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.

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.

Aesthetic and Anatomic Reconstruction of Polysyndactyly of the Fifth Toe Fused With the Fourth Toe

BACKGROUND

The aim of the study was to present a new operative technique for aesthetic and anatomic reconstruction of polysyndactyly of the fifth toe fused with the fourth toe.

METHODS

Surgery was performed in 86 feet in 73 patients with polysyndactyly of the fifth toe fused with the fourth toe. The operation involved polydactyly excision, syndactyly release using an improved dorsal asymmetric gullwing flap for web space reconstruction without skin grafting, and simultaneous correction of valgus deformity and brachydactyly of the toes. The web shape (height and width),scar contracture, and aesthetic outcomes (foot contour and morphology of the reconstructed fifth toe) were assessed using the criterion of D'Arcangelo, Vancouver Scar Scale score, and older children and parent-based satisfactory questionnaire, respectively.

RESULTS

The patients were followed up for 12 to 36 months. The reconstructed web spaces were slightly deeper than normal, with an hourglass shape and a physiological slope. Valgus deformity was completely corrected without recurrence. The reconstructed fifth toes appeared to be visually lengthened. On the basis of the criterion of D'Arcangelo, the height and width of the webs were good in 76, fair in 10, and poor in none of the feet. The mean Vancouver Scar Scale score was 1.5. All parents and patients were satisfied with the appearance and function.

CONCLUSIONS

Our new operative procedure could achieve aesthetic and anatomic reconstruction of polysyndactyly of the fifth toe fused with the fourth toe with good shape of the reconstructed web space without skin grafting, favorable appearance and axis alignment of the reconstructed fifth toes, and good foot contour.

Clinical Characteristics and Distribution of Thumb Polydactyly in South China: A Retrospective Analysis of 483 Hands

PURPOSE

This study was intended to characterize the epidemiological features of thumb polydactyly (TP) in South China.

METHODS

Clinical records were retrieved from 1 central hospital in South China to identify the patients with a definite diagnosis of TP from January 2004 to January 2017. The cases were classified by their x-ray appearance. The data collected included sex, age at first operation, reoperation, family history, unilateral/bilateral polydactyly, right/left hand involvement in unilateral cases, classification of polydactyly, and the presence of associated congenital anomalies.

RESULTS

A total of 428 patients with a definite diagnosis of TP were identified (278 males and 150 females) involving 483 cases, 373 unilateral and 55 bilateral. A syndrome or associated congenital anomaly was found in 26 (18 unilateral and 8 bilateral cases). A dominant thumb, larger and more developed, was observed in 448 hands (93%), and was the ulnar thumb in 433. Owing to postoperative complications, 31 thumbs (6.4%) underwent reoperation. The average interval from initial surgery to reoperation was 4.8 years.

CONCLUSIONS

Thumb polydactyly had a male predominance in this Chinese cohort, mostly occurring on the right hand with an ulnar dominant thumb. Bilateral cases had a higher incidence of associated anomaly and positive family history than unilateral cases. The need for additional surgery for TP might occur as late as 4.8 years after primary surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Isolated hexadactylia: A rare case of central polydactyly of the foot

BACKGROUND

Central polydactyly of foot is uncommon form of polydactyly but it usually causes intermetatarsal widening because of metatarsal bifurcation. Central polydactyly associated with T shaped bifurcation of metatarsal in vertical plane has not been reported yet.

CASE

We present a 4 year male child with extra toe on the dorsal aspect of right foot with complains of difficulty in wearing footwear and poor cosmesis. The extra digit was fully developed with bifurcation of 2^nd metatarsal bone proximal to the head without any intermetatarsal widening. The angular deviation was 45° to the longitudinal axis of foot and in a plane vertical to the transverse arch of foot. The child was operated with excision of extra toe without any residual bony deformity.

CONCLUSION

The central polydactyly is rare type of polydactyly of foot. Central polydactyly with metatarsal extension causing intermetatarsal widening has been well described entity. But the previous classifications need to be modified to include central polydactyly with vertical oriented T bifurcation of metatarsal bone without intermetatarsal widening.

