Reconstruction for Wassel Type III Radial Polydactyly With Two Digits Equal in Size

doi:10.1016/j.jhsa.2009.07.018

The Journal of Hand Surgery

Volume 34, Issue 10, December 2009, Pages 1802-1807

https://doi.org/10.1016/j.jhsa.2009.07.018 Get rights and content

Purpose

To report the surgical outcomes for Wassel type III radial polydactyly thumbs of equal or nearly equal size treated by excising the radial thumb with augmentation.

Methods

We have reconstructed 15 cases of Wassel type III radial polydactyly, in which the duplicated digits were equal or almost equal in size, by ablation of a radial digit. The distal articular surface of the radial proximal phalanx was preserved in order to maintain stability of the interphalangeal joint. The stability of the retained thumb was further augmented by tendon repositioning, restoration of the radial collateral ligament, and transfer of soft tissues from the radial digit. Eleven of 15 cases were followed up for more than 2 years and were available for assessment using the Japanese Society for Surgery of the Hand evaluation form. The average age at follow-up was 8 years and 3 months. The size of the nail and distal phalanx was measured to assess the growth of the thumb.

Results

An average functional point was 12 points (maximum 14 points), and restricted interphalangeal joint motion and extension lag were the disadvantages of this technique. The width of the distal phalanx was increased from 62% of the size of the metacarpal before surgery to 78% at the final follow-up. The cosmetic score averaged 3.6 (maximum 4 points), and slightly small nails without a central ridge were deemed acceptable.

Conclusions

Our technique can provide a functionally good thumb for Wassel type III radial polydactyly.

Type of study/level of evidence

Therapeutic IV.

Section snippets

Surgical technique

The principle of surgery was excision of the radial thumb and reconstruction of the ulnar thumb. A dorsal curved incision and volar zigzag incision were made for exploration (Fig. 1A). In earlier cases, the dorsal incision was also zigzag in configuration, but it was later changed to a radial curved incision. Tendon excursion of both the extensor pollicis longus (EPL) and flexor pollicis longus (FPL) was examined in order to determine the tendon balance in reconstructing the thumb. The IP

Results

Surgical outcomes for 11 patients are listed in Table 1. The functional point score averaged 12 (maximum 14 points). Stability and alignment of the MCP joint and abduction of the thumb were good in all cases. Less than 20° of malalignment at the IP joint was observed in cases 6 and 7. Less than 20° of instability of the IP joint was observed in cases 6 and 11. Flexion motion was restricted to 60% of the other side in 7 cases (cases 2, 3, 7–11). In another 6 cases (cases 1, 4, 6, 8, 9, 11), less

Discussion

When radial polydactyly is equal in size and shape, both digits are often hypoplastic and thus difficult to reconstruct. The Bilhaut procedure is often applied for these cases. Dobyns et al.¹⁶ stated that the retained thumb should be at least 80% of the normal size. Tonkin et al¹² recommended this procedure when the size of the nail was less than 70% of that of the contralateral nail. Despite being a well-known technique, the details of surgical outcomes by the Bilhaut procedure have not been

References (19)

J.C. Cheng et al.
Polydactyly of the thumb: a surgical plan based on ninety-five cases
J Hand Surg
(1984)
T. Ogino et al.
Long-term results of surgical treatment of thumb polydactyly
J Hand Surg
(1996)
E. Horii et al.
Duplicated thumb bifurcation at the metacarpophalangeal joint level: factors affecting surgical outcome
J Hand Surg
(1997)
D.J. Townsend et al.
Thumb duplication, 66 years' experience—a review of surgical complications
J Hand Surg
(1994)
A. Naasan et al.
Duplication of the thumbA 20-year retrospective review
J Hand Surg
(1994)
P.R. Manske
Treatment of duplicated thumb using a ligamentous/periosteal flap
J Hand Surg
(1989)
M.A. Tonkin et al.
The Bilhaut-Cloquet procedure for Wassel types III, IV and VII thumb duplication
J Hand Surg
(2007)
M. Iwasawa et al.
Long-term results of nail fusion plasty of the duplicated thumb
J Plast Reconstr Aesthet Surg
(2008)
C.A. Goldfarb et al.
Thumb size and appearance following reconstruction of radial polydactyly
J Hand Surg
(2008)

There are more references available in the full text version of this article.

