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Clinical and Radiological Outcome following Kim’s Step cut Translation Osteotomy for Cubitus Varus and Valgus in Children

Volume 2 | Issue 2 | May-Aug 2016 | Page 34-37|Dhurvas Ramlal Ramprasath, Vasudevan Thirunarayanan, Murugan Shanmuga Sundaram Authors :Dhurvas Ramlal Ramprasath [1], Vasudevan Thirunarayanan [1], Murugan Shanmuga Sundaram [2] [1] Senior Assistant Professor, Department of Orthopaedic Surgery, Government Royapettah Hospital,Westcott road,Royapettah,Chennai,India-600014. [2] Junior Resident, Department of Orthopaedic Surgery, Government Royapettah Hospital, Chennai, India- 600014. Address of […]

Pollicisation: Embryology, History, Technique and Results

Volume 2 | Issue 2 | May-Aug 2016 | Page 29-33|Amita S. Hiremath, Binita N. Raut, Amit A. Yadav, Mukund R. Thatte Authors :Amita S. Hiremath [2], Binita N. Raut [1], Amit A. Yadav [2], Mukund R. Thatte [3] [1] KLE University’s J.N.Medical College,Belgavi, [2] Bombay Hospital and Institute of Medical Sciences Mumbai. [3] Bombay Hospital […]

Clinical and Radiological Outcome following Kim’s Step cut Translation Osteotomy for Cubitus Varus and Valgus in Children

Pollicisation: Embryology, History, Technique and Results

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Clinical and Radiological Outcome following Kim’s Step cut Translation Osteotomy for Cubitus Varus and Valgus in Children

Volume 2 | Issue 2 | May-Aug 2016 | Page 34-37|Dhurvas Ramlal Ramprasath, Vasudevan Thirunarayanan, Murugan Shanmuga Sundaram

Authors :Dhurvas Ramlal Ramprasath [1], Vasudevan Thirunarayanan [1], Murugan Shanmuga Sundaram [2]

[1] Senior Assistant Professor, Department of Orthopaedic Surgery, Government Royapettah Hospital,Westcott road,Royapettah,Chennai,India-600014.
[2] Junior Resident, Department of Orthopaedic Surgery, Government Royapettah Hospital, Chennai, India- 600014.

Address of Correspondence
Dr Ramprasath D.R.,
12/23, Murugappa street, Purasawakkam, Chennai, India. PIN- 600007.
Email ID: dhurvasramprasath@gmail.com

Abstract

Several osteotomies are available to correct cubitus varus and valgus deformities in children. The purpose of this study was to evaluate clinical and radiological outcome following Kim’s step cut translation osteotomy for such deformities.
Materials and Methods: We have instituted Kim’s step cut translational osteotomy in seven children having deformities of elbow (cubitus varus – 4 and cubitus valgus – 3). Patients were followed up for a period of 8 to 14 months during the period of August 2014 to October 2015. Clinically and radiologically, preoperative and postoperative Humerus-Elbow-Wrist angle, Range of motion of elbow, Lateral/Medial Prominence Index and neurological examination for ulnar nerve were determined. Results were evaluated according to modified Oppenheim et al criteria.
Results: The mean postoperative Humerus-Elbow-Wrist angle in patients with cubitus varus was 8.5±2.06 0 (range, 50 to 100). The mean improvement in Lateral Prominence Index was 7.4 ±1.28% (from –13.15% to -5.75% ). In cubitus valgus patients, mean
postoperative Humerus-Elbow-Wrist angle was 12.33±3.510(range, 80 to 150) . The mean improvement in MPI was 8.7±0.83% (from -15.5% to -6.8% ) . In all patients range of motion was comparable with normal side elbow. Bone union was achieved in all patients. According to Oppenheim’s criteria, six patients had excellent results and one patient had good result. .None of them had any complications.
Conclusion: Even though multiple procedures are available for correcting deformities of elbow, Kim’s step cut translational osteotomy provides good correction angle, lesser prominence of the condyle, better stability and three dimensional correction.
Key Words: Cubitus varus, Cubitus valgus, Kim’s osteotomy, Lateral/ Medial prominence Index.

