Polydactyly of the Hand

Surgical management of bilateral preaxial and postaxial polydactyly with syndactyly: A case report

INTRODUCTION AND IMPORTANCE

Polydactyly is the most common congenital malformation in the limbs. However, it is rare for a patient to exhibit concomitant preaxial and postaxial polydactyly alongside syndactyly in both limbs, and there are limited recommendations for such conditions. This report presents a case of bilateral preaxial and postaxial polydactyly with syndactyly of the feet.

PRESENTATION OF CASE

A 2-year-old girl was presented with an excess number of toes on both feet and an abnormal connection between the second and third toes. After a physical examination and plain radiography, the patient was diagnosed with bilateral preaxial and postaxial polydactyly with syndactyly. We performed a one-stage surgical correction consisting of ablation at the extra digit of bilateral great and little toes, followed by syndactyly release using z-plasty. The surgery was uneventful, and the parents were satisfied with the result.

DISCUSSION

A plain radiograph is necessary for pre-operative planning. We discarded the excess digits for cosmetics and soft and hard tissue for optimal function. It is necessary to preserve the soft tissues, remove the auxiliary digit, realign the digit, and restore the ligaments to preserve digit stability.

CONCLUSION

The complexity of this case required a meticulous surgical approach to address the structural abnormalities, restore functionality, and improve cosmetic appearance. In this case, the surgery can be performed in one procedure to minimize patient morbidity.

Cancer risk in individuals with polydactyly: a Swedish population-based cohort study

BACKGROUND

Polydactyly is a feature of several cancer predisposition syndromes (CPS), however, cancer risk in individuals with polydactyly is largely unknown.

METHODS

We performed a matched cohort study using data from Swedish national registers. We included 6694 individuals with polydactyly, born in Sweden between 1970-2017. Polydactyly was categorised as thumb polydactyly, finger polydactyly, polydactyly+ (additional birth defects and/or intellectual disability) or isolated polydactyly. Each exposed individual was matched to 50 comparisons by sex, birth year and birth county. Associations were estimated through Cox proportional hazard models.

FINDINGS

An increased childhood cancer risk was found in males (HR 4.24, 95% CI 2.03-8.84) and females (HR 3.32, 95% CI 1.44-7.63) with polydactyly+. Isolated polydactyly was associated with cancer in childhood (HR 1.87, 95% CI 1.05-3.33) and young adulthood (HR 2.30, 95% CI 1.17-4.50) in males but not in females. The increased cancer risk remained after exclusion of two known CPS: Down syndrome and neurofibromatosis. The highest site-specific cancer risk was observed for kidney cancer and leukaemia.

CONCLUSIONS

An increased cancer risk was found in individuals with polydactyly, especially in males and in individuals with polydactyly+. We encourage future research about polydactyly and cancer associations and emphasise the importance of clinical phenotyping.

Characterizing the Timing of Surgical Repair of Congenital Hand Differences in the United States

Background: Suggested timing of reconstruction of congenital hand differences varies widely. The goal of timely intervention is to achieve near-normal appearance and function. We evaluated national trends in surgical timing of congenital hand differences to determine whether interventions align with the literature. Methods: Recommended ages for surgical reconstruction were identified. The Pediatric National Surgical Quality Improvement Project database was queried from 2012 to 2020 for children who underwent surgery for simple syndactyly (SS), complex syndactyly (CS), polydactyly, or congenital trigger finger. Subgroup analysis was conducted to assess whether the surgeon's subspecialty (plastic surgery vs orthopedic surgery, pediatric vs generalist) influenced the timing of repair. Results: Congenital trigger finger and CS reconstructions occurred largely within the recommended age range (73.8% and 52.2%, respectively). Polydactyly repairs primarily occurred earlier than the recommendations (54.0%). Timing of SS reconstruction was split, either occurring before (44.3%) or after (41.4%) the recommendations. For children with polydactyly, plastic surgeons were more likely to perform polydactyly reconstruction at a younger age compared with orthopedic surgeons (P = .0001). Conclusions: Established expert recommendations for the treatment of congenital hand differences are largely not followed in practice in the United States. This suggests that practice patterns may not be determined by the surgical literature.

