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2008 Annual Meeting Abstracts

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Refinements in Pollicization: An Experience with 312 Hands
Amir H. Taghinia, M.D.1, J. William Littler, M.D.2, Joseph Upton, M.D.1.
1Children's Hospital and Harvard Medical School, Boston, MA, USA, 2Roosevelt Hospital, New York, NY, USA.

PURPOSE: Index pollicization is the ideal treatment for types IIIB, IV, and V (Blauth) congenital hypoplastic thumbs, and remains the most elegant, signature operation in the field of hand surgery. Although this procedure improves both function and appearance, these thumbs never achieve normalcy. Constant improvements in technique are, therefore, necessary to simulate a normal thumb as closely as possible.

METHODS: Three hundred and twelve index pollicizations for congenital thumb hypoplasia or aplasia were performed by the senior author from 1977 to 2007. These cases were retrospectively analyzed by reviewing the medical records, photographs, radiographs, molds and videotapes. Follow-up ranged from 1 to 28 years.

RESULTS: All pollicization procedures were successful in providing a radial digit in palmar abduction. There were no vascular complications, but wound healing problems occurred in 15 patients. Secondary procedures were performed in 37 hands and included extensor tenolyses, tendon or muscle transfers for inadequate palmar abduction, epiphysiodeses of the metacarpal head, excision of ectopic bone, and soft tissue releases of the first web space. The functional outcomes sorted into two major groups which were directly related to the range of motion and functional status of the transposed index finger preoperatively.
Five important refinements in technique have lead to improved function and appearance: (1) Incisions - a racket type incision at the base of the transposed digit and a thenar crease incision for inset provided the best exposure and web space configuration; (2) Positioning - the metacarpal head is placed anterior to the index metacarpal base in a hyperextended position to simulate the normal concavity of the metacarpal arch; (3) Intrinsic muscle rebalancing - intrinsic muscles are rebalanced with inset into both bone and the extensor mechanism; (4) Extrinsic tendon rebalancing - the extrinsic flexor and extensors are shortened and rebalanced for the stiff digits seen in more severe radial deficiencies; and (5) Thenar eminence augmentation - the normally discarded tissue in types IIIB and IV thumbs is harvested as an adipofascial flap and added as bulk to improve the appearance of the thenar eminence.

CONCLUSION: Index pollicization is perhaps the most elegant and complex in the field of congenital hand surgery. This procedure requires both technical precision and attention to detail to provide dramatic results. During the past 30 years, the aforementioned refinements have improved both the function and appearance of these new thumbs. Good function should be synonymous with good appearance; any reconstructive operation “¼should encompass both aspects, for the one generally embraces the other.” (1)
FIGURES: Figure below shows 28-year follow up after bilateral pollicization.

REFERENCES: 1. Hentz, V. R., Littler, J.W. The surgical management of congenital hand anomalies. In J.M. Converse and J.W. Littler (eds.) Reconstructive Plastic Surgery, 2nd Ed., Vol. 6, Philadelphia: WB Saunders, 1977, pp. 3341.

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