PMID: 24359797 DOI: 10.1016/j.jhsa.2013.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 11/04/2013] [Accepted: 11/04/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the implications of the transverse bone in cleft hand by assessing outcomes after reconstruction in comparison with a control group. METHODS This study is a retrospective review of 23 hands in 18 patients following surgical reconstruction of the cleft hand. Eleven hands had a transverse bone component, and 12 hands (control group) did not. Patients and their families were contacted to assess overall satisfaction following reconstruction. Clinical and radiographic records were reviewed to assess aesthetic and functional outcomes, the need for additional surgery, and radiographic divergence angles. RESULTS There was no difference in aesthetic or functional subjective outcomes. There was no statistically significant difference in any objective outcome measure between the two groups. The use of the cleft for pinch was more dependent on the status of the index finger and the preoperative thumb-index webspace rather than the presence of a transverse bone. Eleven (4 transverse and 7 control) hands required additional surgery to address abnormal function or posture of the index and ring fingers. Preoperative radiographic divergence angles were larger in the transverse bone group than in the control group, whereas postoperative divergence angles were nearly equivalent. CONCLUSIONS Similar outcomes between the two groups demonstrate that the presence of a transverse bone in cleft hand was not associated with worse outcomes following cleft reconstruction. Preoperative narrowing of the thumb webspace and postoperative index finger metacarpophalangeal joint abnormality are associated with worse functional outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Alexander W Aleem
- Department of Orthopaedic Surgery, Shriner's Hospital for Children and St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO
| | - Lindley B Wall
- Department of Orthopaedic Surgery, Shriner's Hospital for Children and St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO
| | - M Claire Manske
- Department of Orthopaedic Surgery, Shriner's Hospital for Children and St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO
| | - Valerie Calhoun
- Department of Orthopaedic Surgery, Shriner's Hospital for Children and St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO
| | - Charles A Goldfarb
- Department of Orthopaedic Surgery, Shriner's Hospital for Children and St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO.
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Abstract
This article explores recent developments for 6 common congenital hand differences, including polydactyly, syndactyly, camptodactyly, clinodactyly, trigger thumb, and cleft hand. These differences are challenging because the surgeon must understand the potential for both functional and social (ie, appearance) issues in order to provide ideal treatment for each child and family. Therapy or surgical correction plays a role for most of these children. Recent investigations have provided additional data on the expected outcomes following intervention.
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Affiliation(s)
- Charles A Goldfarb
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Oberlin C, Korchi A, Belkheyar Z, Touam C, Macquillan A. Digitalization of the second finger in type 2 central longitudinal deficiencies (clefting) of the hand. Tech Hand Up Extrem Surg 2009; 13:110-2. [PMID: 19516138 DOI: 10.1097/bth.0b013e31819f20a2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In central longitudinal deficiency of the hand type 2 (Manske and Halikis), the second finger presents itself anatomically and functionally as a second thumb. It is therefore necessary to undertake digitalization of the index, performed exactly as a reverse pollicization technique, with the same principles: minimum volar scarring and reconstruction of a large first web space without scars at the fold of the commissure. The incision surrounds the second digit at the level of the midproximal phalanx, extends over the dorsal edge of the cleft, and finishes on the radial side of the third finger where the second web space is to be created. Through this approach, the index metacarpal is freed (extraperiosteally), preserving the dorsal venous network, and translocated into the space of the missing third ray. After internal bone fixation, the flap, with its wide and safe volar cutaneous pedicle, is easily transposed to reconstruct the first web space, avoiding the need for skin grafting. This technique is easier and safer and does not impair the normal thumb musculature compared with the classic Snow-Littler procedure.
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Abstract
Syndactyly is one of the two most common congenital hand anomalies, the other being polydactyly. Traditionally, syndactyly is considered simple when only skin is involved; complex when there is bone connection; complete when the web involvement includes the nail folds; incomplete or partial when the nail folds are not involved, but when the web depth is distal to its normal position; and complicated when there are multiple tissue abnormalities. This article discusses the various types of syndactyly, the current state of known genetic mechanisms, and the author's preferred surgical techniques for correction.
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Affiliation(s)
- Michael A Tonkin
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, University of Sydney, St Leonards, NSW, Australia.
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Abstract
Congenital hand surgery has advanced during the last 10 years with surgical technique improvements, the incorporation of new technologies, and an enhanced understanding of the basic pathology of upper extremity anomalies. This article reviews the literature with a survey of 70 articles from seven leading journals published in the last 12 years. The author concludes that the next decade should be even more exciting with the incorporation of an improved understanding of tissue engineering and molecular genetics into classification and treatment algorithms. Understanding the genetic pathways of normal, and therefore abnormal, development should allow improved classification schemes and intervention to prevent, modify, or remedy these birth abnormalities.
