Soft-Tissue Surgery for Camptodactyly Corrects Skeletal Changes:

Camptodactyly: From Embryological Basis to Surgical Treatment

Camptodactyly is a relatively rare hand deformity presenting as the proximal interphalangeal joint's nontraumatic and progressive flexion contracture. Most cases are limited to the fifth finger. The severity and type of camptodactyly should be considered to optimize treatment. Since many structures at the finger base can be involved in the pathogenesis of the deformity, surgical treatment for this particular type of deformity is challenging. This paper aims to bring insight into camptodactyly's pathogenesis and treatment options. We discuss the indication and pitfalls of surgical treatment options for particular camptodactyly types and present a case of a fourteen-year-old boy who was admitted to our department with proximal interphalangeal joint flexion contracture of the left fifth digit.

Treatment of camptodactyly with a new progressive correction device

The aim of this study was to introduce a new progressive correction device and present treatment results in camptodactyly patients. Eight patients (11 fingers) were treated for camptodactyly by an external fixator between February 2019 and April 2020. Mean follow-up was 28.7 ± 3.3 months (range, 24-35 months). Operative times and treatment complications were recorded. Pre- and post-operative flexion contracture, total active range of motion (TAM) and esthetic satisfaction were evaluated at final follow-up. Esthetic satisfaction was rated by the patient on a 1-5 point scale. Seven patients were male, and 1 female. Mean age was 21.6 ± 8.5 years (range, 15-42 years). Mean surgery time was 14.9 ± 2.4 min (range, 10-18 min). Mean preoperative flexion contracture was 85.9 ± 7° (range, 75-95°), and mean postoperative flexion contracture was 4 ± 3° (range, 0-10°). Transient proximal interphalangeal joint swelling was seen in 1 case and pin tract infection in 1. TAM was perfect in 5 fingers and good in 6. Patients were either very satisfied (n = 5) or satisfied (n = 3) with the esthetic appearance of each operated finger. Camptodactyly could be managed with a hinged external fixator simply and effectively with gratifying results in selected patients. LEVEL OF EVIDENCE: Level IV, case series.

Surgical Treatment of Camptodactyly with Malek Cutaneous Approach and Stepwise Release: A Retrospective Multi-centre Study

Background: Clinical manifestations of camptodactyly are varied and no official consensus on the etiopathogenesis or best treatment is available. Conservative treatment is generally preferred and, in refractory patients, surgery might be considered. However, reported results of surgery are often unsatisfactory and it is difficult to compare outcomes as different classification systems are adopted. We reported the outcomes of surgical treatment of camptodactyly with the Malek cutaneous approach and stepwise release, assessed using the Siegert classification. Methods: A retrospective analysis of paediatric patients (≥1 and ≤18 years) with congenital camptodactyly refractory to conservative management (flexion contracture >30°), treated with Malek cutaneous approach and stepwise release surgery between June 2009 and June 2019 with at least 1 year of follow-up was performed. Pre- and post-operative clinical and radiographic assessments were evaluated for degrees of flexion contractures and early (<30 days) or late (>30 days) complications were recorded. Results: A total of 59 patients underwent surgery, of whom 38 (64%), including 42 fingers, were enrolled; mean patient age was 8 years (range 1-18). Post-operative mean flexion contracture was significantly improved (p > 0.001) and no infections were recorded. Mean follow-up was 6 years (range 1-10) and proximal interphalangeal joint extension deficits were rated according to Siegert classification as excellent (69%), good (12%), or fair (9.5%) and poor (9.5%). Conclusions: The Malek cutaneous approach and stepwise release of the retracting soft tissues allow prompt evaluation of the anatomical structures involved in the deformity and seem to be an effective surgical correction in the long term. Level of Evidence: Level IV (Therapeutic).

