Radiographic Features of the Metacarpal in Blauth Type III Thumb Hypoplasia.

PURPOSE: The purpose of this study was to investigate whether radiographs can be used to aid in the determination of Blauth IIIA and IIIB thumbs. METHODS: Six pediatric hand surgeons were asked to evaluate the radiographs of 77 thumbs and classify the thumb as IIIA or IIIB and indicate which morphologic features influenced their decision. Quantitative measurements and ratios of radiographs were obtained and compared between IIIA and IIIB thumbs. RESULTS: The radiographic features selected for type IIIA thumbs include near-normal length and near-normal width and for type IIIB thumbs, abnormally short, tapered proximal end, and round proximal end. The six surveyed surgeons reached consensus in 82% (63/77) of thumbs, and this matched the enrolling surgeon's classification in 77% (59/77) cases. The ratio of the length of the thumb metacarpal compared with the length of the index metacarpal was different between IIIA and IIIB thumbs (66% ± 0.08% and 46% ± 0.18%, respectively). The ratio of the width of the thumb metacarpal shaft at its narrowest aspect to the width of the thumb metacarpal base was notably different between IIIA and IIIB (68% ± 0.13% and 95% ± 0.28%, respectively). CONCLUSIONS: Near-normal length and near-normal width of the metacarpal were used to predict IIIA and abnormally short, abnormally narrow, and a round or tapered base of the metacarpal were used to predict IIIB classification. The length of the thumb metacarpal relative to the index metacarpal is on average 66% of the length of the index metacarpal in IIIA thumbs compared with 46% in IIIB thumbs. The width of the shaft of the thumb metacarpal at its narrowest is 68% of the width of the thumb metacarpal base in IIIA thumbs, indicating a flared base. In IIIB thumbs, the shaft width was on average 95% of the base width, indicating a tapered base. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic level III.

The Effects of Radial Longitudinal Deficiency on Long-Term Use of the Thumb in Pediatric Patients Following Index Pollicization.

PURPOSE: To assess the effect of radial longitudinal deficiency on the function of pollicized digits as determined by the Thumb Grasp and Pinch (T-GAP) assessment. METHODS: We retrospectively evaluated 25 hands with thumb hypoplasia that underwent index finger pollicization. Patients were followed for an average of 10.4 years. Hands were divided by severity into two groups: no or mild radial longitudinal deficiency (RLD) (Group 1 = 16) and moderate to severe RLD (Group 2 = 9). We collected demographic information and completed physical examination measures, including hand strength, elbow, wrist, and hand range of motion, the Kapandji opposition score, active grasp span, and T-GAP total score. RESULTS: Patients with moderate to severe forms of RLD had stiffer long fingers, lower Kapandji opposition scores, and limited active and passive range of motion for elbow flexion, wrist ulnar deviation, and pollicized thumb interphalangeal flexion. They had shorter forearms, decreased active grasp span, and fewer thumb creases at the interphalangeal thumb joint. In addition, the T-GAP total score was significantly lower when comparing the two groups. Children with mild dysplasia were able to achieve 32% of age-matched normal grasp strength. Patients with more severe radial dysplasia averaged 17% less grasp strength compared with children with mild dysplasia. Patients with moderate to severe RLD also had lower T-GAP total scores and strength measurements if they had limited wrist ulnar deviation. CONCLUSIONS: Individuals with moderate to severe RLD have unique anatomical factors that affect outcomes after pollicization. These individuals use their thumbs for fewer activities, have weaker grasp, and retain more primitive grasp patterns compared with those who have milder forms of RLD. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Long-Term Functional and Radiological Results in Tonkin Type 3B Thumb Hypoplasia Treated With Nonvascularized Toe Phalanx Transfer as an Alternative to Pollicization.