Cited by (27)

Classification of radial polydactyly based on physical characteristics
2024, Pediatrics and Neonatology
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.
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.
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.
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.
Diagnostic Level IV.
Modified Wassel-Flatt Type III Radial Polydactyly: Subtypes and Their Outcomes
2024, Journal of Hand Surgery
We aimed to subdivide modified type III radial polydactyly and evaluate the applied surgical procedures and outcomes according to the subtypes.
This study included 32 thumbs of 32 patients treated for modified Wassel-Flatt type III radial polydactyly from March 2008 to December 2018. Each patient was subclassified into parallel, divergent, and convergent types according to the alignment of the duplicated digit. The parallel type was further divided according to the treatment method applied. The parallel A group comprised patients treated with reconstructing the radial collateral ligament of the interphalangeal (IP) joint after removing only the distal phalanx and preserving the proximal phalanx of the extra digit, and the parallel B group comprised patients treated with excision of the extra digit at the bifurcation site of the proximal phalanx. We evaluated the Japanese Society for Surgery of the Hand scores and radiographic angulation of the IP and metacarpophalangeal joints at a mean follow-up of 38 months.
Fourteen cases were parallel type (6 and 8 in the parallel A and B groups, respectively), 14 were divergent type, and 4 were convergent type. Patients in the parallel A group had significantly better IP and metacarpophalangeal joint angulation and Japanese Society for Surgery of the Hand scores than those in the parallel B group. Patients in the parallel A group had significantly better Japanese Society for Surgery of the Hand scores than those in the divergent and convergent groups.
Reconstructing the radial collateral ligament of the IP joint after removing only the distal phalanx and preserving the proximal phalanx of the extra digit was associated with better outcomes than the excision of the extra digit at the bifurcation site in the parallel type cases. The parallel type treated with proximal phalanx preservation and ligament reconstruction had better clinical outcomes than other types of modified Wassel-Flatt type III radial polydactyly.
Prognostic IV.
Neurovascular Island Flap for Pulp and Nail Augmentation in Thumb Duplication Reconstruction: A Surgical Method With Long-Term Follow-Up
2021, Journal of Hand Surgery
Citation Excerpt :
Iwasawa et al10 recommended meticulous suturing of the nail bed and using only a small piece of cortex from the excised phalanx. Rather than combining the 2 nail beds, Horii et al11 reported the technique of soft tissue augmentation by a skin fillet from the radial thumb to reduce the asymmetry of the pulp. In our series, the improvement in thumb size, reflected by a nail width that is similar to the contralateral thumb, persisted in long-term follow-up.
Pulp and nail atrophy and asymmetry are commonly seen in thumb duplication. In hypoplasia of both digits, conventional reconstruction or Bilhaut-Cloquet procedure and its modifications may not be possible or may lead to a poor cosmetic outcome. The purpose of the study was to review a reconstruction technique with a neurovascular island flap developed to improve the aesthetic and functional results of treatment.
Fourteen patients with thumb duplication aged 8 to 18 months were operated between 2002 and 2013 in our center. All patients had significant hypoplasia and asymmetry of the pulp and nail of the digit planned to be retained. A neurovascular island flap including part of the pulp tissue, nail bed, with or without the associated phalangeal bone, was raised from the planned ablated digit base on its single neurovascular bundle. The nail bed, nail fold, and pulp tissue from the 2 digits were apposed with fine sutures under magnification. All patients were followed to monitor the aesthetic, functional, and radiological outcome.
The mean follow-up period was 7 years, 11 months. Thirteen patients underwent the flap procedure and all flaps survived. In 1 patient, the flap procedure was aborted because the vascular pedicle was not well formed. The nail width and pulp circumference were restored to a similar size as the contralateral thumb.