One-Stage Extension Shortening Osteotomy for Syndromic Camptodactyly

Syndromic camptodactyly often affects multiple fingers, and severe deformities are common compared to idiopathic camptodactyly. This study aimed to evaluate the use of a one-stage extension shortening osteotomy of the proximal phalanx for patients with syndromic camptodactyly without tendon surgery. Forty-nine cases of syndromic camptodactyly were included. Forty fingers (81.6%) were associated with arthrogryposis multiplex congenita, and nine (18.4%) with other syndromes. Six fingers presented with a moderate form (30° to 60°) of camptodactyly, whereas 43 fingers manifested the severe form (>60°). The mean age at the time of surgery was 8.5 years, and the patients were followed for a mean of 3.9 years. The mean length of the shortening of the proximal phalanx was 4.9 mm, which averaged 17.8% of the proximal phalanx’s original preoperative length. The mean operative time was 25.8 min, and the PIP joint was fixed using Kirschner wires with an average flexion position of 7.6°. The mean flexion contracture improved from 76° preoperatively to 41° postoperatively. The mean preoperative active arc of motion was 23°, which improved to 49° postoperatively. A one-stage extension shortening osteotomy is a straightforward and effective technique for the improvement of finger function through the indirect lengthening of volar structures without the flexor tendon lengthening. The osteotomy could simultaneously correct bony abnormalities. This simple procedure is especially suitable for surgery on multiple fingers in patients with syndromic camptodactyly.

Surgery and Conservative Management of Camptodactyly in Pediatric Patients: A Systematic Review

Camptodactyly is a pediatric hand condition, the treatment of which remains controversial. The authors' aim was to improve patient care through clarifying the definition of camptodactyly and indications for surgical and/or conservative management, summarizing outcomes, and defining risks. A systematic review was conducted of articles in all languages on outcomes following surgical and/or conservative management of idiopathic camptodactyly in children using MEDLINE (Medical Literature Analysis and Retrieval System Online), PubMed, EMBASE (Excerpta Medica database), AMED (Allied and Complementary Medicine), and CINAHL (Cumulative Index of Nursing and Allied Health Literature) (until January 2017). The primary outcome was posttreatment flexion contracture, and the secondary outcomes were indications for surgery, complications, and patient satisfaction. Database searching generated 16 final articles, with 7 case series and 9 retrospective cohort studies. There was a lack of consistency on the definition of camptodactyly and in outcome reporting. All 16 studies received a "Weak" global rating and demonstrated low-quality evidence, suggesting that treatment of camptodactyly with operative or nonoperative measures reduces the degree of flexion contracture in most patients (from pretreatment averages of 20°-85° to posttreatment averages of 5°-37°). There was general agreement that surgery should be reserved for contracture >30° or failure to respond to conservative management. Surgery generally led to more complications compared with conservative management. Only one study reported on functional limitations, and another reported on patient-reported outcomes. Current evidence of the effectiveness of camptodactyly treatment in addressing both joint-specific deformity and patient-perceived function and appearance is insufficient to guide patient care. Future research may consider the development of decision aids to guide patients and families through selecting management strategies and to promote shared decision making.

Radiographic Remodeling of the Proximal Phalangeal Head Using a Stretching Exercise in Patients With Camptodactyly

PURPOSE

The aims of this study were to verify proximal phalangeal head normalization after a stretching exercise in patients with infantile-type camptodactyly and to propose radiographic indices for quantifying bony deformities.

METHODS

Forty-eight fingers of 20 patients with camptodactyly were enrolled in this study. All patients and their parents received instruction on how to perform the stretching exercise. The qualitative assessments of proximal phalangeal head remodeling were conducted by consensus of 2 hand surgeons. Two radiographic parameters, head triangle ratio (HTR) and head angle (HA), were measured on finger lateral radiographs taken at the initial visit and at 12-month follow-up. The intra- and interobserver reliability of both parameters was assessed. Those parameters of the patients were compared with those of 177 fingers of 80 children without camptodactyly. The extent of proximal interphalangeal (PIP) joint flexion contracture was used to evaluate clinical outcomes resulting from nonsurgical treatment.

RESULTS

Qualitative assessments of proximal phalangeal head remodeling exhibited meaningful improvements. Both radiographic parameters showed significant change between their status before and after intervention and had excellent intra- and interobserver reliability. Average PIP joint flexion contracture significantly improved. In the noncamptodactyly group, neither parameter showed significant differences in accordance with finger types and age ranges.

CONCLUSIONS

Stretching improved movement within the proximal phalangeal joint and helped to restore proximal phalangeal head roundness and concentricity in patients with infantile-type camptodactyly. The HTR and HA would be useful indices for objectively assessing the degree of bony deformity in patients with camptodactyly.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Treating Congenital Proximal Interphalangeal Joint Contracture

The management of congenital proximal interphalangeal joint deformity, also known as camptodactyly, is challenging. There are numerous theories on the cause of this abnormal finger posture, leading to variations in classification, definition, and treatment approaches. This article assesses the previous literature and provides clarity and guidance for the practical treatment of camptodactyly.