A Matched Comparative Study of the Bilhaut Procedure Versus Resection and Reconstruction for Treatment of Radial Polydactyly Types II and IV

Classification of radial polydactyly based on physical characteristics

BACKGROUND

Previous classifications in polydactyly of the thumb were by the level of duplication on radiography. This study aimed to develop a practical algorithm based on physical characteristics for treatment guidelines.

METHODS

The polydactylies were stratified using four physical characteristics: floating, symmetry, dominant side, and joint angulation/nail size. The algorithm identified the hypoplastic type and then stratified the polydactylies as symmetric and asymmetric. The asymmetric type was divided into ulnar dominant and radial dominant. The symmetric type was divided into adequate type and inadequate type. The prediction of treatments was studied retrospectively by the distribution of surgical procedures in 500 patients with 545 affected thumbs, by the new classification and the Wassel-Flatt classification.

RESULTS

Of the 545 polydactylies, 78 (14.5%) were categorized as the hypoplastic type, 369 (67.5%) as the ulnar-dominant type, 8 (1.5%) as the radial-dominant type, 70 (12.8%) as the symmetric adequate nail type, and 20 (3.7%) as the symmetric inadequate type. Treatments were excision and reconstruction in 403 polydactylies (73.9%), simple excision in 135 polydactylies (24.8%), and the Bilhaut-Cloquet procedure, ray amputation, and on-top plasty procedures were only performed in 7 polydactylies (1.3%). The distribution of surgical procedures was distinct among the new classification types and was similar among the Wassel-Flatt types.

CONCLUSIONS

The new classification stratified polydactylies by physical findings in a stepwise manner. Though surgical technical details are not included, this simple classification is useful for paediatricians and parents to understand how a surgical decision is made.

LEVEL OF EVIDENCE

Diagnostic Level 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.

Reporting of scar outcomes in the hand and wrist; a state-of-the-art literature review

OBJECTIVES

The aim of this literature review was to synthesise and report current practice in evaluation and reporting of scar outcomes in hand and wrist clinical research.

METHODS

A systematic search from inception to 2022 was conducted using three electronic databases. English language randomized controlled trials and observational cohort studies reporting standardised scar outcome measures and/or scar symptoms, appearance, impairment, function, or mental health outcomes in patients with hand and wrist scars were included. Two independent reviewers determined study eligibility and performed data extraction of a priori identified scar outcome domains. Data analysis included descriptive statistics and identification of discordance in taxonomy.

RESULTS

Fifty-nine studies were included. Elective surgery cohorts were the most frequently included clinical population (n = 28; 47%) followed by burns (n = 16; 27%). Six different standardised scar outcome measures were reported by 25% of studies however only 7% of studies utilised a patient-reported measure. Scar symptoms were the most frequently reported outcome domain (81%); but taxonomy was incongruous, constructs lacked working definitions required for generalisability and outcome measurement was variable and unreported. Nineteen different measures of scar appearance and structure were reported by 30 (51%) of studies however only nine (23%) were patient-reported. Seven different hand function PROMs were reported by 25 (43%) studies. Person-centred domains including scar acceptability (12%), mental health impact (5%), and social participation (4%) were rarely reported.

CONCLUSIONS

This review highlights that evaluation and reporting of hand and wrist scar outcomes is not standardised, assessment methods and measures are under-reported and there is discordance in taxonomy. Evaluation is not person-centred, rather it is dependent on clinician assessment. Domains including scar acceptability, mental health, and social participation are rarely addressed. A stakeholder consensus derived hand and wrist scar core outcome measurement set will promote standardisation and underpin improvements in clinical research quality, transparency, and rigour.

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.

Resection and reconstruction for radial polydactyly Type IV-D in 206 cases: a retrospective clinical analysis

Background

Radial Polydactyly Type IV-D deformity is difficult to treat because of the most complex bone and soft tissue anomalies. Resection and reconstruction for one of the two thumbs was an option for treatment.

Objective

The study was to present our method of resection and reconstruction with a new incision for radial polydactyly Type IV-D and evaluate the clinical efficacy comprehensively using Rotterdam assessment system in a large sample.

