Pulgarización del índice en el tratamiento de la hipoplasia de pulgar: técnica quirúrgica / Index finger pollicization in the treatment of thumb hypoplasia: surgical technique

La pulgarización del dedo índice permite reconstruir la pinza de la mano. Fue ampliamente realizada para una reconstrucción de una pérdida de pulgar en condiciones de trauma. Sin embargo, hoy por hoy, es la técnica de elección para las hipoplasias congénitas de pulgar. En los niños permite crear una pinza, especialmente para objetos grandes y entrega una apariencia más normal de la mano. Es una técnica demandante, pero con pasos que están bien definidos y perfeccionados, que al ser realizados de forma cuidadosa, reducen al mínimo sus complicaciones.

The pollicization of the index finger allows reconstructing the hand's ability to pinch. It has been broadly used to address traumatic loss of the thumb. However today it is the procedure of choice for severe congenital thumb hypoplasia. It allows children to pinch, particularly large objects, it also gives the hand a more normal appearance. It is a demanding procedure, with a series of technical steps that are well defined and perfected, such that if they are performed in a careful way, complications are minimized.

Surgical Treatment of Congenital Hypoplasia of the Thumb / 대한정형외과학회잡지

PURPOSE: We evaluated the results and complications of surgical treatment for congenital thumb abnormalities. MATERIALS AND METHODS: Between 2002 and 2011, nine thumbs were surgically treated (Pusan National University Hospital, Busan, Korea). There were five males and four females. The mean age of patients at the time of operation was 4.7 years (seven patients were under five years old and two patients were over 10). Five cases of Blauth type V hypoplasia (aplasia) were treated by pollicization (using the Buck-Gramcko technique). Four cases of type I or II hypoplasia were treated by opponensplasty and tendon transfer (for extensor and abductor augmentation). The Mehta scoring system was used for analysis of outcomes. RESULTS: Among nine cases, outcomes were good in five cases, fair in three cases, and poor in one case. Second operations were required due to muscle weakness and metacarpo-phalangeal joint subluxation in three cases of aplasia and one case of hypoplasia. In all cases, the range of active abduction of the thumb was more than 40degrees and pinch power was at least 40% of that on the normal side at the latest follow up. CONCLUSION: Surgical reconstruction using pollicization and opponensplasty for congenital thumb aplasia and hypoplasia, with additional surgery for muscle weakness, provided good results both functionally and cosmetically.

Reconstruction of Mutilating Hand with Pollicization and Anteromedial Thigh Perforator Free Flap: A Case Report

PURPOSE: Thumb reconstruction plays most important role in hand injuries because total loss of a thumb constitutes about 40% disability in the hand. The reconstruction can be accomplished by pollicization, free toe-to-thumb transfer, wrap around procedure and lengthening extraction. However, we sometimes need consecutive or double free flaps in the reconstruction of mutilating hand injuries. METHODS: We reconstructed a mutilating hand injury in a 54-years old man. Because of severe crushing injury of right thumb and index fingers, we reconstructed a thumb with pollicization using nearly amputated middle finger. Although it survived completely, the adjacent soft tissues which had been covered by fillet flap from the space past was necrosed on 1 month. We debrided the necrotic tissues and covered it with anteromedial thigh perforator free flap consecutively because he had an anatomical variation in branches of lateral femoral circumflex artery. RESULTS: He had an uneventful postoperative course without any complication such as infection, dehiscence and flap necrosis. Three months later, he had undergone tenolysis and defatting procedure of flap site. He recovered the some amount of grip function and was happy with the result. CONCLUSIONS: In severe hand trauma including thumb amputation, thumb reconstruction using pollicization and perforator free flap could be an alternative option. It provides minimal donor site morbidity and an acceptable functional result.