PURPOSE: Parents of children with hypoplastic thumbs often reject the option of pollicization for various reasons and enquire about alternate choices. Our study aimed to assess the outcome in children who underwent nonvascularized toe phalanx transfer for Tonkin type 3B thumb hypoplasia and compare it with a similar cohort of children treated with pollicization. METHODS: At an average follow-up of 7 years for toe phalanx transfer and 6 years of pollicization, five children from each group were tested for thumb length, stability of the first carpometacarpal (CMC) joint, mobility, opposition, and donor-site morbidity. Parents were asked to report improvements in function and appearance. All cases were Tonkin type 3B thumb hypoplasia. RESULTS: The CMC joint was found to be stable in all children, and the Kapandji score was 6 in 3 children and 5 in 2 children with toe phalanx transfer compared to 9 in all children with pollicization. The average palmar abduction was 24°, and the average radial abduction was 36° in the toe phalanx transfer group compared to 40° and 45°, respectively, in children with pollicization. The average thumb length was 50.8% of the index finger's proximal phalanx in the toe phalanx group compared to 60 % in the pollicization group. The mean visual analog scale scores for the thumb's function and appearance were 6.8 and 6.4, respectively, compared to 9.2 and 8.8, respectively, in the pollicization group. No resorption was noted in the donor phalanx at a mean follow-up of 7 years with no donor-site morbidity other than mild shortening of the toes. CONCLUSIONS: We noted increased palmar abduction and radial abduction in the pollicization group. No resorption was noted in the donor toe phalanx at the longest follow-up of 9 years. Toe phalanx can be considered an alternative for those children in whom a five-finger hand is a priority. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Does Preservation of Metacarpophalangeal Joint Vascularity Protect Against Physeal Arrest in Index Finger Pollicization?

PURPOSE: To determine whether preservation of blood supply to the index metacarpophalangeal joint decreases the rate of physeal arrest. METHODS: A retrospective review of 41 pollicized digits in 35 patients with 2-year minimum radiographic follow-up was conducted at a single institution. Other complications evaluated included nonunion at the pollicized digit base and clinical instability at the new carpometacarpal joint. Findings were compared to historical controls, which were performed by our group prior to routine identification and sparing of the metacarpophalangeal joint blood supply. No other modifications to surgical technique were made between the previous and current patient cohorts. RESULTS: Two pollicized digits in two different patients had radiographic evidence of physeal arrest, one of which was partial and the other complete, for an arrest rate of 4.9%. This was significantly less than the arrest rate in our historical cohort of 24.7% (21 of 85 patients). Five patients did not have radiographic bony union at the base of the index metacarpal, but only one patient had clinical instability at the new carpometacarpal joint. CONCLUSIONS: Significantly fewer patients who underwent index finger pollicization with preservation of the metacarpophalangeal joint blood supply went on to develop physeal arrest when compared to patients who underwent pollicization prior to adoption of this technique. This finding suggests that sparing of the physeal blood supply is preventative against proximal phalanx physeal arrest. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Bilateral ST-coalition with thumb hypoplasia and scaphoid synchondrosis.

Carpal coalitions are rare wrist anomalies and are most often diagnosed incidentally. Due to their infrequent occurrence, there is a lack of treatment guidelines in the literature. We present a case study of a 13-year-old boy who presented with symptomatic synchondrosis in both scaphoids along with a bilateral osseous coalition between the scaphoid and trapezium bones in combination with bilateral thumb hypoplasia. We initiated a 10-week immobilization of the wrist, followed by gradual increasing weight-bearing. The patient showed significant symptom relieve after immobilization, further supporting the conservative treatment. In conclusion, a definitive treatment recommendation cannot be made. For young patients, we suggest initiating conservative treatment as the first option. A precise analysis of the pathology and wrist kinematics is mandatory to recommend further therapy especially if operative interventions might be considered.

Validity and Reliability of the Thumb Grasp and Pinch Assessment for Children After Reconstruction of Congenital Hypoplastic Thumbs.

