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Index pollicization in congenital deformity. A long-term follow up of 62 cases
8
THE JOURNAL
CONGENITAL A new classification of hand malformation G. F. Tajana, E. M. Corrado* Universitci Reggio Calabria, * Chirurgia versitd, Italy
Istologia
Mano Uni-
The authors propose a new classification of the main upper limb and hand malformations, by an analysis of factors governing the growth of the ectodermic apical crest (CEA). The authors consider the molecular mechanisms regulating the CEA growth and propose a classification of upper limb malformations, according to the natural growth axes: l Proximo-distal axis malformations due to an alteration of the secondary interaction mechanism. l Antero-posterior axis malformations due to an alteration of growth factors and/or morphogenetic factors. l Dorso-ventral axis malformations due to an alteration of myogenesis and/or tendinogenesis.
The authors underline the practicality of this classification and suggest that the identification of the molecular mechanism of upper limb growth is an useful taxonomic criterion.
Duplicated procedure
thumb; modification
of the Bilhaut-Cloquet
A. Nachemson, S. Edshage
OF HAND
SURGERY
VOL. 19B SUPPLEMENT
I
Pollicization of the index finger in congenital aplasia of the thumb is a well established surgical procedure; nevertheless, as recently published in literature, the results are frequently disappointing not in terms of vitality of the transposed digit, but in terms of quality of function and appearance. Our experience consists of 72 pollicizations performed with the technique of Buck Gramko between 1969 and June 1993. We followed the very strict method of evaluation proposed by Gilbert in which are taken into account the degrees of antep&ion and rotation, the stability of the MP joint, opposition with the long fingers and finally the aesthetic aspect of the new thumb (position, quality of web space, length of thumb). In order to better evaluate the incidental excess growth of thumb, due to incorrect resection of the metacarpal epiphysis we reviewed the patients operated up to 1990. For this reason we present a series of 62 pollicizations (38 monolateral and 12 bilateral). Radial club hand was present in 30 limbs, all previously treated with ulnar centralization (10 bilateral). The average age of pollicization was 3 years and 8 months. Excellent and good results were achieved only in 32 cases(57.6%) according to the Gilbert evaluation scale; these results have been partially improved by secondary operations such as osteotomies, tendon transfers, scar contractures revisions. This low average of good results is mainly due to the association with club hand deformity, where the malformation of the second finger (camptodactyly, tendon absence,joint stiffness) lead to a thumb limited both functionally and aesthetically. With regard to excessgrowth in length, that represent a cause of bad results in a normal pollicized finger, in radial club hand in which joint mobility is very limited, it may be helpful to obtain a better functional pinch despite a poor appearance.
Hand Surgery Division, Sahlgrenska University Hospital, Gothenburg, Sweden
The aim of the surgical treatment of duplicated thumbs is not only to restore the normal number of digits, but also to achieve a well-functioning thumb with a good cosmetic appearance. If the two thumbs are of approximately the same size a BilhautCloquet procedure is often recommended. In this operation a new thumb is constructed by resection of one half of each thumb and fusion of the two other halves including both skeletal and soft tissues. The advantage of this operation, over a single resection of one of the bifid thumbs, is that the reconstructed thumb will be straight and will not deviate during growth. In the original technique the nail of the thumb remained split in the midline. This can be an aesthetic disadvantage and patients also often complain that a split nail is irritating and tends to tear off. To overcome the disadvantage of a split thumb nail we have developed a technique to save the nail bed. Instead of dividing the nail beds of the two thumbs, one of the nail beds is left intact and shared by the two halves of the thumbs. The result is improved not only by saving the whole nail bed, but also by saving the nail groove from one of the thumbs. The operative technique will be described in detail and some results presented.
Index pollicization in congenital deformity. A long-term follow up of 62 cases P. L. Raimondi, M. Petrolati, G. Delaria, A. Ciapparelli Hand Surg(ery Department, Legnano Hospital, Italy
Aetiology of the triphalangeal thumb J. Zguricas, S. E. R. Hovius, D. Lindhout Department of Plastic and Reconstructive Surgery, Academic Hospital, Rotterdam, The Netherlands
Triphalangeal thumb (TPT)-a long, fingerlike thumb with three phalanges instead of two, is regarded as a subtype of preaxial polydactyly. It can occur as a sporadic disorder, but is more often seen as a dominant familial trait. The underlying genetic defect is unknown, but must involve genesthat regulate the differentiation of the developing limb. Definition of the molecular basis for congenital limb deformities can help us establish new classifications on a genetic basis and provide insight into a barely understood pathomorphology of the hand. During the past 10 years 19 children have been treated for triphalangeal thumb in Sophia Childrens Hospital in Rotterdam. Sixteen of those children had a positive family history for this disorder, and all the families had their origin in the same small region in the south-west part of The Netherlands. The patients and their affected relatives had a strikingly similar phenotype varying from an opposable thumb with a deltashaped extra phalanx to a non-opposable index-like digit instead of a thumb. Sometimes this was associated with a preaxial extra ray, rudimentary postaxial polydactyly, and cutaneous syndactyly between the fourth and the fifth digit. Consistency of the phenotype among the families, together with their common geographic and demographic origin, strongly suggests that all affected individuals share the same genetic
THE JOURNAL
CONGENITAL A new classification of hand malformation G. F. Tajana, E. M. Corrado* Universitci Reggio Calabria, * Chirurgia versitd, Italy
Istologia
Mano Uni-
The authors propose a new classification of the main upper limb and hand malformations, by an analysis of factors governing the growth of the ectodermic apical crest (CEA). The authors consider the molecular mechanisms regulating the CEA growth and propose a classification of upper limb malformations, according to the natural growth axes: l Proximo-distal axis malformations due to an alteration of the secondary interaction mechanism. l Antero-posterior axis malformations due to an alteration of growth factors and/or morphogenetic factors. l Dorso-ventral axis malformations due to an alteration of myogenesis and/or tendinogenesis.
