514479 research-article2013
CPJ53510.1177/0009922813514479Clinical PediatricsMills et al
Article
Ulnar Polydactyly: Long-Term Outcomes and Cost-Effectiveness of Surgical Clip Application in the Newborn
Clinical Pediatrics 2014, Vol. 53(5) 470–473 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813514479 cpj.sagepub.com
Janith K. Mills, MPAS, PA-C1, Marybeth Ezaki, MD1, and Scott N. Oishi, MD1
Abstract Background. Postaxial polydactyly type B (PAPD-B) refers to the nonfunctional, floppy extra digit on the ulnar border of the hand. Suture ligation is applied in the newborn unit if the base is narrow or pedunculated. However, wart-like scars, residual bumps, or neuromas are frequent complications. Wider-based extra digits are treated at a later age by surgical excision under general anesthesia. Surgical clip application expands the indications for PAPD treatment in the newborn unit or outpatient setting with lesser incidences of complications. Design. A retrospective review identified 231 hands with PAPD-B in 132 newborns treated with surgical clips between January 1, 1996, and November 30, 2010, having a minimum of 2 years of follow-up. Medical records were queried for complications, revision procedures, and parent satisfaction. A relative cost survey compares the costs of surgical clips to surgery. Conclusions. In all, 16 extremities in 9 patients (7%) required surgical scar revision. No wound complications were noted. Keywords infants, ulnar polydactyly, outpatient procedure, local anesthesia, outcomes
Introduction Ulnar or postaxial polydactyly (PAPD) has 2 forms. In type A, there is a well-formed extra digit with skeletal continuity at the base, whereas in PAPD type B (PAPD-B), there is a nonfunctional, partially formed ulnar-sided extra digit with no bony attachments. The base of the digit may be pedunculated on a small stalk or more sessile on a broader base. PAPD-B is usually transmitted as an autosomal dominant gene and is more common in patients of African descent.1-5 Treatment of PAPD-B with a small base is often by suture ligature in the newborn nursery.6 However, rates of suture ligation complications related to scarring and neuroma formation are reported to be as high as 23.5%.7 Infants with a broader-based PAPD-B and PAPD type A are referred by the primary care pediatrician to the surgeon for treatment. Decision making is based on the width and thickness of the base of the polydactylous digit. If it is smaller and thinner, surgical clip application is appropriate8; if too broad or thick, an elective procedure under general anesthesia when the infant is older will be scheduled to remove the extra digit. The purpose of this article is to describe the technique of surgical clip application in PAPD-B, to report
results, and to report cost-effectiveness of this technique over surgical care.
Methods A medical records search identified infants with the diagnosis of PAPD-B treated January 1, 1996, through November 30, 2010. All infants seen in our pediatric orthopaedic hand service with PAPD-B having a flat base and ≤6 mm in width were candidates for this technique. The contraindication to the use of this technique was a wide, thick base of the PAPD-B. Polydactylous digits with a wide, thick base are scheduled for surgical removal when the infant is approximately 1 year of age. Medical records were reviewed for gender, ethnicity, family history, date of birth, PAPD type, location of the extra digit, surgical clip application, complaints of
1
Texas Scottish Rite Hospital for Children, Dallas, TX, USA
Corresponding Author: Janith K. Mills, Texas Scottish Rite Hospital for Children, 2222 Welborn St, Dallas, TX 75219, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 10, 2015
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Mills et al
Figure 1. Example of surgical clips applied at the base of the PAPD stalk.
Figure 2. Example of adequate bandaging technique for the infant’s hand after surgical clip application.
residual nubbins or neuromas, and need for surgical revision.
not excised, bleeding is not a complication at the time of application. A follow-up visit is given for approximately 10 to 14 days after surgical clip application. If the desiccated digit is still adherent at the time of follow-up, it is gently removed with the bevel of an 18-gauge needle.
Technique for Surgical Clip Application in the Outpatient Clinic Setting After obtaining informed consent from the parent and complying with identification and surgical “time-out” policy per the facility protocol, the base of the polydactylous digit is swabbed with alcohol or betadine and injected with approximately 0.5 mL 1% lidocaine. The base of the digit is flattened with either the surgical clip applicator or by compressing between the surgeon’s fingertips. Then, 2 or 3 appropriately sized surgical clips are applied to the base of the stalk, as close as possible to the normal side of the finger, stacking the clips to prevent slipping. No attempt to remove the digit is made at this point (see Figure 1). The clips are wrapped with a small piece of gauze or cotton to protect the adjacent skin; the infant’s hand is wrapped with a gauze bandage, covering and securing the polydactylous digit (see Figure 2).