PURPOSE: The Thumb Grasp and Pinch Assessment (T-GAP) is a new instrument for evaluating thumb use in children with congenital hypoplastic thumbs. The assessors video-record the children while they perform nine specific activities and score their grasp types using T-GAP. A high T-GAP score indicates more mature grasp patterns. The developers reported the instrument's validity and reliability for index finger pollicization. This study investigated T-GAP's validity and reliability in children with reconstructed hypoplastic thumbs. METHODS: Four hand surgeons and two hand therapists from two hospitals rated video clips of 20 Manske type II and IIIa hands twice in 17 patients who performed the T-GAP at least 1 year after opposition transfer and thumb ligament reconstruction. To investigate the validity, we calculated correlation coefficients for T-GAP scores and clinical outcomes, including thumb ROM, grip and pinch strength, and visual analog assessments of thumb function and appearance. To estimate T-GAP's inter- and intrarater reliability, we calculated intraclass correlation coefficients and their 95% confidence intervals (CIs). RESULTS: Thumb Grasp and Pinch Assessment score showed a strong linear correlation (r = 0.815-0.944) and a moderate to strong nonlinear correlation (ρ = 0.527-0.744) with visual analog scale assessments of thumb function and appearance, respectively; a moderate nonlinear correlation (ρ = 0.464) with grip strength; and a moderate nonlinear correlation (ρ = 0.541) with thumb MCP joint range of motion. The intraclass correlation coefficient for the interrater reliability was 0.892 (95% CI, 0.768-0.954) in round 1 and 0.898 (95% CI, 0.754-0.959) in round 2, and for intrarater reliability, the mean was 0.882 (95% CI, 0.785-0.980). CONCLUSIONS: Thumb Grasp and Pinch Assessment score had a moderate to strong construct validity and a moderate concurrent validity. Both inter- and intrarater reliability was strong. CLINICAL RELEVANCE: This study supports the T-GAP instrument's validity and reliability for assessing functional outcomes in congenital hypoplastic thumb reconstruction.

Nonvascularized Iliac Crest Bone Graft for Reconstruction of the First Metacarpal in Type IIIB Thumb Hypoplasia: A Radiographic Follow-Up Study.

PURPOSE: To present a radiographic follow-up study of the use of a nonvascularized iliac crest bone graft as a treatment for modified Blauth type IIIB thumb hypoplasia. METHODS: From January 2015 to December 2019, nonvascularized iliac crest bone grafts were used to reconstruct the first metacarpal in 23 cases with type IIIB thumbs. The average follow-up duration was 1.9 years (range 1.0-3.9 years). We evaluated the patients' serial x-rays and measured the width and length changes of the reconstructed first metacarpals. RESULTS: Survival of the graft, judged radiographically, was achieved in 20 cases (20/23, 87%), with an average reduction of 33% in the width of the graft. Shortening of the graft (average 2.3 mm, range 0.1-5.6 mm) was noted in 11 of the 20 cases, and an increase in the length of the graft (average 4.2 mm, range 0.7-8.6 mm) was observed in the other 9. Bone graft failure (3/23, 13%) occurred in 3 cases because of significant bone resorption. CONCLUSIONS: For type IIIB thumb hypoplasia, a nonvascularized iliac crest bone graft was a feasible method to reconstruct the first metacarpal, with a 13% risk of graft failure, 33% average reduction in graft width, and 55% reduction in graft length. However, in cultures that value the preservation of a 5-digit hand, this technique may provide an alternative to excision with index pollicization. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Outcome After Pollicization for Congenital Thumb Deficiency: A Cohort Study of Cases in a Single Unit, 1987 to 2016.

