Epidemiological analysis of rare polydactylies

Extreme bilateral polydactyly in a wild-caught western grey kangaroo

Polydactyly is a congenital malformation resulting from an autosomal dominant mutation manifesting as supernumerary digits of the hands or feet. It is most commonly reported in humans and domestic mammals, though there have also been isolated examples across a range of wild vertebrate species. Here we report a case of extremely unusual bilateral preaxial polydactyly on the pectoral limbs of a male western grey kangaroo (Macropus fuliginosus) from the South West region of Western Australia, in which two supernumerary digits were present on each manus. A supernumerary digit I on each manus was rudimentary in morphology without extrinsic muscular connections. However, supernumerary digit II present on each manus had fully developed extrinsic and intrinsic muscular connections, suggesting that these digits possessed normal function in flexion and extension. An alternative hypothesis is that the two supernumerary digits are both representatives of the most radial digit I, though this would then require the true digit I to have taken on the appearance of digit II by acquiring an additional phalanx and modified muscular attachments. The carpal bones exhibited a number of subtle differences in morphology when compared to normal pentadactyl individuals. The presence of a distal, rather than proximal, epiphysis on the first metacarpal was unexpected but further investigation suggested that this characteristic is perhaps more variable (in this species at least) than has been previously recognized. This case provides an unusual example to be considered within the broader context of limb development.

Pregnancy and Neonatal Outcomes Following Prenatal Exposure to Dolutegravir

BACKGROUND

Birth outcome data with dolutegravir exposure during pregnancy, particularly in the first trimester, are needed.

SETTING

Data were prospectively collected from the Antiretroviral Pregnancy Registry and European Pregnancy and Paediatric HIV Cohort Collaboration.

METHODS

We reviewed 2 large, independent antiretroviral pregnancy registries to assess birth outcomes associated with maternal dolutegravir treatment during pregnancy.

RESULTS

Of 265 pregnancies reported to the Antiretroviral Pregnancy Registry, initial exposure to dolutegravir occurred at conception or first trimester in 173 pregnancies and during the second or third trimester in 92 pregnancies. There were 246 (92.8%) live births resulting in 255 neonates (9 twins), 6 (2.3%) induced abortions, 11 (4.2%) spontaneous abortions, and 2 (0.8%) stillbirths. Birth defects occurred in 7 (2.7%) of 255 live-born neonates, 5 (3.1%) of 162 (includes 6 twins) with conception/first-trimester exposure. Of 101 pregnancies reported to the European Pregnancy and Paediatric HIV Cohort Collaboration, outcomes were available for 84 pregnancies (16 continuing to term and 1 lost to follow-up). There were 81 live births (80 with known initial dolutegravir exposure at conception or first, second, and third trimesters in 42, 21, and 17 live births, respectively), 1 stillbirth (second-trimester exposure), 1 induced abortion (first-trimester exposure), and 1 spontaneous abortion (first-trimester exposure), respectively. Birth defects occurred in 4 live births (4.9%; 95% confidence interval: 1.4 to 12.2), 3 of 42 (7.1%) with exposure at conception or first trimester.

CONCLUSIONS

Our findings are reassuring regarding dolutegravir treatment of HIV infection during pregnancy but remain inconclusive because of small sample sizes.

Isolated postaxial polydactyly: Epidemiologic characteristics from a multicenter birth defects study

Isolated postaxial polydactyly (I-PAP), as a single defect, is a frequent malformation, characterized by an extra digit placed on the ulnar or fibular side of the limbs. Worldwide prevalence varies from as high as 225/10,000 in Nigerians to so low as 6.08/10,000 in Argentinians. Genetic-ethnic background significantly affects worldwide prevalence and type of I-PAP. Herein we describe the epidemiological characteristics of I-PAP in 697 newborns, 383 males and 314 females identified in 1,178,993 examined live births from a multicenter case-control hospital-based population study, the Mexican program of Registry and Epidemiological Surveillance of Congenital Malformations (RYVEMCE). The main characteristics analyzed included total I-PAP, stratified in Types A and B, defined as complete or incomplete extra-digit formation, respectively, sex prevalence, affected limb, laterality, parity, prematurity, delivery-type, twinning, consanguinity, and parental age. Males (6.35/10,000) are significantly more frequently affected than females (5.45/10,000), hands more than feet, left more than right limbs, and Type B (74.50%) more than A (25.50%). Prematurity and forceps use were significantly more frequent in cases than controls. An evident decreasing time-trend prevalence was present. Similar findings with other studies were males, upper and left limbs more frequently affected. Findings that were not previously reported include prematurity, forceps use, a significant decreasing time trend and an inverse ethnic prevalence for Types A (75%) and B (25%) in the Mayan population in contrast to other worldwide ethnic groups.

