Sum of parts: an approach to reconstruction for Type A postaxial polydactyly using metacarpal transposition

runs under the fascia. A second 2 cm incision is made in the crease of the popliteal fossa where identification of the proximal SN can be facilitated by gently moving the distal SN. Absence of motor response upon direct electrical stimulation is used for positive SN identification. The tibial and peroneal nerves are identified. The SN is dissected as far proximally as possible and then cut. The SN is then gently lead through the ankle incision and cut as far distally as possible. Both incisions are closed in a subcuticular fashion. A third mid-calf incision may be required for neurolysis at the level where the SN crosses through the fascia if it cannot be reached through the ankle incision. Since January 2000 we have used this technique to harvest one or two SNs as needed in approximately 400 infants with BPBI. Due to incomplete coding in our database, the exact number of patients or the number of SNs harvested per patient cannot be provided. Our surgical time to harvest one SN graft of 10–13 cm, from incision to wound dressing, has ranged between 35 to 55 minutes. We have found paracetamol to be sufficient in controlling postoperative pain in our series. Surgical scars have been barely visible using skin line incisions and subcuticular closure. Our postoperative complications included one superficial wound infection and one partial palsy of foot extension that resolved spontaneously. None of the patients required conversion to open dissection. Our modifications of supine positioning of the child allows synchronous brachial plexus exploration and SN nerve harvesting, thus reducing operating time. The decision to harvest one or two SNs can be made after assessment of the severity of the nerve lesion. The use of a Kilian nasal speculum provides an ideal working corridor to neurolyse the SN and helps to minimize the number of skin incisions.