Factors affecting hand cosmesis and the aesthetic impact of surgery on congenital hand differences in Finland.

We assessed the appearance and cosmetic impact of surgery in congenitally different hands in Finland. A questionnaire was sent to 1165 respondents (786 female) with a mean age of 33 years (range 3-84). Participants were shown nine image pairs and seven pairs of pre- and postoperative images twice in a random order and asked to choose the more cosmetically pleasing one. We found that the appearance and number of fingers had an important aesthetic role, with higher number and more normal appearing digits consistently scoring higher than its counterpart (range 59-99%). Postoperative appearances were perceived as better than preoperative ones in syndactyly (98%), thumb duplication (92%), cleft hand (93%) and radial dysplasia (99%). Toe transfer and pollicization had little impact on cosmesis. This study demonstrated that surgery could improve cosmesis in congenitally different hands and overall, most respondents prefer an appearance that is as close as possible to normality. Level of evidence: IV.

Appearance of congenital hand anomalies.

BACKGROUND AND OBJECTIVE: Impact of appearance of congenital hand anomalies has not previously been reported. The purpose of this study was to describe the common perception about how different congenitally malformed hands look. METHODS: We developed a questionnaire in a game format to evaluate the appearance of different hands. Altogether 1450 (954 females) 4- to 84-year-old residents (296 children) of two European and one Asian (n = 102) country were asked to rate the appearance of different looking hands on a five-point pictorial Likert-type scale. Standardized photographs of the dorsal aspect of 17 different congenitally malformed non-operated hands and a normal hand were presented to respondents. Significance of age, gender, nationality, and profession of the respondents was assessed. RESULTS: The respondents' ranking order of the hands was nearly consistent. The normal hand (mean = 4.43, standard deviation = 0.85, Md = 5) and clinodactyly (mean = 4.37, standard deviation = 0.86, Md = 5) were perceived to have the best appearance. Symbrachydactyly (mean = 1.42, standard deviation = 0.68, Md = 1) and radial club hand (mean = 1.40, standard deviation = 0.68, Md = 1) received the lowest scores. Adults rated the appearance of hands higher than children regarding 14 hands, females higher than men regarding 15 hands, and Europeans higher than Asians in 4 hands (p < 0.05, respectively). Europeans rated four-finger hand (mean = 3.21, standard deviation = 1.18, Md = 3) better looking than six-finger hand (mean = 2.92, standard deviation = 1.18, Md = 3, p < 0.005), whereas Asians gave higher scores to six-finger hand (mean = 2.66, standard deviation = 1.26, Md = 3) compared to four-finger hand (mean = 2.51, standard deviation = 1.14, Md = 2). Medical doctors and nurses gave higher scores compared to the other profession groups, school children, and high school students in five hands (p < 0.05). CONCLUSIONS: A normal hand is perceived distinctly better looking than most congenitally different hands. Different malformations' appearance was ranked very coherently in the same order despite of participants' age, gender, nationality, or profession. Asians seem to prefer an additional digit to a four-finger hand.

New Simple Technique for Syndactyly Release.

Can good functional and cosmetic result be achieved in syndactyly separation using a straight midline incision with a hexagonal dorsal skin flap? METHODS: We performed 39 web reconstructions at a median of 20 months of age (11-43 months) to 26 consecutive children (21 male) with 30 simple, 4 complex, and 5 complicated syndactylies. Eighteen of the simple syndactylies were incomplete, ending at the proximal interphalangeal joint in 15 and at the distal interphalangeal joint in 3. Inguinal skin grafts were used in 2 children with either complex or complicated syndactyly. Operation time was recorded. Complications were registered. Height of the new web spaces was calculated. Parents' satisfaction on both functional and cosmetic outcome was assessed using a Visual Analog Scale from 0 to 100. RESULTS: Duration of one web reconstruction ranged from 50 to 95 minutes in simple incomplete, 56 to 135 in simple complete, 116 to 151 in complex, and 72 to 123 in complicated syndactylies. One child had a self-induced bilateral postoperative infection that lead to web creep. Two patients developed hypertrophic scars, which responded well to silicone treatment. Mean cosmetic and functional Visual Analog Scale scores were 87 (45-100) and 92 (63-100), respectively, at a mean follow-up of 1.3 years (range, 0.5-3.7). CONCLUSION: Web reconstruction using a hexagonal dorsal skin flap and straight midline incisions with closure at mid-lateral lines is safe, with good cosmetic and functional outcome in our short-term follow-up.

Mid-Term Outcome after Selective Neurotization of the Infraspinatus Muscle in Patients with Brachial Plexus Birth Injury.

Active shoulder external rotation in adduction can be restored by selective neurotization of the infraspinatus muscle with the spinal accessory nerve in select patients with brachial plexus birth injury. Does the improved shoulder external rotation stand the test of time? METHODS: Fourteen consecutive brachial plexus birth injury patients with active shoulder external rotation in adduction of ≤ 0 degrees and active shoulder elevation ≥ 90 degrees underwent selective neurotization of the infraspinatus muscle at mean 2 years of age between 2012 and 2016. All 14 patients had congruent shoulders joints with passive external rotation in adduction of 30 degrees. Pre-and postoperative electromyography was done to seven patients. Shoulder function and the subjective outcome was assessed after a mean follow-up of 3.8 years. RESULTS: Shoulder external rotation in adduction improved by a mean 57 degrees in the 12 children who did not develop shoulder internal rotation contracture. Shoulder external rotation in abduction and shoulder abduction increased in all 14 patients. Reinnervation of the supraspinatus muscle was evident in all seven children who underwent postoperative EMG. Thirteen patients' parents were satisfied with the outcome. CONCLUSIONS: Functionally significant shoulder external rotation can be restored and maintained by reinnervation of the infraspinatus muscle in brachial plexus birth injury patients with congruent shoulder joints, if internal rotation contracture does not develop.

Selective Neurotization of the Infraspinatus Muscle in Brachial Plexus Birth Injury Patients Using the Accessory Nerve.

The authors present a new technique to improve active shoulder external rotation in patients with brachial plexus birth injury. Eight brachial plexus birth injury patients (aged 1.5 to 4.7 years) lacking active external rotation in adduction (<10 degrees) with congruent glenohumeral joints and no significant internal rotation contracture (passive external rotation >45 degrees) underwent neurotization of the infraspinatus branch of the suprascapular nerve with the spinal accessory nerve. Active and passive range of shoulder motion was measured postoperatively (3, 6, and 12 months). Parents' satisfaction was assessed. At 1-year follow-up, mean improvement for active external rotation was 47 degrees (range, 20 to 85 degrees) in adduction and 49 degrees (range, 5 to 85 degrees) in abduction. All but one patient's parents were satisfied. Functionally significant active external rotation can be restored in brachial plexus birth injury by direct neurotization of the infraspinatus muscle.