Surgical Treatment of Congenital Syndactyly of the Hand

Khiem D. Dao, MD, Alexander Y. Shin, MD, Annette Billings, MD, Kerby C. Oberg, MD, and Virchel E. Wood, MD

Abstract
Syndactyly is a congenital anomaly of the hand that is more common in males, is present bilaterally in 50% of affected patients, and often is associated with other musculoskeletal malformations or systemic syndromes. The goal of syndactyly release is to create a functional hand with the fewest surgical procedures while minimizing complications. For simple syndactyly, surgical reconstruction can begin at approximately 6 months, although many surgeons prefer to wait until the infant is 18 months old. Special situations, such as complex syndactyly and involvement of border digits, may warrant surgical intervention earlier than 6 months. Reconstruction of the web commissure is the most technically challenging part of the operation, followed by separation of the remaining digits. Full-thickness skin grafting is almost always required for soft-tissue coverage. Complex syndactyly and syndactyly associated with other hand anomalies warrant special consideration. After reconstruction, patients should be examined periodically until they have achieved skeletal maturity because late complications such as web creep can occur. J Am Acad Orthop Surg 2004;12:39-48 On a molecular level, the formation of separate and independent digits occurs via a complicated interaction between broblast growth factors (FGFs), sonic hedgehog protein, bone morphogenic proteins (BMPs), and homeobox transcription factors, with MSX2 the most important.9-12 These factors, in turn, are regulated by the apical ectodermal ridge (AER), which is known to have a critical role in determining digit identity and formation of the interdigital space. Early in limb development, FGF10 expression within the lateral plate mesoderm induces FGF-8 and FGF-4 expression in the distal ectoderm des-

Syndactyly is a congenital anomaly that may be the most common1,2 or second most common3 hand malformation. It may hinder hand function if not corrected appropriately during infancy. Although the basic principles of surgical release of simple syndactyly have been well established, each patient requires a thorough assessment of the soft-tissue and bony components in the syndactylized region. Reconstruction must be planned carefully when more than two digits are involved or when the syndactyly is a component of a systemic congenital syndrome.

Embryology
Isolated syndactyly of the hand is estimated to occur in 1 per 2,000 to 2,500 live births.4 It is more common in males than females (56% to 84%)4-7 and occurs with equal frequency uni-

laterally or bilaterally. This autosomal dominant trait has variable expression or reduced penetrance.8 Advances in molecular biology have provided insight into the embryologic etiology of syndactyly. During the fourth week of gestation, the hand plate emerges, partially rimmed by a digital plate. During the fth week, radial condensations of mesoderm within the digital plate form the ngers, or digital rays. The digital rays are separated by webs of interdigital tissue. Within the interdigital space, radial apoptotic zones form, and programmed cell death rst indents the dorsal surface. The distal tips then separate, and programmed cell death carves out the interdigital space proximally toward the central carpal region. The interdigital space has formed by the end of the sixth week, but the digits continue to elongate and develop ventral tactile pads and undergo phalangeal differentiation.

Dr. Dao is an Orthopaedic Hand Surgeon, Westminster, CA. Dr. Shin is Assistant Professor, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN. Dr. Billings is Orthopaedic Resident, Department of Orthopaedic Surgery, Loma Linda University School of Medicine, Loma Linda, CA. Dr. Oberg is Professor of Anatomy, Department of Anatomy, Loma Linda University School of Medicine. Dr. Wood is Chief, Hand Surgery Service, Department of Orthopaedic Surgery, Loma Linda University School of Medicine. None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Dao, Dr. Shin, Dr. Billings, Dr. Oberg, and Dr. Wood. Reprint requests: Dr. Dao, West Valley Orthopaedics and Sports Medicine, Suite 150, 23101 Sherman Place, West Hills, CA 91304. Copyright 2004 by the American Academy of Orthopaedic Surgeons.

