Nonvascularized Iliac Crest Bone Graft for Reconstruction of the First Metacarpal in Type IIIB Thumb Hypoplasia: A Radiographic Follow-Up Study

Exploring reconstructive alternatives to pollicization for modified Blauth type IIIB-V congenital thumb hypoplasia: A systematic review

Background

Although pollicization remains the traditional treatment strategy for modified Blauth type IIIB-V grade congenital thumb hypoplasia, many patients and parents express interest in alternative reconstructive approaches that maintain a five-digit hand. The aim of this study was to provide a summary of these alternative techniques and to assess for differences in their outcomes, with the hypothesis that techniques featuring vascularized bone grafts would have fewer instances of bone resorption or nonunion relative to non-vascularized techniques.

Methods

A systematic literature review was conducted in PubMed, Embase, and CINAHL using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies describing the reconstruction of modified Blauth type IIIB-V hypoplastic thumbs were included. Chi squared tests (or Fisher exact tests where appropriate) were performed to compare aggregate complication data.

Results

Twenty-four articles met inclusion criteria, yielding 207 patients with 210 thumbs undergoing reconstruction. Mean patient age at surgery was 3.4 years, while the mean follow-up time was 4.2 years. 203 of the 207 patients underwent reconstruction using one of five techniques: PIPJ/MTPJ transfer, hemi-metatarsal transfer, toe and metatarsal transfer, iliac crest transfer, and toe phalanx transfer. PIPJ and MTPJ transfers were the most performed procedures (n = 54, 26 %). Vascularized grafts were used in 89 cases (43 %), while non-vascularized grafts comprised 114 cases (55 %). Rates of bone resorption and nonunion were higher in non-vascularized grafts, though not significantly so (n = 203, p = 0.19). Conversely, donor site complications were significantly higher in vascularized bone grafting techniques (n = 203, p = 0.0056). The most frequently reported outcome measures were Kapandji scores (46 %) and key pinch strength (46 %). Kapandji scores had a weighted mean of 5.6 (range 3.1-6.7).

Conclusion

A variety of alternative techniques exist for reconstructing severely hypoplastic thumbs, though no technique demonstrates clear superiority. Vascularized grafts trend towards a lower bone resorption/nonunion rate relative to non-vascularized grafts, though there is evidence of heightened risks of donor site complications when taking vascularized bone grafts from the foot. Objective outcome measures showed variability across studies limiting comparisons between techniques.

The Effects of Radial Longitudinal Deficiency on Long-Term Use of the Thumb in Pediatric Patients Following Index Pollicization

PURPOSE

To assess the effect of radial longitudinal deficiency on the function of pollicized digits as determined by the Thumb Grasp and Pinch (T-GAP) assessment.

METHODS

We retrospectively evaluated 25 hands with thumb hypoplasia that underwent index finger pollicization. Patients were followed for an average of 10.4 years. Hands were divided by severity into two groups: no or mild radial longitudinal deficiency (RLD) (Group 1 = 16) and moderate to severe RLD (Group 2 = 9). We collected demographic information and completed physical examination measures, including hand strength, elbow, wrist, and hand range of motion, the Kapandji opposition score, active grasp span, and T-GAP total score.

RESULTS

Patients with moderate to severe forms of RLD had stiffer long fingers, lower Kapandji opposition scores, and limited active and passive range of motion for elbow flexion, wrist ulnar deviation, and pollicized thumb interphalangeal flexion. They had shorter forearms, decreased active grasp span, and fewer thumb creases at the interphalangeal thumb joint. In addition, the T-GAP total score was significantly lower when comparing the two groups. Children with mild dysplasia were able to achieve 32% of age-matched normal grasp strength. Patients with more severe radial dysplasia averaged 17% less grasp strength compared with children with mild dysplasia. Patients with moderate to severe RLD also had lower T-GAP total scores and strength measurements if they had limited wrist ulnar deviation.

CONCLUSIONS

Individuals with moderate to severe RLD have unique anatomical factors that affect outcomes after pollicization. These individuals use their thumbs for fewer activities, have weaker grasp, and retain more primitive grasp patterns compared with those who have milder forms of RLD.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Acute Thumb Reconstruction with Iliac Crest Bone Graft and Groin Flap: A Case Report

Crush injury with bone loss results in shortening the length of the thumb. Most of the immediate intervention is amputation and stump closure. Revision amputation with stump closure gives loss of functional length and the patient is unable to do daily activities as before. In most of all hand functions, the opposition of the thumb plays an important role. Reconstruction of the thumb with iliac crest bone graft with its functional length is one of the major achievements for the patient. As in our case, the patient is right-hand dominant he is more concerned about the functional length of the thumb, whatever the aesthetic appearance. Here we present a case of a 24-year-old male with thumb reconstruction in a severely injured thumb with loss of bone and soft tissue just distal to the base of the proximal phalanx. Nine months postoperatively, the patient showed a great outcome with restored thumb length, function, grip strength, and a good range of motion.

Keywords

case reports; injury; thumb.

Recent Advancements in the Diagnosis and Treatment of Congenital Hand Differences

Congenital hand and upper limb differences include a wide spectrum of structural abnormalities that affect functional, appearance, and psychosocial domains of affected children. Ongoing advances in the understanding and treatment of these differences continue to shape management. Over the past 10 years, new developments have been made in areas of molecular genetics, noninvasive treatments, surgical techniques, and outcome measures in several commonly seen congenital hand differences. Applying these advances in knowledge and management of congenital hand differences will enable surgeons to achieve the best outcomes possible for these children.