GLI3-related polydactyly: a review

GLI3 mutations are known to be associated with nine syndromes/conditions in which polydactyly is a feature. In this review, the embryology, pathogenesis, and animal models of GLI3-related polydactyly are discussed first. This is followed by a detailed review of the genotype-phenotype correlations. Based on our review of the literature and our clinical experiences, we recommend viewing GLI3-related syndromes/conditions as four separate entities; each characterized by a specific pattern of polydactyly. These four entities are: the preaxial polydactyly type IV-Greig-acrocallosal spectrum, postaxial polydactyly types A/B, Pallister-Hall syndrome (PHS), and oral-facial-digital overlap syndrome. We also provide illustrative clinical examples from our practice including a family with a novel GLI3 mutation causing PHS. The review also introduces the term 'Forme Fruste' preaxial polydactyly and gives several conclusions/recommendations including the recommendation to revise the current criteria for the clinical diagnosis of PHS.

Paleodysmorphology and paleoteratology: Diagnosing and interpreting congenital conditions of the skeleton in anthropological contexts

Most congenital conditions have low prevalence, but collectively they occur in a few percent of all live births. Congenital conditions are rarely encountered in anthropological studies, not least because many of them have no obvious effect on the skeleton. Here, we discuss two groups of congenital conditions that specifically affect the skeleton, either qualitatively or quantitatively. Skeletal dysplasias (osteochondrodysplasias) interfere with the histological formation, growth and maturation of skeletal tissues leading to diminished postural length, but the building plan of the body is unaffected. Well- known skeletal dysplasias represented in the archeological record include osteogenesis imperfecta and achondroplasia. Dysostoses, in contrast, interfere with the building plan of the body, leading to e.g. missing or extraskeletal elements, but the histology of the skeletal tissues is unaffected. Dysostoses can concern the extremities (e.g., oligodactyly and polydactyly), the vertebral column (e.g., homeotic and meristic anomalies), or the craniofacial region. Conditions pertaining to the cranial sutures, i.e., craniosynostoses, can be either skeletal dysplasias or dysostoses. Congenital conditions that are not harmful to the individual are known as anatomical variations, several of which have a high and population-specific prevalence that could potentially make them useful for determining ethnic origins. In individual cases, specific congenital conditions could be determinative in establishing identity, provided that ante-mortem registration of those conditions was ensured. Clin. Anat. 29:878-891, 2016. © 2016 The Authors Clinical Anatomy published by Wiley Periodicals, Inc. on behalf of American Association of Clinical Anatomists.

NOSOLOGY OF HAND DISEASES IN CHILDREN AND ADOLESCENTS OPERATED IN PROVISIONAL FACILITIES IN A MODEL HOSPITAL - PERNAMBUCO STATE, BRAZIL

To report the frequencies of congenital hand diseases in patients who underwent surgery on a collective mobilization basis at SOS Hand, Recife, Pernambuco, between 2005 and 2009. Methods: Information was collected from 833 children and adolescents who were examined in eight missions. Results: Among the patients, 306 (36.7%) underwent surgery: 240 (78.4%) because of congenital malformation and 66 (21.6%) because of acquired lesions. The most frequent congenital malformations were: syndactyly, 72 cases (30.0%); polydactyly, 30 cases (12.5%); bifid thumb, 19 cases (7.9%); complex hand malformation, 14 cases (5.8%); cleft hand, 13 cases (5.4%); trigger finger, 12 cases (5.0%); camptodactyly, 11 cases (4.6%); and brachysyndactyly, 9 cases (3.7%). The most frequently acquired injuries were: obstetric traumatic lesions, 26 cases (39.4%); hand trauma sequelae, 18 cases (27.3%); cerebral paralysis sequelae, 7 cases (10.6%); electric shock sequelae, 5 cases (7.6%); and burn sequelae, 4 cases (6.1%). Conclusion: The nosology of hand diseases is similar to that of large series of elective surgery, especially regarding congenital deformities. The frequency of acquired hand lesions seems to be higher than the frequency in international series. The collective mobilization system for hand surgery is important for decreasing the need for this activity in public institutions, and it has been shown to be very efficient. The success of the project may provide support for the Brazilian National Health System to enroll hand surgeons in the on-call system, in emergency units.