Methods

206 cases of type IV-D thumb duplication underwent resection and reconstruction surgical treatment between 2010 and 2019. Two equal triangle flap incisions were designed around the radial thumb. The radial thumb was resected and the ulnar thumb was reconstructed in aspects of bone, tendons, ligaments and abductor pollicis brevis.

The clinical results were evaluated using Rotterdam assessment system.

Results

The mean follow–up period was 2.2 years (SD 1.5). The mean age of the patients was 9 months (SD 1.8) at the time of operation. The mean ranges of active IP and MP joint flexion and extension were 110° and 26°. The mean angulations for IP and MP joint instabilities were 3° and 11°, relatively. Angulation for palmar abduction was 58°. The mean appearance domain score was 8.9. The average parental satisfaction score was 2.5 and the average patient-reported pain score was 2.1. The mean functional domain score for all patients was 6.6. The average appearance domain score was 8.9. The mean patient-reported domain score was 4.5. The mean Rotterdam outcome score was 20.0, equivalent to 67% of the full score. The postoperative score of patients over two years old was significantly lower than that of patients under two years old.

Conclusion

Resection and reconstruction method with two equal triangle flap incisions was a recommended treatment for radial polydactyly Type IV-D.

Level of evidence

IV

Polydactyly of the thumb: a modification of the Wassel-Flatt classification

Although the Wassel-Flatt classification system has been widely used for radial polydactyly, it has some limitations. We modified the classification system by introducing the hypoplastic types and refining the definition of triphalangeal thumb without changing the main structure of the original classification system. A total of 200 consecutive duplicated thumbs of 183 patients treated surgically from June 2016 to June 2018 were included. We evaluated intra-observer and inter-observer reliability using the kappa coefficient in the modified and original Wassel-Flatt classification systems (three examiners evaluated each case twice, with an interval of 4 weeks). We also evaluated the surgical methods according to the types of deformity in the modified and original Wassel-Flatt classification systems. The modified Wassel-Flatt classification system had good inter-observer reliability and provides useful information for determining the surgical plan according to the types of radial polydactyly.Level of evidence: IV.

What's New in Congenital Hand Surgery

BACKGROUND

Congenital conditions of the hand and upper extremity are a frequent source of consultation among pediatric orthopaedists and hand surgeons. Advances in the fields of molecular biology and genetics have helped to better understand some of these conditions and redefine previous classification systems. New outcome measurement tools have been used to assess surgical results and have brought into focus a different aspect of the patients' experience.

METHODS

We searched PubMed database for papers related to the treatment of congenital hand anomalies published from January 1, 2015 to October 31, 2018. The search was limited to English articles yielding 207 papers. Three pediatric hand surgeons selected the articles based upon the criteria that the topic was germane, the article fell under the subheadings within the manuscript, and the conclusions were meaningful.

RESULTS

A total of 40 papers were selected for review, based upon their quality and new findings. Research articles with significant findings were included for syndactyly, symbrachydactyly, cleft hand, polydactyly, radial longitudinal deficiency, congenital radio-ulnar synostosis, and macrodactyly.

CONCLUSIONS

Our knowledge of the embryology and pathophysiology of congenital upper extremity conditions continues to evolve. Functional assessments combined with patient and parent-reported outcomes have our understanding of the results following surgical procedures. Further research and standardization of our scientific data will provide better answers and higher quality of evidence.

LEVEL OF EVIDENCE

Level V-literature review and expert opinion.