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Surgical Treatment of Congenital Syndactyly of the Hand

tined to become the AER.13,14 Subsequently, cooperative interaction between AER-generated FGFs and sonic hedgehog protein secreted from the zone of polarizing activity regulates BMP expression within the mesoderm, forming a gradient across the cranial-caudal axis (anterior-posterior axis) that provides positional cues for digit identity.15,16 By mechanisms that are as yet unclear, AER-generated FGFs then orchestrate the production of BMPregulating molecules that induce chondrogenesis at digital locations (ie, BMP antagonists Gremlin17 and activins18). These FGFs also orchestrate the expression of factors associated with the apoptotic cascade at interdigital spaces (ie, MSX2,12 Snail11). Thus, within the digital plate, the AER helps establish digital and interdigital identity. As programmed cell death ensues within the interdigital zone, the overlying AER also begins to regress. However, the AER persists over the chondrogenic zones, and continued FGF expression is associated with digital growth and extension beyond the hand plate.19 Because of the complex molecular interactions, disruption of several factors that relate to AER regression, interdigital identity, or programmed cell death can lead to syndactyly. Ectopic expression of the BMP-modifying factor Gremlin,17 BMP overexpression,20 or a reduction in AER-related FGF expression11,20 all have been linked to the formation of simple syndactyly. Conversely, overproduction of AERrelated FGF also has been associated with syndactyly.21 Presumably, both alterations in FGF production disrupt the apoptotic cascade. Three mechanisms are likely to inuence syndactyly formation: correct digital patterning and the subsequent establishment of interdigital identity; induction of the apoptotic cascade; and regression of the proliferative activity of the AER. For example, if digital patterning is appropriate and the

AER regresses but a defect in apoptosis occurs, interdigital tissue will persist but not extend with the digits as they continue to elongate. Simple syndactyly will occur, forming proximal webbing. Alternatively, if digital patterning is appropriate but the AER persists over the interdigital region and fails to induce the intact apoptotic cascade, the interdigital tissue will grow with the digits as they extend beyond the hand plate. Finally, if there is a disruption in the digital patterning, the AER will persist in inappropriate locations, and the intact apoptotic cascade will not be appropriately activated. Such disruption can lead to abnormal induction of digital rays, simple or complex syndactyly, and clefting.22 Syndactyly also may be secondary to intrauterine insults, such as early amnion rupture, in which the digits initially develop independently but later fuse in utero.23

be associated with other conditions (eg, syndactyly of the toes, polydactyly of the toes, cleft feet) or be a component of a syndrome.6 The three most common syndromes associated with syndactyly are Polands syndrome, in which the syndactyly is associated with unilateral hypoplasia of the sternal head of the pectoralis major muscle and the entire upper extremity23,25; Aperts syndrome, consisting of complex syndactyly of the hand along with craniosynostosis, hypertelorism, exophthalmos, and mild mental retardation; and acrosyndactyly (ie, amniotic disruption sequence), in which interdigital clefts or sinuses are present proximal to the level of the syndactyly. Many of these syndromes that include syndactyly also have visceral and thoracic abnormalities that are close chronologically to the embryologic development of the hand. These abnormalities should be addressed before the hand is surgically reconstructed.

Classification
Syndactyly is classied as simple when only soft-tissue structures are involved in the webbing and as complex when bone or ngernails of adjacent ngers are involved. With complete syndactyly, the entire length of adjacent digits is involved in the webbing; with incomplete syndactyly, the webs do not extend the entire length of the digit. Complicated syndactyly is the term used to label complex cases that involve a mixture or collection of synostoses.24 Syndactyly of the hand occurs most commonly between the ring and long ngers (40% to 50%), with the next most common site being between the ring and small ngers (25% to 28%).6,7 The least common location is between the thumb and index nger (7% to 9%).6,7,23

Surgical Treatment
The overall goal of syndactyly release is to produce a hand with as many independent and functional digits as possible with the fewest number of surgical corrections and complications. Many techniques have been described to accomplish this goal; Upton26 reported 46 different methods used over the past two centuries. The intent with each is to produce a web space commissure that is both deep and wide27,28 to cover the remaining sides of the digits with as much local soft tissue as possible and to cover any remaining skin decits with skin grafts.

