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Doucet O, Njessi P, Jaloux C, Bougie E. Secondary complications in Wassel II & IV thumb duplication: a comprehensive review of preventive measures. HAND SURGERY & REHABILITATION 2024; 43:101642. [PMID: 38215882 DOI: 10.1016/j.hansur.2024.101642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/04/2024] [Accepted: 01/05/2024] [Indexed: 01/14/2024]
Abstract
OBJECTIVES Thumb duplication is one of the most challenging pediatric reconstructive hand surgeries. Wassel types II and IV are the most frequent, but also the most complex reconstructions as the duplication arises at the joint level. Ablation and reconstruction, the most widely used technique, aims at achieving a stable, well-aligned, mobile and esthetically acceptable thumb. The paucity of reliable surgical guidelines leads to high rates of suboptimal surgical outcomes. This review evaluated the various reconstruction techniques detailed in the literature and highlighted useful methods to prevent common secondary complications. METHODS A comprehensive PubMed and Embase literature search was made. Inclusion criteria were Wassel type II and/or IV, pediatric patients, and primary or secondary surgeries. Exclusion criteria were Bilhaut-Cloquet reconstruction and its modifications. Techniques were screened, collected and analyzed for the following secondary complications: instability, axial deformity, and contour deformity. RESULTS Thirty-two articles met the inclusion criteria and were reviewed. Postoperative instability was prevented by tightening the joint capsule by plication, advancement of the volar plate, or reconstruction of the collateral ligaments using a periosteal flap or the double-breasting technique. Axial deformity was prevented by arthroplasty, shaving a triangular portion of the metacarpal head, centralization of eccentric tendons, pulley reconstruction using flexor pollicis longus, or corrective osteotomies of the phalangeal or metacarpal bones using the wedge or oblique techniques. Limited range of motion was prevented by first webspace Z-plasty, and soft-tissue contouring was addressed by planned skin incisions and soft-tissue augmentation. Preoperative, perioperative and postoperative considerations, including splinting, imaging and immobilization, were also described. CONCLUSION Despite the ongoing advances and abundant knowledge in reconstructive strategies for thumb duplication, there are few studies that reviewed and analyzed the various reported options. This review provides physicians and trainees with guidance in surgical planning to prevent common secondary complications. Further research should focus on the development of standardized assessment tools, enabling reliable prospective comparative studies on thumb duplication reconstruction. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Ophélie Doucet
- Division of Plastic and Reconstructive Surgery, University of Montreal, Montreal, QC, Canada
| | - Pharel Njessi
- Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Charlotte Jaloux
- Department of Hand Surgery and Reconstructive Surgery of the Limbs, La Timone University Hospital, Marseille, France; Institute of Neurophysiopathology, Marseille, France
| | - Emilie Bougie
- Division of Plastic and Reconstructive Surgery, University of Montreal, Montreal, QC, Canada; Division of Plastic and Reconstructive Surgery, CHU Sainte-Justine, Montreal, QC, Canada.
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Yin C, Liu W, Yu W, Wei S, Yu A, Jiang Y, Shen X. On-top plasty combined with modified Bilhaut-Cloquet procedure for reconstructing complicated radial polydactyly. J Plast Reconstr Aesthet Surg 2023; 86:315-320. [PMID: 37797379 DOI: 10.1016/j.bjps.2023.09.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 09/06/2023] [Accepted: 09/12/2023] [Indexed: 10/07/2023]
Abstract
PURPOSE To present a surgical technique of combining the on-top plasty with modified Bilhaut-Cloquet procedure for reconstructing a rare type of complicated radial polydactyly and evaluate the outcomes. METHODS Fourteen complicated radial polydactyly in 13 patients were corrected by combining the on-top plasty with modified Bilhaut-Cloquet procedure. Osteotomies were performed as required, and the acral part of the ulnar thumb was transposed onto the proximal part of the radial thumb. The distal parts of the two thumbs were isolated as neurovascular pedicled composite tissue flaps, including part of the distal phalanx and nail bed, and were attached together in an extra-articular way. The tendons were rebalanced, and the nail bed was reconstructed. Objective and subjective outcomes were assessed. RESULTS The average follow-up time was 32.4 months (6-60 months). All reconstructed thumbs were rated as good in appearance and function. The mean Vancouver Scar Scale score was 1.3 (range 1-2) and the mean Wang-Gao score of the reconstructed thumbnail was 9.4 (range 8-11). The Tada score for the function of the reconstructed thumb was 5.5 (range 5-6). The main active range of motion (ROM) of the interphalangeal joint (IPJ) was 2.1-38.9°. All parents were satisfied with the outcomes. CONCLUSIONS Because of the diverse manifestations of thumb polydactyly, individualized surgical treatment is recommended, and careful preoperative planning should be made with the principle of combining the best parts of the two thumbs. By combining an on-top plasty with modified Bilhaut-Cloquet procedure, a satisfactory result can be achieved for treating complicated radial polydactyly.
