Microsurgical reconstruction of the hypoplastic thumb, type IIIB

If a classically hypoplastic thumb, type IIIA, presenting with a first carpometacarpal joint, is amenable to reconstruction, a type IIIB case without the basal joint, is classically treated by pollicization. The authors concur with this opinion, but found two circumstances in which reconstruction is an option in a type IIIB thumb, either when an adolescent asks for improvement of an unstable but utilized thumb, or when a parent definitely refuses pollicization. In such cases, a free, vascularized metatarsophalangeal joint is the first step of the reconstruction, followed by classic non-microsurgical steps. The authors reviewed five cases, with a mean follow-up of 7.8 years. Hypoplasia of the reconstructed thumb, and a limited pinch, allow this option only with restricted indications.     

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.     

Reconstructive surgery of Blauth type III hypoplasia of the thumb

Thumb hypoplasia type III according to Blauth remains a rare congenital malformation. Recently Manske has promoted reconstruction versus pollicization in the sub-type IIIA where a first carpometacarpal joint is present. However we felt that pollicization is the solution for sub-type IIB where the basal joint is absent. We have reviewed 14 cases of thumb hypoplasia type III, four of them being type IIIB. After performing a first step with a free vascularized second metatarso-phalangeal joint transfer, the secondary steps were identical in both sub-groups. After a mean follow up of five years, no great difference was found in the two sub-groups and basal stability was even better in type IIIB. However the results were functionally and cosmetically inferior to the ones observed after pollicization. When the relatives refuse pollicization or the patient consults late for functional improvement, reconstruction remains worthwhile.     

采用掌骨部分移位重建改良Blauth 3B及3C型发育不良拇指的疗效观察

目的 观察第2掌骨纵向半侧骨干移位和二期拇对掌功能重建治疗改良Blauth 3B和3C型拇指发育不良的疗效.方法 2013年12月至2018年6月,复旦大学附属华山医院手外科收治的改良Blauth3B和3C型患儿资料12例.将第2掌骨纵向半侧移位延长第1掌骨,稳定第一腕掌关节.确认骨折愈合后,二期行肌腱移位拇对掌功能重...     

The axes of rotation of the thumb carpometacarpal joint.

Two axes of rotation of the carpometacarpal (CMC) joint of seven cadaver thumbs were located using an axis finder. The flexion-extension axis is located in the trapezium and the abduction-adduction axis is in the first metacarpal. These axes are fixed, are not perpendicular to each other or to the bones, and do not intersect. Motion of the first metacarpal on the trapezium can be defined by these two axes. Understanding of the movements of the basal joint of the thumb is essential to the study of its function and reconstruction.     

Suspensionplasty with the abductor pollicis longus tendon for osteoarthritis in the carpometacarpal joint of the thumb

PURPOSE: Many surgical procedures have been described for treating painful osteoarthritis at the carpometacarpal joint of the thumb. This article reports our clinical and radiographic results in performing suspensionplasty using the abductor pollicis longus (APL) tendon without tendon interposition after a complete trapeziectomy for patients with painful osteoarthritis in the carpometacarpal joint of the thumb. METHODS: Eighteen patients (2 men, 16 women), including 21 thumbs with advanced arthritis of the first carpometacarpal joint, who were treated by suspensionplasty using the APL tendon after a complete trapeziectomy were evaluated both clinically and radiographically. Ten thumbs were classified as stage III and 11 were classified as stage IV (Eaton's classification). The average follow-up period was 33.3 months. RESULTS: All patients (18 patients, 21 thumbs) reported pain with daily use before surgery; after surgery 13 of the 21 thumbs had no pain, 5 thumbs had mild pain with strenuous activity, and the remaining 3 thumbs had mild pain with light work. At the final follow-up evaluation the radial and palmar abductions each were 56 degrees +/- 9 degrees and 56 degrees +/- 6 degrees. The grip and key-pinch strengths were 16 +/- 6 kg and 4 +/- 1 kg, respectively. The first metacarpal subsidence at rest was 15% and the additional subsidence when performing a 2-kg key pinch was 6% in the final follow-up radiographic findings. CONCLUSIONS: This study showed that the APL suspensionplasty has a favorable outcome for painful osteoarthritis in the carpometacarpal joint of the thumb and that the APL tendon can be removed as a deforming force without any abduction weakness. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Dynamic suspension-sling arthroplasty with intermetacarpal ligament reconstruction for the treatment of trapeziometacarpal osteoarthritis