Towards the resolution of a long-standing evolutionary question: muscle identity and attachments are mainly related to topological position and not to primordium or homeotic identity of digits

Signaling for limb bone development usually precedes that for muscle development, such that cartilage is generally present before muscle formation. It remains obscure, however, if: (i) tetrapods share a general, predictable spatial correlation between bones and muscles; and, if that is the case, if (ii) such a correlation would reflect an obligatory association between the signaling involved in skeletal and muscle morphogenesis. We address these issues here by using the results of a multidisciplinary analysis of the appendicular muscles of all major tetrapod groups integrating dissections, muscle antibody stainings, regenerative and ontogenetic analyses of fluorescently-labeled (GFP) animals, and studies of non-pentadactyl human limbs related to birth defects. Our synthesis suggests that there is a consistent, surprising anatomical pattern in both normal and abnormal phenotypes, in which the identity and attachments of distal limb muscles are mainly related to the topological position, and not to the developmental primordium (anlage) or even the homeotic identity, of the digits to which they are attached. This synthesis is therefore a starting point towards the resolution of a centuries-old question raised by authors such as Owen about the specific associations between limb bones and muscles. This question has crucial implications for evolutionary and developmental biology, and for human medicine because non-pentadactyly is the most common birth defect in human limbs. In particular, this synthesis paves the way for future developmental experimental and mechanistic studies, which are needed to clarify the processes that may be involved in the elaboration of the anatomical patterns described here, and to specifically test the hypothesis that distal limb muscle identity/attachment is mainly related to digit topology.

Review of literature: genes related to postaxial polydactyly

BACKGROUND

Postaxial polydactyly (PAP) is one of the commonest congenital malformations and usually is associated to several syndromes. There is no primary investigational strategy for PAP cases with single gene disorder in literature. PAP cases with single gene disorder can be classified according to common pathways and molecular basis. Molecular classification may help in diagnostic approach.

MATERIALS AND METHODS

All single gene disorders associated with PAP reported on PubMed and OMIM are analyzed and classified according to molecular basis.

RESULTS

Majority of genes related to cilia structure and functions are associated with PAP, so we classified them as ciliopathies and non-ciliopathies groups. Genes related to Shh-Gli3 pathway was the commonest group in non-ciliopathies.

CONCLUSION

Genes related to cilia are most commonly related to PAP due to their indirect relationship to Shh-Gli3 signaling pathway. Initially, PAP may be the only clinical finding with ciliopathies so those cases need follow up. Proper diagnosis is helpful for management and genetic counseling. Molecular approach may help to define pleiotropy.

Polydactyly 24 in a female neonate

Polydactyly is perhaps one of the most common congenital hand and foot anomalies. Tetrapolydactyly (polydactyly 24) is a very rare form of hand and foot anomalies. Postaxial ray polydactyly usually occurs in male blacks without associated congenital abnormalities. We report a case of postaxial ray tetrapolydactyly in a female neonate which occurred sporadically and without associated congenital abnormalities.

Evolution of brains and behavior for optimal foraging: a tale of two predators

Star-nosed moles and tentacled snakes have exceptional mechanosensory systems that illustrate a number of general features of nervous system organization and evolution. Star-nosed moles use the star for active touch--rapidly scanning the environment with the nasal rays. The star has the densest concentration of mechanoreceptors described for any mammal, with a central tactile fovea magnified in anatomically visible neocortical modules. The somatosensory system parallels visual system organization, illustrating general features of high-resolution sensory representations. Star-nosed moles are the fastest mammalian foragers, able to identify and eat small prey in 120 ms. Optimal foraging theory suggests that the star evolved for profitably exploiting small invertebrates in a competitive wetland environment. The tentacled snake's facial appendages are superficially similar to the mole's nasal rays, but they have a very different function. These snakes are fully aquatic and use tentacles for passive detection of nearby fish. Trigeminal afferents respond to water movements and project tentacle information to the tectum in alignment with vision, illustrating a general theme for the integration of different sensory modalities. Tentacled snakes act as rare enemies, taking advantage of fish C-start escape responses by startling fish toward their strike--often aiming for the future location of escaping fish. By turning fish escapes to their advantage, snakes increase strike success and reduce handling time with head-first captures. The latter may, in turn, prevent snakes from becoming prey when feeding. Findings in these two unusual predators emphasize the importance of a multidisciplinary approach for understanding the evolution of brains and behavior.