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Affiliation(s)
- Chunhua Yin
- Department of Pediatric Orthopaedics, Children's Hospital of Soochow University, Suzhou, Jiangsu, China.
| | - Wei Liu
- Department of Pediatric Orthopaedics, Children's Hospital of Soochow University, Suzhou, Jiangsu, China.
| | - Wentao Yu
- Department of Pediatric Orthopaedics, Children's Hospital of Soochow University, Suzhou, Jiangsu, China.
| | - Song Wei
- Department of Pediatric Orthopaedics, Children's Hospital of Soochow University, Suzhou, Jiangsu, China.
| | - Aiping Yu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
| | - Yongkang Jiang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
| | - Xiaofang Shen
- Department of Pediatric Orthopaedics, Children's Hospital of Soochow University, Suzhou, Jiangsu, China.
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Du Z, Cui Y, Jiang H, Han D. Aesthetic outcomes of and anatomic reconstruction for Wassel type IV-D radial polydactyly using a modified Bilhaut-Cloquet procedure. Front Pediatr 2023; 11:1192168. [PMID: 37484763 PMCID: PMC10360172 DOI: 10.3389/fped.2023.1192168] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/26/2023] [Indexed: 07/25/2023] Open
Abstract
Wassel type IV-D thumb duplication is the most complex form and anatomic reconstruction is difficult. The aim of this study was to create an aesthetically satisfactory anatomical reconstruction for Wassel type IV-D radial polydactyly thumbs using the modified Bilhaut-Cloquet procedure. Surgery was performed on 24 thumbs with Wassel type IV-D radial polydactyly. To align the joint surfaces, the proximal phalanxes were unequally joined, primarily on the ulnar, and the distal phalanx was either symmetrically joined or unequally joined via curvature osteotomy. The patients were followed up for 12-91 months. The interphalangeal joint remained stable in all cases. The average functional score was 13.5 points (maximum 14 points). The overall average cosmetic score was 3.3 (maximum 4 points). Our modification of the Bihaut-Cloquet procedure produced good functional results for patients with Wassel type IV-D radial polydactyly. This method is used to correct the alignment and to stabilize the interphalangeal joint in both hypoplastic thumbs.
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Affiliation(s)
- Zijing Du
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Cui
- Department of Hand Surgery, Jinshan Hospital of Fudan University, Shanghai, China
| | - Hao Jiang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dong Han
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Thumb and first webspace reconstruction in nonsyndromic congenital mitten hand with symbrachydactyly. J Plast Reconstr Aesthet Surg 2022; 75:1902-1906. [PMID: 34972652 DOI: 10.1016/j.bjps.2021.11.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 11/11/2021] [Accepted: 11/22/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Nonsyndromic congenital mitten hand with thumb and index finger syndactyly is rare. Reconstruction of this condition is challenging, requiring repositioning of the thumb and creation of a wide and deep first webspace. The aim of this paper is to describe the characteristics of patients with this condition and also to describe our surgical technique. METHODS We describe our technique in 16 consecutive children utilizing complete mobilization of the first metacarpal and thumb as an island flap on the neurovascular bundle, with a rotational osteotomy to reposition the thumb in pronation. In addition, a dorsal M flap was used to reconstruct the first webspace. Patients in this series also had varying degrees of symbrachydactyly with hypoplastic or aplastic phalanges of the central digits. RESULTS There were 9 male and 7 female patients, with a mean age of 24.4 ± 22.4 months at the time of surgery. Mean follow-up was 19.1 ± 18.3 months. All reconstructions healed well. The mean thumb web distance in the affected hands was 4.2 cm (range 3.5 to 5). All reconstructed thumbs had a good opposition. Two children initially had mild hypertrophic scarring, which resolved with pressure gloves. No other complications were observed. CONCLUSION One-stage reconstruction of the thumb and first webspace can be effectively achieved with our technique of complete mobilization of the thumb unit, rotational osteotomy, and a dorsal interdigitating M flap.
