Long-term outcomes following radial polydactyly reconstruction

Surgical correction of radially deviated Wassel type III thumb polydactyly: a prospective case series

We report our experience with correction of radially deviated Wassel type III thumb polydactyly. After comprehensive assessments from preoperative radiographs, physical examinations and intraoperative reports, we corrected the metacarpophalangeal joint in 34 cases of radially deviated Wassel type III thumb polydactyly. Opening-wedge osteotomies combining bone graft and soft tissue reconstruction were used in 28 cases and soft tissue reconstruction only in six cases. Absorbable sutures were used instead of traditional Kirschner (K)-wires to fix the bone grafts. Patients were followed up for 12-78 months (mean 47 months). According to the Tada scoring system, 25 patients achieved good results, seven fair results and two poor results. Our modified technique for correcting radially deviated Wassel type III thumb polydactyly yielded satisfactory results. Continued follow-up and further studies will contribute to a better understanding of the long-term efficacy and potential refinements of this technique.Level of evidence: IV.

Postoperative deviation in Wassel types II and III radial polydactyly: a retrospective analysis of 73 thumbs

This study examined the relationship between osteochondral stability and postoperative deviation at the interphalangeal (IP) joint in Wassel types II and III radial polydactyly. Cases with cartilaginous fusion between the radial distal phalanx and the proximal phalanx were classified as type IIB, while the remaining cases were categorized as type IIA. In conventional surgery, the cartilage was routinely resected on the radial aspect of the proximal phalangeal head, while in the modified procedure, this was preserved to avoid postoperative radial deviation. Postoperatively, there was no significant difference between both procedures in type IIA thumbs regarding IP joint deviation, whereas in type IIB/III thumbs, IP joint deviation was significantly higher in the conventional group (mean 19° [SD 16°]) compared to the modified group (mean 0.8° [SD 4.9°]). Surgeons should exercise caution against excessive cartilage excision to preserve osteochondral stability during procedures, especially for type IIB and III radial polydactylies.Level of evidence: IV.

Complications after radial polydactyly surgery: analysis, prevention and management

Long-term follow-up after surgical correction of patients with radial polydactyly might reveal unexpected or undesired outcomes that are accentuated by growth. It should be stressed that assessment of outcomes differs considerably by the system used. Preoperative examination can elucidate the underlying pathological anatomy of these anomalies and consequently, these anatomical differences should be corrected as much as possible during the first operation to prevent worse outcomes at long-term follow-up. In various long-term studies, the reoperation rate was in the range of 7%-28%, with the most common reasons being deviation, instability, nail deformity and suboptimal appearance. Most unfavourable results occur during growth and are frequently revealed only at longer-term follow-up. Concentration of care to a few centres is advised since these malformations occur in small numbers and experienced surgeons tend to have better results. Consensus on the used assessment system and multicentred studies are essential in future to better understand how we can prevent reoperations.

Modified Wassel-Flatt Type III Radial Polydactyly: Subtypes and Their Outcomes

PURPOSE

We aimed to subdivide modified type III radial polydactyly and evaluate the applied surgical procedures and outcomes according to the subtypes.

METHODS

This study included 32 thumbs of 32 patients treated for modified Wassel-Flatt type III radial polydactyly from March 2008 to December 2018. Each patient was subclassified into parallel, divergent, and convergent types according to the alignment of the duplicated digit. The parallel type was further divided according to the treatment method applied. The parallel A group comprised patients treated with reconstructing the radial collateral ligament of the interphalangeal (IP) joint after removing only the distal phalanx and preserving the proximal phalanx of the extra digit, and the parallel B group comprised patients treated with excision of the extra digit at the bifurcation site of the proximal phalanx. We evaluated the Japanese Society for Surgery of the Hand scores and radiographic angulation of the IP and metacarpophalangeal joints at a mean follow-up of 38 months.

RESULTS

Fourteen cases were parallel type (6 and 8 in the parallel A and B groups, respectively), 14 were divergent type, and 4 were convergent type. Patients in the parallel A group had significantly better IP and metacarpophalangeal joint angulation and Japanese Society for Surgery of the Hand scores than those in the parallel B group. Patients in the parallel A group had significantly better Japanese Society for Surgery of the Hand scores than those in the divergent and convergent groups.

CONCLUSIONS

Reconstructing the radial collateral ligament of the IP joint after removing only the distal phalanx and preserving the proximal phalanx of the extra digit was associated with better outcomes than the excision of the extra digit at the bifurcation site in the parallel type cases. The parallel type treated with proximal phalanx preservation and ligament reconstruction had better clinical outcomes than other types of modified Wassel-Flatt type III radial polydactyly.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Prediction of Surgical Outcomes of Radial Polydactyly From the Wassel-Flatt Type and Symmetry of Duplication

BACKGROUND

The Wassel classification is commonly used for cases of radial polydactyly but has not been used to predict surgical outcomes. This study aimed to investigate the predictive factors of surgical outcomes using the Wassel type and symmetry of duplication.

METHODS

Forty-five patients with 47 radial polydactylies were reviewed using the Japanese Society for Surgery of the Hand (JSSH) scores 4.6 years after minor thumb excision and reconstructive surgery. The symmetry index was defined as the metaphyseal width ratio of the minor thumb to the dominant thumb. The relationships between the JSSH scores and operation age, sex, side, follow-up duration, Wassel type, symmetric index, divergent angle, and joint angulation were analyzed by linear regression.