Postprocedure Care Written instructions about anticipated postoperative experience are provided to the parents. Acetaminophen is recommended for pain control for the first day or two. The infant dose of acetaminophen is reviewed with the caregiver (10-15 mg/kg every 4-6 hours as needed). Finally, signs of wound infection are reviewed. Possible complications include wound infection and dislodging of the surgical clips, resulting in a venous tourniquet. Because the clips are applied and the digit is
Results A total of 406 extremities were identified in 229 patients with upper-limb PAPD-B. Of these, 132 patients with 231 hands underwent the surgical clip application in the outpatient clinic. The group was predominantly African American, with 81 of the 132 patients or 61.3% being of this ethnicity. The Hispanic population totaled 40% patients or 30.3%. Lesser-involved ethnic groups included 3 Caucasians of non-Hispanic origins (2.2%), 3 of middleeastern descents (2.2%), 1 native American (1%), and 4 of unknown ethnicity (3.3%). There were more male patients in the overall group: 55 female (42%) and 77 male (58%) patients. The preponderance of hand involvement was bilateral: 94 (71.2%) patients. It was found that 85 (64.4%) had a positive family history for PAPD and 47 did not. The average age of surgical clip application was 8 weeks (range 2-40 weeks). The median and mode of application of the surgical clip was 6 weeks. All patients were seen at 2 weeks following the procedure. No wound complications were reported. Parents requested scar revision for 16 extremities (7%) in 9 patients at an average age of 45 months (range 14-142 months) for painful, residual nubbins. Also, 5 patients had reports of residual nubbins but did not require surgical intervention.
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Clinical Pediatrics 53(5)
Table 1. Cost Comparison for Treatment With Surgical Clips and Outpatient Surgery Done Under General Anesthesia. Reconstruction of polydactylous, soft tissue CPT code 11200: $9716 Excision of benign lesions of neck, hands, and feet—various sizes CPT code 11420: $7050 CPT code 11426: $10 000 Surgical clips Large-size cartridge: $110—18/box; unit cost, $6.11 Medium-size cartridge: $112—36/box; unit cost, $3.11 Small-size cartridge: $93—36/box; unit cost, $2.58 Lidocaine, syringe, needle, alcohol, dressings, tape: ~ $5.00
Discussion No prior reports have described results, compared costs, and reported complications, such as failure of the digit to fall off, infection, and residual scarring, of treatment with surgical clips for PAPD-B.8 In our review of the 132 consecutive patients with 231 extremities identified that had surgical clip applications for PAPD-B, the procedure was well tolerated by all the infants, even those
CPJ53510.1177/0009922813514479Clinical PediatricsMills et al
Article
Ulnar Polydactyly: Long-Term Outcomes and Cost-Effectiveness of Surgical Clip Application in the Newborn
Clinical Pediatrics 2014, Vol. 53(5) 470–473 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922813514479 cpj.sagepub.com
Janith K. Mills, MPAS, PA-C1, Marybeth Ezaki, MD1, and Scott N. Oishi, MD1
Abstract Background. Postaxial polydactyly type B (PAPD-B) refers to the nonfunctional, floppy extra digit on the ulnar border of the hand. Suture ligation is applied in the newborn unit if the base is narrow or pedunculated. However, wart-like scars, residual bumps, or neuromas are frequent complications. Wider-based extra digits are treated at a later age by surgical excision under general anesthesia. Surgical clip application expands the indications for PAPD treatment in the newborn unit or outpatient setting with lesser incidences of complications. Design. A retrospective review identified 231 hands with PAPD-B in 132 newborns treated with surgical clips between January 1, 1996, and November 30, 2010, having a minimum of 2 years of follow-up. Medical records were queried for complications, revision procedures, and parent satisfaction. A relative cost survey compares the costs of surgical clips to surgery. Conclusions. In all, 16 extremities in 9 patients (7%) required surgical scar revision. No wound complications were noted. Keywords infants, ulnar polydactyly, outpatient procedure, local anesthesia, outcomes
Introduction Ulnar or postaxial polydactyly (PAPD) has 2 forms. In type A, there is a well-formed extra digit with skeletal continuity at the base, whereas in PAPD type B (PAPD-B), there is a nonfunctional, partially formed ulnar-sided extra digit with no bony attachments. The base of the digit may be pedunculated on a small stalk or more sessile on a broader base. PAPD-B is usually transmitted as an autosomal dominant gene and is more common in patients of African descent.1-5 Treatment of PAPD-B with a small base is often by suture ligature in the newborn nursery.6 However, rates of suture ligation complications related to scarring and neuroma formation are reported to be as high as 23.5%.7 Infants with a broader-based PAPD-B and PAPD type A are referred by the primary care pediatrician to the surgeon for treatment. Decision making is based on the width and thickness of the base of the polydactylous digit. If it is smaller and thinner, surgical clip application is appropriate8; if too broad or thick, an elective procedure under general anesthesia when the infant is older will be scheduled to remove the extra digit. The purpose of this article is to describe the technique of surgical clip application in PAPD-B, to report
results, and to report cost-effectiveness of this technique over surgical care.