Fetal polydactyly: a study of 24 cases ascertained by prenatal sonography

Records of 24 pregnancies with fetal polydactyly were reviewed for the type of polydactyly, family history, associated sonographic findings, genetic testing, and postnatal/postmortem examination findings. The importance of fetal polydactyly can be mainly elucidated by the family history and absent or associated anomalies on a specialized malformation scan. Fetal karyotyping diagnoses frequent chromosomal anomalies in about half of cases with additional malformations, and array comparative genomic hybridization may be a future means of detecting cryptic chromosomal aberrations. Syndromic disorders of monogenic origin demand a careful interdisciplinary clinical assessment for establishing a clinical diagnosis and prognosis for the outcome of the child.

Plastic repair for a case with synpolydactyly

On March 23, 2010, we successfully treated a boy with synpolydactyly who had a total of 31 fingers and toes. Although there was bone syndactyly both the hands of the boy, one-step correction of four extremities was successful, this operation lasted 5 h and 20 min and intraoperative bleeding was about 50 ml. Skin grafting was successful after operation and all incisions healed well. The appearance and function of hands and feet were satisfactory.

Sporadic familial ulnar hexadactyly of all four limbs

BACKGROUND

Polydactyly belongs to skeletal anomalies and may be a symptom of more complex genetic syndromes.

MAIN OBSERVATION

We observed an index case of ulnar hexadactyly of all four limbs in a 20-year-old man from India with three more brothers affected in his family. No additional anomalies were observed. The diagnosis of a sporadic (ulnar) postaxial hexadactyly was made.

CONCLUSION

Sporadic postaxial hexadactyly is one of the most common polydactylies in humans. In contrast, in the dermatologic literature the condition has only rarely been described.

CONCLUSION

Presence of supernummary digits or toes, i.e. polydactyly, is seen occasionally in the dermatologic practise. The present case is extraordinary since all limbs were involved and the same was true for three of his brothers. If treatment is asked, hand surgery would be necessary.

Why did the savant syndrome not spread in the population? A psychiatric example of a developmental constraint

A developmental constraint is a mechanism that limits the possibility of a phenotype to evolve. There is growing evidence for the existence of developmental constraints in the biological literature. We hypothesize that a developmental constraint prevents the savant syndrome, despite its positive aspects, from spreading in the population. Here, the developmental constraint is the result of the high interactivity among body parts in an early stage in embryological development, namely early organogenesis or the phylotypic stage. The interactivity during this stage involves all components of the embryo, and as a result mutations that affect one part of the embryo also affect other parts. We hypothesize that a mutation, which gives rise to the development of the positive aspects of the savant syndrome (e.g., an impressive memory capacity), will virtually always have a deleterious effect on the development of other phenotypic traits (e.g., resulting in autism and/or impaired motor coordination). Thus, our hypothesis states that the savant syndrome cannot spread in the population because of this developmental constraint. The finding that children with savant syndrome often have autism and physical anomalies, which are known to be established during early organogenesis, supports our hypothesis.

