Bilateral Syndactyly Release of Third and Fourth Fingers

CHAPTER 1

Good morning everybody. My name is Mark Perlmutter, I'm a orthopaedic hand surgeon from the Raleigh area of North Carolina. This is my colleague, Dr. Rodriguez from San Pedro Sula here in Honduras where we're going to be filming a surgery this morning on approximately a 1-year-old little girl with bilateral syndactyly's. Her right hand, shows a complex syndactyly, which means bones are fused at some point within the fusion of the fingers that in this girl's case, the index long and ring finger are fused together at the tip, at the bony level and at the skin level that renders it the title of a complex syndactyly. On her left hand, just the tip of the long finger and the ring finger are fused together. No bone involvement- you could actually put a thin, metal instrument in between them. So all that's required is a separation of the skin. Because this is a simple surgery on the left side, and because she's coming from very far away, and because we may never see her again, we're going to try both hands at the same time. She'll be a captive audience for a little bit. So hopefully, one surgery will free up the left hand completely. It will do that. The right hand will not be freed up completely. Because of unknown anatomy, particularly the radial artery or the ulnar artery, and for the long finger and the radial artery, for the ring finger, the anatomy's unknown- we're only going to separate out the ring finger today because of the- when you see the pictures, you'll understand- her anatomy is so complex, trying to separate these out at the same time would invite a problem. It's better to do it in a staged procedure where you know you can hit a home run- home run on both of them. A home run is defined as separating the fingers, and hopefully she'll regain function out of everything that you've accomplished. This is certainly dysfunctional. Giving her at least one more digit out of it would increase her functionality significantly. This will not require a skin graft on her left, her right will. We'll fashion- they're fused together- there's no separation here, we'll fashion and rearrange the skin in a premeditated way through calculated incisions to- take a large piece of skin from the back of the hand, fold it down, and create a web space. And then take the skin from the dorsum of these fingers and from the palmar half of these digits, and zigzag the incisions such that the skin will close over one digit completely, and the skin that's gapping on the ring digit probably will be skin grafted. That'll be harvested from the groin. It'll have a fair amount of adipose tissue on this child. We'll take the adipose tissue strategically off of the skin graft- called defatting- and then we'll trim that graft, tack it down in place, and really tuck it in very flatly and very neatly. Every place that needs a skin graft will get it. My friend and colleague, Dr. Rodriguez will now tell you how we'll deal with the wounds afterwards. So we have 3 wounds. We have a wound at the tip of these fingers, we have a wound- we have a wound on the inside of this digit, and we have a wound on the groin. Well, we leave the dressings for 2 weeks. Afterwards, we take it off and see if the wounds are enough healed. We leave the kid with full range of motion, and we suture with absorbable sutures, so we don't have to take them out. Correct. And that's it. And then we'll follow up when we come back.