Methods A medical records search identified infants with the diagnosis of PAPD-B treated January 1, 1996, through November 30, 2010. All infants seen in our pediatric orthopaedic hand service with PAPD-B having a flat base and ≤6 mm in width were candidates for this technique. The contraindication to the use of this technique was a wide, thick base of the PAPD-B. Polydactylous digits with a wide, thick base are scheduled for surgical removal when the infant is approximately 1 year of age. Medical records were reviewed for gender, ethnicity, family history, date of birth, PAPD type, location of the extra digit, surgical clip application, complaints of
1
Texas Scottish Rite Hospital for Children, Dallas, TX, USA
Corresponding Author: Janith K. Mills, Texas Scottish Rite Hospital for Children, 2222 Welborn St, Dallas, TX 75219, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 10, 2015
471
Mills et al
Figure 1. Example of surgical clips applied at the base of the PAPD stalk.
Figure 2. Example of adequate bandaging technique for the infant’s hand after surgical clip application.
residual nubbins or neuromas, and need for surgical revision.
not excised, bleeding is not a complication at the time of application. A follow-up visit is given for approximately 10 to 14 days after surgical clip application. If the desiccated digit is still adherent at the time of follow-up, it is gently removed with the bevel of an 18-gauge needle.
Technique for Surgical Clip Application in the Outpatient Clinic Setting After obtaining informed consent from the parent and complying with identification and surgical “time-out” policy per the facility protocol, the base of the polydactylous digit is swabbed with alcohol or betadine and injected with approximately 0.5 mL 1% lidocaine. The base of the digit is flattened with either the surgical clip applicator or by compressing between the surgeon’s fingertips. Then, 2 or 3 appropriately sized surgical clips are applied to the base of the stalk, as close as possible to the normal side of the finger, stacking the clips to prevent slipping. No attempt to remove the digit is made at this point (see Figure 1). The clips are wrapped with a small piece of gauze or cotton to protect the adjacent skin; the infant’s hand is wrapped with a gauze bandage, covering and securing the polydactylous digit (see Figure 2).
Postprocedure Care Written instructions about anticipated postoperative experience are provided to the parents. Acetaminophen is recommended for pain control for the first day or two. The infant dose of acetaminophen is reviewed with the caregiver (10-15 mg/kg every 4-6 hours as needed). Finally, signs of wound infection are reviewed. Possible complications include wound infection and dislodging of the surgical clips, resulting in a venous tourniquet. Because the clips are applied and the digit is
Results A total of 406 extremities were identified in 229 patients with upper-limb PAPD-B. Of these, 132 patients with 231 hands underwent the surgical clip application in the outpatient clinic. The group was predominantly African American, with 81 of the 132 patients or 61.3% being of this ethnicity. The Hispanic population totaled 40% patients or 30.3%. Lesser-involved ethnic groups included 3 Caucasians of non-Hispanic origins (2.2%), 3 of middleeastern descents (2.2%), 1 native American (1%), and 4 of unknown ethnicity (3.3%). There were more male patients in the overall group: 55 female (42%) and 77 male (58%) patients. The preponderance of hand involvement was bilateral: 94 (71.2%) patients. It was found that 85 (64.4%) had a positive family history for PAPD and 47 did not. The average age of surgical clip application was 8 weeks (range 2-40 weeks). The median and mode of application of the surgical clip was 6 weeks. All patients were seen at 2 weeks following the procedure. No wound complications were reported. Parents requested scar revision for 16 extremities (7%) in 9 patients at an average age of 45 months (range 14-142 months) for painful, residual nubbins. Also, 5 patients had reports of residual nubbins but did not require surgical intervention.
Downloaded from cpj.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 10, 2015
472
Clinical Pediatrics 53(5)
Table 1. Cost Comparison for Treatment With Surgical Clips and Outpatient Surgery Done Under General Anesthesia. Reconstruction of polydactylous, soft tissue CPT code 11200: $9716 Excision of benign lesions of neck, hands, and feet—various sizes CPT code 11420: $7050 CPT code 11426: $10 000 Surgical clips Large-size cartridge: $110—18/box; unit cost, $6.11 Medium-size cartridge: $112—36/box; unit cost, $3.11 Small-size cartridge: $93—36/box; unit cost, $2.58 Lidocaine, syringe, needle, alcohol, dressings, tape: ~ $5.00
Discussion No prior reports have described results, compared costs, and reported complications, such as failure of the digit to fall off, infection, and residual scarring, of treatment with surgical clips for PAPD-B.8 In our review of the 132 consecutive patients with 231 extremities identified that had surgical clip applications for PAPD-B, the procedure was well tolerated by all the infants, even those