Introduction
Cubitus varus and valgus deformities are complications of elbow fractures in children[1]. Cubitus varus has multiple components that include varus malalignment, hyperextension and internal malrotation[2,3]. The most important indication for osteotomy is to achieve a good cosmesis[2,4]. Many surgical techniques have been described to correct these deformities including closing wedge, opening wedge, dome and step cut osteotomies[5-12]. The closing wedge osteotomy has a tendency to produce prominent condyles after correction,often compromising the cosmetic outcome[2,13-16]. The inclusion of translation in the osteotomy improves cosmetic appearance by minimizing the persistent prominence of the medial or lateral condyle. This can be achieved by Kim’s osteotomy. The aim of our study was to evaluate clinically and radiologically, the preoperative and postoperative Humerus-Elbow-Wrist(HEW) angle, Lateral/Medial Prominence Index(LPI/MPI), Range of Motion(ROM), in children undergoing Kim’s step cut translation osteotomy for cubitus varus and valgus.

Materials and Methods
This is a retrospective study, from August 2014 to October 2015, involving seven paediatric patients in the age group 8 – 14 years with male:female ratio of 4:3. Those with cubitus varus deformity had sustained supracondylar humerus fracture and those with valgus deformity had fracture lateral condyle. All the patients had undergone native treatment immediately after injury, and presented to our department after a period of 14 months to 34 months after injury.
We have instituted step cut translational osteotomy of Hui Taek Kim [1] in all the seven patients. Preoperatively, radiological and clinical planning includes measurement of HEW angle, lateral/medial prominence index (using the method described by Wong et al [2,16]),range of motion of elbow, neurological examination for ulnar nerve and internal rotation malalignment (using the method described by Yamamoto[17,18]). Same radiological and clinical parameters were evaluated postoperatively.
HEW angle was measured by drawing two lines, one line along the anatomical axis of humerus ,and another line joining midpoints of two transverse lines(one proximal and one distal) across the forearm that connected the medial cortex of ulna and lateral cortex of radius (Fig-1). The Lateral/Medial Prominence Index was measured by using the formula shown in (Fig-2).
We determined the Correction Angle (CA) for patients with cubitus varus by adding varus HEW angle with normal side HEW angle, and for patients with cubitus valgus by subtracting normal side HEW angle from affected side valgus HEW angle. A template using X-ray film, was prepared preoperatively, to mark the site and size of osteotomy, using following technique(Fig-3).
The outline of the bone was drawn on a trace paper. A horizontal line was drawn perpendicular to anatomical axis of humerus at a level 0.5 to 1 cm proximal to the olecranon fossa. Now the trace paper was cut along the horizontal line and the distal fragment was rotated laterally and translated medially(in case of cubitus varus) so as to achieve HEW angle of normal side. Vice versa was done for cubitus valgus deformity. An inverted V was marked on the trace paper. We then cut out the triangular overlapping area from the paper and prepared X-ray film of same size and shape. This triangular X-ray film was sterilised for
use during osteotomy.

Figure 1: Humerus-Elbow-Wrist (HEW) Angle

Figure 2: Lateral/Medial Prominence Index % (LPI/MPI)

LPI (%)=(AB-BC)/AC×100

Figure 3: Preop Templating

Method of Osteotomy
With the patient in lateral decubitus position,through posterior approach ,ulnar nerve was isolated and protected. The triceps aponeurosis was split. The triangular X-ray template (turned face downward because of posterior approach) was placed over the bone 1cm proximal to olecranon fossa and necessary osteotomy was done to remove an identical piece of bone. The distal fragment was rotated laterally for cubitus varus(and medially for cubitus valgus) and inserted into the inverted V shaped defect. The deformity correction was assessed clinically and then the fixation was done with distal radius T-Plate and 3.5mm cortical
screws. The ulnar nerve was transposed anteriorly in patients who had tardy ulnar nerve palsy due to cubitus valgus deformity.
Patient was immobilised in long arm slab for 2 weeks following which active and assisted mobilisation was done intermittently retaining the splint until radiological union was achieved.