A case-control study characterizing polydactyly risk factors in Bogotá and Cali, Colombia between 2002 and 2020

BACKGROUND

Polydactyly is a congenital abnormality characterized by the presence of additional fingers on one or more extremities. In Colombia, polydactyly accounted for 17% of musculoskeletal congenital abnormalities in 2021, with a prevalence of 6.03 per 10,000 live births. The purpose of this study was to determine the prevalence of polydactyly and identify associated risk factors in Bogotá and Cali, Colombia, from 2002 to 2020.

METHODS

A retrospective case-control study design was employed, analyzing data from birth defect reports provided by the Program for the Prevention and Follow-up of Congenital Defects and Orphan Diseases surveillance system. Cases included live births or stillbirths with polydactyly, while controls consisted of infants without congenital abnormality, matched in terms of birth date and hospital. Prevalence of polydactyly was calculated and risk factors were assessed through odds ratios obtained by logistic regression models, considering a 95% confidence interval.

RESULTS

Among the 558,255 births included in the study, 848 cases of polydactyly were identified, resulting in a prevalence rate of 15.19 per 10,000 live births. Risk factors associated with polydactyly included male newborn sex, pregestational diabetes, and a family history of malformation among first-degree relatives.

CONCLUSION

These findings highlight the importance a surveillance system aimed to characterize populations with congenital abnormalities, providing a better option for analyzing risk factors, help improving prevention, diagnosis, notification, and optimal treatment in patients.

Modified Bilhaut-Cloquet procedure for Wassel type III-IV polydactyly

BACKGROUND

To investigate the functional and aesthetic results of a new modified Bilhaut-Cloquet procedure for the treatment of Wassel type III-IV thumb polydactyly.

METHODS

Thirteen patients with Wassel type III-IV thumb polydactyly who visited the Department of Orthopedics of Hebei Provincial Children's Hospital from 2019 to 2022 were selected. The surgical procedure involved a modified Bilhaut-Cloquet surgery, where two-thirds of the distal part of the dominant finger was retained as the p body of the reconstructed thumb. The triangular bone block of the ablated distal thumb that did not contain the epiphysis and articular cartilage was sutured and fixed, and the neurovascular flap of the ablated distal thumb was used as an augmenting segment of the reconstructed thumb, with the nail bed and nail matrix exquisitely sutured. The evaluation performed according to the Japanese Society for Surgery of the Hand (JSSH) system.

RESULTS

All 13 children showed bone healing, no wound infection, nonunion, or deformity healing. None of the children showed a significant reduction in the active and passive mobility of the thumb postoperatively compared with preoperatively. Postoperative evaluation was performed based on the JSSH score, with a mean of 17.15 points (14-19 points), with 11 children rated as excellent and two as good. No severe nail ridges, nail gaps, or nail split deformities of the thumb were observed postoperatively. Postoperative metacarpophalangeal and interphalangeal joint movements were not reduced compared with preoperative movements. All parents were satisfied with the appearance and function of the reconstructed thumb.

CONCLUSION

The modified Bilhaut-Cloquet procedure designed in this study was satisfactory for Wassel type III-IV thumb polydactyly without affecting the stability of the interphalangeal joints and preserving joint mobility. The postoperative thumb has a comparable circumference and nail width and was cosmetically and functionally satisfactory, especially for the asymmetric two thumbs, which achieved favorable results.

A Rare Presentation of Postaxial Polydactyly in a 2-Year-Old Female with Ellis-van Creveld Syndrome

Postaxial or ulnar polydactyly is the most common form of polydactyly that may present with the duplication of soft-tissue structures only or with additional bony involvement. Surgical excision is the only viable treatment option for postaxial polydactyly with bony involvement, and psychological or cosmetic reasons are the main rationale for treatment. Ellis-van Creveld syndrome (EVC) is a rare congenital disorder characterized by chondral and ectodermal dysplasia, particularly postaxial polydactyly. The exact prevalence of EVC is unknown, and fewer than 300 cases have been reported. We present a case of a 2-year-old Hispanic female with EVC who presented with bilateral postaxial polydactyly and complete duplication of the metacarpal and phalanges. We describe the presentation and treatment of this patient, who ultimately underwent staged resection of the duplicated digits with reconstruction of the abductor muscle.