Laurin-Sandrow syndrome: review and redefinition

We report on a newborn infant with characteristics of Laurin-Sandrow syndrome (LSS). She had hypertelorism, flat nose with grooved collumella, "V" shaped mouth with thin lips, 7 well-recognized and fused digits and 1 additional postaxial bilateral appendix on each hand. The right and left feet had 12 and 11 toes, respectively, the 4 external ones were recognizable, and the rest were fused in a uniform mass but with independent nails. There was also a 2.3 cm-long digitiform appendix in the internal part of both feet. Radiographs showed seven metacarpals and seven metatarsals with similar morphology; both hands lacking thumbs. The four lateral-most toes had regular shaped phalanges and the rest were irregular. The left digitiform appendix had three bones and the right only two. Tibiae were shorter than fibulae. Central Nervous System examination showed an abnormally shaped olivary nucleus, cerebellar cortical heterotopias, gray matter ectopias in both spinal cord and hemispheric white matter, marked ventricular dilatation, and moderate diffuse white matter gliosis. Karyotype was 46XX. A complete necropsy study is presented and all reported cases are reviewed focusing on their phenotypic differences and their nosologic classification. We propose the entity LSS only in cases with symmetric tetrameric polysyndactyly, especially cup-shaped hands and mirror feet, in association with nasal anomalies.

An eight-toed foot: a rare pedal polydactyly

Polydactyly is a fairly common congenital condition of the foot and is characterized literally by supernumerary toes (digit or metatarsal). The frequency of polydactyly varies widely among populations. It may be an isolated condition or part of a congenital syndrome. Eight-toed polydactyly is a distinctly rare congenital foot anomaly. In this report, an 18-month-old child with pre-axial 8-toed right foot had been treated with excision of the excess rays with muscular, tendentious, and ligamentous reconstructions. The patient had presented a good postoperative result. Through monthly follow-up visits for 1 year, the parents expressed excellent cosmesis, shoe fit, and walking function.

Hypoplastic synpolydactyly as a new clinical subgroup of synpolydactyly

A large kindred which was first described in 1995 was investigated again. We present the clinical, radiological, genetic and surgical findings of the hand deformities found in homozygote individuals which we called "hypoplastic synpolydactyly". There were 125 affected (heterozygote or homozygote) people out of 245 subjects in the five last generations. We identified seven marriages of two affected people. Twelve offsprings, of these marriages had a homozygote genetic pattern and "hypoplastic synpolydactyly". From both the clinical and surgical perspectives, their hand deformity was distinctive from that of their parents. We surgically treated both hands of three individuals with this deformity. The hand deformity of these homozygotes was so complicated and distinctive that it can be evaluated as a new subgroup of synpolydactyly.

[Complex polydactyly of the limbs: mirror foot. Report of two cases and review of literature]

Polydactyly is the most common congenital limb anomaly occurring both as an isolated defect or as part of a syndrome. However mirror foot is an exceptional abnormality (14 cases reported). The authors describe two sporadic cases of mirror foot. The first case presents a mirror polydactyly of the left foot, an hexadactyly of the right foot and a central polysyndactyly of both hands. The second case presents a mirror polydactyly of both feet. Mirror foot is a very rare defect. Both sporadic and familiar cases have been reported. This malformation can affect one or both feet. Some cases are associated with other congenital anomalies. The definition of mirror foot is warying according to the authors and the review of literature shows an important variability in the patterns of mirror polydactyly. Mirror duplication of hands and feet result of aberrant positioning of the zone of polarizing activity in relation to the apical ectodermal ridge during limb bud development. Different genes encoding limb pattern have been described.

The chick oligozeugodactyly (ozd) mutant lacks sonic hedgehog function in the limb

We have analyzed a new limb mutant in the chicken that we name oligozeugodactyly (ozd). The limbs of this mutant have a longitudinal postaxial defect, lacking the posterior element in the zeugopod (ulna/fibula) and all digits except digit 1 in the leg. Classical recombination experiments show that the limb mesoderm is the defective tissue layer in ozd limb buds. Molecular analysis revealed that the ozd limbs develop in the absence of Shh expression, while all other organs express Shh and develop normally. Neither Ptc1 nor Gli1 are detectable in mutant limb buds. However, Bmp2 and dHAND are expressed in the posterior wing and leg bud mesoderm, although at lower levels than in normal embryos. Activation of Hoxd11-13 occurs normally in ozd limbs but progressively declines with time. Phase III of expression is more affected than phase II, and expression is more severely affected in the more 5' genes. Interestingly, re-expression of Hoxd13 occurs at late stages in the distal mesoderm of ozd leg buds, correlating with formation of digit 1. Fgf8 and Fgf4 expression are initiated normally in the mutant AER but their expression is progressively downregulated in the anterior AER. Recombinant Shh protein or ZPA grafts restore normal pattern to ozd limbs; however, retinoic acid fails to induce Shh in ozd limb mesoderm. We conclude that Shh function is required for limb development distal to the elbow/knee joints, similar to the Shh(-/-) mouse. Accordingly we classify the limb skeletal elements as Shh dependent or independent, with the ulna/fibula and digits other than digit 1 in the leg being Shh dependent. Finally we propose that the ozd mutation is most likely a defect in a regulatory element that controls limb-specific expression of Shh.

