Keys To Correcting Syndactyly And Avoiding Surgical Complications

I met with a charming young family several weeks ago. They came in with a very articulate, rambunctious 3-year-old boy who had a simple complaint. “My toes are stuck together!” he said.

When questioned a little further, he admitted that, “Sometimes it rubs on my shoes and my toes stay over each other.” I was amazed how just a few words given by this young lad pretty much gave me all the information I needed to start discussing what was going on with the parents of this very bright child.
 
Interestingly, the most common type of syndactyly is in the foot and of the second and third toes, which is what this little boy had.1 It occurs in approximately one in 2,000 births and can have significant psychological impact on the people it affects.2 There are two types of syndactyly: type 1, which presents as mostly cosmetic issues, and type 2, which presents functional issues and usually demands surgical intervention.3
 
After more discussion with the child’s parents, it was clear that this was beginning to present a functional issue with their child as he was having a hard time with shoes and blistering. His second toe distally overlapped the distal aspect of his third toe as the syndactyly ended between the proximal and distal interphalangeal joints. They had also already tried buddy splinting the toe, which the child didn’t tolerate and also failed to relieve the deformity.

I first had them get radiographs (in that particular office, we send out for films) to make sure the young lad had normal bone structures. He did. In the past, I have seen one proximal phalanx to the two distal aspects of the toes so I wanted to make sure this was not the case this time.
 
I explained to the parents that the goals of our treatment would be to relieve their son’s pain and achieve proper alignment of the toes so he can wear his shoes comfortably.4 Happily, I’ve had a good bit of experience correcting these cases so I explained to the parents what the potential surgical repair would entail.
 
There are two common types of procedures to correct this mostly dermatological issue. One involves creating a triangular flap out of the skin in the interspace area, using a skin graft (mostly from the sinus tarsi) to reconstruct any tissue that the triangular flap does not take into account.2 I do not prefer this method as I find that creating a rectangular flap both dorsally and plantarly creates a better template for full defect coverage without any ancillary skin requirement. One aspect of this I hadn’t really ever considered was that there may be a skin color difference between the plantar and dorsal skin, and this could cause the toes to be different colors.5 I had never encountered this complaint but I can see how this can be a concern for the parents as the child grows.
 
Some have discussed using absorbable sutures for skin closure. While this can cause less psychological trauma for the child, I do not personally favor this method.6 I find it causes both excessive swelling and irritation as the sutures resorb. This in turn can cause the child to pick at the area and disrupt the very fragile flaps created. I will use non-absorbable sutures and have the child take a mild sedative (antihistamine or anti-nausea medicine) prior to the suture removal visit.

I should mention that flap necrosis is a very real possibility with this procedure, even with the young, healthy tissue we are dealing with, so this is something to discuss with the family as a potential complication. This may even require some form of skin grafting down the road but there are so many skin equivalents available, a second trip to the OR is rarely indicated.
 
This is a very challenging situation in many respects. One should have the utmost confidence in discussing the potential outcomes and complications for such a delicate procedure as you may be dealing with apprehensive parents and potentially, a very scared little boy or girl. Postoperative care of the wounds is also an important aspect to discuss with parents. Finally, the procedure is technically challenging. The skin is very fragile and it is important to avoid the very tiny neurovascular bundles in the area. Performing this procedure successfully can be stomach churning. 

The most unfortunate aspect of this deformity is how rarely we see it. It is even more rare to see it in the operating room. I would like to hear your thoughts on this topic. Please send me your thoughts or questions.

References

1. Castilla EE, Paz JE, Orioli-Parreiras IM. Syndactyly: frequency of specific types. Am J Med Genet. 1980; 5(4):357-64.
2. Marsh DJ, Floyd D. Toe syndactyly revisited. J Plast Reconstr Aesth Surg. 2011; 64(4):535-40.
3. Mondolfi PE. Syndactyly of the toes. Plast Reconstr Surg. 1983; 71(2):212-18.
4. Lee HS, Lee WC. Congenital lesser toe abnormalities. Foot Ankle Clin. 2011; 16(4):659-78.
5. Kajikawa A, Ueda K, Katsuragi Y, Momiyama M, Horikiri M. Aesthetic repair for syndactyly of the toes using a plantar rectangular flap. Plast Reconstr Surg. 2010; 126(1):156-62.
6. Cisco RW, Pitts TE, Cicchinelli LD, Caldarella DJ. Bilateral syndactyly: a unique case with surgical correction. J Am Podiatr Med Assoc. 1993; 83(11):645-50.



Stephensays: October 14, 2012 at 3:42 pm

I have a quick question for you Dr. Raducanu. You speak of the syndactyly surgery and, if memory serves me correctly, the Evans procedure in a prior blog. How many of these procedures have you performed in the past 12 months?

Thank you.

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Dr. Ron Raducanusays: October 16, 2012 at 8:43 pm

I have not performed the syndactyly procedure in quite some time but since I saw a patient recently with this deformity, it piqued my interest in doing some research and brought back memories of the ones I've done in the past. I would challenge any of my colleagues to relate doing more than a handful every few years of these. As I'm sure you know, these types of things come in fits and spurts.

I believe that when the Evans procedure blog was written, I had been through a few in the last couple of years prior to writing that particular blog. I have not had a patient who needed the procedure done since I moved to Philadelphia. Interestingly, I am about to give a lecture on that topic to the podiatric surgical residents at Temple University as they don't get a lot of experience with callus distraction, and I've been lucky to have a good bit of experience in my 10-year career.

I find that both of these procedures are what I would consider "specialized" and I don't get to see them perhaps as much as I'd like. However, I also feel I've had enough experience with both of these procedures, that if someone would walk into the office tomorrow needing either one of those two procedures performed, I would be comfortable and confident in both recommending and performing either of them on my patient.