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任 洪, 杨 勇, 钟 文, 赵 占. [Soft tissue balance technique by flexor pollicis longus tendon transfer for Wassel Ⅳ-D thumb duplication in children]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:395-399. [PMID: 35426275 PMCID: PMC9011073 DOI: 10.7507/1002-1892.202110058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 01/24/2023]
Abstract
Objective To investigate the effectiveness of soft tissue balance technique by flexor pollicis longus (FPL) tendon transfer for Wassel Ⅳ-D thumb duplication in children. Methods A clinical data of 14 children with Wassel Ⅳ-D thumb duplication met the selection criteria between January 2017 and January 2021 was retrospectively analyzed. There were 5 boys and 9 girls with an average age of 21.6 months (range, 18-35 months). Ten cases were left hand deformity and 4 cases were right hand deformity. During operation, the radial thumb was excised, and the FPL tendon of the radial thumb was used to reconstruct the soft tissue balance of the ulnar thumb. Postoperative evaluation included the range of motion (ROM) of passive flexion and extension of the interphalangeal joint (IP) and metacarpophalangeal joint (MCP), the alignments of the IP and MCP, the percentage of the width of the nail plate and the circumference of the thumb at the level of the IP to contralateral thumb. Results All operations were completed successfully, and all incisions healed by first intention. The children were followed up 12-36 months (mean, 21.7 months). At last follow-up, the ROM of passive flexion and the deviation of the IP, and the deviation of the MCP significantly improved when compared with those before operation (P<0.05); the ROM of passive extension of the IP and the ROM of passive flexion of the MCP did not significantly improve when compared with those before operation (P>0.05). The ROMs of passive extension of the MCP were 0° before and after operation. The width of the nail plate was 76.6%±4.1% of the unaffected side, and the circumference of the thumb at the level of the IP was 92.0%±9.1% of the unaffected side. Conclusion The soft tissue balance technique by FPL tendon trasfer can effectively correct the alignment of the Wassel Ⅳ-D thumb duplication in children, and maintain the correction effect effectively, but further follow-up and comprehensive evaluation are needed to investigate the long-term effectiveness.
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Affiliation(s)
- 洪军 任
- 北京水利医院手外科(北京 100036)Department of Hand Surgery, Beijing Shuili Hospital, Beijing, 100036, P. R. China
| | - 勇 杨
- 北京水利医院手外科(北京 100036)Department of Hand Surgery, Beijing Shuili Hospital, Beijing, 100036, P. R. China
| | - 文耀 钟
- 北京水利医院手外科(北京 100036)Department of Hand Surgery, Beijing Shuili Hospital, Beijing, 100036, P. R. China
| | - 占卫 赵
- 北京水利医院手外科(北京 100036)Department of Hand Surgery, Beijing Shuili Hospital, Beijing, 100036, P. R. China
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Feng SM, Zhao JJ, Migliorini F, Maffulli N, Xu W. First dorsal metacarpal artery flap with dorsal digital nerve with or without dorsal branch of the proper digital nerve produces comparable short-term sensory outcomes. J Orthop Surg Res 2021; 16:685. [PMID: 34794478 PMCID: PMC8600886 DOI: 10.1186/s13018-021-02838-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/10/2021] [Indexed: 12/11/2022] Open
Abstract
Background The first dorsal metacarpal artery flap, including dorsal digital nerves with or without dorsal branches of the proper digital nerves, can be used to reconstruct thumb pulp defects with good results. However, it is still unclear whether there are differences in the sensory outcomes between preserving or not preserving the dorsal branches of the proper digital nerves. Methods This retrospective cohort study included 137 thumb pulp defect patients who underwent first dorsal metacarpal artery flap reconstruction procedure from October 2015 to June 2019. Patients were divided into two groups according to whether the dorsal branches of the proper digital nerves were preserved. In the non-preservation group (n = 80), the dorsal digital nerves were included in the flap for sensory reconstruction. In the preservation group (n = 57), the dorsal digital nerves and the dorsal branches of the proper digital nerves of the index finger were included in the flap. The stump of the proper digital nerves in the defect was coaptated to the donor nerves of the flap using the end-to-end fashion. At the last follow-up, static two-point discrimination, Semmes–Weinstein monofilament scores, pain, cold intolerance of the reconstructed finger, and patient satisfaction in both groups were compared. Results All patients were followed up for at least 17 months. No significant differences were found regarding pain of thumb pulp, static two-point discrimination, Semmes–Weinstein monofilament score, cold intolerance in the injured finger, and patient satisfaction. The non-preservation group presented slightly shorter operative times (p < 0.05). Conclusion There are no differences at 2 years in postoperative clinical outcomes when dorsal digital nerves are used to reconstruct flap sensation regardless of preservation of the dorsal branches of the proper digital nerves in the first dorsal metacarpal artery flap. Level of evidence: Level III, retrospective comparative study.
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Affiliation(s)
- Shi-Ming Feng
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, No. 1055, the Sanxiang Road, Suzhou, 215004, Jiangsu, People's Republic of China.,Department of Orthopaedics, Xuzhou Central Hospital, Xuzhou Clinical College of Xuzhou Medical University, Xuzhou, 221009, Jiangsu, People's Republic of China
| | - Jia-Ju Zhao
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, No. 1055, the Sanxiang Road, Suzhou, 215004, Jiangsu, People's Republic of China
| | - Filippo Migliorini
- Department of Orthopaedics, Trauma, and Reconstructive Surgery, RWTH University Hospital Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Salerno, Italy.,Guy Hilton Research Centre, School of Pharmacy and Bioengineering, Keele University, Stoke-on-Trent, Staffordshire, ST4 7QB, England.,Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England
| | - Wei Xu
- Department of Orthopaedics, The Second Affiliated Hospital of Soochow University, No. 1055, the Sanxiang Road, Suzhou, 215004, Jiangsu, People's Republic of China.
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