Parent Perspectives for Type B Ulnar Polydactyly Management

BACKGROUND

Type B ulnar polydactyly is one of the most commonly encountered congenital hand differences and can be treated with ligation or excision. The purpose of this study was to determine what factors families consider in selecting treatment for their child with type B ulnar polydactyly.

METHODS

We reviewed treatment outcomes and administered a survey by telephone to parents of children with type B ulnar polydactyly treated at a pediatric hospital between 2015 and 2020. We assessed satisfaction, reasons for choosing treatment, and post-management complications.

RESULTS

The families of 70 of the 156 consecutive treated patients were successfully contacted and agreed to participate (45% response rate). The mean follow-up was 27 months. Twenty-eight chose in-office suture ligation and 42 chose excision. Rapid treatment was prioritized by those who opted for in-office ligation (P = .044). The complication rate for suture ligation was significantly higher than excision (P < .0001), with the most common complication being a residual remnant (nubbin or neuroma stump) (64%). Respondents with residual remnant reported significantly less satisfaction with the appearance of their child's hand (P < .001) and with treatment outcomes (P = .028) compared to those without residual remnants.

CONCLUSIONS

Factors considered by parents in choosing type of treatment for type B ulnar polydactyly vary and may be significantly influenced by the surgeon. Although the majority of parents remain extremely satisfied with their child's outcome regardless of management type, time to treatment plays a determinative role in parents opting for ligation rather than excision in the operating room.

Congenital Upper-Limb Differences: A 6-Year Literature Review

➤ The Oberg-Manske-Tonkin (OMT) classification of congenital hand and upper-limb anomalies continues to be refined as our understanding of the genetic and embryonic etiology of limb anomalies improves.➤ We have conducted an evaluation of graft and graftless techniques for syndactyly reconstruction; strengths and drawbacks exist for each technique.➤ Treatment for radial longitudinal deficiency remains controversial; however, radialization has shown promise in early follow-up for severe deformities.➤ Recent emphasis on psychosocial aspects of care has demonstrated that children with congenital upper-limb differences demonstrate good peer relationships and marked adaptability.

Surgical Excision of Postaxial Polydactyly Type B in the Office Setting

BACKGROUND

Simple postaxial polydactyly (type B) is a common congenital hand malformation often treated by suture or clip ligation.

METHODS

We present a case series of patients with simple postaxial polydactyly treated by surgical excision using local anesthesia in an office setting.

RESULTS

The procedure was performed on 78 digits in 48 children with a mean age of 10.2 weeks. There were no intraoperative or early postoperative complications. A follow-up by phone interview was performed at an average of 3.2 years postoperatively. All patients were reported to be pain-free and have normal function without a perceived range of motion deficits. All parents selected the highest level of satisfaction regarding cosmetic outcomes and overall experience with the procedure.

CONCLUSIONS

These results demonstrate that an office-based surgical excision is a safe, effective, and economical treatment option and has developed into our standard of care for this common condition.

Orthopaedic Diagnoses in the Black Pediatric Population

The Black pediatric population is one that has been historically underserved and continues to have unmet needs. Factors including lack of diversity in orthopaedic studies and in historical standards, such as bone age, may inadvertently lead to inferior care. There are certain conditions in this population for which the practicing orthopaedic surgeon should have a higher degree of suspicion, including slipped capital femoral epiphysis, Blount disease, and postaxial polydactyly. Systemic diseases with higher rates in this population have orthopaedic manifestations, including sickle cell disease, vitamin D deficiency, and obesity. Racial discrepancies in access to prenatal care can have orthopaedic consequences for babies, especially cerebral palsy and myelodysplasia. Racial discrepancy exists in evaluation for nonaccidental trauma. Increased awareness of these issues better prepares practitioners to provide equitable care.

An Evolution of the Surgical Management of Synpolydactyly: A Case Series of 21 Hands

INTRODUCTION

Synpolydactyly is a rare congenital anomaly characterized by syndactyly and polydactyly in the central hand. Limited treatment guidelines exist for this complex condition.

METHODS

A retrospective review of synpolydactyly patients was conducted at a large, tertiary pediatric referral center to describe our surgical experience and evolution of management. The Wall classification system was used to categorize cases.