Our new dynamic suspension-sling arthroplasty of the trapeziometacarpal joint stabilizes the base of the first metacarpal after the removal of the trapezium in patients who have trapeziometacarpal joint osteoarthritis. Other techniques involving ligament reconstruction are accompanied by complications such as proximal migration, dorsal subluxation of the first metacarpal base, and impingement of the first and second carpometacarpal joints. In our technique, the first metacarpal is suspended by using a series of tendon loops derived from one-half of the flexor carpi radialis tendon and, therefore, anatomically reconstructs the intermetacarpal and palmar oblique ligaments. From 1988 to 2000, 197 patients (238 thumbs) underwent this procedure. Follow-up was an average of 1.92 years. After surgery, pain decreased, grip strength increased from 24 to 48.7 lb, key pinch increased from 4 to 7.6 lb, and Kapandji scores increased from 6 to 9.3 (averages). Our technique provides an interposition between the bases of the thumb and index metacarpals, resulting in decreased pain, greater strength, and increased flexibility of the trapeziometacarpal joint.     

桡侧腕长伸肌腱与拇长展肌腱重建韧带治疗拇指腕掌关节脱位

在手外科工作中，拇指腕掌关节脱位比较常见，治疗方法比较多，但为了使此关节稳定，就必须行韧带重建术。根据拇指腕掌关节的解剖学特点及力学分析，我们应用了桡侧腕长伸肌腱与拇长展肌腱各一半的腱束交叉重建拇指腕掌关节韧带治疗拇指腕掌关节脱位。从１９８７年～１９９０年对１１例病人１２个拇指进行了治疗，术后随访２年以上，疗效满意。我们认为，这种方法比较简单、损伤小，值得推广。     

An isolated ring finger metacarpal shaft fracture?--beware an associated little finger carpometacarpal joint dislocation

Dislocations of the ulnar carpometacarpal joint are easily missed because of a low index of suspicion as well as their subtle clinical and radiological features. Often, the presence of a more obvious adjacent injury also draws attention away from the carpometacarpal joint. Two cases of ring finger metacarpal shaft fractures with associated little finger carpometacarpal joint dislocations are presented. In both cases, the metacarpal fractures were diagnosed but the carpometacarpal joint dislocations were initially overlooked. The presence of an apparently isolated ring finger metacarpal fracture due to an indirect force should raise the possibility of an associated carpometacarpal joint injury.     

Thumb reconstruction

Thumb reconstruction aims to restore the cardinal thumb traits and actions including mobility, stability, sensibility, length, and appearance. The level of thumb loss is divided into thirds: distal (tip to interphalangeal [IP] joint), middle (IP joint to metacarpal neck), and proximal (metacarpal neck to carpometacarpal joint). Distal third reconstruction usually requires only soft tissue restoration. Many options exist for middle third reconstruction, including increasing thumb ray length (metacarpal lengthening, osteoplastic reconstruction, toe transfer) and increasing relative length (phalangization). Proximal third reconstruction is best accomplished with toe transfer, pollicization, or on-top plasty (pollicization of a damaged index finger).     

Partial trapeziectomy and interposition of fascia lata allograft in the operative treatment of thumb base osteoarthritis

Aim: The purpose of this retrospective cohort study was to evaluate the results of fascia lata allograft interposition after partial trapeziectomy in patients with symptomatic first carpometacarpal joint osteoarthritis. Methods and results: Twenty-one patients (22 thumbs) with Eaton-Glickel stage II or III first carpometacarpal joint osteoarthritis were included. After a mean follow-up duration of 70.2 months, most patients experienced minimal pain. The operation was graded excellent or good by 15 patients (15 hands). Active range of motion and strength measurements were comparable to the contralateral hand, except for extension, which was slightly better in the contralateral hand. The mean radiologically measured difference pre- and postoperatively in distance between distal part of the trapezium and base of the metacarpal was 2.7 mm. Two patients had reoperations in the first year after the initial operation because of ongoing pain. Conclusion: Partial trapeziectomy with interposition of fascia lata allograft in patients with symptomatic first carpometacarpal joint osteoarthritis can achieve reasonable results. It may be considered a reliable operative treatment option in patients with first carpometacarpal joint osteoarthritis.     

Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint: a study of the benefit of ligament reconstruction or tendon interposition

PURPOSE: To investigate whether palmaris longus interposition or flexor carpi radialis ligament reconstruction and tendon interposition improved the outcome of excision of the trapezium for the treatment of painful osteoarthritis of the trapeziometacarpal joint. METHODS: 183 thumbs with trapeziometacarpal osteoarthritis were randomized for treatment by either simple trapeziectomy, trapeziectomy with palmaris longus interposition, or trapeziectomy with ligament reconstruction and tendon interposition using 50% of the flexor carpi radialis tendon. A K-wire was passed across the trapezial void during each of the 183 surgeries to hold the base of the thumb metacarpal at the level of the index carpometacarpal joint and was retained for 4 weeks in every case. All patients wore a thumb splint for 6 weeks. Each patient had subjective and objective assessments of thumb pain, stiffness, and strength before surgery and at 3 months and 1 year after surgery. RESULTS: The 3 treatment groups were well matched for age, dominance, and presence of associated conditions. Complications were distributed evenly among the 3 groups and no cases of subluxation/dislocation of the pseudarthrosis were observed. Of the 183 thumbs 82% achieved good pain relief and 68% regained sufficient strength to allow normal activities of daily living at the 1-year follow-up evaluation. Neither of these subjective outcomes nor the range of thumb movement was influenced by the type of surgery performed. Thumb key-pinch strength improved significantly from 3.5 kg before surgery to 4.6 kg at 1 year but the improvement in strength was not influenced by the type of surgery performed. CONCLUSIONS: The outcomes of these 3 variations of trapeziectomy were very similar at 1-year follow-up evaluation. In the short term at least there appears to be no benefit to tendon interposition or ligament reconstruction.     

On-top and side-to-side plasties for thumb polydactyly

Introduction“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.Presentation of casesThe 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.DiscussionWe could not find similar cases in the literature with detailed long-term postoperative results.Conclusion“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.     

Abductor digiti minimi opponensplasty in hypoplastic thumb

Ten cases of hypoplastic thumbs were treated by abductor digiti minimi opponensplasty in order to restore opposition of the thumb and reform the wasted thenar eminence. In eight of these ten cases operations were combined with multiple Z-plasty or rotation flap to correct the narrowing of the first web space. Adductor plasty using extensor indicis proprius was performed in six cases to restore the stability of the metacarpophalangeal joint of the thumb and ligament reconstruction of the carpometacarpal joint in one hand. In all cases, the transferred abductor digiti minimi was strong enough to abduct the thumb and provide good functional and cosmetic results. We modified Littler's procedure by transferring the origins of abductor digiti minimi muscle from the flexor carpi ulnaris to the palmaris longus tendon. Our modified method gave a better cosmetic appearance than that provided by Littler's method.     

介绍几种残指延长拇指再造的方法

本文报告带血管神经蒂组织瓣移位及手残指缓慢延长术治疗６４例拇指缺损，拇指平均延长２．６ｃｍ，平均随访时间３年６个月，再造拇指外形及功能均较满意。本法简单、安全、有效。拇指掌指关节以远缺如，残端指骨长１ｃｍ以上者行指骨延长术，不足１ｃｍ者可行第１掌骨延长术、二期行虎口加深术。掌指关节平面缺如采用第１掌骨延长术或带血管蒂皮瓣移位再造拇指。也可用带桡骨片的前臂桡侧皮瓣一期再造拇指。第１掌骨近侧平面缺如，     

Isolated radial palmar dislocation of the fifth carpometacarpal joint with ulnar neuropathy associated: successful treatment with closed reduction and internal fixation

Carpometacarpal dislocations may be dorsal, volar or divergent type but most are dorsal with involvement of fourth and fifth metacarpal. Isolated volar dislocation of the fifth carpometacarpal joint is an uncommon injury specially when there is no associated fracture. We report a case of radial palmar dislocation of the base of fifth carpometacarpal joint associated to compression of the fourth interdigital nerve in the hand.     