RESULTS

The mean JSSH score of the 47 thumbs was 18.3 points (range, 15-20). Five thumbs had fair or poor outcomes (scores <17), all of which were Wassel type IV. The hypoplastic type had a better JSSH score (19.4) than other Wassel types. The symmetric index had a negative relationship with JSSH scores, especially for Wassel type IV (r=-0.68, P =0.001). Linear regression revealed that the symmetric index was the only independent factor significantly associated with JSSH scores among Wassel type IV polydactylies ( P <0.05). The receiver operating characteristic curve suggested a symmetric index <0.74 could predict good or excellent outcomes.

CONCLUSION

The symmetry of the 2 duplicated thumbs is an important factor for surgical outcomes. The Wassel type IV polydactylies with a symmetric index >0.74 are at greater risk of fair or poor outcomes after excision and reconstruction, and further studies are warranted to confirm whether the Bilhaut-Cloquet procedure is a good choice.

LEVEL OF EVIDENCE

Level IV-Case-control study.

Thumb Duplication Surgical Treatment: Outcomes and Results

Aim

This study aims to evaluate functional and esthetic outcomes of thumb duplication correction in pediatric age.

Methods

Retrospective study including all pediatric patients with thumb duplication undergoing surgical treatment between 2012 and 2017. We analyzed demographic data, surgical technique, and surgical outcomes considering Tada, Horii, and Tien scores, according to the following parameters: active mobility of the metacarpophalangeal and interphalangeal joints, stability, alignment, and family's opinion about cosmetic and function of the thumb. The Wassel-Flatt classification was used to classify the duplicated thumbs.

Results

A total of 11 patients were included, predominantly male (ratio 1.8:1), with a median age at time of surgery of 19[10-26] months and a median follow-up time after surgery of 23 [3-63] months. The Wassel- Flatt type IV thumb was the most frequent (73%). The postoperative evaluation revealed that 82% of patients had good results in Tada score, 73% had good results in Horii score, and all patients showed good results in Tien score. We found a relation between lower age and fair postoperative alignment (P = .047) and between fair postoperative alignment and fair final Tada (P = .022), Horii (P = .006), and Tien (P = .009) scores.

Conclusions

Excision and reconstruction procedures are good options in the treatment of thumb duplication providing good clinical results, with excellent parent satisfaction. Timing of surgery is important for favorable esthetic outcomes, while angular deformity is a determining factor that for postoperative dissatisfaction.

Mid-term to Long-term Follow-up Results of Reconstruction for Thumb Radial Polydactyly

BACKGROUND

Preaxial or radial polydactyly is one of the most common hand congenital anomalies in newborns. Contemporary reconstruction methods include ligament reconstruction, excision of the polydactylous thumb, osteotomy, and other surgical techniques according to the type of polydactyly. The purpose of this study was to report mid-term to long-term reconstruction results for thumb (radial) polydactyly.

METHODS

We retrospectively reviewed the medical records of patients who underwent reconstruction surgery for preaxial polydactyly. Clinical outcomes, including the range of motion (ROM), pain, and complications, were evaluated. We assessed the final radiographs of the reconstructed thumb to identify the potential development of arthritis or other remaining deformities. After excluding cases without a simple radiograph and cases with a short follow-up period of fewer than 5 years, 26 thumbs were included. The surgical technique followed including excision of polydactylout thumb was tailored to the type of polydactyly. If the nail size of the thumbs was similar, the Bilhaut-Cloquet method was preferred.

RESULTS

The mean age of the patients at the surgery and final follow-up was 14.9 months (range: 8 to 30 mo) and 11.9 years (range: 5.8 to 19.3 y), respectively. The mean follow-up was 128.8 months years (range: 60 to 219 mo), and the mean ROM of the thumb was 32.7 and 57.5 degrees in the distal interphalangeal joint (DIP) and metacarpophalangeal (MP) joint, respectively. Ulnar or radial side instability was prominent in 7 patients in the involved joints (26.9%). One patient underwent interphalangeal (IP) fusion for extension lag with pain. The radiologic evaluation revealed that 2 patients developed radiographic evidence of IP joint arthritis (7.7%). Radial deviation of the MP or IP joint existed in 13 cases (range: 5 to 40 degrees) (50.0%), and ulnar deviation of the MP or IP joint existed in 2 cases (range: 19 to 20 degrees) (7.7%).

CONCLUSIONS

In mid-term to long-term experience, sequelae such as joint instability, joint stiffness, and remaining deformity cannot be neglected. An unstable MP joint may result if the DIP joint remains stiff or has a lower ROM.

LEVEL OF EVIDENCE

Level IV-therapeutic studies.

Natural History of Poland Syndrome: A Long-term Study of Functional and Psychosocial Outcomes

BACKGROUND

Poland syndrome (PS) is a congenital condition characterized by pectoralis hypoplasia and an ipsilateral hand anomaly that frequently necessitates surgery in childhood. This study aimed to determine long-term functional and psychosocial implications of PS.

METHODS

Patients underwent strength testing of their affected limb by comparing with their contralateral arm. They completed Disabilities of the Arm, Shoulder, and Hand (DASH), 36-item Short-Form Health Survey (SF-36), and several Patient-Reported Outcome Measurement Information System (PROMIS) surveys. Aggregate scores were compared with population norms.