RESULTS

Eleven patients (21 hands) with synpolydactyly were identified. Most of the patients were White and had at least one first-degree relative who also had synpolydactyly. The Wall classification yielded the following results: 7 type 1A hands, 4 type 2B hands, 6 type 3 hands, and 4 uncategorizable hands. Each patient had an average of 2.6 surgeries and an average follow-up time of 5.2 years. The rates of postoperative angulation and flexion deformities were 24% and 38%, respectively, with many of these cases also demonstrating preoperative alignment abnormalities. These cases often required additional surgeries including osteotomies, capsulectomies, and/or soft tissue releases. The rate of web creep was 14% with 2 of these patients requiring revision surgery. Despite these findings, at the time of final follow-up, most patients had favorable functional outcomes, were able to engage in bimanual tasks, and were able to perform activities of daily living independently.

CONCLUSIONS

Synpolydactyly is a rare congenital hand anomaly with a significant degree of variability in clinical presentation. The rates of angulation and flexion deformities as well as web creep are not insignificant. We have learned to prioritize correcting contractures, angulation deformities, and skin fusion, over simply trying to delete the "extra" number of bones as this may destabilize the digit(s).

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.

Incidental finding of a hidden central polydactyly: A case report

Congenital hand anomalies are common, and must always be considered as a differential diagnosis in patients with hand pathology. We report the case of a child who sustained a fingertip injury to highlight an unusual presentation of central polydactyly.

Comparison of Surgical Wait Times and Procedure Length in the Management of Postaxial Polydactyly Using Local or General Anesthesia

Introduction: For infants with ulnar polydactyly, surgical removal of the supernumerary digit can be performed under general or local anesthetic. This study evaluated the wait times, surgical duration, and sedation times associated with performing the procedure under local versus general anesthetic in infants with ulnar polydactyly. Methods: The databases of three surgeons at our institution were reviewed for children less than 2 years of age who underwent surgery for non-syndromic ulnar polydactyly. Data collection included patient demographics, wait times, duration of surgery and sedation and complications. Results: The study included children (n  =  55) who received treatment under local (n  =  22) or general (n  =  33) anesthesia. The wait times for the local anesthetic group were significantly shorter than the general anesthetic group (p < 0.05) for: referral to first consultation appointment; referral to surgery date, and decision date to surgery date. The duration of surgery (17.9  ±  6.9 vs 36.6  ±  20.2 min) and sedation time (26.3  ±  11.1 vs 74.8  ±  29.1 min) were significantly shorter in the local anaesthetic group (p < 0.05). There were no differences in complication rates between the groups. Conclusion: In this single-institution retrospective analysis, treatment of non-syndromic ulnar polydactyly with local anesthetic and bottle sedation was associated with shorter wait times, and duration of surgery and sedation. Level of Evidence: III, retrospective chart review and quality improvement initiative

Local Anesthesia Alone for Postaxial Polydactyly Surgery in Infants

BACKGROUND

Surgical excision for postaxial polydactyly type B is advocated to avoid long-term complications. Excision with local anesthesia (LA) in infancy represents a safe and effective treatment for this condition, although general anesthesia (GA) is employed by many surgeons. We present a comparison of surgical outcomes, cost, and time between LA and GA to support widespread change in management.

METHODS

A retrospective review of patients under 12 months of age undergoing surgical polydactyly excision by a single surgeon was performed. Anesthesia type, patient demographics, and complications were recorded. Comparisons were made between LA and GA groups on procedure cost, operating time, length of stay (LOS), and time from procedure end to discharge. Stepwise forward regression was used to identify the best model for predicting total costs.

RESULTS

Ninety-one infants with a mean age of 3 months (±1.9) were examined; 51 (56%) underwent LA alone, 40 (44%) underwent GA. Mean operating time was 11.53 ± 4.36 minutes, with no difference observed between anesthesia groups (P = .39). LA infants had a significantly shorter LOS (2.5 vs 3.5 hours; P < .05), quicker postoperative discharge (32 vs 65 minutes, P < .05), and fewer overall expenses, 2803 vs 6067 U.S. dollars (USD), P < .05. Two minor surgical complications (1 in each group) were reported.

CONCLUSIONS

This study demonstrates significantly decreased cost, LOS, and time to discharge using LA alone for surgical excision of postaxial polydactyly type B. Results suggest the approach is quick, economical, and avoids the risks of GA in early infancy.

