TREATMENT OF GRADE 1TO 3A THUMB HYPOPLASIA
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1 TREATMENT OF GRADE 1TO 3A THUMB HYPOPLASIA G. Dautel Centre Chirurgical Emile Gallé Nancy
2 Any reason to such a restricted field? Grade I to IIIA of thumb hypoplasia : Reconstruction of the existing thumb Grade IIIB and IV : Index finger pollicisation
3 Nothing of financial value to disclose
4 Thumb Hypoplasia : A spectrum Manske s Classification Manske PR, McCarroll HR, J.-R. Reconstruction of the congenitally deficient thumb. Hand Clin Feb; 8(1): Credits : Management of thumb Hypoplasia, WB Kleinman, Hand Clinics, 1990, 6 (4), Manske PR, McCarroll HR, Jr., James M. Type III-A hypoplastic thumb. J Hand Surg Am Mar; 20(2): Blauth s Classification Blauth W. Der hypoplastische daumen. ArchOrthopUnfallchir. 1967; 62: 225.
5 Grade 1
6 Grade 1 hypoplasia
7
8 STRATEGY IN GRADE I THUMB HYPOPLASIA No treatment!!!
9 Grade 2
10 Grade 2
11 CLINICAL FEATURES OF GRADE II THUMB HYPOPLASIA Functional impairment Power of grasp (?) Opposition Narrow web space (?) Cosmetic consequences Contour of the Thenar eminence Too slender thumb
12 Grade IIIA and IIIB of thumb Hypoplasia
13 Grade IIIA
14 Instability of the MCP joint in a grade IIIA thumb hypoplasia
15 Radial sided instability Ulnar sided instability
16 «Pollex abductus» a variant of Grade IIIA thumb hypoplasia J T e pt Tur p
17 CLINICAL FEATURES OF GRADE IIIA THUMB Functional impairment HYPOPLASIA power of grasp (?) opposition narrow web space (?) instable MP joint (ulnar side and/or radial side) instable CMC joint ROM of the IP and MP joints Cosmetic consequences Contour of the Thenar eminence Too slender thumb
18 Grade IV
19 Type1 Type II Type 1IIA Type IIIB Type IV No surgery Reconstruction of the existing thumb Reconstruction of the existing thumb Index finger pollicisation Index finger pollicisation Indications
20 Improve stability of the MP joint ligamentoplasty Increase the power of grasp Opponens plasty Enlarge the first web space web plasty? Increase the Range of Motion of the IP Joint
21 Vanc Lisa, 2004, Pre-op Vanc Lisa, 2011, follow-up
22 GOALS Results of a combination of surgical steps including a first web plasty, an opponens plasty and an MP Joint ligamentoplasty
23 MATERIALS AND METHODS Retrospective study, 1998 to patients, three bilateral cases Age : 22 to 180 months, mean 64 months 10 grade IIIA and 7 grade II Right hand : 10 cases
24 Functional Evaluation (preop and postop)
25 FUNCTIONAL ASSESSMENT Spontaneous posture of the thumb Ability to handle small objects Fully opposable thumbs versus side to side pinch between the index and middle finger
26 FUNCTIONAL ASSESSMENT Stability of the MCP joint No instability (less than 30 of angular deviation with provocative maneuvers Mild instability (30 to 60 of angular deviation with provocative maneuvers) Severe instability (more than 60 )
27 FUNCTIONAL ASSESSMENT IP and MP motion (pre & postop) Active and Passive ROM of the IP and MP joint
28 FUNCTIONAL EVALUATION Opposition score Kapandji s Score Kapandji I. La rotation du pouce sur son axe longitudinal lors de l'opposition. Rev Chir Orthop. 1982; 58:
29 FUNCTIONAL EVALUATION Retraction of the first web space Comparison with the opposite side Absent, mild or severe
30 FUNCTIONAL EVALUATION Overall function of the reconstructed thumb Standardized set of manual tasks designed by Manske to evaluate the results of pollicisation Manske PR, Rotman MB, Dailey LA. Long-term functional results after pollicization for the congenitally deficient thumb. J Hand Surg Am Nov; 17(6):
31 METHODS
32 METHODS : SURGICAL TECHNIQUES Enlarging the first web space First web plasty : four-flaps Z plasty in mild cases (grade II) 4 cases
33 Enlarging the first web space Combination of a kite flap + LLL plasty Foucher G, Braun JB. A new island flap in surgery of the hand. Plast Reconstr Surg. 1979; 63: Dufourmentel C. La fermeture des pertes de substance cutanée limitées. Le lambeau de rotation en L pour Losange. Annales de Chirurgie Plastique. 1962;7: 61-6.
