AAPS, American Association of Plastic Surgeons
AAPS, American Association of Plastic Surgeons
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2008 Annual Meeting Abstracts

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Development of a Classification System for Congenital Digital Aplasia and Hypoplasia and an Algorithm for Reconstruction using Microsurgical Toe-to-Hand Transfers
Neil F. Jones, MD, Scott L. Hansen, MD, Steven J. Bates, MD.
UCLA, Los Angeles, CA, USA.

PURPOSE:
The purpose of this study was to develop a simple classification system of congenital absence or hypoplasia of the digits and to develop an algorithm for microsurgical reconstruction of these children by toe-to-hand transfers.
METHODS:
78 toe transfers have been performed in 65 children for congenital digital aplasia, classified by the Swanson system as transverse deficiencies or symbrachydactyly (32); radial longitudinal deficiencies (5); cleft hand (9) and constriction ring syndrome (17). X-rays and photographs were analyzed to determine which rays were missing and the level of absence. Each hand is described by two letters R(radial) & U(ulnar) and two numbers. The first letter and number describe the absent rays and the second letter and number describe rays that are present. A normal hand would be designated R0U5 or U0R5 and complete aplasia would be designated R5 or U5. Symbrachydactyly with a thumb but absent fingers would be U4R1. Level of absence proximal to the carpus is designated (c), from the carpus to the metacarpophalangeal joints (m) and distal to the metacarpophalangeal joints (p).
RESULTS:
Based on this classification system, there are 9 phenotypes of digital aplasia. Only 5 phenotypes are suitable indications for microsurgical toe-to-hand transfers, namely R2U3, R3U2, R4U1, U4R1 and U5 or R5. An algorithm for microsurgical reconstruction by 4 different combinations of toe-to-hand transfers has evolved. Optimal reconstruction of the 3 severe radial deficiency phenotypes R2U3, R3U2 and R4U1 is a toe-to-thumb transfer using either the second toe (21) or great toe (14). For severe transverse or ulnar longitudinal deficiencies U4R1, there are two options - either a second toe transfer into the ring or small finger position(25), or two second toes transferred either simultaneously or in separate procedures into the middle finger and small finger positions to provide three point pinch(5). Finally, the aplastic hand U5 or R5 phenotype is best reconstructed with two second toe transfers into the thumb and small finger positions(6).
CONCLUSIONS:
Retrospective analysis of a large series of children with congenital digital aplasia or hypoplasia has resulted in the development of a simplified classification system and a treatment algorithm which directly predicts which of four possible microsurgical toe-to-hand transfers will provide the most optimal reconstruction of each of the 5 digital aplasia phenotypes.


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