A novel homozygous variant in the GLI1 underlies postaxial polydactyly in a large consanguineous family with intra familial variable phenotypes

Polydactyly is a human inherited disorder caused by to anomalies in the genes involved in autopod development. The disorder segregates in both autosomal recessive and autosomal dominant form. Up till now, eleven genes causing non-syndromic polydactyly, have been identified. This includes ZNF141, GLI3, ZRS in LMBR1, MIPOL1, PITX1, IQCE, GLI1, FMA92A1, KIAA0825, STKLD1, and DACH1. In the present study, we have investigated a large consanguineous family of Pakistani origin segregating polydactyly in autosomal recessive pattern. Clinical examination of affected individuals revealed a non-syndromic form of the disorder. Genetic study based on homozygosity mapping and Sanger sequencing using DNA of the normal and affected individuals found a novel homozygous missense sequence variant [NM_005269.3: c.1133C > T, p.(Ser378Leu)] in the GLI1 located on human chromosome 12q13.3. In silico analysis of the identified variant showed a significant change in the secondary structure of the mutant protein that affects its function. Findings of the present study expand the mutation spectrum of the GLI1. In addition, the study will help in prevention of the disorder through carrier testing and bringing awareness among families affected with polydactyly.

Mid-term to Long-term Follow-up Results of Reconstruction for Thumb Radial Polydactyly

BACKGROUND

Preaxial or radial polydactyly is one of the most common hand congenital anomalies in newborns. Contemporary reconstruction methods include ligament reconstruction, excision of the polydactylous thumb, osteotomy, and other surgical techniques according to the type of polydactyly. The purpose of this study was to report mid-term to long-term reconstruction results for thumb (radial) polydactyly.

METHODS

We retrospectively reviewed the medical records of patients who underwent reconstruction surgery for preaxial polydactyly. Clinical outcomes, including the range of motion (ROM), pain, and complications, were evaluated. We assessed the final radiographs of the reconstructed thumb to identify the potential development of arthritis or other remaining deformities. After excluding cases without a simple radiograph and cases with a short follow-up period of fewer than 5 years, 26 thumbs were included. The surgical technique followed including excision of polydactylout thumb was tailored to the type of polydactyly. If the nail size of the thumbs was similar, the Bilhaut-Cloquet method was preferred.

RESULTS

The mean age of the patients at the surgery and final follow-up was 14.9 months (range: 8 to 30 mo) and 11.9 years (range: 5.8 to 19.3 y), respectively. The mean follow-up was 128.8 months years (range: 60 to 219 mo), and the mean ROM of the thumb was 32.7 and 57.5 degrees in the distal interphalangeal joint (DIP) and metacarpophalangeal (MP) joint, respectively. Ulnar or radial side instability was prominent in 7 patients in the involved joints (26.9%). One patient underwent interphalangeal (IP) fusion for extension lag with pain. The radiologic evaluation revealed that 2 patients developed radiographic evidence of IP joint arthritis (7.7%). Radial deviation of the MP or IP joint existed in 13 cases (range: 5 to 40 degrees) (50.0%), and ulnar deviation of the MP or IP joint existed in 2 cases (range: 19 to 20 degrees) (7.7%).

CONCLUSIONS

In mid-term to long-term experience, sequelae such as joint instability, joint stiffness, and remaining deformity cannot be neglected. An unstable MP joint may result if the DIP joint remains stiff or has a lower ROM.

LEVEL OF EVIDENCE

Level IV-therapeutic studies.

Long-Term Outcomes After Treatment for Type B Ulnar Polydactyly

BACKGROUND

Type B ulnar polydactyly is a common congenital hand difference and can be treated with either ligation or surgical excision. There is a paucity of literature, however, evaluating long-term patient reported outcomes of these treatments. The purpose of this study was to compare the long-term outcomes after ligation and excision for the management of type B ulnar polydactyly.

METHODS

We created a database of patients who underwent treatment for type B ulnar polydactyly at a single pediatric health system from 2005 to 2014. We administered the Patient Reported Outcomes Measurement Information System (PROMIS) Pediatric Upper Extremity survey to patients through telephone and assessed for their satisfaction.