Divergent fracture-dislocation of the hamatometacarpal joint: case report

Hamatometacarpal fracture-dislocation is a rare injury that consists of a fourth metacarpal fracture and a fifth carpometacarpal joint injury. We present the case of a 21-year-old man with a divergent hamatometacarpal fracture-dislocation that consisted of a combination of dorsal intra-articular fracture-dislocation of the fourth carpometacarpal joint, palmar dislocation of the fifth carpometacarpal joint, and fracture of the hook of the hamate. The mechanism of palmar dislocation of the fifth metacarpal base and fracture of the hook of the hamate involved extension of the fifth metacarpal and ulnopalmar load transmission.     

Treatment of a type 3B hypoplastic thumb using extra phalanges from the contralateral duplicated thumb: case report

A boy was born with a right duplicated thumb (Wassel type 6) and a left radial club hand (type 3) associated with a hypoplastic thumb (type 3B). He underwent surgical centralization of the left wrist when he was 13 months old. At age 38 months, he underwent reconstruction of the carpometacarpal joint of the hypoplastic left thumb. This procedure involved transplantation of the radial ray of the right duplicated thumb to the base of the left thumb. When he was 6 years old, the patient underwent an abductor digiti minimi muscle transfer to create opposition for the left thumb and deepening of the first web. At the final follow-up, he could grasp items in the first web space and pick up small items between the thumb and other digits of the left hand. The treatment represents a method of using otherwise discarded tissues for effective reconstruction.     

A new abductor pollicis longus suspension arthroplasty

PURPOSE: Surgical treatment of osteoarthritis of the first carpometacarpal joint aims to achieve complete pain relief with restoration of thumb strength and stability. The aim of this study was to introduce a variation of the abductor pollicis longus (APL) sling arthroplasty and to determine its efficacy in comparison with other tendon sling arthroplasty procedures. METHODS: Between January 1999 and December 2003, 104 trapeziectomies in 74 consecutive patients (30 bilateral cases) were performed using a new APL sling arthroplasty. Patients were evaluated at 6 and 12 months after surgery. The outcomes were analyzed subjectively by questionnaire and objectively by clinical and radiographic evaluation. RESULTS: After 6 months, excellent results in terms of pain relief were achieved in 95 thumbs (91%) of 65 patients. The remaining 9 thumbs had ongoing pain and had a secondary surgery performed between 6 and 12 months after the initial surgery. Pain relief was achieved in 1 thumb by scaphotrapezoid arthrodesis and in the other 8 thumbs by excision of the osteophyte on the ulnar-volar surface of the base of the first metacarpal, which was impinging on the base of the second metacarpal or the trapezoid. The gap was filled with a palmaris tendon anchovy. After 12 months, the 65 patients with successful trapeziectomies and APL sling remained pain-free. In these patients tip pinch, key pinch, and power grip strength increased by 46%, 19%, and 41%, respectively, from the preoperative values. In the 35 unilateral cases, tip pinch, key pinch, and power grip strength increased from 53%, 77%, and 65% of the contralateral hand strength before surgery to 82%, 89%, and 90%, respectively. CONCLUSIONS: This modified APL sling arthroplasty is a new and effective way of creating a suspension sling with the APL tendon after trapeziectomy, with results comparable or better than other published methods, for the treatment of osteoarthritis of the first carpometacarpal joint. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Basal joint arthritis of the thumb

The carpometacarpal joint of the thumb is the second most common site of arthritis in the hand. Patients in whom conservative treatment fails benefit from surgical intervention, although no consensus exists as to the best method to provide maximum pain relief and functional outcomes. The pathophysiology of carpometacarpal arthritis is loss of the integrity of the palmar oblique ligament, which allows for dorsal subluxation of the metacarpal on the trapezium. Most treatments revolve around resection or replacement of the arthritic carpometacarpal joint and restoration of the palmar oblique ligament. A critical appraisal of the current evidence-based research offers no guidance in treatment in the early stages of carpometacarpal arthritis; however, several evidence-based studies exist for more advanced stages. Although these studies exhibit limitations in regard to validated outcomes, power analysis, and blinded assessment, their conclusions question the clinical benefits of ligament reconstruction and tendon interposition. Further research is needed to delineate the best treatment of early stages of arthritis as well as the clinical significance of metacarpal subluxation and subsidence. Further, a standardized set of outcome tools is needed for the interpretation and comparison of data in regard to clinical outcomes.