EDITORIAL TO: THE OPEN FINGER TECHNIQUE FOR RELEASE OF SYNDACTYLY

Abstract

Even if the established methods for treating syndactyly produce acceptable results, it is worthwhile to look for other techniques which might produce better results at a lower cost, especially as treatment costs are coming under increased scrutiny. The article by Withey et al. (p. 00) in this issue of the journal is therefore of great interest, but there are a few points which require comment or clarification, so as to avoid misunderstanding. Although the title and summary of the paper suggest that skin grafts are not necessary with the open technique, and that skin defects close by secondary wound healing, split thickness skin grafts were necessary in some instances at the commisure. Neither the indication for skin grafting, the number of occasions when it was used, nor the technique of fixation are mentioned. It would be of great interest to know if the need for skin grafting depended on the wideness of the skin bridges between the syndactylized fingers. Furthermore it is important to know if the skin grafts were attached with only a very few stitches, as this may explain the dierent levels of scarring in the two treatment groups. Although the new ‘‘open’’ technique was compared with historical controls who were treated with the ‘‘closed’’ technique, it is questionable whether one can compare these two groups. The mean age at operation in the ‘‘closed group’’ is twice that of the ‘‘open group’’ and the follow-up period of the ‘‘closed group’’ is twice as long as that of the ‘‘open group’’. In my experience, wound healing in children aged less than 1 year is good and produces less scarring than in older children: thus the observed dierences in scarring between the two treatment techniques may be age-related rather than attributable to the dierent treatments. Furthermore, as scar contractures may progress with growth, especially in adolescence, it seems quite questionable to compare the two groups at this relatively short follow-up, especially because it is not stated whether the scar contracture occurred immediately following a disturbed wound healing or during later growth. In my opinion it is also diAcult to assess some of the operative results, including those for ‘‘flexion‐extension deformity’’. Flexion contractures should be evaluated by measuring the range of motion of each joint and comparing these values to those of the neighbouring fingers which are not involved in the syndactyly. Also the exact location and amount of the angular lateral flexion deformity should be mentioned. Unfortunately there is also no mention of the reconstructed nail walls and pulp regions and Figures 3 and 4 do not allow assessment of the flaps at this level. These factors are of special interest, especially as Figure 2 shows a tight syndactyly with an almost common nail. All surgeons who treat syndactyly recognize that the reconstruction of the nail region in such cases is most diAcult. In our patients we use a standard technique for reconstruction of the nail walls and fingertips. This is the ‘‘pulp-plasty’’ described by Dieter Buck-Gramcko, with which we have obtained good results. However in cases of complex syndactyly with extremely narrow fingertips and long bone fusions, as occur in Apert’s syndrome, we now perform a very careful ‘‘cross-finger’’ soft-tissue distraction using a specially developed modular mini-fixator as a first stage operation. This increases the amount of skin and soft-tissue available at the second stage syndactyly release, and allows primary, good quality skin closure in the pulp and nail regions. Withey et al. (p. 4) used the same web construction in both groups, and thus the outcome in this area should be the same in both unless other unrecognized factors influence the result. In Figure 4 the 3rd web space appears narrow in comparison to the 4th space, and this could be due to a scar contracture within the transverse palmar incision. I have experienced this problem and now routinely use dorsal and palmar triangular flaps to cover the web spaces. I also wonder whether the open technique could be used for syndactylies with very narrow skin bridges between the fingers. In those cases where no skin grafting was needed, perhaps the width of the skin bridge between the syndactylized fingers was greater than in the cases in which skin grafts were required?