PURPOSE: To investigate the functional and aesthetic outcomes in a cohort with pollicizations performed due to congenital anomalies in our hospital. METHODS: From 1987 to 2016, we performed pollicizations in 32 hands of children aged 1 to 8 years (median, 2 years). We followed-up on 31 of the hands from 1 to 31 years (median, 10 years) after the procedure. The participants and their caregivers self-assessed their function and appearance with visual analogue scales and patient-reported outcome measures (Patient-Reported Outcomes Measurement Information System Pediatric Upper Extremity; the short version of the Disability of Arm, Shoulder and Hand Outcome Measure; and EQ-5D-3L). We examined the hands with regard to motion, strength, sensitivity, and function. RESULTS: There were 2 complications and 6 reoperations. Participants with mild anomalies (radial longitudinal deficiency Bayne type N/0 to 2) had better subjective and objective hand function than participants with severe anomalies (radial longitudinal deficiency Bayne type 3-4, ulnar dimelia, 5-finger hand). Hands with preoperatively near-normal index fingers had, in most cases, good thumb opposition and pinch, and hands in both groups benefited from the creation of a cylinder grip. Grip and pinch strength were lower than reported in cohort studies where an additional opponensplasty had been performed. CONCLUSIONS: Hands with severe congenital anomalies also benefited from the procedure. We recommend a simplified follow-up program to identify cases where additional surgeries to enhance strength should be considered during growth of the child. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Defining Features of Hand Anomalies in Severe Thumb Hypoplasia: A Classification Modification.

PURPOSE: To investigate morphologic hand anomalies in children with severe but unclassifiable forms of thumb hypoplasia and radial-sided hand deficiency. METHODS: We identified 15 extremities in 13 patients with severe thumb hypoplasia and associated absent radial-sided digits through the Congenital Upper Limb Differences registry. All patients had forearm involvement. Medical records, clinical photographs, and radiographs were evaluated. Radial longitudinal deficiency (RLD) and thumb hypoplasia were classified according to the Bayne and Klug classification and modified Blauth classification, respectively. Unusual or defining associated hand characteristics were identified and categorized. RESULTS: The most common type of forearm abnormality was absence of the radius (Bayne and Klug type IV), which was present in 10 extremities in the cohort. All 15 extremities had absent thumbs with loss of additional digits. In 6 patients, RLD was part of a syndrome (46%). CONCLUSIONS: Severe forms of thumb hypoplasia in RLD are uncommon. We propose a further modification of the Blauth classification of thumb hypoplasia, type VI, for improved communication regarding this severe type of radial deficiency involving the hand. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Treatment of Blauth Type IIIB Thumb Hypoplasia Using a Nonvascularized Toe Phalanx.

PURPOSE: The purpose of this study was to evaluate surgical outcomes of thumb preservation surgery for Blauth type IIIB hypoplastic thumbs using a nonvascularized toe phalanx to reconstruct the carpometacarpal joint. METHODS: We reviewed the records of 12 patients with Blauth type IIIB thumb hypoplasia who underwent nonvascularized toe proximal phalanx transfer from the fourth toe. Stability and mobility of the thumb, lateral pinch power, and the percentage of the thumb length relative to the index finger proximal phalanx were evaluated. Outcomes were also assessed with the Functional Dexterity Test, a visual analog scale for daily use of the operated thumb, and for overall functional and appearance satisfaction of the parents. RESULTS: Age at operation ranged from 0.9 to 11 years (mean, 3.0 years; median, 1.5 years). The mean follow-up period was 7.6 years (minimum, 3 years). Secondary reconstruction was planned in all 12 patients, but 2 families did not desire a second surgery. Secondary reconstruction consisted of tendon transfer for opposition, adduction, and/or extension of the reconstructed thumb and/or realignment surgery of the thumb axis by arthrodesis or corrective osteotomy. Eleven patients had good carpometacarpal joint stability. Thumb opposition was possible to the little finger in 7, to the middle finger in 3, and not possible in 2 patients. The mean lateral pinch strength was 18% of the contralateral normal side. The relative length of the thumb was 57% of the index finger. Time in seconds to complete Functional Dexterity Test was 83 seconds in the affected side and 38 seconds for the contralateral side. The visual analog scale suggested parental satisfaction for both the appearance and the function. The parents felt that their child used the reconstructed thumb more frequently when manipulating large objects than when manipulating small objects. CONCLUSIONS: Nonvascularized toe phalanx transfer is a useful procedure to preserve the thumb in Blauth type IIIB thumb hypoplasia. It provides a mobile, stable thumb that is functionally useful for the child and satisfying for the family. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Thumb Hypoplasia Occurring in Patients With Preaxial Polydactyly.