Associated Conditions
Although syndactyly of the hand typically is an isolated condition, it may

Indications for Surgery The major indication for surgical syndactyly release is a bridge of soft tissue, with or without bony synostoses, that joins two or more digits and hinders functional use of the hand. One contraindication to surgi-

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cal release is webs associated with socalled super digits.29 Two types of super digits have been described: type I involves two metacarpals supporting a single oversized digit (Fig. 1); type II involves a single metacarpal supporting two or more digits distally. With growth, both types pose several potential complications, such as enlargement, deviation, angulation, loss of motion, and undergrowth. Very rarely can super digits be reconstructed into normally functioning digits. In such cases, surgery to create two digits often fails because frequently one of the two digits becomes stiff, atrophic, and cosmetically unacceptable. Another contraindication to surgery is complex synpolydactyly, consisting of conjoined ngers that functionally move in unison (Fig. 2). Separating such jumbled masses may signicantly jeopardize postoperative function.8,30 Surgery also is contraindicated in hands with no active mus-

Figure 2 Anteroposterior radiograph of a complex synpolydactyly showing a jumble of bones and joints that may function more poorly if separated. (Reprinted with permission from Dao KD, Wood VE, Billings A: Treatment of syndactyly. Tech Hand Upper Ext Surg 1998; 2:166-177.) Figure 3 Complete syndactyly between the small and ring ngers and partial webbing between the ring and middle ngers. (Reprinted with permission from Dao KD, Wood VE, Billings A: Treatment of syndactyly. Tech Hand Upper Ext Surg 1998;2:166-177.)

cular control or in adults whose syndactylized digits and hands are very functional.

Figure 1 Anteroposterior radiograph of the hand of a child with a typical type I super digit. Attempting to make two digits of this one good nger is inadvisable. (Reprinted with permission from Dao KD, Wood VE, Billings A: Treatment of syndactyly. Tech Hand Upper Ext Surg 1998;2:166-177.)

Timing of Surgery Although surgical correction may be started at age 6 months, some surgeons wait until 18 months. The type of syndactyly required also may inuence the timing of surgery. Operating when the infant is at least 6 months old allows the bone and soft tissue to grow and minimizes the anesthetic risks inherent when operating on an infant younger than 6 months. Furthermore, starting at this age allows time for staged reconstruction while the child is growing. However, if border digits are involved, reconstruction may be started as early as 3 to 4 months. The differentials in longitudinal growth rates between the thumb and index nger and between the ring and little ngers are so great that, inevitably, bone and joint deformity develop if the ngers are not released early (Fig. 3). However, the optimal age to perform syndactyly release in a child, especially for single-web syndactyly of nearly equal-length ngers (ie, mid-

dle and ring), is a point of controversy. Kettelkamp and Flatt6 recommend waiting until age 18 months because 75% of their cases that met this age criterion had satisfactory results. Operating at this age may be acceptable for simple syndactyly involving only digits of nearly equal length. The prognosis may be poorer when surgery is delayed beyond age 2 years because the cerebral cortex patterns of hand use must be retrained.31 Regardless, correction should be done before the child reaches school age. Multiple-digit syndactyly requires staged surgery because releasing both sides of a digit at the same time risks necrosis to the digit if it is supplied by only a single artery. For syndactyly that involves all of the digits, the ring and long ngers and the thumb and index ngers typically are released rst, followed by the index and long ngers and the ring and small ngers in a second procedure 4 to 6 months later. This approach minimizes the number of surgeries and the an-

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Surgical Treatment of Congenital Syndactyly of the Hand

esthetic risk.23 In patients with syndactyly of all ngers, the rst operation may be done before age 6 months.32