34
35
36 METHODS : SURGICAL TECHNIQUES Enlarging the first web space Omega K-wire
37 Opponens plasty with a ring finger superficialis tendon
38 MP ligamentoplasty UCL alone or both UCL + RCL
39
40 Extrinsic Tendons abnormalities Search for abnormal connexions between extensor and flexor tendons (pollex abductus) No attempt in this series to retrieve and correct such abnormalities at the forearm level
41 RESULTS
42 RESULTS First web space enlargement First web space was inadequate in 15/17 cases Kite flap + «LLL plasty» : 10 cases - All flaps fully completely - Average improvement of M1-M2 angle : 15 - Maximal breadth of the skin island : 15, 5 mm (12 to 20)
43 RESULTS Mobility Mean opposition score : 6 (5 to 8) Mean active ROM of the IP joint : 21 (0 to 60 ) Mean active ROM of the MP joint : 43 (30 to 60 )
44 RESULTS Stability Stable MP Instable MP Pre-Operative findings Instability involving at least one side of the MCP joint (either UCL or RCL) 16/17 Ulnar sided instability : 14/17 Radial sided instability : 10/17 Isolated radial sided instability : 2 cases
45 RESULTS Stability Post-operative assessment Ulnar sided instability : all but one cases were improved - 3 cases of severe instability (sup to 60 ) : residual laxity of more than 30 Isolated radial sided instability : residual angular deviation : less than 20
46 RESULTS Use Grasping large objects with the reconstructed thumb: All but one case Handling small objects with a fine tip to tip pinch: 3 failures (still use of a II-III lateral pinch)
47 preop status Grade IIIA Pre-Operative X ray Kite flap + triple L Opponens plasty Double ligamentoplasty Omega Kwire immediate post op Post-op
48 Final func nctional evalu luation: 43 months follow ow-up
49 DISCUSSION
50 OTHERS OPTIONS FOR FIRST WEB ENLARGMENT Strauch and Sandzen (1975) : flap from the dorsal aspect of the thumb Skin graft of the donor site Spinner (1969) : pedicle flap from the radial side of the index Skin graft of the donor site Discussion
51 FOUCHER S KITE FLAP Can be designed to match the shape of the skin defect Primary closure of the donor site Easy to harvest? Reliable Discussion
52 FOUCHER S KITE FLAP Bad reputation? Anatomical variations Technical trick : thick pedicle with a strip of the aponeurosis of the dorsal interosseous muscle Discussion
53 OPPONENS PLASTY Alternative : The abductor digiti minimi flap (Huber-Littler) iscussion
54 ABD DIGITI MINIMI VERSUS SUPERFICIALIS TRANSFER - Difficult to reach the radial border of the thumb + Easy to reach the radial border of the thumb + Improve the contour of the thenar eminenceno way to restore MP stability iscussion + Do not modify the contour + Ligamentoplasty on
55 INSTABILITY Instability on the radial side is rarely mentionned in the litterature Both ligament (UCL and RCL) should be reconstructed if required Discussion
56 TREATMENT OF EXTRINSIC TENDON ABNORMALITIES IN GRADE 3A HYPOPLASIA Abnormal tendon interconnexions on the radial aspect of the first ray in pollex abductus pulley reconstruction tendon transfers (EIP on EPL) section of abnormal tendinous connexions No attempt in this series to explore the flexor and extensor tendons at the forearm level (Graham and Louis, 1998)
57 CONCLUSIONS Type II and IIIA thumb hypoplasia can be functionally improved by a surgical protocol that includes a web plasty, an opponens plasty and a ligamentoplaty of the MCP joint
58 CONCLUSIONS (2) Ulnar and radial sided instability can be encountered in grade III A patients. Both should be treated
59 CONCLUSIONS (3) The combination of a pedicled kite flap + an «LLL» Dufourmentel plasty is an effective method to enlarge the first webspace without any skin graft. s
60 THANK YOU
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