RESULTS

We successfully collected outcomes from 69 of 173 eligible patients treated in infancy (40% response rate). The mean follow-up was 11.1±2.5 years, and the average age of the participant at the time of the survey was 11.7±2.6 years of age. Twenty-four patients were treated with in-office ligation and 45 underwent formal surgical excision. Ten patients who were initially treated with ligation required future treatment with surgery because of symptomatic neuroma stump or persistent polydactyly (42%). Patients who were treated with surgical excision rated significantly higher satisfaction with their treatment than those who underwent ligation (P=0.003). Patients in both cohorts rated similar satisfaction with the esthetic appearance of their hand (P=0.07). There was no significant difference in PROMIS-rated hand function between the ligation and surgical cohort (P=0.765) and treated adolescents PROMIS scores were not statistically different than age-matched controls without polydactyly.

CONCLUSION

While ligation and surgical excision result in similar function and esthetics, patient satisfaction is higher after surgery. Furthermore, a significant number of patients fail ligation and ultimately undergo surgery for symptomatic neuroma or persistent polydactyly. Counseling parents of patients with type B ulnar polydactyly should include these considerations to assist them in selecting the best treatment for their child.

LEVEL OF EVIDENCE

Level III.

Surgical Results of Ulnar Component Excision and Radial Component Reconstruction in Patients With Preaxial Polydactyly of the Hand

PURPOSE

Resection of the underdeveloped digit and reconstruction of the robust digit is the standard treatment option for preaxial polydactyly of the hand. As an underdeveloped digit, the radial component is usually excised, whereas the ulnar component excision is rarely needed. This study aimed to evaluate the surgical results of ulnar component excision and radial component reconstruction in patients with preaxial polydactyly of the hand.

METHODS

We retrospectively reviewed the medical records and radiographs of 809 patients (861 thumbs) who underwent surgery for preaxial polydactyly of the hand from November 2006 to June 2018. Among these, 22 (2.6%) thumbs in which the ulnar component was more hypoplastic or had more severe deformities than the radial component were treated with ulnar component excision and radial component reconstruction. The mean follow-up duration was 49 months (range, 12-142 months). We evaluated the Japanese Society for Surgery of the Hand scores and whether the patients were satisfied with the thumb function and appearance at the final follow-up. We also recorded any complications, such as reoperation.

RESULTS

The mean Japanese Society for Surgery of the Hand score was 12.8 (range, 5-17). Six patients had poor results, 7 had fair results, and 2 had good results; however, none of the patients had an excellent result. Satisfaction with thumb function and appearance was reported in 11 (50%) and 6 (27%) cases, respectively. Thirteen of 22 (59.1%) cases involved reoperations, and the most common reason for reoperation was interphalangeal joint deviation of the remaining thumb.

CONCLUSIONS

Ulnar component excision and radial component reconstruction are rare operative choices in preaxial polydactyly of the hand. Surgeons and patients should be aware that a considerable number of patients treated with this method required reoperations and had low clinical outcome scores.

TYPE OF STUDY/ LEVEL OF EVIDENCE

Prognostic IV.

Pedicle complex tissue flap transfer for reconstruction of duplicated thumbs with unequal size

BACKGROUND

Thumb polydactyly is one of the most common congenital hand deformities, and the Bilhaut-Cloquet procedure or a modified one is often used. However, controversy remains over the rare instances in which both thumbs are not of similar length or far apart in distance.

AIM

To evaluate the clinical outcomes of pedicle complex tissue flap transfer in the treatment of duplicated thumbs with unequal size.

METHODS

From January 2014 to December 2020, 15 patients underwent duplicated thumb reconstruction by pedicle complex tissue flap transfer at our hand surgery center. The technique was used when it was necessary to combine different tissues from both severed and preserved thumbs that were not of similar length or far apart in distance. Subjective parents’ evaluations and functional outcomes (ALURRA and TATA criteria) were obtained. The alignment deviation, instability, range of motion (percent of opposite thumb) of the interphalangeal and metacarpophalangeal joints, and the aesthetic aspects, including circumference, length, nail size, and nail deformity, were used to assess the clinical outcomes.