Does timing of surgery influence the long-term results of foot polydactyly treatment?

BACKGROUND

There is an evident lack of research on timing of polydactyly surgery and its effects on treatment results.

METHODS

Retrospective comparative study on foot polydactyly patients treated at our department from 1995 to 2009. Patients were divided into 2 groups, group A - under the age of 5 at surgery, and group B - 5 years and older.

RESULTS

There were 24 patients (8 male, 16 female), 30 feet. Median age at surgery was 1 year (range, 9 months-4.5 years) for group A, and 8.5 years (range, 6-37 years) for group B. Median follow-up was 16.2 years (range, 7-21 years). There were 16 postaxial and 8 preaxial cases. At the last follow-up 12 patients' feet were "excellent" and 12 "good". No significant differences were identified between the two groups at final follow-up.

CONCLUSIONS

Timing of surgery for foot polydactyly is not crucial for final results.

Management of Postaxial Polydactyly in the Neonatal Unit

Postaxial type B polydactyly is the presence of a supernumerary digit attached by soft tissue in a pedunculated fashion to the fifth digit. In the present case, a newborn with bilateral postaxial type B polydactyly underwent suture ligation to remove the supernumerary digit, but multiple ligation attempts were required. Ultimately, residual tissue remained bilaterally, but it did not seem to be painful. A comprehensive review of the literature revealed no clear recommendation on treatment options for patients with postaxial polydactyly. Although suture ligation has been common practice, surgical excision is an acceptable option that can be performed in the neonatal unit and may result in fewer complications than suture ligation.

Isolated heptadactylia: A case report of central polydactyly of the foot

RATIONALE

Heptadactylia is a rare congenital disorder from the polydactyly family. Polydactyly is generally classified into 3 major groups: preaxial (medial ray), postaxial (lateral ray), and central polydactyly. Most common cases are related to preaxial or postaxial polydactyly. The rarity of central polydactyly can be explained in 3 ways. First, central polydactyly with duplication appearing on metatarsal is pretty uncommon. Second, the duplication appears isolated on the foot. Polydactyly is mostly associated with other physical defects or others duplications. Last, the duplication of the digital rays does not appear once but twice concerning all the digital rays and makes 7 functional toes appear. We describe this malformation with supporting iconography and radiography as well as its surgical management and functional results.

PATIENT CONCERNS

We analyzed an original case of isolated heptadactylia on the foot of a 14-month-old girl. The supernumerary toes made it impossible for the child to wear standard shoes and her parents were worried about this problem.

DIAGNOSES

Clinical foot examination and radiographs revealed the presence of 7 complete rays. Every toe was composed of phalanx and metatarsal ray. There was no other congenital deformity.

INTERVENTIONS

Decision was made to resect the second and third rays (the two most misaligned toes in our consideration). The first stage of surgery was the ray resection and the second stage was the reconstruction of the intermetatarsal ligament to achieve a good functional and cosmetic results.

OUTCOMES

After wound healing, the child was able to walk alone while wearing normal shoes.

LESSONS

We demonstrated that treatment of foot polydactyly requires careful preoperative assessment, including radiographs and photography. A good clinical evaluation of the medial polydactyly improves type-specific recognition which may enhance the accuracy of surgical treatment. Polydactyly is frequently associated with other malformations. We recommend performing a general clinical examination to exclude concomitant malformations. We recommend surgical treatment around the onset of walking.

[Effects of different doses of dexmedetomidine combined with ropivacaine for brachial plexus nerve block in children undergoing polydactyly surgery]

OBJECTIVE

To observe the anesthetic effect and safety of different doses of dexmedetomidine combined with ropivacaine for brachial plexus nerve block in children undergoing polydactyly surgery.