PURPOSE: Thumb polydactyly and thumb hypoplasia are generally regarded as separate clinical entities. However, several case reports indicate that hypoplasia of both the thumb and the radius can occur in patients with thumb polydactyly and improved understanding of the genetics of the developing upper limb may give an embryologic explanation for this occurrence. Our hypothesis was that patients with preaxial polydactyly can have ipsilateral thumb hypoplasia that may not be recognized until after surgical reconstruction of the extra digit. METHODS: We searched our surgical database for all procedures performed on patients with a diagnosis of preaxial polydactyly between 2002 and 2014. We reviewed the medical record for demographic data, surgical procedures, and follow-up information. In addition, all available radiographs were reviewed. Through this, we identified patients with a diagnosis of ipsilateral thumb hypoplasia, including when in the course of treatment the diagnosis was made, and any related subsequent procedures. RESULTS: We reviewed 132 patients who underwent reconstruction of thumb polydactyly, 10 of whom were identified as having evidence of ipsilateral thumb hypoplasia, an incidence of 8.2%. The diagnosis of thumb hypoplasia was made before surgery in 3 of the 10 patients. One additional patient was noted to have a duplicate thumb on one side and a hypoplastic thumb on the contralateral side. CONCLUSIONS: This study supports the hypothesis that children with preaxial polydactyly can have ipsilateral thumb hypoplasia that may not be noted before surgery. In this study group, 8% of patients with preaxial polydactyly had ipsilateral hypoplasia. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

[Pollicization in the management of congenital hypoplasias and aplasias of the thumb, functional results, about 13 cases]. / Pollicisation dans la prise en charge des hypoplasies et aplasies congénitales du pouce, résultats fonctionnels, à propos de 13 cas.

INTRODUCTION: Pollicization of the index finger as a treatment for aplasia and severe congenital thumb hypoplasia remains a demanding surgical procedure. In aplasias, it is generally well-accepted, less in hypoplasias. However, it is often the only solution to give back to the child the possibilities of a pollici-digital grip, guaranteeing an excellent function of the hand. We decided to evaluate the long-term results of this intervention. MATERIAL AND METHODS: We reviewed all children operated of index pollicization for a congenital aplasia or hypoplasia of the thumb between 2006 and 2018. The evaluation was performed with a specialized reeducator. The analytical and functional characteristics of the neo-thumbs were evaluated, as well as the consequences on the daily life of the child. RESULTS: Thirteen pollicisations were performed on 10 patients. The mean age at surgery was 21 months (10; 43). It was a Blauth stage IIIB in 1 case, IV in 5 cases, and V in 7 cases. Seven children, and eight hands, could be evaluated. The average postoperative follow-up was 6.5 years. The mean age at the examination was 7.7 years (3.3, 12.1). The mean Percival score was 18 out of 22. The adapted video-assisted scoring system had an average score of 11 out of 14. Children described a momentary psychosocial discomfort for 5 of them, and still present in 3 of them. CONCLUSION: The pollicization of the index finger in congenital aplasia or severe hypoplasia (stage IIIB and IV) of the thumb remains for us the only way to create a sensitive thumb, mobile, with satisfactory strength and appearance, and to bring a normal function of the hand. The evaluation of our functional results are good to very good in the majority of patients, and show the benefits give by this intervention.

Restoration of Five Digit Hand in Type III B & C Thumb Hypoplasia-A Game Changer in Surgical Management.