Shh and Gli3 are dispensable for limb skeleton formation but regulate digit number and identity

Most current models propose Sonic hedgehog (Shh) as the primary determinant of anteroposterior development of amniote limbs. Shh protein is said to be required to direct the formation of skeletal elements and to specify digit identity through dose-dependent activation of target gene expression. However, the identity of genes targeted by Shh, and the regulatory mechanisms controlling their expression, remain poorly understood. Gli3 (the gene implicated in human Greig cephalopolysyndactyly syndrome) is proposed to negatively regulate Shh by restricting its expression and influence to the posterior mesoderm. Here we report genetic analyses in mice showing that Shh and Gli3 are dispensable for formation of limb skeletal elements: Shh(-/-) Gli3(-/-) limbs are distally complete and polydactylous, but completely lack wild-type digit identities. We show that the effects of Shh signalling on skeletal patterning and ridge maintenance are necessarily mediated through Gli3. We propose that the function of Shh and Gli3 in limb skeletal patterning is limited to refining autopodial morphology, imposing pentadactyl constraint on the limb's polydactyl potential, and organizing digit identity specification, by regulating the relative balance of Gli3 transcriptional activator and repressor activities.

Mirror foot

Mirror image polydactyly is a rare congenital abnormality that may occur in isolation, or in association with multiple congenital anomalies. A case of unilateral mirror foot with an ipsilateral short, broad tibia is described. The clinical, radiologic, and operative findings are presented, and current theories of embryo-pathogenesis are reviewed.

The development of a biological novelty: a different way to make appendages as revealed in the snout of the star-nosed mole Condylura cristata

The nose of the star-nosed mole Condylura cristata is a complex biological novelty consisting of 22 epidermal appendages. How did this new set of facial appendages arise? Recent studies find remarkable conservation of the genes expressed during appendage formation across phyla, suggesting that the basic mechanisms for appendage development are ancient. In the nose of these moles, however, we find a unique pattern of appendage morphogenesis, showing that evolution is capable of constructing appendages in different ways. During development, the nasal appendages of the mole begin as a series of waves in the epidermis. A second deep layer of epidermis then grows under these superficial epidermal waves to produce 22 separate, elongated epidermal cylinders embedded in the side of the mole's face. The caudal end of each cylinder later erupts from the face and rotates forward to project rostrally, remaining attached only at the tip of the snout. As a result of this unique ‘unfolding’ formation, the rostral end of each adult appendage is derived from caudal embryonic facial tissue, while the caudal end of each appendage is derived from rostral facial tissue. This developmental process has essentially no outgrowth phase and results in the reversal of the original embryonic orientation of each appendage. This differs from the development of other known appendages, which originate either as outgrowths of the body wall or from subdivisions of outgrowths (e.g. tetrapod digits). Adults of a different mole species (Scapanus townsendii) exhibit a star-like pattern that resembles an embryonic stage of the star-nosed mole, suggesting that the development of the star recapitulates stages of its evolution.

Complex camptopolydactyly: an unusual hand malformation

Different types of polydactylies and other hand malformations are commonly seen. Here, we describe a very unusual type of hand malformation characterised by campto-polydactyly with totally disorganised configuration of digits. The role of possible genes involved in development of hands and digits is discussed.