Correction of Thumb Duplication: A Systematic Review of Surgical Techniques

Surgical intervention for thumb duplication can be divided into three categories: simple excision of the accessory thumb, excision of the accessory thumb with reconstruction from available "spare parts," and combining the two thumbs into one, as described by Bilhaut. This prospectively PROSPERO registered systematic review evaluates the overall, aesthetic and functional outcomes for the latter two options (reconstruction from spare parts vs. combining two thumbs into one), aiming to facilitate evidence-based decision making when addressing thumb duplication and direct future research. The review was performed in accordance with the Cochrane Handbook of Systematic Reviews and PRISMA statement. Embase, PubMed, Medline, and Cochrane databases were systematically searched. Studies offering comparisons of techniques were included. Risk of bias was assessed using the Risk of Bias In Non-randomized Studies-of Intervention tool. The quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation. Ten retrospective observational studies were included. Data did not consistently allow analysis by procedure type. Four studies reported similar overall outcomes between techniques, while two specifically reported poor overall outcomes for the Bilhaut procedure. Two studies reported comparatively worse aesthetic outcomes for the Bilhaut procedure with four studies reporting comparatively improved functional outcomes for this procedure. Overall, interpretation of outcomes was challenging with no patient-reported outcome measures used. The quality of the evidence was universally "very low" due to all studies being at risk of methodological bias. Based on the available evidence, surgical techniques for thumb duplication correction appear comparable regarding overall outcome. There is limited evidence suggesting reconstruction with spare parts offers superior aesthetic outcomes at the expense of stability. The level of evidence is III.

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.

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.

My 40-year perspective on hand surgery

The author presents his transition of his preferred methods for managing acute trauma and degenerative and congenital conditions of the hand. Based on his career-long experience, he discusses conceptual evolution and current status of treatment of Dupuytren's disease and several congenital anomalies of the hand.

A Modified Bilhaut-Cloquet Procedure for Zigzag Thumb Polydactyly Types III and IV

Background:

A review of the English literature over the least 43 years revealed only a total of 53 cases of Wassel types III, IV, and VII treated by the Bilhaut–Cloquet (B–C) procedure. Furthermore, the detailed results and range of motion were only given in 2 series (a total of 9 cases).

Methods:

Four cases of Wassel types III and IV thumb duplications with zigzag deformity were treated with a modified B–C procedure. The main modification was minimal central resections at the joints aiming for joint preservation to improve the postoperative range of motion of the new thumb.

Results:

The results showed an excellent overall functional score (Tada score of 5 of 5 in all cases). The mean range of motion at the metacarpophalangeal joint was excellent (60°), but the mean at the interphalangeal joint was only 20°. Cosmetically, all thumbs were “too wide” and a panel of 3 hand surgeons scored the cosmetic result (0–10 scoring system) between 5.7 and 6.7. No secondary procedures were done, and all parents were “very satisfied” despite the wide thumbs and split nails. This was attributed to the presence of an ugly preoperative zigzag appearance, and hence the comparative postoperative appearance was satisfactory.

Conclusion:

The modified B–C procedure gives a satisfactory function, but the cosmetic outcome is suboptimal.

On-top and side-to-side plasties for thumb polydactyly

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“On-top” and “side-to-side” plasties are techniques used for treating thumb duplications.

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The functional results of these techniques have not been reported in the literature.

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We report on two cases and document excellent functional results.

Introduction

“On-top” and “side-to-side” plasties are techniques used for treating thumb duplications in which one thumb is adequate proximally and the other thumb contains a better pulp and nail distally. The detailed functional results of these techniques have not been reported in the literature. We report on two cases.

Presentation of cases

The first case had Wassel type VI duplication. The ulnar duplicate had a functioning interphalangeal joint and the radial duplicate had a functioning carpometacarpal joint. “On-top” plasty was done by putting the distal part of the ulnar duplicate on top of the proximal part of the radial duplicate. At 10 years after surgery, the outcome was excellent both cosmetically and functionally. In the second case (Wassel type VII with a zigzag deformity), the radial duplicate had a hypoplastic distal phalanx with no nail. The ulnar duplicate had a functioning interphalangeal joint and the radial duplicate had a functioning carpometacarpal joint. “Side-to-side” plasty was done by joining both thumbs side-to-side at the level of the proximal phalanx. At 3 years after surgery, the outcome we considered acceptable cosmetically and excellent functionally.

Discussion

We could not find similar cases in the literature with detailed long-term postoperative results.

Conclusion

“On-top” and “side-to-side” plasties in the management of specific cases of thumb polydactyly obtain excellent functional results with excellent or acceptable cosmetic outcome.