Background Hypoplasia of thumb is the second common congenital difference of the thumb, next only to duplication. It may occur as an isolated hand difference or as a part of radial longitudinal deficiency. In approximately 60% of these children, the radius shows hypoplasia. The incidence of thumb hypoplasia is one in 100,000 live births. In 50% of these children, the other hand will also have similar deficiency, although variable in severity. Hypoplasia of thumb has been classified into five major categories, according to the increasing severity of hypoplasia. Type III hypoplasia of thumb is characterized by skeletal hypoplasia involving the first metacarpal and carpometacarpal joint, absent intrinsic muscles and rudimentary extrinsic muscles. It was further subclassified into types A, B & C. Type III B, described by Manske and McCarroll, involves extensive deficiency of extrinsic and intrinsic musculature with aplasia of the metacarpal base. Type III C, described by Buck-Gramcko, has hypoplastic metacarpal head. Methods It is widely believed that reconstruction of Type III B & C hypoplastic thumb will not be functionally useful, and they are often included in the indications for pollicization in thumb hypoplasia. In India, we frequently come across parents, who are not willing to remove the hypoplastic digit. This forced us to find out a way to reconstruct the hypoplastic thumb into a functionally useful digit. We describe our surgical technique of reconstruction of hypoplastic thumbs and our experience in utilization of the technique in five children with Type III B & C hypoplasia of thumb. Carpometacarpal joint of thumb was reconstructed and stabilized with a toe phalangeal transfer in the first stage and an opponensplasty was done in the second stage to improve movement. Results In all the five operated children, our surgical technique yielded a stable thumb which was functional. The donor site morbidity was acceptable. The parents were satisfied with the appearance and functional improvement. Conclusion Surgical reconstruction of hypoplastic thumbs of Type III B & C is possible, and conversion of these poorly developed remnants into a useful digit by our surgical technique is a gamechanger in the management of thumb hypoplasia.

Feasibility of Ultrasound in Infant Wrist and Thumb Imaging.

OBJECTIVES: To determine the feasibility of ultrasound (US) in infant lateral carpal and base-of-the-thumb imaging. We hypothesized that US would be a practical modality for visualizing the unossified structures. METHODS: Institutional review board approval was obtained for this single-center pilot study. Healthy infants aged 12 months or younger were enrolled. Ultrasound examinations of the distal radial epiphysis through the first metacarpal were performed with a high-frequency transducer. RESULTS: Ultrasound evaluations of the base of the thumb were performed in 18 healthy infants (mean age ± SD, 13.8 ± 9.1 weeks; 44% female). Assuming an elliptical shape, the mean areas of the scaphoid and first metacarpal epiphysis measured 0.85 ± 0.19 and 0.44 ± 0.087 cm2 , respectively. The mean areas of the trapezium and ossified first metacarpal as approximate rectangular shapes measured 0.23 ± 0.069 and 0.49 ± 0.16 cm2 . A perimeter tracing was also used as an alternative area calculation. The mean trapezium area-to-scaphoid area ratio (0.28 ± 0.10) showed less variability compared to the first metacarpal epiphysis area-to-scaphoid area ratio (0.55 ± 0.20) or first metacarpal area-to-scaphoid area ratio (0.64 ± 0.31). CONCLUSIONS: Our data suggest that US is well suited for the evaluation of the lateral carpus and base of the thumb in young infants. These data serve as a reference to which wrist and thumb abnormalities can be compared.

Pollicization of the Index Finger in the United States: Early Readmission and Complications.

PURPOSE: Pollicization is a well-accepted treatment for thumb hypoplasia, yet little is known about the reasons why patients return early in the postoperative period and complications that occur after surgery. The purpose of this investigation was to describe 30-day returns, readmission, and complication rates after pollicization in the United States. METHODS: A total of 459 pollicization procedures performed in 408 patients at 38 U.S. pediatric hospitals from 2003 to 2014 were identified using the Pediatric Health Information System database. A stepwise search strategy identified returns and readmissions within 30 days after pollicization to quantify complications and/or additional procedures. Risk factors for readmission and complications were compared across groups using uni- and multivariable general linear modeling. RESULTS: There were 61 patients who returned to the hospital (emergency department, ambulatory surgery, or inpatient hospitalization) within 30 days of their pollicization. Of those, 39 patients returned for suture removal, cast changes, or other expected aspects of postoperative care. The remaining 22 patients had a total of 26 complications, accounting for a 4.8% complication rate. The majority had vascular complications and wound problems. Single complications ranging from wound infection to hemorrhage were found in 20 cases. Overall, 35 of the 61 returns were readmitted to the hospital for treatment of complications or additional procedures. There was no effect of age group, diagnosis, geographical region, or physician subspecialty on the likelihood of complication or readmission. CONCLUSIONS: Sixty-one patients returned within 30 days of their pollicization, and 22 presented with a complication (4.8%), most commonly vascular in nature. These baseline data are informative because they identify opportunities for future preventative measures and quality improvement. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Methods for Congenital Thumb Hypoplasia Reconstruction. A Review of the Outcomes for Ten Years of Surgical Treatment.