I hope I answered your question to your satisfaction. I would be interested to know your full name. Perhaps we can continue our discussion over e-mail?

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Stephensays: October 20, 2012 at 9:43 am

Doctor, thank you for your response. Since this is a public blog, I see no reason to continue the discussion privately. Isn't the purpose of a blog to be open to discussion and comments?

During my recent residency training, my director kept hammering home the point that one of the keys to successful surgery is repetition. He feels that repittion results in consistency and reproducible results. He is also feels that with experience and repittion you pick up pearls that also contribute to successful outcomes. Though you can remember the mechanics of the procedure, not performing the procedure regularly often results in forgetting these pearls.

I have witnessed this personally. An attending during my training performed a unique surgery she hadn't performed in years, even though she said she used to do a lot of them years ago. This surgeon who is pretty good, had a hard time with some of the intricate portions of the case and she said she forgot those little pearls. Unfortunately the case didn't turn out as anticipated.

I'm in my second year of practice, and recently performed a surgery for the first time since graduation. During my third year I did this procedure a lot. When I did it for the first time in two years in private practice, I realized that I forgot some of those little pearls that probably would have resulted in better results.

If you or your more importantly your children (if you have kids) needed a surgical procedure, would you seek out a surgeon with significant recent experience, or a surgeon who hasn't performed the surgery in a couple of years? I think the answer is pretty obvious.

During my training I was also taught to do the best for the patient and to put my ego on hold. Somehow, I can't see how performing a procedure after years of not performing the procedure is in the best interest of the patient. Maybe I'm young and naive or too idealistic, but I can tell you that I hope I stay this way.

While shadowing a doc who was my eventual employer, I witnessed this scenario. He is extremely well trained, certified in rear foot and recon surgery and is excellent. A patient came in requiring a surgery he hadn't done in a few years. As a result he referred the case to a colleague. In my mind, he did the right thing for the patient. That's the primary reason I accepted his offer despite receiving more financially rewarding offers.

I think performing procedures without enough recent experience occurs way too often in our profession. I'm seeing that way too much with total ankle implants. There are going to be a lot of unhappy patients and happy lawyers as a result.

There are too many who place their ego over the welfare of the patient. That is a statement based on my recent observations and not targeted at you. Only you can determine what is truly best for the patient.

Reply to this comment »
Ron Raducanu, D.P.M.says: October 22, 2012 at 12:34 pm

After re-reading your post, and having submitted a response already, I do have some comment to make.

I guess I need a true definition for "recent." On one hand, you are saying that people in our profession perform too many procedures without recent experience. Prior to this, you also mention doing a procedure for the first time after not performing said procedure since residency, and that it was at least a year since you've performed that procedure. You then mentioned that you would have liked to have remembered those pearls with the procedure you learned in residency, which would have likely led to a better outcome.

I'm confused. Aren't you perpetuating what you are criticizing? Did you do right by your patient by not referring this patient to someone who does this procedure more often and who did it more recently? How much follow-up care of this procedure were you exposed to in residency?

Reply to this comment »
Ron Raducanu, D.P.M.says: October 22, 2012 at 11:05 am

Hello again Stephen,

I've also heard of and seen surgeons who do cases routinely and things can go equally wrong (some regularly!), leading to a flock of legal issues. Everyone has a bad day (or several). If you aren't confident in performing a procedure, I wholeheartedly agree that it should be left in more capable hands.

I also am in agreement with practicing "defensive medicine" but it is a delicate balance as I'm sure you'll agree as well. Your observation of what is going on with the ankle Implants is very astute. I scratch my head when I hear about guys/gals doing 20-30 of these a year. See my "can of worms" comment below.

I can say that as silly as this sounds, I haven't done one 1st MPJ fusion in my whole career. I'm just not a "fusion guy" (a topic for another blog one day) for the 1st MPJ. Is it a forefoot procedure that I feel I have the skill set to perform? I'm sure I have the skill to do it but I haven't done any. I'm sure there are others in our group better suited to perform it and manage the postoperative course. Crazy, right?

I do also agree with you that sometimes we let our egos get away with us but then how does one advance their art? Why even push to improve or try new equipment? I think you'll agree that all of our truly cutting edge colleagues push themselves to new heights in new techniques, not necessarily to inflate their egos, but to advance our profession. I'm hardly cutting edge, but with my training (thanks Dr. Stran and Dr. Agnew!) and experience I wouldn't perform any procedure on any patient unless truly confident I can manage the pre, intra and post operative courses,

As to the two procedures within my blogs, there aren't many who do them they way I propose, as per the Evans, and correction of a syndactyly is just plain uncommon across all surgical specialties (plastics, vascular, neuro, podiatry). I don't know of more than a handful who do the Evans Procedure using a callus distraction technique and for those that I've converted, they can't imagine doing it any other way. I speak to some of those I've converted once in awhile (when I bump into them at conferences) and even they don't see it "that often." That also brings the whole other can of worms of why some people do "a ton" of them. Are there that many people out there that need that particular procedure?

As to the syndactyly procedure, there just aren't that many out there. The literature I cited is pretty clear about that. So to answer your question, if there is a surgeon with more experience than most but who doesn't have the opportunity to do this procedure often, I would choose that surgeon for the procedure since he or she actually does have experience with it. I do understand that if there are a host of doctors doing said procedure in your direct community, I would certainly pick the one with the most experience. What do you do if there is a vacuum?

I think you'll see that when I chose to respond to a blogger on this site, I always put my full name so the blogger knows who the comments (good or bad) are coming from. Since you are maintaining that we should continue in this public forum, I would appreciate the same courtesy. Excellent interaction by the way! Keep it coming! Just let me know who you are!

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