RESULTS

The average age of patients at the time of surgery was 13 mo, and the mean final follow-up occurred at 42 mo. An appropriate volume with a stable joint and good appearance was obtained in 14 reconstructed thumbs. An unstable interphalangeal joint occurred in one thumb. The flexion-extension arc at the metacarpophalangeal joint was good, while that at the interphalangeal joint was poor. Most of the parents were satisfied with the cosmetic and functional results of the reconstructed thumbs. The mean ALURRA score was 21.8 (range: 20-24), and the Tada score was 6.9 (range: 5-8). Compared with the non-operated side, the length of the operated thumb was approximately 95%, the girth was 89%, and the nail width was 82.9%. The mean ranges of motion were 62.1% of that of the unaffected thumb in the interphalangeal joint and 78.3% in the metacarpophalangeal joint.

CONCLUSION

Harvesting a pedicle flap from a severed thumb is a safe and reliable procedure. Defects of the preserved thumb, such as the skin, nail, and bone, can be effectively restored using the complex tissue flap.

Pediatric Office Procedures

Pediatric patients are frequently evaluated in primary care clinics. Thus, there exists a need to understand common pediatric problems and to acquire a degree of familiarity with pediatric procedures. This article will review techniques and the current evidence for frequently performed pediatric procedures, including umbilical granuloma chemocautery, frenotomy, suture ligation of type B postaxial polydactyly, reduction of nursemaid's elbow, hair tourniquet removal, and tympanometry.

Rare phenotype: Hand preaxial polydactyly associated with LRP6-related tooth agenesis in humans

Low-density lipoprotein receptor-related protein 6 (LRP6) is a pathogenic gene of selective tooth agenesis-7 (OMIM#616724). Although the malformation of the digits and fore- and hindlimbs has been reported in Lrp6-deficient mice, it has been rarely discovered in humans with LRP6 mutations. Here, we demonstrate an unreported autosomal dominant LRP6 heterozygous mutation (c.2840 T > C;p.Met947Thr) in a tooth agenesis family with hand polydactyly, and another unreported autosomal dominant LRP6 heterozygous mutation (c.1154 G > C;p.Arg385Pro) in a non-syndromic tooth agenesis family. Bioinformatic prediction demonstrated the deleterious effects of the mutations, and LRP6 structure changes suggested the corresponding functional impairments. Analysis on the pattern of LRP6-related tooth agenesis demonstrated the maxillary lateral incisor was the most affected. Our study report that LRP6 mutation might be associated with hand preaxial polydactyly in humans, which broaden the phenotypic spectrum of LRP6-related disorders, and provide valuable information on the characteristics of LRP6-related tooth agenesis.

When Is Primary Metacarpal Corrective Osteotomy Recommended in Patients with Flatt Type IV Radial Polydactyly?

BACKGROUND

The aim of this study was to determine when primary metacarpal corrective osteotomy is recommended in patients with Flatt type IV radial polydactyly.

METHODS

A total of 78 patients with Flatt type IV radial polydactyly were included. The authors performed metacarpal osteotomy if the angulation of the metacarpophalangeal joint was not correctable by the intraoperative radial stress test. The authors measured the metacarpal deviation angle of the thumb in simple posteroanterior radiographs. The clinical outcomes were assessed using Japanese Society for Surgery of the Hand evaluation total score and the metacarpal deviation angle correction angle. These outcomes were compared between the patients who underwent metacarpal osteotomy and those who did not. Of the patients who did not undergo metacarpal osteotomy, the relationships between preoperative metacarpal deviation angle and the metacarpal deviation angle correction angle were formulated using segmented linear regression analysis.

RESULTS

There were no significant differences in the demographic features and the value of preoperative metacarpal deviation angle between the two groups. However, the metacarpal deviation angle correction angle and Japanese Society for Surgery of the Hand evaluation total score were significantly higher in the patients who underwent metacarpal osteotomy. The segmented linear regression analysis demonstrated a breakpoint, indicating that the soft-tissue procedure alone does not sufficiently correct the metacarpal deviation angle. For the postoperative metacarpal deviation angle to be 5 degrees, the preoperative metacarpal deviation angle was calculated as 10.8 degrees.