RESULTS

Twenty-eight patients were enrolled, and 16 returned for strength testing. The average age was 42 years (range, 18-65 years), and the average follow-up was 25 years (range, 1-52 years). Dynamometer testing showed decreased strength in shoulder internal rotation and abduction/adduction, hand grip, and key pinch/tip pinch. Average DASH and SF-36 scores were comparable with population norms. The PROMIS Upper Extremity score (46.2) was significantly lower than the average 50 (SD, 10.0); the Social Roles score (57.3) indicated significantly less disability than the general population. Seventy-nine percent reported higher than average satisfaction with life, 82% had normal self-esteem, and 21% and 4% met screening criteria for depression and anxiety, respectively. The Derriford Appearance Scale revealed that 68% of patients identified PS as their most self-conscious feature, with 36% reporting subsequent life adjustments.

CONCLUSIONS

This cohort of PS patients self-reported more favorable functional, psychological, and emotional outcomes than expected based on significant shoulder and hand strength deficits. Despite these deficits, patients make adaptations, allowing fulfilling lives with psychosocial functioning similar to their peers.

Radial Polydactyly

» Radial polydactyly is one of the most common congenital anomalies of the hand, with an incidence of 0.08 to 1.40 per 1,000 live births; it requires surgical treatment early in life.» Polydactyly occurs during weeks 5, 6, 7, and 8 of embryogenesis, principally due to misregulation of the sonic hedgehog protein within the developing limb bud.» The Flatt classification system of preaxial polydactyly (types I to VII), as published by Wassel, categorizes preaxial polydactyly based on osseous abnormalities, but it has substantial limitations.» For improved function and appearance, preaxial polydactyly ideally requires surgical intervention at an early age (between 1 and 2 years of age) before the development of fine motor skills.

Reoperation after primary operation for pre-axial polydactyly of the hand: A 12-year experience at a single institute

BACKGROUND

This study aimed to evaluate and describe the rate, reasons, and detailed procedures of reoperations for pre-axial polydactyly of the hand at our institute conducted within 12 years.

METHODS

We retrospectively reviewed the medical records and radiographs of 268 patients (292 digits) with pre-axial polydactyly of the hand, who were treated surgically at our institute from November 2006 to May 2018 and followed up for >12 months.

RESULTS

Fifty-two thumbs of 47 patients underwent reoperations, yielding a 17.8% reoperation rate. According to the initial deformity type, the highest reoperation rate was observed in the cases classified under modified Wassel type VIIA (60.9%, 14/23 thumbs), followed by those under type VIIB (44.4%, 8/18 thumbs). Scheduled reoperations were performed in seven type VIIA and four type VIIB cases with a triphalangeal thumb and eight with triangular epiphysis of the distal phalanx. Unexpected reoperations were conducted in 33 cases, 31 (93.9%) of which had deviated thumbs. Various surgical treatments, including corrective osteotomy, collateral ligament plication, and flexor pollicis longus tendon relocation, were performed to correct deviations. A total of 23 cases (74.2% of 31 thumbs) received a corrective osteotomy at the second or third operation.

CONCLUSIONS

The reoperation rate after primary operation for pre-axial polydactyly of the hand was 17.8%. It was higher in the cases initially classified under modified Wassel type VII; however, a considerable number of cases received scheduled reoperations. A deviated thumb was the most common cause of unexpected reoperation, and corrective osteotomy was the most commonly performed procedure. The rate and details of reoperation should be routinely mentioned for preoperative planning and patient education in pre-axial polydactyly.

LEVEL OF EVIDENCE

Therapeutic level IV.

Surgical Results of Ulnar Component Excision and Radial Component Reconstruction in Patients With Preaxial Polydactyly of the Hand

PURPOSE

Resection of the underdeveloped digit and reconstruction of the robust digit is the standard treatment option for preaxial polydactyly of the hand. As an underdeveloped digit, the radial component is usually excised, whereas the ulnar component excision is rarely needed. This study aimed to evaluate the surgical results of ulnar component excision and radial component reconstruction in patients with preaxial polydactyly of the hand.

METHODS

We retrospectively reviewed the medical records and radiographs of 809 patients (861 thumbs) who underwent surgery for preaxial polydactyly of the hand from November 2006 to June 2018. Among these, 22 (2.6%) thumbs in which the ulnar component was more hypoplastic or had more severe deformities than the radial component were treated with ulnar component excision and radial component reconstruction. The mean follow-up duration was 49 months (range, 12-142 months). We evaluated the Japanese Society for Surgery of the Hand scores and whether the patients were satisfied with the thumb function and appearance at the final follow-up. We also recorded any complications, such as reoperation.

RESULTS

The mean Japanese Society for Surgery of the Hand score was 12.8 (range, 5-17). Six patients had poor results, 7 had fair results, and 2 had good results; however, none of the patients had an excellent result. Satisfaction with thumb function and appearance was reported in 11 (50%) and 6 (27%) cases, respectively. Thirteen of 22 (59.1%) cases involved reoperations, and the most common reason for reoperation was interphalangeal joint deviation of the remaining thumb.