Pollicization: The Concept, Technical Details, and Outcome

Pollicization substitutes a functioning finger for a deficient thumb. The most indication is thumb hypoplasia with absence or instability of the carpometacarpal joint. However, there are additional causes that may negate thumb function, such as trauma, macrodactyly, multi-fingered hand, and a mirror hand. The technique of pollicization represents a consolidation of contributions from surgeons over the last 100 years. A meticulous stepwise approach from incision to closure is necessary to optimize outcome. Following pollicization, cortical plasticity and motor relearning play a pivotal role in function following pollicization with connections and adjacent sprouting from nearby cortical and/or subcortical territories. Occupational therapy is necessary to encourage large object acquisition followed by smaller objects and ultimately fine pinch. Pollicization is more reliable in patients with isolated thumb hypoplasia and a mobile index finger with robust extrinsic and intrinsic muscle-tendon units compared to and patients with radial forearm deficiencies and diminished index mobility.

Pollicization: The Concept, Technical Details, and Outcome

Pollicization substitutes a functioning finger for a deficient thumb. The most indication is thumb hypoplasia with absence or instability of the carpometacarpal joint. However, there are additional causes that may negate thumb function, such as trauma, macrodactyly, multi-fingered hand, and a mirror hand. The technique of pollicization represents a consolidation of contributions from surgeons over the last 100 years. A meticulous stepwise approach from incision to closure is necessary to optimize outcome. Following pollicization, cortical plasticity and motor relearning play a pivotal role in function following pollicization with connections and adjacent sprouting from nearby cortical and/or subcortical territories. Occupational therapy is necessary to encourage large object acquisition followed by smaller objects and ultimately fine pinch. Pollicization is more reliable in patients with isolated thumb hypoplasia and a mobile index finger with robust extrinsic and intrinsic muscle-tendon units compared to and patients with radial forearm deficiencies and diminished index mobility.

Surgical Correction of Hexadactyly: Innovation of New Technique and Its Application

PURPOSE: Hexadactyly without thumb is a rare congenital anomaly of the hand where six triphalangeal digits are symmetrically distributed without thumb. Contrary to mirror hands, triphalangeal six digits are symmetrically distributed on each side at the midline with well-differentiated carpal bones, extensor tendons, one ulna and one radius. The authors developed a new surgical technique based on a three-dimensional concept to correct the hexadactyly and applied to 2 cases of hexadactyly with good functional and aesthetic results. Here we document the surgical technique and its result. METHODS: A 16 month old male patient visited our clinic with chief complaints of bilateral hexadactyly deformity. On physical examination most radial first and second digits showed no opposition and adduction motion on both side hands. Radiography showed 6 triphalangeal digits with normal development of carpal, radial and ulnar bone. Right side abnormality was corrected by removal of most radial side extra-digit, rotation and migration of 2nd ray to thumb position and creation of 1st web by transposing a mid-palm based rectangular palmar flap as in Snow & Littler procedure which has been being applied for correction of 1st web syndactyly in cleft hand deformity. Seven months later, left side abnormality was also corrected with the same procedure. RESULTS: Postoperative appearances of the both hands were satisfactory. Flexion, extension, opposition and grasping were possible with the pollicized 2nd ray. Pinching power was 3.0kg 15 months after the surgery and 2.5kg 22 months after in right hand respectively. CONCLUSION: In correction of hexadactyly deformity, satisfactory aesthetic and relevant functional results can be expected with authors' newly developed technique: removal of most radial digit, rotation and migration of 2nd digit to thumb position as well as creation of the 1st web space by transposition of mid-palm based rectangular flap.

Phocomelia: The Clinical Manifestation, Classification and Surgical Treatment of Korean Patients with Phocomelia / 대한정형외과학회잡지