CHAPTER 2

So this child has bilateral syndactyly's. It's when the- the fingers are fused together. These are apical syndactyly's, meaning that there is some gapping between the fingers proximally, and they're fused distally. We're operating on both fingers because the right hand that is between my fingers here is very simple, that you can see that there's no tips of the fingers, and they're fused at the tip. So this will be a very simple separation. On the left hand, Dr. Rao is- going to be operating on the much more complex side- we'll show X-rays when we're done. We see 2 little nubbins at the end that are actually the finger tips- those are 2 fingernails. There's 3 fingertips here, so I'm pointing, right now to the, the pinky digit. This is the ring digit, the long digit, and the index digit, and the thumb is hiding over here. All 3 of these digits in the central part of the hand are fused together at the tip. There's a little bit of separation between the- the fourth digit here, which will pass all the way through. We're going to separate out the fourth digit today, and then in another surgery, separate the long digit from the index digit. The point being that you cannot do very extensive surgeries on a small hand at the same time. The right hand is here. Unlike the left hand, there's no fingertips, you know, but the hand is very functional. Marking pen. So we're going to operate on the hands concurrently. The right hand will be completed because of its simplicity much sooner than the- than the left. And now I'm exposing where the- the left- flank. This is the pelvic bone right here. This is the groin over here under my fingers. And we're going to harvest skin from this region here. Move skin from the groin area to his left hand. He will not need any on his right hand. So Dr. Rao is wrapping and ACE wrap around the hand. There's a blood pressure-type cuff device high up on the arm by the armpit. It's a tourniquet. We'll exsanguinate the arm, which means remove the blood from the arm by compressing it with this ACE wrap. We'll start at the fingers and squeeze up the- arm. Force the blood above the tourniquet. And then I'll tell you to press in just a minute. So he's squeezing the hand. He'll squeeze all the way up the arm. I'm ready for the blue one. The tourniquet has been elevated- the cuff around the arm, very much like a blood pressure cuff. Now I'm going to repeat that on my side. Monocryl 4-0, 4-0. Dr. Rao has asked for a suture, he's going to put a tag on a finger tip, so that he could keep control of the fingers. While he's doing that, I'm doing the same process here, I'm wrapping... Pickups. Adson. ...from distal to proximal- turn up the other tourniquet please, on the right. So he's putting a suture through the finger tip, just so he can keep control of it. Tell her I don't like this needle holder. I need a different one.

CHAPTER 3

Dr. Andre is going to perform his first surgery in medical school. We're going to hold it like a pen. Hold closer to the tip where you have more control over it. Okay, so you're going to use that to just hold it in place, okay? No weight. Get another one please? We'll surrender this one to you to get started. Okay. See how your incision left that line there a little bit, right? Very small incisions, okay, very small baby. Hold this with your other hand, Tariq. No, the thumb. Right here. Thank you. So you'll see a triangular flap that Dr. Rao has developed there. That flap will swing around to the palmar side. And there'll be an opposing flap- from the ring finger space that will flip up and close that defect once the digits are separated. Just put some tension on that. Keep it tight. Are you waiting for this? I can wait. It's okay. It's okay, we don't need another one. Okay, I'll be done with this very quickly. So then you want to stay in the crease. Do they have tiny skin hooks? Tiny ones, little ones. So will you finish that for me? Can you see? So these are separated fingertips. Then all we have to do is close those with a small suture. No flap needed for these. See how that will close primarily? Yeah. He has excessive skin on both sides that will allow us to close this quite nicely. Because in my experience here, they work. Do you have a light handle here? A little bit of housekeeping so that it closes nicely. 6-0 Monocryl, please? That's 4-0. In Spanish, 6. Could you hold the wrist up like that, please? So what I don't like, is when I close that primarily, see how it puckers up there? I don't like that. And there's a fascial band that… See how I spread underneath the skin?