Technical Considerations Surgical techniques to manage syndactyly have not changed radically over the past century. Dividing webbed digits by separating them with a pair of scissors in the nursery, as was done in the very early 1800s, is not recommended because of the inevitable risk of exion contractures caused by longitudinal scarring. A full-thickness skin graft (FTSG) usually is recommended to cover areas of the ngers not covered by local aps. FTSGs are preferred over splitthickness skin grafts because FTSGs have a lesser tendency to scar and contract. Pedicle aps usually are not required for congenital syndactyly coverage. The surgical plan for syndactyly release includes the following: establishment of a wide and deep commissure; separation of the digits with zigzag skin incisions both dorsally and palmarly; separation of the nail, if necessary; division of any bony interconnections; and application of FTSGs to decient areas. Surgical Technique Surgery should be done under general anesthesia with a tourniquet on the involved extremity; the opposite groin is prepared for FTSG harvesting.32 The commissure is designed dorsally to have its medial and lateral base borders at the midsagittal line of the contiguous digits, starting at the metacarpophalangeal joints (Fig. 4). Distally, the bases of the ap are tapered slightly toward each other to accommodate the width of the proximal phalanges on either side after the ap is inset. Making the ap length approximately two thirds the length of the proximal phalanx provides a palmar commissure edge approximately one third the length of the proximal phalanx, once the ap is inset.23 The distal border of the ap

is shaped like a dart to minimize scarring at the commissure border between the dorsal and palmar skin. A reciprocal V-shaped incision is then marked on the palmar surface of the proposed new webspace to accommodate this ap. It is important that the created commissure slope in the proximal-dorsal to distal-palmar direction. Starting at the distal tip of the dart, the dorsal incision is extended in a zigzag fashion from the midsagittal line of one digit to that of the adjacent digit. If two separate nails are present, the dorsal incision is extended distally, bisecting the two ngertips. When a complex nail is present, as in a complex syndactyly, the nail matrix and nail bed should be divided in line with the division of the distal phalanges. The nail bed, matrix, and nail may be narrowed in preparation for coverage with a double ap.33 Accordingly, a narrow ap is raised parallel to the distal nail edge, based in the center of the common pulp to cover one side (Fig. 5). The adjacent side of the nail bed is then covered by a broader, longer ap based more proximally on the palmar surface of the other digit. The defect remaining after elevating the narrow

ap may be closed primarily, but the one left by the broader ap may require an FTSG. The palmar incision for the syndactyly release is drawn by visually projecting the apices of the dorsal zigzag aps to the palmar midsagittal line of each digit. These marks become the geometric center of the bases of the corresponding aps to be designed on the palmar side. The palmar zigzag incision is then drawn. Proximally, this line meets the center of the previously drawn V-shaped palmar anchor line, which is located approximately at the junction between the proximal and middle third of the proximal phalanges (Fig. 4, B). Once all of the skin incisions are made, the dissection is begun dorsally by raising the dorsal aps. The thin natatory ligaments near the metacarpal heads are divided to fully separate the digits; the transverse intermetacarpal ligaments are not divided. The incision is rst taken distally between the nails, then palmarly. The interdigital soft tissue is carefully divided to protect the neurovascular structures. If the common digital nerves and arteries bifurcate proximal to the new commissure, as is commonly the case,

Figure 4 Dorsal (A) and palmar (B) views. The dorsal ap (a), the V-shaped palmar ap (b), and the zigzag aps for the syndactylized digits. (Adapted with permission from Dao KD, Wood VE, Billings A: Treatment of syndactyly. Tech Hand Upper Ext Surg 1998;2:166-177.)