METHODS

Eighty children undergoing polydactyly surgery were randomized into 4 groups to receive brachial plexus nerve block with dexmedetomidine at 0.25, 0.50 or 0.75 µg/kg combined with 0.25% ropivacaine (0.20 mL/kg) (D1, D2, and D3 groups, respectively) or with 0.25% ropivacaine (0.20 mL/kg) only (control group). The onset time, duration of brachial plexus nerve block, awakening time, success rate, and incidence of complications were compared among the groups. Results In D2 and D3 groups, the onset time and awakening time were shorter and anesthesia lasted longer than those in the control group. The onset time and awakening time were shorter and anesthesia maintenance time was longer in D3 group than in D1 group. The success rates of brachial plexus nerve block were significantly higher in D1-3 groups than in the control group (P<0.05). Hematoma was found in one of the patients. In each of the 4 groups, laryngeal nerve block occurred in 1 child and respiratory depression in another; 2 or 3 patients had Horner syndrome, and 1 patient in D3 group experienced an episode of lowered heart beat to below 70 min^-1. All the complications were managed properly and the patients all recovered uneventfully.

CONCLUSION

Brachial plexus nerve block with 0.5 µg/kg dexmedetomidine combined with 0.25% ropivacaine (0.20 mL/kg) is safe for effective anesthesia in children undergoing surgery for polydactyly.

[Reconstruction for dysplastic polydactyly of thumb with an island compound flap]

OBJECTIVE

To investigate the necessity and feasibility of digit fusion with an advanced island flap in thumb dysplasia of radial polydactyly.

METHODS

From February 2007 to January 2015,we collected the patients with radial polydactyly, whose nail width or thumb girth was less than 80％ of contralateral side. Among them, some patients were also associated with radial deviation deformities in two thumbs or a shorter radial thumb compared with ulnar thumb. In these cases, an island compound flap, which was based on proper palmar digital artery (PPDA) in radial thumb and contained nail, part distal phalanx and skin, combining with ulnar side of ulnar thumb was used to reconstruct a new thumb. Only the patients with a smaller thumb girth were treated by an island flap to augment the thumb size. There were 26 patients, including 29 sides.Preoperative Doppler ultrasonic examination was assigned to observe the amount and distribution of princepspollicisartery(PPA) and PPDA. Appearances were evaluated by Wang -Gao scoring system and functions were evaluated by Tata scoring system.

RESULTS

There were two basic artery forms through preoperative ultrasonography and surgical exploration in 29 hands: both thumbs only had one PPDA; the main thumb had two while the extra thumb still had one. The former was responsible in 82.76％ (24 hands).All cases were operated according to preoperative design using an island compound flap.26 hands in 23 patients were followed up more than 6 months. Flap results included survival in 22 patients, tension vesicle in 2 patients and tip necrosis in 2 patients. The incision was infected in one patient with the treatment of changing dressing regularly. The function results were excellent in 21 patients, good in 4,fair in 1.Aesthetic results were excellent in 13 patients, good in 4 and fair in 1.

CONCLUSIONS

There is always one developed PDAA in extra thumb, which can be used to design a flap. The longitudinal advanced flap can also eliminate the tension caused by unequal length in two thumbs. Using an axial or island flap to reconstruct a new thumb can not only change the appearance, but also make the reconstructed thumb acquire two sets of blood supply and nerve system.

Long-Term Follow-Up of Surgical Treatment for Thumb Duplication

There are few long-term follow-up reports concerning the treatment of thumb duplication. We reviewed the treatment of 19 of 74 patients treated at our institution between 1956 and 2002. The average follow-up was 22 (range, 7 years to 35 years) years. Satisfactory function was achieved in 18 thumbs and cosmesis in 12 thumbs. Six thumbs were cold-intolerant at this late follow-up. Pinch strength was similar to the contralateral normal thumbs. Collateral ligament repair did not significantly contribute to joint stability. An objective method of postoperative evaluation showed good results in five, fair results in 12 and poor results in two thumbs.