CONCLUSIONS

Ulnar component excision and radial component reconstruction are rare operative choices in preaxial polydactyly of the hand. Surgeons and patients should be aware that a considerable number of patients treated with this method required reoperations and had low clinical outcome scores.

TYPE OF STUDY/ LEVEL OF EVIDENCE

Prognostic IV.

Congenital Disorders of the Pediatric Thumb

»

Surgical timing for pediatric trigger thumb treatment is controversial for numerous reasons including the potential for spontaneous resolution, the possibility of bilateral involvement, and anesthesia concerns regarding the developing brain. Hence, a reasonable approach is to delay the surgical procedure until the patient is ≥3 years of age.

»

Preaxial polydactyly is usually unilateral and sporadic, with the most common reconstruction method consisting of excision of the diminutive thumb with preservation and soft-tissue reconstruction of the dominant thumb. The surgical procedure is typically performed around the patient age of 1 year to decrease the risks of anesthesia but allow reconstruction prior to the development of a tip-to-tip pinch.

»

Triphalangeal thumb and thumb hypoplasia are often found in the setting of systemic anomalies such as Holt-Oram syndrome, thrombocytopenia absent radius syndrome, Fanconi anemia, VACTERL (vertebral anomalies, anal atresia, cardiac anomalies, tracheoesophageal fistula, renal defects, and limb anomalies), and/or Blackfan-Diamond anemia. As such, patients should receive adequate workup for these entities. A surgical procedure should be performed only once patients have been medically cleared.

»

The status of the carpometacarpal joint in thumb hypoplasia determines whether reconstruction with first web space deepening, collateral ligament stabilization, and opponensplasty compared with index pollicization is performed.

Mothers caring experiences of children with congenital hand or foot abnormalities: A phenomenological study

PURPOSE

To explore the mothers' caring experiences of children with congenital hand or foot abnormalities, and to inform the development of tailored intervention strategies to improve the mothers' well-being.

DESIGN AND METHODS

A qualitative study design was used. A purposive sample of 23 women whose children had congenital abnormalities of the hand or foot were enrolled. Semi-structured, in-depth interviews were conducted from December 2019 to May 2020. The Colaizzi's phenomenological approach was used for data analysis.

RESULTS

Data analysis revealed four main themes: (a) dynamic negative affect; (b) low health literacy; (c) mothers' need for support; and (d) the shift in social activity and family role. Eleven subthemes were involved in these themes.

CONCLUSIONS

Women whose children have abnormal hands or feet have complicated care experiences and are under tremendous psychological pressure. Some mothers also encounter financial difficulties.

PRACTICE IMPLICATIONS

This study assessed the psychological impact on mothers of children with congenital hand or foot abnormalities. Our findings illustrate the needs of mothers, and call attention to this specific group. The findings may help inform healthcare and social interventions to facilitate the recovery of the affected children and cater to the needs of these families. Healthcare providers should provide adequate instructions to the parents regarding the provision of home management care following discharge from the hospital.

Nail-based reconstruction strategies for Wassel-Flatt type IVh thumb polydactyly with a floating ulnar digit: A preliminary report with 63 thumbs

PURPOSE

To present a surgical regimen based on nail morphology for Wassel-Flatt type IVh thumb polydactyly with a floating ulnar digit.

METHODS

Cases within six years were retrospectively analyzed and followed up for an average of 18 months. Three types of classifications were defined based on nail morphology ‒ ulnar nail dominant type with two subtypes of nail lateral fold symmetric or asymmetric, radial nail dominant type, and equal nail size type. One out of three procedures, on-top plasty (Ⅰ), soft tissue augmentation (Ⅱ), and the combination of the above two (Ⅲ), was performed. The Tada scoring system was used to evaluate the results.

RESULTS

Sixty-three thumbs were enrolled, forty-one of better ulnar nail type underwent top transposition, and in cases of asymmetric nail lateral fold subtype, the result of procedure Ⅲ was better than that of procedure Ⅰ, thirteen of the radial nail dominant type and nine of equal nail size type both had procedure Ⅱ. The equal nail size type was the least effective among groups, with an average Tada of four points. Six cases underwent secondary revision surgery. According to the Tada scoring system, the results were excellent in 61, fair in two.

CONCLUSIONS

Classifications based on the morphology of the nail can guide surgical planning. On-top plasty is suitable for symmetric nail lateral fold subtype. Soft tissue augmentation is ideal for radial nail dominant type and equal nail size type, and the combination of the two procedures is a better option for asymmetric nail lateral fold subtype.

Congenital Upper Limb Differences Registry (CoULD): Registry Inclusion Effect

PURPOSE

To advance the understanding of the epidemiology and treatment outcomes of congenital upper limb differences, a multicenter registry for Congenital Upper Limb Differences (CoULD) was established. After 4 years of recruitment, we sought to examine whether the relative frequency of congenital conditions compares with prior cross-sectional research and how the data have matured over time by (1) comparing our registry population with previous studies in similar populations and (2) evaluating the change over time of relative frequencies of selected conditions within the CoULD registry cohort, specifically to investigate for registry inclusion effects.

METHODS

Data from the 2 founding centers in the CoULD registry were analyzed over a 4-year period. We compared patients included in the CoULD registry against 2 prior studies by matching each condition according to the Oberg-Manske-Tonkin classification system. The relative frequency of 4 representative conditions was calculated to evaluate change over time and to determine when the inception cohort effect diminished.