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Figure 5 A and B, Creating a nail fold using skin from adjacent ngertips. a = dorsal ap, b = palmar ap. C, Intraoperative photograph of double ap being raised. D, The ap is swung proximally before it is secured with sutures. (Panels A and B adapted with permission from Dao KD, Wood VE, Billings A: Treatment of syndactyly. Tech Hand Upper Ext Surg 1998;2: 166-177. Panels C and D courtesy of Professor Dieter Buck-Gramcko, Hamburg, Germany.)

they will not require separation and will not impede insetting the dorsal commissure ap. Should they bifurcate distal to this site, the digital nerves must be carefully separated from distal to proximal. Should the digital arteries bifurcate distally, the smaller of the two arteries can be ligated if there is only a simple webspace syndactyly, because both digits still will have an arterial supply based on the opposite side of the nger. When a central digit has syndactyly on each side (eg, index-middlering nger syndactyly), the digital artery supplying the side digits bordering the middle nger may be ligated because they also will have one remaining digital arterial supply ulnarly or radially.

Syndactyly of the central digit is less an issue when both sides of the digit are not operated on simultaneously. Alternatively, one may clamp a vessel, deate the tourniquet, and evaluate the resultant blood ow before ligating the artery in question. Vascular complications are rare when only one side of a digit is operated on at a time, and neither preoperative arteriograms nor exploration of the opposite side of a digit is necessary. Before securing the aps, excess subcutaneous fat should be trimmed until only approximately 1 mm of thickness remains. This decreases postoperative edema and the risk of a tight closure. The tourniquet is deated before skin closure to control

potential bleeding. The dorsal commissure ap is sewn to its reciprocating V-shaped palmar anchor with 5-0 absorbable sutures. The dorsal aps along the digits are swung palmarly, and palmar aps are swung dorsally and sutured. Tight closure should be avoided to minimize ap necrosis. Usually one nger may be closed completely with skin aps, whereas the other requires an FTSG. Nearly all cases other than a very simple incomplete syndactyly require grafting. Harvesting the FTSG lateral to the femoral artery prevents future pubic hair growth on the aps. Other donor sites include the antecubital fossa and the medial aspect (ie, instep) of the foot. Care must be taken to obtain an accurate template of the total area of skin defect to be covered. This template is transferred to the proposed donor site before harvesting the FTSG. The skin graft also requires defatting before being applied to the digits to prevent fat necrosis and graft loss. Gauze dressings are placed deep between the separated digits because any exposed open area can heal and resyndactylize the digits. As a nal check, the vascularity of the digits must be evaluated before casting to ensure that the gauze placed between them will not constrict arterial ow. A long-arm club cast with the elbow exed past 110 should be used to protect the ngers from excessive motion while the skin graft is consolidating. To allow the wound to be examined, the cast can be changed at 10 days and then reapplied for 1 week or more. Examination of the wounds can be delayed for 3 weeks if no signs of infection are present. Other than careful attention to the postoperative dressing and immobilization, most children do not require extensive therapy after the 2 to 4 weeks of immobilization required for wound healing. This is also true for aftercare of complex syndactyly reconstruction.

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Surgical Treatment of Congenital Syndactyly of the Hand

Special Considerations
Although the techniques described are adequate for most patients, other conditions, such as a short, incomplete proximal web, complex syndactyly, cleft hand, central polydactyly, and acrosyndactyly, require alternative techniques.

Incomplete Proximal Web In hands with short, incomplete simple syndactyly involving less than one-third the length of the proximal phalanx, a three-ap webplasty, as described by Ostrowski et al,34 is effective in creating a commissure from excess web skin without the need for a skin graft. The aps are composed of a dorsal rectangular ap and two equal-length palmar triangular aps (Fig. 6). The border between the dorsal and palmar aps should be at the most distal extent of the web. The optimal ratio of the length to be recessed and the width of the web space is 1:1, although ratios of 1.5:1 have been used without complication.35 For incomplete thumbindex nger syndactyly or other mildly narrowed webs, a four-ap Z-plasty36 or a central V-Y with lateral Z-plasty37 can be used to both widen and deepen the web space. These techniques avoid the need for a skin graft on the lateral walls, which are the working surfaces of the thumb web.24 For a narrow rst web space, a dorsal transpositional ap can create a functional working surface38 (Fig. 7). Complex Syndactyly Syndactyly involving bony interconnections between adjacent digits requires a plan that prioritizes the early establishment of normal or nearnormal osseous architecture, after which the denitive web release may be staged. A synostosis may be separated simultaneously with the syndactyly release by using a knife or an osteotome. Phalangeal angulation is corrected with closing wedge osteotomies and held with a longitudinal