Thumb Polydactyly with Symphalangism

Three cases of thumb polydactyly in which one of the components demonstrates symphalangism are reported. This is a very rare anomaly and only one similar case could be found in the literature. The rarity of this anomaly was explained by the occurrence of two different abnormal molecular events along two different limb growth axes. Finally, the anomaly does not fit into the classification systems described for thumb polydactyly.

Polydactyly of the hand

Polydactyly is considered either the most or second most (after syndactyly) common congenital hand abnormality. Polydactyly is not simply a duplication; the anatomy is abnormal with hypoplastic structures, abnormally contoured joints, and anomalous tendon and ligament insertions. There are many ways to classify polydactyly, and surgical options range from simple excision to complicated bone, ligament, and tendon realignments. The prevalence of polydactyly makes it important for orthopedic surgeons to understand the basic tenets of the abnormality.

[The classification and surgical treatment of the terminal phalanx of congenital thumb duplication ]

OBJECTIVE

To study the classification and individualized treatment of the terminal phalanx of thumb duplication.

METHODS

From Apr. 2003 to Dec. 2012, 76 patients with 77 involved thumbs duplication at the level which is distal to the interphalangeal joint were retrospectively studied. Based on the morphology (the nail width and the thumb circumference) and the deviation of the thumb, we classified the terminal phalanx of thumb duplication into 5 types as Type A (no bony connection called floating thumb), Type B(asymmetry and no deviation), Type C(asymmetry and deviation), Type D (symmetry and no deviation) and Type E(symmetry and deviation). Different surgical procedures were selected according to different types. Simple excision of the smaller thumb was adopted for Type A case. Removement of the smaller thumb (usually the radial) and of the collateral ligament of the interphalangeal joint were selected for Type B. Removement of the smaller thumb (usually the radial) and reconstruction of the collateral ligament of the interphalangeal joint, as well as corrective osteotomies at the neck of the proximal phalanx were performed for Type C. The modified Bilhaut-Cloquet procedure with reconstruction of the collateral ligament of the interphalangeal joint were adopted in Type D. The classical Bilhaut-Cloquet procedure, or the modified Bilhaut-Cloquet procedure with reconstruction of the collateral ligament of the interphalangeal joint and corrective osteotomies at the neck of the proximal phalanx were performed in Type E. The results were assessed by an evaluation form for thumb duplication by the Japanese Society for Surgery of the Hand.

RESULTS

According to our new classification standard, there were 3 cases with Type A duplicated thumbs, 36 with Type B, 13 with Type C, 15 with Type D, 10 with Type E. All the 76 patients underwent the individualized surgical treatment. The patients were followed up for 6-60 months. According to the evaluation form, excellent results were achieved in 66 thumbs, good in 9 thumbs and fair in 2 thumbs.

CONCLUSIONS

The new classification could comprehensively describe the clinical features of the terminal phalanx of congenital thumb duplication. Individualized therapy, including basic and repeated surgical procedure could be adopted for each type with satisfactory results.

[CLINICAL RESEARCH OF POSTOPERATIVE DEVIATION SECONDARY TO THUMB DUPLICATION RESECTION]

OBJECTIVE

To study the causes and treatment of postoperative deviation secondary to thumb duplication resection.

METHODS

Between February 2007 and June 2013, 32 cases (33 thumbs) of postoperative deviation secondary to thumb duplication resection were treated, and the clinical data were retrospectively analyzed. There were 13 males and 19 females, aged 2-34 years (median, 8 years). The left thumbs were involved in 7 cases, the right thumbs in 24 cases, and bilateral thumbs in 1 case. Of 33 thumbs, 2 were rated as type II, 4 as type III, 10 as type IV, 7 as type V, and 10 as type VII according to Wassel classification. The average time between duplicated thumb resection and admission was 6.5 years (range, 1-29 years). Nine thumbs only had ulnar deviation of the metacarpophalangeal (MP) joint; 8 thumbs only had radial deviation of the interphalangeal (IP) joint; 10 thumbs only had ulnar deviation of the IP joint; and 6 thumbs had ulnar deviation of the MP joint combined with radial deviation of the IP joint. The mean deviation degree of the MP joint was 32.3 (range, 20-40*), and the mean deviation degree of the IP joint was 42.5° (range, 30-110°). Operation methods were chosen specially according to the deformity, including remnant bone or cartilage resection, restoring normal alignment, and soft tissue balance.