RESULTS

The CoULD cohort of 1,381 patients was found to have notable differences compared with a 1-year cross-sectional cohort from the U.S. Midwest and a Swedish birth registry. Each of these registries had differences from the CoULD population in prevalence for approximately 33% of the diagnosis categories. The CoULD registry identified and included more pathologies of late presentation and those that do not commonly require surgical care. Changes in relative frequencies of incident and prevalent conditions, the registry inclusion effect, occurred early and stabilized by the third year.

CONCLUSIONS

The CoULD registry captures a different relative frequency of conditions than prior studies in similar populations. The findings highlight the CoULD registry may be a more accurate representation of clinical practice in tertiary referral centers; however, it is important to note that there was a registry inclusion effect identified.

CLINICAL RELEVANCE

Inclusion criteria are an important consideration with any longitudinal data collection method and data should display stability prior to registry reporting.

A systematic review of the use of psychological assessment tools in congenital upper limb anomaly management

STUDY DESIGN

This study is a systematic review.

INTRODUCTION

Congenital upper limb anomalies (CULAs) are often associated with psychosocial difficulties including negative body image, low self-esteem, and withdrawal from social activities.

PURPOSE OF THE STUDY

The purpose of the study was to identify, describe, and evaluate all published psychosocial assessment tools used in the assessment and management of CULAs, to direct the use of these tools in clinical practice, and to identify areas requiring development.

METHODS

A systematic search of Medline, EMBASE, Pubmed, and PsychInfo databases was performed. In total, 23 studies were included for analysis. Data extracted included study and population characteristics, psychosocial measures utilized, psychosocial outcomes reported, and the reliability and validity of measures.

RESULTS

Seventeen patient-reported measures were identified. The most commonly used tool was a Likert scale (n =7) with satisfaction with appearance and function, the most commonly evaluated outcome (n = 18). Other evaluated domains included quality of life or psychosocial functioning (n = 9), self-image (n = 2), and psychological well-being (n = 5).

DISCUSSION AND CONCLUSIONS

There is no well-established, validated assessment tool in regular use to effectively address psychosocial outcomes for children with CULAs. Although the majority of children born with a CULA appear to adjust well, this is by no means the case for all children. There is a need for routine psychosocial evaluation preoperatively and postoperatively with long-term follow-up data to help direct patient-orientated management. A clear understanding of these, and how to measure them, is needed to help for a patient-centred, multidisciplinary, evidence-driven approach to CULA management.

Modified method for reconstruction of thumb abduction function in children undergoing surgical treatment of thumb duplication

PURPOSE

This study was performed to evaluate a modified method of reconstructing the thumb abduction function in children undergoing surgical treatment of thumb duplication.

METHODS

This retrospective study included 33 children (38 thumbs) with Wassel type III to VII thumb duplication who underwent excision of the polydactylism and osteotomy of the preserved thumb. Among them, 16 children (19 thumbs) underwent reconstruction of the attachment of the articular capsule and collateral ligament of the metacarpophalangeal joint, abductor pollicis brevis and flexor pollicis brevis by the anchor technique (Group A), while 17 children (19 thumbs) underwent suturing the attachment of the above-mentioned soft tissues to the periosteum (Group B). All children were followed up for six years after surgery. The appearance, function and joint stability of the preserved thumb were compared between the two groups; the bone alignment and development were observed.

RESULTS

The deformity rate of preserved thumbs and the positive rate of lateral stress test were significantly lower in Group A than B (p < 0.05). The modified Tada score and the distance of first web were significantly higher in Group A than B (p < 0.05). Flexion, extension, adduction, abduction and palmar movement of the thumbs were good; bone alignment and development were good and no osteophyte or anchor shadow was left in the preserved thumbs in Group A.

CONCLUSION

Reconstruction of the abduction function using the anchor technique is effective in children undergoing surgical treatment for Wassel type III to VII thumb duplication and it may be superior to the conventional technique.

LEVEL OF EVIDENCE

III.

Reconstruction of Wassel IV-D radial polydactyly with a boot-shaped neurovascular island flap: A Consecutive series of 91 thumbs

INTRODUCTION

Reconstruction of Wassel IV-D radial polydactyly is challenging and requires a custom strategy dependent on the relative size and shape of the radial and ulnar duplicates. Herein, we describe a technique using a boot-shaped neurovascular island flap and review our outcomes.

METHODS

Ninety-one consecutive patients had reconstruction with a boot-shaped neurovascular island flap. The flap was dissected out from the thumb to be removed. Specific flap modifications were inclusion of the lateral nail fold, Bruner incisions dorsally and volarly to reduce scarring at the interphalangeal (IP) joint and also complete mobilization of the island flap on its pedicle to allow easier inset. A flexor pollicis longus and extensor tendon rebalancing technique was used to correct the deviation of the reconstructed thumb IP joint.

RESULTS

All boot-shaped neurovascular island flaps survived with good contour, shape, and symmetry. The average follow-up period was 25 months (range 6-60 months). Using the Japanese Society for Surgery of the Hand (JSSH) score for classification of outcomes, seven cases were classified as excellent and 84 cases as good. The median JSSH score was 18. The median Kapandji score for opposition was 9 (range 8-10).