CONCLUSION

If the preoperative metacarpal deviation angle is greater than 10.8 degrees, metacarpal osteotomy can be considered even in patients with correctable metacarpophalangeal joint by intraoperative radial stress test.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

BMSC-derived exosomes from congenital polydactyly tissue alleviate osteoarthritis by promoting chondrocyte proliferation

In the past decade, mesenchymal stem cells (MSCs) have been widely used for the treatment of osteoarthritis (OA), and exosomes may play a major role. Here, we acquired a special kind of MSCs from the bone marrow of surgically resected tissue from the hand of a patient with polydactyly. Experiments were focused on the role of polydactyly bone marrow-derived MSCs (pBMSCs) in osteoarthritis. The results showed that the pBMSCs had a greater ability than the BMSCs to differentiate into chondrocytes. Mechanistically, the expression of BMP4 was significantly higher in the pBMSCs than it was in the BMSCs. Furthermore, we showed that the migration and proliferation of chondrocytes were stimulated by exosomes secreted by pBMSC (pBMSC-EXOs). Notably, the downregulation of BMP4 in pBMSCs by siRNA inhibited both the chondrogenic differentiation potential of the MSCs and the function of the chondrocytes. In addition, the injection of pBMSC-EXOs and BMSC-EXOs attenuated OA in an OA mouse model, but the pBMSC-EXOs had a superior therapeutic effect compared with that of the BMSC-EXOs. Taken together, the data indicate that pBMSCs have greater ability to differentiate into chondrocytes and regulate chondrocyte formation through BMP4 signaling. Therefore, pBMSC-EXOs may represent a novel treatment for OA.

Maternal occupational exposure to chemicals in the textile factory during pregnancy is associated with a higher risk of polydactyly in the offspring

Background: The number of children with polydactyly seen in our clinic is increasing. In addition to genetic factors, an influence of environmental effects during pregnancy is becoming increasingly apparent; however, epidemiological data on these effects are lacking.Methods: This hospital-based, case-control study enrolled 143 patients with polydactyly and 286 control patients with no genetic diseases, to evaluate the association between maternal exposure to a textile factory environment during pregnancy and the likelihood of giving birth to a child with polydactyly.Results: Maternal exposure to a textile factory environment during pregnancy was associated with an increased risk of giving birth to a child with polydactyly (exposure to textile factory environment: unadjusted odds ratio (OR) = 3.31, 95% confidence interval (CI) = 1.75-6.27, p = .0002; work seniority of exposed occupation: unadjusted OR 1.28, 95% CI = 1.13-1.47, p = .0002). Covariate screening indicated that certain risk factors (family monthly income per capita, mother's emotional state during pregnancy, colporrhagia, passive smoking, smoking, and history of consanguineous marriage) were potential confounding factors. After adjusting for these variables, the OR of exposure to a textile factory environment remained significant (exposure to textile factory environment: adjusted OR = 3.08, 95% CI = 1.32-7.19, p = .0094; work seniority of exposed occupation: adjusted OR = 1.58, 95% CI = 1.20-2.08, p = .0010). The risk of polydactyly increased with the number of years of employment.Conclusions: Maternal exposure to a textile factory environment appears to be a risk factor for polydactyly in newborns.

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.

A Review of Benign Congenital Anomalies

Benign congenital anomalies are common in neonates. Some of these common benign congenital anomalies include preauricular pits, sacral dimples, supernumerary digits, accessory nipple, and natal teeth. It is important for health care providers who take care of newborns to recognize these benign anomalies so that unnecessary evaluations and investigations are not performed. However, some of these anomalies may be associated with clinically significant conditions. In this article, we discuss when further evaluation should be performed in babies presenting with these common benign congenital anomalies. [Pediatr Ann. 2020;49(2):e66-e70.].

Holt-Oram Syndrome With Multiple Cardiac Abnormalities

Holt-Oram syndrome (HOS) is a rare monogenic disorder characterized by upper limb abnormalities, congenital heart defects and/or conduction abnormalities. It is determined by mutations of TBX5 gene and is inherited in an autosomal dominant manner. Penetrance is complete, but variable expressivity is present, which gives sometimes diagnostic difficulties. Our case is a young adult with a personal history of preaxial polydactyly operated in infancy, multiple cardiac malformations (atrial septal defect, bicuspid aortic valve, left ventricular non-compaction) and radiologic findings consistent with HOS. Family history is negative for HOS. In conclusion, we present a case of HOS diagnosed in the adult period to highlight the diagnostic problems for the proband and the family and the importance of an early diagnostic.