Results
The HEW angle, LPI/MPI, ROM were measured and analysed (Table -1).

Table-1: Preoperative and Postoperative Measurements.
HEW- Humerus-Elbow-Wrist angle, LPI /MPI – Lateral/Medial Prominence Index, CA- Correction Angle

In cubitus varus patients, mean postoperative HEW angle was 8.50(range, 50to 100),with mean correction of 21.50(range,190 to 250). The mean improvement in LPI was 7.4% (from -13.15% to -5.75% ) .In cubitus valgus patients(Fig-5), mean postoperative HEW angle was 12.330(range, 80 to 150),with mean correction of 21.660(range,200 to 230). The mean improvement in MPI was 8.7% (from -15.5% to -6.8% ).In all patients, range of motion was comparable with normal side elbow (Table 1). Pronation and supination movements were normal in all our cases. Bone union was achieved in all patients.

Figure 4: Osteotomy and Fixation

Figure 5: X-ray(Preop and Postop)

According to Oppenheim’s criteria [7], excellent result (Fig-6) was achieved in 6 patients and good result in one patient, and no patient had poor result.

Figure 6: Lateral/Medial Prominence Index % (LPI/MPI)

Discussion
In patients with cubitus varus/valgus, the following problems need to be addressed deformity correction in coronal plane(valgus/varus), sagittal plane(fixed flexion/hyperextension),horizontal plane(internal/external rotation deformity); ulnar nerve palsy, if any.
The deformity is better corrected during childhood. Correction, particularly in cubitus varus, in adult is challenging due to mature skeleton, inherent instability at osteotomy site, risk of delayed union/non union, implant failure, infection, stiffness and neurovascular complications [19]. A rough estimate will be around a year after original injury. Again patient demands, growth potential and status of physis should be taken into account while planning surgery[20].
Major types of osteotomies are – simple closing wedge [17,21,22],step cut translation [1,17,23], dome rotational osteotomy[13,14,17,24] and spike translation osteotomy[17]. Many of these osteotomies have got their own disadvantages, like lateral scar, medial and lateral condylar prominence and difficulty in correcting rotational deformities( due to contractures)[1,24,25,26].
Various method of fixation include use of K-wires, screws, plates and external fixators (Ilizarov technique) [5,13,25,27-29]. We have used Kim’s method of step cut translation Osteotomy, and fixed with distal radius T-plate.
This method has got multiple advantages. Adequate Correction Angle (CA) is achieved by moving the apex more medially (in cubitus varus) or laterally (in cubitus valgus). The stability of fixation is enhanced because the distal fragment is inserted into the inverted V shaped proximal fragment and fixation was done with plates. The prominence of condyles (lateral condyle in cubitus varus and medial condyle in cubitus valgus) is less with Kim’s osteotomy (when compared to other methods ) because distal fragment is translated. With Kim’s osteotomy, three dimensional correction is possible. The correction of internal rotation is recommended when the difference in rotational alignment in both sides is greater than 100 [1,17,18]. In our study ,we did not encounter patient with hyperextension, or internal rotation more than 100, when compared to normal side. Hence we have not attempted correction in sagittal/horizontal planes.
The limitations of our study is smaller sample size and follow up of only 14 months duration.

Conclusion
This simple step cut translation osteotomy(Kim’s) results in good cosmetic deformity correction,very firm fixation,earlier elbow movement and also avoids problems of condylar prominence and non union. Deformities in sagittal/horizontal plane can also be corrected.