Figure 6 Dorsal (A and B) and palmar (C and D) views of the three-ap webplasty, which is excellent for incomplete simple syndactyly or web creep in recurrent syndactyly. Usually, no skin graft is required. A, Dorsal ap is raised. B and D, Rotation and inset of dorsal and palmar aps. C, Design of palmar triangular aps. a = dorsal ap, b and c = palmar triangular aps. (Adapted with permission from Dao KD, Wood VE, Billings A: Treatment of syndactyly. Tech Hand Upper Ext Surg 1998;2:166-177.)

Kirschner wire passed centrally through the pulp and advanced in retrograde fashion. The wires are cut with 1 cm protruding outside the skin for ease of removal (without anesthesia) 4 weeks postoperatively. If the distal or proximal interphalangeal joints are not stable, the collateral ligaments also must be advanced or tightened.23 In an extremely complex syndactyly, sacricing a nonfunctional ray and establishing a three-ngered

hand provides the best functional result. Although resection is difficult for parents to accept, it is a necessary part of the preoperative discussion in certain instances.

Cleft Hand Cleft hand deformities usually involve a central ray deciency with webbing between the two remaining digits of each border component (ie, ring-small nger syndactyly, thumb index nger syndactyly). The stan-

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central defect may be achieved simultaneously with either the Snow and Littler technique35,40 (Fig. 8) or the Miura and Komada35,41 procedure.

Figure 7 Dorsal (A) and palmar (B) views demonstrating correct placement of a dorsal transpositional ap for rst web-space release. (Adapted with permission from Friedman R, Wood VE: The dorsal transposition ap for congenital contractures of the rst web space: A 20-year experience. J Hand Surg [Am] 1997;22:664-670.)

dard syndactyly release procedure should be used to release these webbings early (by 6 months), followed by closure of the central defect and

release of the thumb adduction contracture either 6 months later or at age 18 months.39 Release of the thumb adduction contracture and closure of the

Central Polydactyly Central polydactyly, or polysyndactyly, involves polydactyly of the index, long, and ring ngers in association with a complex syndactyly. The ring nger is the most commonly duplicated digit,42 and most cases involve duplication of a digit that has normal components (eg, type II polydactyly in the Turek and Stelling classications).39,43 Parents should be warned about the large number of surgeries required for correction. In one series of 22 patients with central polydactyly, there was a total of 160 operations,44 with one patient requiring 15 procedures. Correction by age 6 months is recommended, especially when both the normal and duplicated digits articulate with the same phalanx. It may be necessary to create a more functional three-ngered hand rather than risk impairing circulation by attempting to preserve all of the digits. Creating a three-ngered hand by sorting out the jumble of bones in a polysyndactyly often is the best method of treatment, requiring far fewer surgeries with better functional results. The surgery itself actually may be easier to do than a simple syndactyly release because more skin is available for closure (Fig. 9). The standard syndactyly release is used, and the extra bony components and soft tissue are resected. Tendons may be transferred from an accessory digit to a retained digit to maximize function. Furthermore, parts of two or three digits may be transferred to make one functional nger. Acrosyndactyly Acrosyndactyly is considered to be a form of secondary syndactyly caused not by a failure of differentiation but from later in utero damage and fusion of the damaged terminal

Figure 8 A, Preoperative photograph of a typical cleft hand. B, The same hand after reconstruction with the Snow and Littler technique. (Reprinted with permission from Dao KD, Wood VE, Billings A: Treatment of syndactyly. Tech Hand Upper Ext Surg 1998;2:166-177.)