Associated anomalies in individuals with polydactyly

An epidemiological analysis of the association of polydactyly with other congenital anomalies was performed in 5,927 consecutively born polydactyly cases. They were grouped into three categories: duplicated fifth digit, duplicated first digit, and rare polydactylies; also into isolated or associated groups, if other birth defects were or were not observed in the same infant. Associated cases were further subdivided into: combined, if the other defect was a limb defect; syndromic, if a non-limb defect constituted a recognized causal or pathogenetic entity; and MCA, if a non-limb defect did not constitute a recognized entity. In 14.6% of the 5,927 polydactyly cases studied, polydactyly was not the only congenital anomaly. This associated proportion was minimal for postaxial (11.8%), intermediate for preaxial-I (20.0%), and maximal for rare polydactyly (54.9%). Duplication of the fifth toe plus syndactyly of fourth and fifth toes, as well as other syndactylies adjacent to the duplicated digit is the most frequent type. Syndactyly of fourth and fifth toes was also combined with a duplicated fifth finger, suggesting the existence of an arrested or amputated in utero sixth toe. Polydactylies are rarely associated with other congenital anomalies except in recognizable syndromes. When syndromes are excluded, most of the significant positive associations disappear. Trisomy 13, Meckel, and Down syndrome explained 255 of the 338 syndromic polydactyly cases. Down syndrome is strongly associated with first-digit duplication, and negatively associated with postaxial polydactyly. The latter could not be explained by maternal age differences among Black and non-Black case sub-sets.

Lack of evidence of a major gene acting on postaxial polydactyly in South America

Data on polydactyly were obtained from two large samples: the Latin American Collaborative Study of Congenital Malformations (ECLAMC), and from a migrant Northeastern Brazilian population of rural origin (Hospedaria). ECLAMC is a case-control clinical epidemiological program comprising 10,035 individuals distributed among 2,030 segregating nuclear families. Hospedaria data consisted of 6,586 examined individuals belonging to 1,040 nuclear families. Using complex segregation analysis methodology we found no evidence of two loci (a major gene and a modifier locus) acting on postaxial polydactyly in the present study. Very high heritability values (in a classical multifactorial model) of postaxial polydactyly were detected, for several sets of analyses in ECLAMC and in Hospedaria. For the whole ECLAMC sample there is a peculiar suggestion of a major recessive gene effect responsible for the trait; however, no comparison with a model involving transmission probabilities (tau) was possible in this highly heterogeneous sample. If the whole ECLAMC sample is divided in subsamples, according to Black admixture proportions, the same multifactorial picture emerges. Two different inheritance patterns were verified for hand (HP) and foot (FP) postaxial polydactyly: For HP there is evidence of a non-Mendelian transmission mechanism, while for FP the parental/sib transmission appears to be due only to multifactorial causes.

Hand and foot postaxial polydactyly: two different traits

The aim of this work was to test whether postaxial hexadactyly had different clinical and epidemiological characteristics depending on hand or foot involvement. In the period 1967-1993, the Latin-American Collaborative Study of Congenital Malformations (ECLAMC) enrolled 1,582,289 births, and 2,271 cases with isolated (nonsyndromal) postaxial polydactyly (5th-digit hexadactyly). The prevalence was 14.3/10,000 births. Postaxial polydactyly (PP) of the hand (HPP) was the most frequent type (N:1,733; 76.3%; prevalence: 11.0/10,000), followed by foot PP (FPP=N:351; 15.5%; prevalence: 2.2), and hand and foot PP (BPP=N:187; 8.2%; prevalence: 1.2). Unlike HPP (55.0% bilateral; 77.2% left), FPP was less frequently bilateral (19.4%), with lower preference for the left side (55.5%). As expected, HPP was associated with African Black ethnicity, male sex, twinning, low maternal education, parental consanguinity, and there was frequent recurrence in 1st-degree relatives. Conversely, FPP was associated with Amerindian racial background, parental subfertility, and bleeding in the 1st trimester of pregnancy. BPP displayed the highest frequency of associated congenital defects (23.4%, vs HPP:6.6%, FPP: 15.4%). In its isolated form, BPP resembled HPP more than FPP with respect to left preference (90.9%), familial recurrence (11.0% of 1st degree relatives), and low maternal education. Although male sex preference and high frequency of twinning was observed in the 3 PP subtypes, statistical significance was present only in HPP. None of the 3 PP subtypes showed abnormal values for perinatal mortality, birth weight, length of gestation, parental ages, or parity. A logistic regression analysis showed Black race only to be associated with HPP, parental subfertility with FPP, parental consanguinity with BPP, and non-Black race with both FPP and BPP. The data presented here are the first indication that HPP and FPP are 2 different entities, with a larger genetic component in HPP than in FPP.