In selected cases of thumb duplication with significant pulp hypoplasia and nail asymmetry, the neurovascular island flap is a safe and effective means to restore size and symmetry.
Therapeutic IV
Reconstruction of Wassel IV-D radial polydactyly with a boot-shaped neurovascular island flap: A Consecutive series of 91 thumbs
2020, Journal of Plastic, Reconstructive and Aesthetic Surgery
Reconstruction of Wassel IV-D radial polydactyly is challenging and requires a custom strategy dependent on the relative size and shape of the radial and ulnar duplicates. Herein, we describe a technique using a boot-shaped neurovascular island flap and review our outcomes.
Ninety-one consecutive patients had reconstruction with a boot-shaped neurovascular island flap. The flap was dissected out from the thumb to be removed. Specific flap modifications were inclusion of the lateral nail fold, Bruner incisions dorsally and volarly to reduce scarring at the interphalangeal (IP) joint and also complete mobilization of the island flap on its pedicle to allow easier inset. A flexor pollicis longus and extensor tendon rebalancing technique was used to correct the deviation of the reconstructed thumb IP joint.
All boot-shaped neurovascular island flaps survived with good contour, shape, and symmetry. The average follow-up period was 25 months (range 6–60 months). Using the Japanese Society for Surgery of the Hand (JSSH) score for classification of outcomes, seven cases were classified as excellent and 84 cases as good. The median JSSH score was 18. The median Kapandji score for opposition was 9 (range 8–10).
Using a boot-shaped neurovascular island flap completely mobilized on its pedicle with a custom strategy for each radial duplicate, good outcomes can be achieved in reconstruction of Wassel IV-D radial polydactyly.
Therapeutic Level IV
Nail size and appearance following nail fusion plasty of thumb duplication <sup>✰</sup>
2019, Journal of Plastic, Reconstructive and Aesthetic Surgery
To evaluate nail appearance after nail fusion plasty to treat thumb duplication.
A modified form of nail fusion plasty was performed on 17 reconstructed thumbs of 16 children with thumb duplications, commencing in January 2010. We assessed nail width and nail, lunular, and nail fold deformities using the Wang-Gao scoring system. All 17 thumbs were evaluated over an average of 32 months (range, 12–48 months) of follow-up.
One patient with bilateral thumb deformities was excluded. The width ratios of 15 reconstructed nails (compared with those of the contralateral thumbs) were 82–118% (average, 97%). Nine thumbs exhibited nail ridges or gaps; the average ridge/gap score was 1.23 (maximum, 2). Six thumbs exhibited lunular deformities; the average score was 1.58 (maximum, 2). Another six thumbs evidenced nail fold deformities; the average score was 1.64 (maximum, 2). Only one thumb exhibited nail dehiscence. Two thumbs had no nail deformity. The final assessments were excellent in 14 cases, good in 2 cases, and fair in 1 case.
We could not significantly reduce the deformity rate of the nail plate, nail fold, or lunula using our new technique, but the deformities were much less marked than previously. Nail fusion plasty usefully enlarges the nail and pulp in patients with hypoplastically duplicated thumbs.
On-top and side-to-side plasties for thumb polydactyly
2017, International Journal of Surgery Case Reports
Citation Excerpt :
The parents were satisfied with the outcome. Although there are numerous papers in the literature written on the management of thumb polydactyly [3–10], we could not find any detailed results of the “on-top” plasty. Our first case had detailed functional results with long term follow-up.
“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.
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.
We could not find similar cases in the literature with detailed long-term postoperative results.
“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.

View all citing articles on Scopus

: No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

View full text

Scientific articleReconstruction for Wassel Type III Radial Polydactyly With Two Digits Equal in Size

Purpose

Methods

Results

Conclusions

Type of study/level of evidence

Section snippets

Surgical technique

Results

Discussion

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Plast Reconstr Aesthet Surg

J Hand Surg

Scientific article
Reconstruction for Wassel Type III Radial Polydactyly With Two Digits Equal in Size