RESULTS

All wounds got first stage healing and there was no complication associated with operation. Postoperative follow-up period ranged from 6 to 70 months (mean, 34 months). The skeleton alignment of the thumbs was improved on the X-ray images; all osteotomy got union at 5-10 weeks (mean, 6 weeks). Deviation was completely corrected in 31 thumbs; the preoperative deviation degree was too large to correct completely in 2 thumbs with a postoperative deviation degree of 10°. The motion degree was similar to that at preoperation in 13 thumbs; the motion degree decreased in 20 thumbs, which did not affect the function of the thumbs. Nineteen cases (20 thumbs) were followed more than 2 years, there was no recurrence of deviation and all thumbs developed well, but the size of affected thumb was smaller than that of the contralateral side in 14 cases (14 thumbs).

CONCLUSION

Getting good result and preventing postoperative deviation for thumb duplication resection acquires appropriate preoperative design, reconstruction of the insertion of the abductor poll icis brevis, transposition of the flexor and extensor pollicis longus insertion, and essential osteotomy play important roles in preventing postoperative deviation after thumb duplication resection. Individualized treatment plan for deviation should be made according to the degree and the cause of deviation.

A case report of bilateral mirror clubfeet and bilateral hand polydactyly

We report a rare case of a patient with bilateral mirror clubfeet and bilateral hand polydactyly. The patient presented to our orthopaedic clinic with bilateral mirror clubfeet, each with eight toes, and bilateral hands with six fingers and a hypoplastic thumb. The pattern does not fit any described syndrome such as Martin or Laurin-Sandrow syndrome. Treatments by an orthopaedic pediatric surgeon and an orthopaedic pediatric hand surgeon are described. The patient achieved excellent functional and cosmetic outcomes at four year follow-up.

[Optimal surgical timing and treatment of thumb duplication in children]

OBJECTIVE

To investigate the optimal surgical timing and treatment of congenital duplication of the thumb in children.

METHODS

A clinical study was performed on 154 fingers of the 132 patients (including 85 males, 47 females;mean age (1.53 +/- 2.47) years; ranged from 2 months to 13 years). Duplicated thumbs were surgically treated from December 2007 to February 2012. All patients underwent detailed physical examination and radiological assessment. Surgical methods should be selected according to the age, Wassel classification and deformity. The operation steps included resection of the most hypoplastic thumb, followed by skin flap plasty, tendon shift (transplantation) , reconstruction of collateral ligament and articular capsule. 11 cases over the age of 6 underwent osteotomy discretion as appropriate.

RESULTS

A total of 117 fingers of the 104 patients were followed up for an average 36. 7 months (range,6-55 months). We adopted upgrade Tada standard to evaluate the follow-up results as excellent in 77 thumbs, good in 21 thumbs, fair in 15 thumbs and poor in 4 thumbs. Three thumbs appeared secondary angular deformity 2 years after operation and one thumb appeared residual osteoepiphysis in the radial side of metacarpophalangeal joint 3 years after operation. The appearance and the function were almost normal after second operation.

CONCLUSIONS

The optimal surgical timing of congenital duplication of thumb should be based on the appearance of thumb ossification center. The surgical timing of Wassel type- I and II should be chosen at 1. 5 years old when the ossification center of distal phalanx appears, Wassel type-III and IV should be chosen at 1 year old when the ossification center of proximal phalanx appears, Wassel type-V and VI should be chosen at 2. 5 years old when the ossification center of metacarpal appears, and Wassel type-VII should be chosen at 2. 5 years old. The surgical method should be selected on individualized principle. The key points are reconstruction of collateral ligament, tendon and articular capsule and correction of ulnar deviation (or radial deviation).