CHAPTER 4

I like that better. It's often, doctor, the smallest little things that you do that make the difference in the outcome. The extra little effort. This is Monocryl suture that I'm sewing with. It's a brand name of Johnson & Johnson. It is a- typical absorbable suture, which brings us to the point of why we're using the suture like this. It's difficult to remove sutures from a baby, number 1. Number two. I'll have you let go of that and hold this. This is a resource poor environment. They may never show up again- to have the sutures removed. So pull hard. And so- having a suture that will dissolve away as opposed to a Nylon is important. Plus it's less- hassle and scary for the baby. Okay, we're going to turn the hand over, so you can remove that. Both of them. Two sutures will cover this digit. Okay. We'll take those retractors back. Needles back please. Okay, hold this. Knife… Pull hard. Can you cut those sutures. Let's give an update over- on of the more complex hand where Professor Rao is working. He's starting to separate deeply the tissue. He's paying particular attention looking for the- the bundle of nerve and artery that travel together typically, and he's spreading apart right now looking for the deep tissues. The superficial separation from the back of the hand is about to be cut right there. Do you have a Bovie? He's going to use an electric knife to cut that to make sure any small little blood vessel won't bleed after he's done. Dr. Rao, point to the end of the bone for me. Well, that's- that's the bone right there, but that's when it starts to turn around. Yes. So, I haven't seen much of the bone yet, so- I'll let you know as soon as I get there. Okay, while- he's doing some exploration, we're going to close this other tip. We're going to turn the hand over again, so take your hooks out. Okay. Hold that. And... Would you help me, doctor, hold that hand. And pull- hard. We've injected the nerves that go to these digits with numbing medicine prior to starting. So, when the baby wakes up, he'll have numb fingertips and will not feel the surgery. And one more suture on this side will be all that we need and we'll put the tourniquet down on this side. And take this, Put that in the light. Take this. Let me have it, drop it down. Four absorbable sutures. Pull really hard. Mark, I got a question. Yes, sir. You can let go. On the hand you're working on, were the fingers fully formed and then fused together, or...? Remove that. No, they never separated in utero, meaning in the uterus they were- they were bound together and never separated. I see. The hand finishes physical development around the fifth week of gestation- to the seventh, and- so here's his hand, completely separated. It's missing the distal phalanges or the distal third of the digit, but at least now they're separated, and this child will have good functioning. If you notice, the web space is a little bit deeper here. Later in life, we'll consider deepening that to make these digits functionally longer, but that's not for today. This hand is done. Can I have a gauze, please? Let's change sides, please. I'll have you come up here, Tariq. So what I'm going to do now is to- Hold that, and hold the- suture here. Switch hands, switch your hands. I'm just wrapping this on very lightly to keep the gauze on there, that'll put just a light amount of pressure, while we- put the tourniquet down, pretty please, Gena, on the- on the right side only. So in 12 minutes we've done the one finger. Now we'll focus all our attention… I think this may be a partially ankylosed joint. It doesn't move, huh? Yeah, well there's very little movement there.

CHAPTER 5

I think I can get the skin there with a little bit of defattening. Yes. So one of the principles of syndactyly release- syn is Latin for together, dactyl is Latin is for finger. This is the triangular-shaped wedge that came from the top of the other finger, the long finger. And so you can see how he created a triangular-shaped hole on the bottom of the finger here, which is the ring finger. And we'll now flip- the triangular wedge down and to that hole, and sew it in place. Prior to being able to flip it down though, one of the principles of syndactyly surgery is judicious defatting. That's fat that he's taking out, it's excessive adipose tissue. It makes the closure tight if you don't remove it. It actually makes it close nicer, puts less tension on the closure, and makes it heal faster and better, and more likely to heal. You can see all that fat that's going down onto the yellowish towel below. There's more fat there. He was probing earlier for the bundle of nerves and arteries, and they weren't there. To make sure he didn't do any harm, he's going to try to flip it back into place. Now that looks like an excellent fit. I'll take some Monocryl 6-0. I'll see what we can do about the skin. These are often surgeries that you grow old with a child with. You have to, like we talked about on the hand that I just finished, make plans to bring them back when they're a little bit older, and do other things, for example, the right hand is going to get a web space deepening on their next surgery on the right side, makes those fingers functionally longer. This child has a partial fusion of that ring finger joint, right past the knuckle, called the proximal interphalangeal joint. The thumb, the index, and the long digit again. Cut please. Can you cut? Thank you. Alright, Can you give me a gauze and saline, please? You can Bovie that, whatever it is. Yeah, I was just looking at that- I want to touch the back to your Bovie? A little bit of electric current to burn a small blood vessel so it doesn't bleed when the tourniquet comes down. We may need a little graft on that- other finger, yeah. You can cut the sutures for him. About 4 or 5 mm tail on the sutures, please. Okay. Cut please. So this is the ring finger closed, largely. This is the defect. The combined index and long finger. That's about 12 by 12 mm. Yeah. It's a square, diamond. Yeah, diamond-shaped, which is good. Okay. 12 by 12. So we're going to head over to the groin now. So, you know, I could make this a more complicated case by doing a Z-plasty and stuff. My feeling is we should let the child grow a little bit. Absolutely. And now the fingers are separated, we can just wait for… A Z-plasty here can happen at the same time as the separation. Exactly. Without it threatening either digit, you know? I'd like that plan. And they need a- they need a web space deepening on this side as well. So I think that's a- a good plan. Yeah. This is not a one surgery baby. Clearly not a one surgery baby. I like it. Needle? If we tried heroics and tried to separate this finger out of- the index finger out from the long finger at the same time, one or both of them would die. And it's better and much more intelligent to stage your procedures when they're complex like this. Okay.