References

1. Hui taek kim, md, Jung sub lee, md, and Chong il yoo, md. Management of cubitus varus and valgus. The journal of bone & joint surgery.Volume 87-a , number 4, april 2005.
2. K. Bali , P. Sudesh, V. Krishnan, A. Sharma, S.R.R. Manoharan, A.k. Mootha. Modified step-cut osteotomy for post-traumatic cubitus varus: our experience with 14 children. Orthopaedics & traumatology: surgery & research (2011) 97, 741-749.
3. Takagi T, Takayama S, Nakamura T, Horiuchi Y, Toyama Y,Ikegami H. Supracondylar osteotomy of the humerus to correct cubitus varus: Do both internal rotation and extension deformities need to be corrected? J bone joint surg am 2010;92(7):1619-26.
4. Pankaj A, Dua A, Malhotra A, Bhan S. Dome osteotomy for posttraumatic Cubitus varus a surgical technique to avoid lateral condylar prominence. J pediatr orthop 2006;26(1):61-6.
5.Y.H. Yun,S.J. Shin,J.G. Moon. Reverse v osteotomy of the distal humerus For the correction of cubitus varus. J bone & joint surg [br].2007;89-b:527-31.
6.Derosa GP, Graziano GP. A new osteotomy for cubitus varus. Clin orthop 1988;236:160-5.
7. Kanaujia RR, Ikuta Y, Muneshige H, Higaki T, Shimogaki K. Dome osteotomy for cubitus varus in children. Acta orthop scand 1988;59:314-17.
8. Kim HS, Jahng JS, Han DY, et al. Modified step-cut osteotomy of the humerus. J Pediatr orthop b 1988;7:162-6.
9. Koch PP, Exner GU. Supracondylar medial open wedge osteotomy with external fixation For cubitus varus deformity. J pediatr orthop b 2003;12:116-22.
10. Laupattarakasem W, Mahaisavariya B, Kowsuwon W, Saengnipanthkul S. Pentalateral osteotomy for cubitus varus: clinical experiences of a new technique. J Bone joint surg [br] 1989;71-b:667-70.
11. Oppenheim WL, Clader TJ, Smith C, Bayer M. Supracondylar humeral osteotomy For traumatic childhood cubitus varus deformity. Clin orthop 1984;188:34-9.
12. Uchida Y, Ogata K, Sugioka Y. A new three-dimensional osteotomy for cubitus Varus deformity after supracondylar fracture of the humerus in children. J pediatr Orthop 1991;11:327-31.
13. Bellemore MC, Barrett IR, Middleton RW, Scougall JS, Whiteway DW. Supracondylar osteotomy of the humerus with correction of cubitus varus. J bone joint surg br 1984;66(4):566-72.
14. Matsushita t, Nagano a. Arc osteotomy of the humerus to correct cubitus varus. Clin orthop relat res 1997;336:111-5.
15. Tien YC, Chih HW, Lin GT, Lin SY. Dome corrective osteotomy for cubitus varus deformity. Clin orthop relat res 2000;380:158-66.
16.Wong HK, Lee EH, Balasubramaniam P.The lateral condylar prominence. A complication of supracondylar osteotomy for cubitus varus. J bone joint surg br 1990;72:859-61.
17. Ali Moradi MD, Ehsan Vahedi MD,Mohammad H.Ebrahimzadeh MD. Spike Translation: A New Modification in Step-cut Osteotomy for Cubitus Varus Deformity. Clin Orthop Relat Res (2013) 471:1564–1571.
18. Yamamoto I, Ishii S, Usui M, Ogino T, Kaneda K. Cubitus varus deformity following supracondylar fracture of the humerus: a method for measuring rotational deformity. Clin Orthop Relat Res. 1985;201:179–185.
19. S Pandey, A Shrestha, AP Regmi, A Prajapati, S Dhakal and G Neupane. Cubitus varus in young adults correction with lateral closing wedge osteotomy and screw, k-wire and ss-wire fixation.Journal of Chitwan Medical College; 2012, 1(2); 60-62.
20. Sandeep patwardhan , Ashok k shyam. Cubitus varus deformity – rationale of treatment and methods. International journal of paediatric orthopaedics | volume 1 | issue 1 | july-sep 2015 | page 26-29.
21. Graham B, Tredwell SJ, Beauchamp RD, Bell HM. Supracondylar osteotomy of the humerus for correction of cubitus varus. J Pediatr Orthop. 1990;10:228–231.
22. Voss FR, Kasser JR, Trepman E, Simmons E Jr, Hall JE. Uniplanar supracondylar humeral osteotomy with preset Kirschner wires for posttraumatic cubitus varus. J Pediatr Orthop. 1994;14:471–478.
23. Davids JR,Lamoreaux DC, Brooker RC,Tanner SL, Westberry DE.Translation step-cut osteotomy for the treatment of posttraumatic cubitus varus.J Pediatr Orthop. 2011;31:353-365
24. Labelle H, Bunnell WP, Duhaime M, Poitras B. Cubitus varus deformity following supracondylar fractures of the humerus in children. J Pediatr Orthop. 1982;2:539–546.
25. French PR. Varus deformity of the elbow following supracondylar fractures of the humerus in children. Lancet. 1959;2:439-41.
26. King D, Secor C. Bow elbow (cubitus varus). J Bone Joint Surg Am. 1951; 33:572-6.
27. Carlson CS Jr, Rosman MA. Cubitus varus: a new and simple technique for correction. J Pediatr Orthop 1982;2:199-201.
28. Levine MJ. Horn BD, Pizzutillo PD. Treatment of posttraumatic cubitus varus in pediatric population with humeral osteotomy and external fixation. J Pediatr Orthop 1996;16:597-601.
29. Karatosun V, Alekberov C, Alici E, Ardic CO, Aksu G. Treatment of cubitus varus using the Ilizarov technique of distraction osteogenesis. J Bone Joint Surg [Br]2000;82-B:1030-3.