BACKGROUND AND OBJECTIVES: Congenital thumb hypoplasia is a rare deformity of upper extremity. The incidence for thumb hypoplasia grade II-V is 1:10,000 newborns per year in Latvia. A technique for extensor indicis proprius (EIP) tendon transfer with subperiosteal fixation was developed and used for thumb hypoplasia grades II and IIIa. Pollicization or second-toe-to-hand transplantation with metatarsophalangeal (MTP) joint arthrodesis was used for the reconstruction of hypoplasia grade IIIb-V. The aim of this retrospective cohort study is to evaluate the outcomes for reconstruction techniques used in one surgical center during a ten-year period by one surgeon to evaluate functional and aesthetical outcomes for new techniques. MATERIALS AND METHODS: In total, 21 patients were operated on during 2007-2017, and 18 of these patients were involved in this study. Long-term follow-up was completed to evaluate the functions and aesthetics of the hands. RESULTS: disabilities of the arm, shoulder and hand (DASH) was 9.35 (8-10.7) for the second-toe-to-hand with MTP joint arthrodesis transplantation method for pollicization method 19.8 (6-26.7), and for the EIP tendon transposition, 14.54 (0.9-56.3). CONCLUSIONS: The postoperative functional parameters of congenital hand hypoplasia patients, regardless of the surgical method, are worse than the functional results of healthy patients. The use of the second-toe-to-hand with MTP joint arthrodesis transplantation method provides patients with congenital hand IIIb-V hypoplasia a stable and functional first finger formation. The functional results are comparable to the clinical results of the pollicization method while ensuring the creation of a five-digit hand.

A New, Direct Measure of Thumb Use in Children After Index Pollicization for Congenital Thumb Hypoplasia.

PURPOSE: After index pollicization for congenital thumb hypoplasia, time-based hand dexterity tests do not indicate whether the new thumb is being used by a child. The Thumb Grasp and Pinch assessment (T-GAP) is a new outcome measure that classifies grasp and pinch styles to quantify use of the new thumb. The goal of this study was to establish concurrent validity and construct validity in the T-GAP. METHODS: Data from children treated with index finger pollicization for congenital thumb hypoplasia were retrospectively reviewed. Measures of strength, range of motion, and scores on the Box and Blocks Test (BBT), 9-Hole Peg Test (NHPT), Functional Dexterity Test (FDT), and Task 7 (Heavy Objects) from the Jebsen-Taylor Test (JTT7) were recorded. Patients also completed the T-GAP consisting of 9 age-appropriate tasks, during which grasp patterns were classified. Spearman correlation coefficients were calculated comparing the T-GAP score with scores on the BBT, NHPT, FDT, and JTT7. RESULTS: We evaluated 21 thumbs in 21 children an average of 71.7 months after pollicization surgery (range, 9-175 months). The T-GAP score was significantly correlated with BBT, NHPT, FDT, and JTT7 (R = 0.69, -0.60,-0.59, and -0.60, respectively). The T-GAP score was significantly correlated with tripod pinch, key pinch, and grip strength (R = 0.77, 0.75, and 0.71, respectively) and with opposition and grasp span (R = 0.50 and 0.52, respectively). The T-GAP was the only functional measure correlated with parent and patient satisfaction with thumb function. CONCLUSIONS: Concurrent validity was supported by significant correlations between T-GAP score for all 4 dexterity measures. Construct validity was supported by significant correlations between strength and range of motion of the thumb and T-GAP score. CLINICAL RELEVANCE: This evaluation may help surgeons and therapists better understand results after pollicization and determine whether the new thumb is being incorporated into daily activities.

Radial Longitudinal Deficiency: Recent Developments, Controversies, and an Evidence-Based Guide to Treatment.