We pre-numbed this. I may take a little graft on that triangle because it's not closing without tension, so- make it slightly bigger than… I think that should serve both of your needs. You can let go right now. We'll just wait till the graft is ready. You find out if she has any other needle holder besides the 2 that she has given us. So what I'm doing now is I've made an elliptical incision in the groin, and I'm taking skin from the center, which will give us the skin that we need. I'm taking some subcutaneous fat, leaving some subcutaneous fat. We'll then use scissors and defat the skin off of the graft. And then sew the graft down to our donor site- I mean our recipient site. I'll close this if you want to defat this. Okay.

One of the things that we want to do before you close a wound is that we always want to note no tension on a wound. Okay. Hemostat? If you pick up, and I try not to ever pinch the skin so hard, right? One more. So I'll go underneath a bit- and- undermine, see what I'm doing? So I'm undermining the skin here- which- what's that? Which loosens it. It'll allow- see how this is relatively tight, right? But if I undermine it, you see the difference? So you want it to stretch? I want the skin to stretch so there's no tension. If there's less tension on the incision, the scar doesn't spread. It's not as unattractive. That's why we put the incision here in the first place, so it's less visible. This kid is- going to go through a lot of peer pressure with his hand deformities. The last thing he wants to see is a scar- another scar on him, or anybody else to see another scar on him. 3-0 Monocryl, please? 3-0 Monocryl. What do you have? Ask her what she has open. 4-0. Monocryl 4-0. I'll take the 4. So now, doctor, it'll- both will go over the midline, so I know that it will close without tension. What Dr. Rao is doing now is using the scissors to take all the fat underneath the graft- all the gross adipose tissue has been removed. Can I just see the underside of that graft, doctor? So there's the entire elliptical-shaped graft from the top. And then the other side of it is removed of- he has removed all the fat so that blood vessels will grow from the finger into this layer of skin, and they would- it'll be incorporated. He's taking a little bit more off. He'll continue that until it's ready to be transplanted. Okay, Monocryl, 6.