How to Cite this Article: Ramprasath DR, Thirunarayanan V, Sundaram MS. Clinical and radiological outcome following Kim’s Step Cut Translation Osteotomy for Cubitus Varus and Valgus in Children International Journal of Paediatric Orthopaedics May-Aug 2016;2(2):34-37.

Dr Dhurvas Ramlal Ramprasath

Dr. Vasudevan Thirunarayanan

Dr. Murugan Shanmuga Sundaram

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Pollicisation: Embryology, History, Technique and Results

Volume 2 | Issue 2 | May-Aug 2016 | Page 29-33|Amita S. Hiremath, Binita N. Raut, Amit A. Yadav, Mukund R. Thatte

Authors :Amita S. Hiremath [2], Binita N. Raut [1], Amit A. Yadav [2], Mukund R. Thatte [3]

[1] KLE University’s J.N.Medical College,Belgavi,
[2] Bombay Hospital and Institute of Medical Sciences Mumbai.
[3] Bombay Hospital and Institute of Medical Sciences Bai Jerbai Wadia Hospital for Children, Shushrusha Citizens’ Co‑op. Hospital,Maharashtra, India

Address of Correspondence
Dr Mukund R. Thatte, Room 6, 2nd Floor, New Wing, Bombay Hospital, New Marine Lines, Mumbai ‑.400 020, Maharashtra, India.
E‑mail: mthatte@gmail.com

Abstract

Thumb hypoplasia/aplasia is one of the components of radial longitudinal deficiency. It can occur either alone or it may be associated with other components of radial longitudinal deficiency. Aim of thumb reconstruction is to provide a functional and stable thumb which will improve the grip and aesthetic appearance of hand. Pollicisation is the treatment for Type IIIB,IIIC, IV and V types of thumb hypoplasia as per Blauth’s Classification as Modified by Manske and Buck-Gramcko. In the opinion of the authors, pollicisation is one of the finest and most difficult operations in reconstructive hand surgery.
Keywords: Pollicisation: History, Principles and Surgical technique.