CONCLUSION

Using a boot-shaped neurovascular island flap completely mobilized on its pedicle with a custom strategy for each radial duplicate, good outcomes can be achieved in reconstruction of Wassel IV-D radial polydactyly.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Evaluation and Management of Preaxial Polydactyly

PURPOSE OF REVIEW

To provide a current review of the embryology, classification, evaluation, surgical management, and clinical outcomes related to preaxial polydactyly.

RECENT FINDINGS

Recent studies include a proposed embryologic link between preaxial polydactyly and other congenital abnormalities, an evaluation of long-term postsurgical outcomes, and an examination of important predictors for postsurgical outcomes. Preaxial polydactyly, while relatively uncommon, is a complex congenital hand abnormality that requires careful preoperative classification and proper surgical intervention timing to yield optimal outcomes.

Treatment for Wassel Types V and VI Thumb Polydactyly

Background: Polydactyly of the thumb is the most common congenital anomaly of the hand, but there have been few reports regarding Wassel types V and VI. The purpose of this study is to present our surgical strategies and outcomes for cases of Wassel types V and VI polydactyly of the thumb.

Methods: Twenty-nine thumbs of 29 patients were included in this study; 17 cases were Wassel type V and 12 cases were type VI. Our strategies for initial surgery were appropriate tendon and muscle relocations. Opponensplasty with the abductor digiti minimi or the flexor digitorum superficialis and osteotomy were not performed in the initial surgery. We evaluated pinch motion ability and the number of additional surgical procedures. The first web space and radial instability of the metacarpophalangeal (MCP) joint were measured by radiography while the patient held a polystyrene foam cone.

Results: Twenty-two patients were able to perform a pulp pinch. Narrowing of the first web defined as the angle between the first and second metacarpus (1–2 MCA) < 40° occurred in five cases. Radial instability of the MCP joint defined as the angle between the first metacarpus and thumb proximal phalanx (1 MPA) > 20° occurred in seven cases. Additional surgery was performed in seven cases (24%) to improve insufficient thumb opposition, radial instability of the MCP joint, and narrowing of the first web. Patients in all reoperation cases were able to perform a pulp pinch.

Conclusions: Our strategies for initial surgery often had satisfactory outcomes, but careful follow-up observations and appropriate reoperation for cases with poor initial outcomes were more important.

Polydactyly a review and update of a common congenital hand difference

PURPOSE OF REVIEW

The purpose of this review is to describe various forms of hand polydactyly and their different treatment approaches. Hand polydactyly is commonly classified as ulnar (small finger) or radial (thumb). Polydactyly can be sporadic, genetic, and/or associated with syndromic conditions.

RECENT FINDINGS

Both ulnar and radial polydactyly can be surgically treated to optimize hand aesthetics and function. Timing of surgery is based on multiple factors, most notably including safety of anesthesia and socialization of the affected child. The pediatrician should be aware of potential associated conditions, such as chondroectodermal dysplasia or Ellis-van Creveld syndrome for ulnar polydactyly.

SUMMARY

Polydactyly is a common congenital hand difference and can be broadly be classified by radial or ulnar involvement. Polydactyly warrants hand surgical referral, as surgical treatment is often indicated. Pediatricians should be aware of treatment options, as well as of commonly associated anomalies and syndromes.

Long-Term Results of Surgically Treated Radial Polydactyly - An Outcome Correlation Study

Background: Thumb polydactyly is one of the commonest congenital hand differences. Traditional surgeon-based outcome scores capture outcomes mainly on bodily structure and function. Outcomes on the long-term well-being of the patients in the domains of activity and participation are not fully studied. Methods: Forty-eight thumbs in forty-five Chinese patients with radial polydactyly underwent surgical treatment at or before 3 years old were recruited. Mean follow-up was 11.6 years. Surgical outcomes were collected and compared to the normal opposite thumb. The results were compiled into the Japanese Society for Surgery of the Hand (JSSH) score, Cheng score and Tada score. Patients' activity involving hands were assessed by both objective tools and patient-reported outcome measure while their health-related quality of life (HRQoL) was assessed by Patient- and Parent-reported Pediatric Quality of Life Inventory (PedsQL). Correlations between outcomes were analysed. Results: Overall, both parents and patients themselves reported good quality of life with mean score of 86.6% and 92.1% respectively in PedsQL. The combined surgical scores ranged from 52% good or excellent results using JSSH score to 100% good result using Cheng score. None of the outcomes on bodily structure and function showed positive correlation with patient's well-being. Negative correlation was noted in total passive range of movement, active movement and Cheng score. All patients reported no activity restriction. Writing test did not show significant slowing. The operated hands had significantly poorer fine motor dexterity than normal. No significant correlation is noted between activity outcomes and PedsQL. Conclusions: Outcomes on bodily structure, function and activity showed little correlation with patients' well-being after thumb polydactyly correction. It should be careful in using or analysing patient/parent-reported outcome measures on HRQoL as outcome assessment of surgical treatment of radial polydactyly.

Long-Term Clinical and Radiographic Follow-Up of Preaxial Polydactyly Reconstruction

PURPOSE

The purpose of the study was to determine the long-term results of preaxial polydactyly reconstruction through evaluating strength, range of motion, pain, arthritis, and functional outcomes.