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Affiliation(s)
- Charles A Goldfarb
- Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes Jewish Hospital, St Louis, MO 63110, USA
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Goldfarb CA, Chia B, Manske PR. Central ray deficiency: subjective and objective outcome of cleft reconstruction. J Hand Surg Am 2008; 33:1579-88. [PMID: 18984341 DOI: 10.1016/j.jhsa.2008.05.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2008] [Revised: 05/02/2008] [Accepted: 05/06/2008] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the long-term subjective and objective outcome of cleft reconstruction in patients with central ray deficiency. METHODS Twelve patients with 16 central ray deficiency hands were included. Each hand had been treated with cleft reconstruction using soft tissue and/or bony procedures. A surgeon and parent assessed the subjective outcome using a visual analog scale to compare preoperative and postoperative appearance. Objective outcome was assessed with a clinical examination for digital range of motion and with a radiographic examination for preoperative and postoperative divergence angles of the index finger and ring finger metacarpals and phalanges. RESULTS The surgeon's visual analog scale score significantly increased from 4 to 7. Nine parents were very satisfied, 4 were satisfied, and 3 were somewhat satisfied with hand appearance. A ring finger proximal interphalangeal joint flexion contracture averaging 31 degrees was the most notable clinical finding. The metacarpal divergence angle significantly improved from 33 degrees to 12 degrees , and the phalangeal divergence angle significantly improved from 38 degrees to 12 degrees . CONCLUSIONS Cleft reconstruction improves hand appearance in patients with central deficiency. A new technique of quantifying the radiographic divergence of the border rays of the cleft demonstrates improved alignment at long-term follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Charles A Goldfarb
- Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes Jewish Hospitals, St. Louis, MO, USA.
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Reconstruction of the first web space in severely burned hand by the reverse posterior interosseous flap. EUROPEAN JOURNAL OF PLASTIC SURGERY 2008. [DOI: 10.1007/s00238-008-0285-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Gülgönen A, Güdemez E. Reconstruction of the first web space in symbrachydactyly using the reverse radial forearm flap. J Hand Surg Am 2007; 32:162-7. [PMID: 17275589 DOI: 10.1016/j.jhsa.2006.10.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2005] [Revised: 10/31/2006] [Accepted: 10/31/2006] [Indexed: 02/02/2023]
Abstract
PURPOSE To present a new approach for the reconstruction of severe first web contractures using a distally based reverse radial forearm flap in symbrachydactyly patients. METHODS This study included 6 hands in 5 patients. Subjective evaluation included appearance, parent satisfaction (and patient satisfaction when appropriate), and ability to perform daily activities such as thumb-index grasp and pinch at follow-up evaluations. We measured the angle between the first and second rays using a goniometer at maximum radial abduction, and pinch and grasp strengths were evaluated as an objective assessment. RESULTS The average follow-up period was 2 years. All parents and patients were happy with the aesthetic appearance. They were completely satisfied in their daily living activities. The average first web angle measurement was 56 degrees . An average of 39 degrees of improvement of web measurement was achieved. For the unilateral 4 patients, the average pinch strength measurement was 80% of the normal contralateral hand and the grip strength was 75% of the normal contralateral hand. CONCLUSIONS The reverse radial forearm flap was found to be a safe and simple method in the reconstruction of severe first web contractures in symbrachydactyly patients. This method provided good coverage of appropriate thickness and skin quality, and supple soft tissue that filled the first web space. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Ayan Gülgönen
- Department of Hand and Microsurgery, VKV American Hospital, Nisantasi, Istanbul, Turkey.
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Foucher G, Loréa P, Hovius S, Pivato G, Medina J. Radial shift of the ulnar fingers: a new technique for special cases of longitudinal central deficiency. JOURNAL OF HAND SURGERY (EDINBURGH, SCOTLAND) 2006; 31:156-61. [PMID: 16442191 DOI: 10.1016/j.jhsb.2005.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2004] [Accepted: 12/01/2005] [Indexed: 05/06/2023]
Abstract
Treatment of central longitudinal deficiencies is well defined, with different techniques established for the classical clefts. However, none of these techniques is easily applied to the treatment of very deep clefts accompanied by a significant divergence of the metacarpal bones. In such cases, the results of current techniques are disappointing. We propose a new technique of "Translocation in the Radial direction of the Ulnar Finger(s)" (TRUF) by intra-carpal osteotomy. The results are illustrated in three clinical cases. The TRUF operation allowed closing of the cleft, alignment of the metacarpal bones and preservation of carpometacarpal mobility. When necessary, a metacarpal synostosis may be treated at the same procedure.
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