Alright, so we're going to start by suturing the graft here. Needle? Okay. So you're going to hold that finger out of the way. Will you cut this Dr. Y? I want to try to look over to the left hand as much as possible. I would… So we don't want to drop the graft here, okay? So I'm going to bring the hand up here, so we don't accidentally drop the graft. Okay doctor, will you come up here and show me how well you sew? Let me do this stitch, see how I go underneath of it, right? And don't go through it, like I just did. Pickup. And then come through- and we're hiding the stitching on the inside because we want it to, again, look as good as possible, right? Let's cover that diaper up. That's not a sterile part of the field. Could you keep one hand on top of here to keep this down? Yeah. And cut that. So, watch what I do here, okay? I'm going to start on the underside here. Hey, John? I want to put that right under the skin. Do you mind looking at the- the temperature of the room please? Thank you. Appreciate it. Right under the skin. That means my knot is going to be tied down deeply. Then I want to come in and start again right under the skin. Try not to come through the skin. See how the needle's tenting it? Yeah. It may pucker the skin, I'm really okay with that, the stitch will dissolve, and the pucker will go away. So I don't know if you folks are seeing this. Two times around. But I'm suturing the full-thickness graft on the defect in the middle finger. And I'm making sure that the graft covers- the edges- anatomically. The graft has a tendency to shrink. So you really have to pull it out to length. Cut that, please. So I'm going to have my assistant pull that finger, so I can see the other end of the defect. I'm going to put this down now and take a look at my partner. And I'm- putting tension on the graft. I'll cut for you. Suture, 6 Monocryl. That's the back of the middle joint of the middle finger that he's sewing now. All this is the skin graft. We'll obviously trim away that which we don't use. So now that I've sutured- all the corners, I can trim the graft off to final size. And you can see how the graft is retracting right as I cut it, and it seems as if I've cut it short, but actually- it is… Save this. Hold that, please. You know, why don't you put it in saline. It's of the right length, and you can see when I pull it back, it fits very nicely. So, 6 Monocryl. We have to put one more small piece on the ring finger. Over here on the- ring finger. She gave me a new piece. Okay. Hand me your needle holder, please. And then once these grafts are sewn into place, we'll come back and make sure that this is closed completely. We're going to inject him with some long-acting numbing medicine. And the dressings will include some non-stick gauze material with a petrolatum gauze with a nice, even pressure dressing. We'll leave that pressure on there for 2 weeks, and then remove the dressing. And by then the skin will be adhered and healed. We'll continue with the dressings- for an additional week or so because this baby's going to put her fingers in- his fingers in his mouth. We're going to put a plaster splint on afterwards. This suture is too small for this needle driver. It's better than the one I had. Yeah. Right? There was a mismatch between the needle drivers that we're able to use, and the- size of the suture we have to use. You can see here a 22 gauge needle, being used bent over as a skin hook. It's usually easier to go from the graft to the tissue, but that's not where- I'm sitting on the wrong side of the table for that. I'm trying to stay shallow. I don't know where the neurovascular bundle is. So I think our graft is secured circumferentially. If you could, yeah, can you keep that sterile? Would you do me a favor? My hand's getting tired sewing, will you switch with me, and show me the mistakes I was doing? We should ask her to get dressings, we need Vaseline gauze, and a gauze. Let's- I think we are done with- the left hand. We've separated the middle and ring fingers. And all the separated areas have been either covered with skin or skin graft. I might put one more stitch at that very end, maybe. Scissor. Ring finger, that'll have to be addressed perhaps at the same time that this index gets separated out. Right in there, you keep probing it. Look at your tip before it goes through. Yup. Take that. So all these are dissolving stitches, so we don't actually have to remove them in little kids. Excellent. And we'll come back later at some point in time and try and separate these 2 digits- if possible. But for right now, we untethered the middle and ring fingers, so both of them can start growing more normally. This child will never have a normal hand, but it'll be a lot better having those fingers separated. I'm going to go ahead and start dressing this. So, Vaseline? So we're going to hold the hand up, and just… So hold the thumb again, please. You're smart.

CHAPTER 6

I'm making a plaster of Paris splint for this child. This is made of a 3 inch roll of plaster of Paris. It's about 16 inches long, and I'm going to dip this in water. And kind of spread it out. And sandwich it- in this layer of cast padding. And hand this over to Mark. I've got- yeah. I'm going to do the same thing for the other side. It's about 12 layers thick. And we're going to go all the way around. And you really have to go above the elbow to make sure it stays on. You don't want it too tight. You want to make sure when you get done, it looks nice and tidy. It takes about 5 minutes to get hard. We'll put some tape, and that should take care of it. How long does it stay on? Two weeks? This will stay on for a couple of weeks to begin with. That's when we change the dressings after 2 weeks or so. The child may have some sort of protection on the hand for another 2 weeks. Would you say that Mark? Yeah. Yeah. You have to protect the- the hands from the baby. Really, until the grafts are healed up completely. And the tape is just to ensure that it doesn't unravel.