METHODS

Patients having preaxial polydactyly reconstruction 15 to 60 years ago completed the Disabilities of the Arm, Shoulder, and Hand (DASH) and the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Computer Adaptive Test (CAT). Aggregate scores were compared with those of the general population. Patients completed a clinical evaluation comprising grip strength, pinch strength, side pinch strength, and range of motion. Mean strength and range of motion were compared with the contralateral extremity. Patients had radiographs of the reconstructed thumb to evaluate for arthritis.

RESULTS

Twenty-five patients, comprising 27 surgical reconstructions, completed patient-reported outcomes questionnaires, and 13 reconstructions underwent clinical and radiographic evaluation. The median follow-up was 36 years. The most common Flatt-Wassel classification was type IV. The mean DASH score was 3.7, similar to the general population mean of 10.1 (SD, 14.5). The mean PROMIS UE CAT score was 51.5, similar to the general population mean of 50 (SD, 10.0). The mean pinch strength, side pinch strength, and grip strength did not differ significantly from the contralateral extremity. There was significantly decreased range of motion at the interphalangeal joint. No patient had pain in the thumb or hand on clinical evaluation. A minority of patients developed radiographic evidence of interphalangeal joint arthritis (15.4%). Nearly half of patients, 46.2%, had angular deformity.

CONCLUSIONS

Preaxial polydactyly reconstruction patients have functional outcomes similar to the general population, despite decreased range of motion at the interphalangeal joint. Patients have maintained pinch strength, side pinch strength, and grip strength. Radiographic findings of arthritis were seen in 15% of patients at follow-up but none of these patients had associated pain. Late angular deformity developed in nearly half of patients, and this highlights the importance of close follow-up until skeletal maturity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

[Recent progress in research of congenital polydactyly]

Surgery is still the main treatment for congenital polydactyly, and the aim of surgical reconstruction is to obtain a thumb with excellent function and appearance. A systematic assessment of polydactyly is required prior to surgery, including bone stress lines, joint deviation, joint activity and joint instability, size and development of finger and nail. Bone shape, joint incongruency, and abnormal tendon insertions must be corrected completely, in order to obtain good function and to avoide secondary surgery. Bilhault-Cloquet procedure can reconstruct the size of the finger and nails. Fine manipulation can improve the postoperative nail deformity, so that the reconstructed nail reaches a satisfactory aesthetic score.

Polydactyly of the Hand

Polydactyly is one of the most common congenital hand deformities managed by orthopaedic surgeons. It is most often found in isolation; however, rarely, it may be associated with genetic syndromes. Polydactyly is classified as postaxial, preaxial, or central depending on the radioulnar location of the duplicated digits. Postaxial polydactyly, which affects the ulnar side of the hand, is most common and is typically managed with excision or suture ligation of the supernumerary digit. Preaxial polydactyly, which affects the thumb or radial side of the hand, often requires reconstructive techniques to ensure a functional, stable thumb. Central polydactyly is much less common, and reconstruction can be challenging.

"On-Top Plasty" for Radial Polydactyly Reconstruction

PURPOSE

To introduce the "on-top plasty" technique and report our long-term outcomes.

METHODS

We evaluated 5 thumbs in 5 patients who underwent radial polydactyly reconstruction using the "on-top plasty" technique between 1998 and 2003. This technique was used when it was felt that neither thumb possessed adequate proximal and distal structures to provide a functional and aesthetically pleasing thumb. Our study group included 1 Flatt type III and 4 Flatt type VII thumbs. The average age at time of surgery was 1.4 years and at final follow-up was 13.5 years. Subjective patient evaluation, objective outcomes values, and validated patient-oriented outcome measures were obtained.

RESULTS

There was no soft tissue loss and union was achieved in all thumbs with no further surgery required in any thumb. Mean flexion-extension arc for the metacarpophalangeal joint was 60° (range, 10° extension to 70° flexion) and at the interphalangeal joint was 19° (range, 25° extension to 35° flexion). Mean percentage of age-matched norms for lateral, tripod, and tip pinch were 47.0%, 45.9%, and 47.8%, respectively. Mean grip strength was 54.2% of age-matched norm. The mean Pediatric Quality of Life Inventory (PedsQL) score for parent questionnaires was 89.0 and for teen/child questionnaires was 89.1. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire revealed a mean score of 4.3.

CONCLUSIONS

For patients with radial polydactyly in which neither thumb possesses adequate distal and proximal components, the on-top plasty is a reliable method of polydactyly reconstruction with durable results at longer than 10 years' follow-up.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Incidence of Acute Complications Following Surgery for Syndactyly and Polydactyly: An Analysis of the National Surgical Quality Improvement Program Database from 2012 to 2014

PURPOSE

Congenital hand differences are infrequent phenomena, and their treatment represents a relatively small fraction of cases performed by hand surgeons. Little is known about the incidence of wound complications and acute postoperative problems given the relative rarity of these procedures. This study sought to characterize the incidence of complications within 30 days of surgery for congenital hand differences.

METHODS

The National Surgical Quality Improvement Program (NSQIP) contains prospective data regarding 30-day morbidity from 64 pediatric centers across the United States. Data from all available years (2012-2014) were queried for Current Procedural Terminology (CPT) codes pertinent to the treatment of congenital hand differences. Bivariate statistics, Fisher exact tests and Poisson 95% confidence intervals (95% CI) were used to assess the incidence of complications and examine risk factors for these outcomes.