PURPOSE: Phocomelia is an extremely rare congenital anomaly of the upper extremity. There have been no clinical reports about phocomlia in Korea except for five birth reports. We present here the clinical features, classifications and surgical treatments of our phocomelia cases. MATERIALS AND METHODS: From January 1993 to August 2007, seven patients were diagnosed as having phocomelia in 9 upper extremities at our clinic. Surgical treatments were performed for five patients on their hand anomalies. We retrospectively reviewed the medical records and radiographs of our cases, and we tried to classify them by the previously suggested systems. We evaluated the functional improvement and measured the VAS scale for parental satisfaction with the operative outcomes. RESULTS: We could not find any problems during the fetal periods or any hereditary features. The bilaterally-affected patients also had deformities of the lower extremity, while the unilaterally-affected patients did not. We couldn't classify our cases according to the Frantz and O'Rahilly system. We found that the classifications suggested by Tytherleigh-Strong and Hooper (2003) and Goldfarb et al. (2005) could be promising alternatives for classification. One upper extremity was classified as type A, one as type B, and 7 as type C by Tytherleigh-Strong and Hooper's system. Using the Goldfarb's system, two upper extremities were classified as proximal radial longitudinal dysplasia, and seven were classified as proximal ulnar longitudinal dysplasia. Three patients who underwent pollicization showed opposition and tip pinch. Two patients who underwent syndactyly division could do lateral pinch. The VAS scale for parental satisfaction with the functional improvement averaged 8.2 postoperatively. CONCLUSION: The bilateral cases had different clinical features from unilateral ones. Phocomelia could not simply be classified by the Frantz and O'Rahilly system, and it may not be a true transverse intercalary deficiency. We could gain functional improvement after operations on the hand anomalies.

Pollicization of Patients with more than Buck-Gramcko Grade IV Congenital Hypoplasia of the Thumb / 대한정형외과학회잡지

PURPOSE: Thumb hypoplasia gives rise to various derangement of hand functions, leading to various degrees of malformation. The treatment of choice for grade IV or V congenital hypoplasia of the thumb, classified by Buck-Gramcko's criteria, is the pollicization of the index finger. The purpose of this article is to review the clinical usefulness of pollicization for more than grade IV hypoplasia. MATERIALS AND METHODS: Three grade IV and 3 grade V hypoplastic thumbs in 6 patients, one with radial club hand, were reviewed retrospectively. They underwent pollicization between 1987 and 1997. The index metacarpi were osteotomized for shortening and readjusted by pronation. To evaluate postoperative function, authors used the criteria of Sundararaj and Mani. RESULTS: Except for the exclusion of one patient, four had excellent and one had good functional statuses. CONCLUSION: Pollicization was considered to be worthwhile for functional improvement of the hands in more than grade IV congenital hypoplasia of the thumb.

Clinical experiences in Thumb reconstruction / 대한정형외과학회잡지

The reconstruction of a mutilated thumb is one of the most fascinating aspect of hand surgery. The hand deprived of the thumb loses approximately 40 per cent of its function. it corresponds to a total body loss of 22 per cent, which is compatible with the loss of an eye. Recently reconstructive operations were performed for the restoration of the mobility, sensibility, and length of thumb. 4-flap Z-plasty were performed for the skin contracture in the first web space. For the sensibility, we transferred the neurovascular island flap from the middle or ring fingers. And we reconstructed the loss of thumb by pollicization, microsurgical reattachment, and toe-to-thumb transfer operation. We selected 11 cases who were followed over one year after operation.

Pollicization: Two Cases report / 대한정형외과학회잡지

Absence of the thumb, either traumatic or congenical, causes a severe deficiency in hand function; in fact grasp and pinch are almost impossible. Thus when the thumb is partially or totally absent, reconstructive surgery is appealing. Usually the thumb should be reconstructed only when amputation has been at the metacarpophal-angeal joint or at a more proximal level. The procedures for reconstruction of the thumb are well known. They include transposition of a digit, procedures to lengthen the thumb metacarpal and methods of total reconstruction including a pedicle graft to obtain sensibility. Although pollicization (transposition of a finger to replace an absent thumb) endangers the finger, that is worthwhile, especially in complete bilateral absence of the thumb or in bilateral traumatic amputation. The each finger with a part or the whole of the metacarpal, has been transplanted to the stump of the metacarpal of the thumb or the trapezium. When all of the fingers are normal, the index finger is the best choice for thumb replacement because of its circumferential size, phalangeal length, independent motion and proximity to the thenar eminence. Recently this operation has been done with conservation of all nerves, vessels, tendons and muscles. We have had two pollicization operations (transposition of index finger) in the patient of bilateral traumatic amputation of the thumbs. Four months later excellent pinch and grasp with normal sensibility in the reconstructed thumbs were obtained with all remaining digits.