The authors underline the practicality of this classification and suggest that the identification of the molecular mechanism of upper limb growth is an useful taxonomic criterion.
Duplicated procedure
thumb; modification
of the Bilhaut-Cloquet
A. Nachemson, S. Edshage
OF HAND
SURGERY
VOL. 19B SUPPLEMENT
I
Pollicization of the index finger in congenital aplasia of the thumb is a well established surgical procedure; nevertheless, as recently published in literature, the results are frequently disappointing not in terms of vitality of the transposed digit, but in terms of quality of function and appearance. Our experience consists of 72 pollicizations performed with the technique of Buck Gramko between 1969 and June 1993. We followed the very strict method of evaluation proposed by Gilbert in which are taken into account the degrees of antep&ion and rotation, the stability of the MP joint, opposition with the long fingers and finally the aesthetic aspect of the new thumb (position, quality of web space, length of thumb). In order to better evaluate the incidental excess growth of thumb, due to incorrect resection of the metacarpal epiphysis we reviewed the patients operated up to 1990. For this reason we present a series of 62 pollicizations (38 monolateral and 12 bilateral). Radial club hand was present in 30 limbs, all previously treated with ulnar centralization (10 bilateral). The average age of pollicization was 3 years and 8 months. Excellent and good results were achieved only in 32 cases(57.6%) according to the Gilbert evaluation scale; these results have been partially improved by secondary operations such as osteotomies, tendon transfers, scar contractures revisions. This low average of good results is mainly due to the association with club hand deformity, where the malformation of the second finger (camptodactyly, tendon absence,joint stiffness) lead to a thumb limited both functionally and aesthetically. With regard to excessgrowth in length, that represent a cause of bad results in a normal pollicized finger, in radial club hand in which joint mobility is very limited, it may be helpful to obtain a better functional pinch despite a poor appearance.
Hand Surgery Division, Sahlgrenska University Hospital, Gothenburg, Sweden
The aim of the surgical treatment of duplicated thumbs is not only to restore the normal number of digits, but also to achieve a well-functioning thumb with a good cosmetic appearance. If the two thumbs are of approximately the same size a BilhautCloquet procedure is often recommended. In this operation a new thumb is constructed by resection of one half of each thumb and fusion of the two other halves including both skeletal and soft tissues. The advantage of this operation, over a single resection of one of the bifid thumbs, is that the reconstructed thumb will be straight and will not deviate during growth. In the original technique the nail of the thumb remained split in the midline. This can be an aesthetic disadvantage and patients also often complain that a split nail is irritating and tends to tear off. To overcome the disadvantage of a split thumb nail we have developed a technique to save the nail bed. Instead of dividing the nail beds of the two thumbs, one of the nail beds is left intact and shared by the two halves of the thumbs. The result is improved not only by saving the whole nail bed, but also by saving the nail groove from one of the thumbs. The operative technique will be described in detail and some results presented.
Index pollicization in congenital deformity. A long-term follow up of 62 cases P. L. Raimondi, M. Petrolati, G. Delaria, A. Ciapparelli Hand Surg(ery Department, Legnano Hospital, Italy
Aetiology of the triphalangeal thumb J. Zguricas, S. E. R. Hovius, D. Lindhout Department of Plastic and Reconstructive Surgery, Academic Hospital, Rotterdam, The Netherlands
Triphalangeal thumb (TPT)-a long, fingerlike thumb with three phalanges instead of two, is regarded as a subtype of preaxial polydactyly. It can occur as a sporadic disorder, but is more often seen as a dominant familial trait. The underlying genetic defect is unknown, but must involve genesthat regulate the differentiation of the developing limb. Definition of the molecular basis for congenital limb deformities can help us establish new classifications on a genetic basis and provide insight into a barely understood pathomorphology of the hand. During the past 10 years 19 children have been treated for triphalangeal thumb in Sophia Childrens Hospital in Rotterdam. Sixteen of those children had a positive family history for this disorder, and all the families had their origin in the same small region in the south-west part of The Netherlands. The patients and their affected relatives had a strikingly similar phenotype varying from an opposable thumb with a deltashaped extra phalanx to a non-opposable index-like digit instead of a thumb. Sometimes this was associated with a preaxial extra ray, rudimentary postaxial polydactyly, and cutaneous syndactyly between the fourth and the fifth digit. Consistency of the phenotype among the families, together with their common geographic and demographic origin, strongly suggests that all affected individuals share the same genetic