RESULTS

We identified a total of 1,656 congenital hand cases that represented 4 different CPT codes, including surgery for simple syndactyly, complex syndactyly, and polydactyly. The overall incidence of complications was 2.2% (95% CI, 1.6%-3.1%; n = 37) with the most common complication being superficial surgical site infection (1.7%; 95% CI, 1.1%-2.4%) followed by related readmission (0.3%; 95% CI, 0.1%-0.7%). There was a higher incidence of complications observed in patients undergoing complex syndactyly repair (5.2% for complex syndactyly repair vs 2.3% for all others).

CONCLUSIONS

The rate of acute complications following procedures to correct syndactyly and polydactyly is low, the most common of which is superficial surgical site infection. The incidence of acute complications may be helpful in counseling patients and families. We suggest that further research must prioritize collecting data on long-term functional outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

The Duplicated Thumb: A Review

Preaxial polydactyly is a common, often sporadic, congenital anomaly that must be addressed surgically early in life. Ideally, the surgeon seeks to accomplish three goals: construction of a thumb that is adequate in size, preservation of pinch function, and reconstruction of all components in one procedure. Although each case is unique, several classification systems attempt to describe the various types. In this article, the authors discuss the various classification systems, procedures, and outcomes after surgery for pediatric thumb duplication.

Congenital Anomalies of the Hand--Principles of Management

Physicians who specialize in pediatric orthopedics and hand surgery frequently encounter congenital hand abnormalities, despite their relative rarity. The treating physician should be aware of the associated syndromes and malformations that may, in some cases, be fatal if not recognized and treated appropriately. Although these congenital disorders have a wide variability, their treatment principles are similar in that the physician should promote functional use and cosmesis for the hand. This article discusses syndactyly, preaxial polydactyly and post-axial polydactyly, and the hypoplastic thumb.

Do Patient- and Parent-reported Outcomes Measures for Children With Congenital Hand Differences Capture WHO-ICF Domains?

BACKGROUND

Patient- and parent-reported outcome measures (PROMs) are increasingly used to evaluate the effectiveness of surgery for congenital hand differences (CHDs). Knowledge of an existing outcome measure's ability to assess self-reported health, including psychosocial aspects, can inform the future development and application of PROMs for CHD. However, the extent to which measures used among children with CHD align with common, accepted metrics of self-reported disability remains unexplored.

QUESTIONS/PURPOSES

We reviewed studies that used PROMs to evaluate surgery for CHD to determine (1) the number of World Health Organization-International Classification of Functioning, Disability and Health (WHO-ICF) domains covered by existing PROMs; (2) the proportion of studies that used PROMs specifically validated among children with CHD; and (3) the proportion of PROMs that targets patients and/or parents.

METHODS

We performed a comprehensive review of the literature through a bibliographic search of MEDLINE®, PubMed, and EMBASE from January 1966 to December 2014 to identify articles related to patient outcomes and surgery for CHD. We evaluated the 42 studies that used PROMs to identify the number and type of WHO-ICF domains captured by existing PROMs for CHD and the proportion of studies that use PROMs validated for use among children with CHD. The most common instruments used to measure patient- and parent-reported outcomes after reconstruction for CHD included the Prosthetic Upper Extremity Functional Index (PUFI), Disabilities of the Arm, Shoulder, and Hand questionnaire, Childhood Experience Questionnaire, and Pediatric Quality of Life Inventory.

RESULTS

Current PROMs that have been used for CHD covered a mean of 1.3 WHO-ICF domains (SD ± 1.3). Only the Child Behavior Checklist and the Piers-Harris Children's Self-Concept Scale captured all ICF domains (body functions and structures, activity, participation, and environmental factors). The PUFI, the only PROM validated specifically for children with congenital longitudinal and transverse deficiency, was used in only four of 42 studies. Only 13 of the 42 studies assessed patient-reported outcomes, whereas five assessed both patient- and parent-reported outcomes.

CONCLUSIONS

The PROMs used to assess patients after CHD surgery do not evaluate all WHO-ICF domains (ie, body structure, body function, environmental factors, and activity and participation) and generally are not validated for children with CHD. Given the psychological and sociological aspects of CHD illness, a PROM that encompasses all components of the biopsychosocial model of illness and validated in children with CHD is desirable.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Reconstruction for Type IV Radial Polydactyly

Type IV radial polydactyly represents a thumb with an extra proximal and distal phalanx. Assessment of the thumb for surgical reconstruction includes observing thumb function, evaluating thumb size and stability, and assessing the first web space. Reconstruction includes excision of the smaller thumb, typically the radial thumb, and re-creating thumb stability and alignment by addressing tendon insertion and joint orientation. Although surgical results are satisfying and complications are uncommon, additional surgical intervention may be required over time owing to thumb malalignment or instability.

Management of complications of congenital hand disorders

This article reviews treatment and presents complications seen in the treatment of 7 common congenital hand differences, including syndactyly, camptodactyly, ulnar and radial polydactyly, thumb hypoplasia, radial longitudinal deficiency, and epidermolysis bullosa. The management of these conditions is challenging but has evolved over the last several decades with refined understanding of the disease processes and treatments. The goal of this article is to synthesize prior knowledge and provide further insights into these conditions that will help the surgeon avoid treatment complications.