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Surgical Treatment of Congenital Syndactyly of the Hand

Complications
The most common complication in syndactyly release is scar formation and progression, either at the web or along the surgical scar (Fig. 10). Web creep is eight times more common with split-thickness skin graft than with FTSG,25 and it is caused by a combination of abnormal tissue, surgical scar, and increasing growth of the underlying osseous structures.24 It may be inevitable even under optimal circumstances. If not corrected, web creep may cause deformity of the growing bones and joints. Parents should be advised of this possible complication, and the patient should be examined periodically through adolescence. Correction requires release of the scar, similar to that of the original procedure, correction with Z-plasty, and possibly an additional skin graft. Web creep may be corrected with a four-ap or three-ap web Z-plasty. The most serious complication is necrosis of the digit secondary to vascular compromise. To avoid this disastrous complication, surgeons should never operate on both sides of the digit simultaneously. Digital nerve injury may be repaired primarily if recognized intraoperatively or corrected with

Figure 9 Preoperative photograph (A) and anteroposterior radiograph (B) of polysyndactyly. (Reprinted with permission from Wood VE: Treatment of central polydactyly. Clin Orthop 1971;74:196-205.)

phalanges. It occurs sporadically, is not hereditary, and may be termed amniotic disruption sequence. No webbing exists proximally between the adjacent digits; rather, they are separated proximally by a fenestration or sinus. When the interconnection between the digits is only a narrow skin bridge, it can be simply divided or tied off with silk sutures in the newborn nursery. For more complex forms of acrosyndactyly, surgical release and reconstruction must include excision of the sinuses and incorporation of the longitudinal cleft in the reconstruction. Despite the FTSG obtained from the fatty skin protuberances after their excision and defatting, abundant FTSGs still will be necessary for complete coverage.

Results
Kettelkamp and Flatt6 reported the results of 69 syndactyly releases in 34 patients using a variety of commissure designs and zigzag incisions with

skin grafting. The most important determinant of outcome was age of the patient at time of surgery, with the best results in patients older than 18 months. The type of commissure design did not inuence the nal outcome. Posch et al45 reviewed 262 cases, including 340 hands, 558 web spaces, and 1,235 sides of ngers. The revision surgery rates (for web creep or exion contractures) after syndactyly release were higher for border digits (eg, thumbindex nger web, ringlittle nger web) than for long and ring ngers. Revision surgery rates also were higher for releases done before age 18 months than for older patients.45 However, in their review of 218 web releases in 100 patients, Percival and Sykes46 did not nd any statistically signicant differences in the rate of web recurrence related to the age of the patient at the time of surgery. They reported poorer outcomes in patients with concomitant ipsilateral congenital hand abnormalities and in those who had split-thickness skin graft rather than FTSG.

Figure 10 An example of web creep. (Reprinted with permission from Dao KD, Wood VE, Billings A: Treatment of syndactyly. Tech Hand Upper Ext Surg 1998;2:166-177.)

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secondary neurorrhaphy or nerve grafting if identied later.

Summary
Reconstructing a hand with syndactyly can be complicated and is fraught with potential pitfalls. Once the anomaly is classied as simple,

complex, or complicated, the surgical procedures and their sequence should be carefully planned. Consideration must be given to whether border digits should be released early, whether skin grafting is needed, or whether one nger should be sacriced to produce a more functional, three-ngered hand. For syndactyly involving dig-

its of nearly equal lengths, surgery should be delayed until age 18 months. Associated anomalies and systemic abnormalities should be addressed by appropriate referrals. Careful planning and meticulous surgical techniques can minimize potential errors and allow satisfactory separation of syndactylized digits.

References
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