Radial longitudinal deficiency (RLD) is the most common congenital longitudinal deficiency at birth and represents a wide spectrum of upper extremity anomalies, from mild thumb hypoplasia to absent radius. Radial dysplasia may be isolated or associated with an array of systemic anomalies that should be familiar to pediatric hand surgeons. The management of RLD has evolved greatly since its inception in the late 19th century, largely due to decades of innovation that followed the thalidomide catastrophe of the 1960s. Yet controversy still exists regarding many aspects of RLD. Traditional treatments of radial dysplasia (ie, centralization) are unfortunately wrought with poor outcomes and high rates of recurrence, leading some authors to recommend alternative techniques for this condition. Reconstruction of the hypoplastic thumb, although less controversial, is just starting to see long-term outcomes. This article reviews the etiology, classification, and treatment options for RLD, highlighting recent developments and outcomes.

Morphology and Mobility of the Reconstructed Basilar Joint of the Pollicized Index Finger.

PURPOSE: To evaluate outcome and function of the reconstructed basilar thumb joint after index finger pollicization in patients presenting congenital thumb deficiency. METHODS: Plain radiographs and 4-dimensional dynamic volume computed tomography scan were used to evaluate the outcome of 23 pollicizations performed on 14 children between 1996 and 2009. The mean follow-up was 8 years. Patients performed continuous movements of thumb opposition during the imaging studies. Four-dimensional scan images made it possible to visualize mobility within the reconstructed joint. RESULTS: In 14 cases, union occurred in the metacarpal head/metacarpal base interface. In the 9 other cases, there was a nonunion at this interface. The reconstructed joint was mobile in 20 cases, including 3 in which there was also mobility at the site of the nonunion. In 3 cases in our series, mobility was present only at the site of the nonunion, between the base and the head of the second metacarpal. Remodeling and flattening out of the metacarpal head occurred in 16 of 23 cases. The transposed metacarpal head remained spherical in 7 cases. CONCLUSIONS: The reconstructed joint adapts, both morphologically and functionally, allowing movement on all 3 spatial planes. Existing mechanical constraints on the reconstructed joint may explain its remodeled appearance. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Flexor Digitorum Superficialis Opposition Transfer for Augmenting Function in Types II and IIIA Thumb Hypoplasia.

PURPOSE: To report the functional outcomes associated with the flexor digitorum superficialis (FDS) opposition transfer for types II and IIIA thumb hypoplasia and determine if there is any noteworthy difference in the outcome dependent on the pulley used. METHODS: We included patients who underwent a ring FDS opposition transfer and had at least 2 years follow-up. The study group consisted of 36 patients with 40 treated thumbs. All patients underwent follow-up examination and standardized testing. Outcome functional measures were recorded using the Pediatric Outcomes Data Collection Instrument (PODCI). There were 9 type II and 31 type IIIA hypoplastic thumbs. All patients underwent a ring FDS opposition transfer and a 4-flap z-plasty for first web space deepening. The pulley for opposition was flexor carpi ulnaris in 19 and the transverse carpal ligament in 21. Thirty-six thumbs had ulnar collateral ligament reconstructions, with 5 of the 36 undergoing combined ulnar collateral ligament/radial collateral ligament stabilizations. Average follow-up was 7.6 years (range, 2-16 years). RESULTS: Average postoperative Kapandji score was 8 (range, 4-10). Grip, lateral pinch, and tripod pinch strengths averaged 46%, 49%, and 48% of age- and sex-matched normal controls, respectively. There was no significant difference between surgical pulleys used. The Pediatric Outcomes Data Collection Instrument global was 91 (range, 53-100), and PODCI happiness was 87 (range, 15-100). CONCLUSIONS: We found the ring FDS opposition transfer to be an effective method for providing opposition for both type II and IIIA thumb hypoplasia. At follow-up, excellent opposition function and PODCI scores were noted, with no difference related to the type of pulley used. Type II thumbs had significantly greater grip and pinch strengths when compared with type IIIA thumbs.