Introduction
Napier has said “The hand without a thumb is at worst, nothing but an animated fish-slice, and at best a pair of forceps whose points don’t meet properly”. [1]
Thumb hypoplasia is a congenital condition, which can range from slightly small digit to deficiency of some musculotendinous units or osseous components to complete absence of thumb.40% of the hand function relies on a strong thumb. [2]For proper functioning of the hand, thumb size, its position,mobility and the relation with other fingers is critical. Children with thumb hypoplasia can manipulate small objects using side to side pinch, between adjacent digits, ‘Chopstick’ action; but it is difficult to grasp large objects. [3]
Thumb hypoplasia/aplasia is one of the components of radial longitudinal deficiency. It can occur either alone or it may be associated with other components of radial longitudinal deficiency. A wide range of manifestations on the preaxial side of the upper limb is seen in radial longitudinal deficiency. Hence, in any case of thumb hypoplasia, one should examine proximal forearm and contralateral thumb.
Incidence
Thumb hypoplasia is a component of various congenital malformations like thumb duplication, transverse deficiencies, brachydactyly, symbrachydactyly, cleft hand complex, constriction ring syndrome etc., and hence it is very difficult to find out the true incidence of thumb hypoplasia alone. Tay SC et al in 2006, reported upto 16% incidence of thumb hypoplasia amongst congenital hand deformities. [4] There is equal distribution of cases between male and female. About 60% cases have bilateral involvement with often asymmetrical involvement. [5] In unilateral cases, right hand is more commonly affected. [6]
In a study by Abdel-Ghani and Amro, [7] 86% cases of thumb hypoplasia were associated with various conditions involving cardiovascular, gastrointestinal and genitourinary system. Various conditions commonly seen in association with thumb hypoplasia are Holt-Oram syndrome, VACTERL association, Fanconi’s anaemia, Thrombocytopenia absent radius(TAR) syndrome. [6] The severity of radial longitudinal deficiency is directly proportional to the degree of thumb hypoplasia according to James et al. [8]

Genetics
The upper limb bud appears at 4th week of embryonic development opposite the caudal cervical somites. Various signalling centres have been identified that are responsible for upper limb development. [4,8]
1. Apical Epidermal Ridge(AER) – responsible for proximal to distal development (shoulder to hand) and is mediated by number of fibroblast growth factors.
2. Zone of Polarizing Activity (ZPA) – responsible for anterior-posterior pattern formation(also called Pre and Post Axial) and is mediated by sonic hedgehog (Shh) and homeobox (HOX) gene products.
3. WNT7a signalling centre – responsible for dorsal ventral development.
The exact mechanism of embryologic insult that leads to thumb hypoplasia is unclear. Abnormalities in AER or ZPA can lead to thumb hypoplasia. Studies have proved that administration of teratogenic agents or inactivating fibroblastic growth factors in rats and mice can lead to radial longitudinal hypoplasia with thumb hypoplasia. [10]
The deletion of chromosome 22q11 can lead to thumb hypoplasia in radial longitudinal deficiency [5]. However, it is difficult to point out single gene or enzymatic defect as the cause for thumb hypoplasia [8].

Classification
Thumb hypoplasia can present with wide range of functional and aesthetic differences. Hence careful inspection and examination is required. One should carefully examine the size, position, skeletal components, intrinsic and extrinsic muscles, joint stability, and first web space and associated conditions. One should correlate soft tissue and skeletal deficiencies while taking decision about the treatment.
Classification helps in taking decision about the treatment. In 1937, Muller first classified thumb hypoplasia. It is currently the Blauth’s classification which is widely accepted in classifying and as a guide for surgical planning. Manske further classified type 3 hypoplasia in A and B depending on stability of CMC joint. [4, 11]

Blauth’s Classification as Modified by Manske and Buck-Gramcko:

Type I: Mild hypoplasia
Slight decrease in thumb size
Slender phalanges and metacarpals
Normal intrinsic muscles
Normal trapezium, scaphoid, distal radius and styloid process

Type II: Moderate hypoplasia
Underdeveloped or absent thenar muscles
Adducted posture- first web space narrowing
Ulnar Collateral ligament (UCL) insufficiency at MP joint
CMC stable

Type III: Severe hypoplasia
All the features of type II plus
Radial carpal aplasia
Extrinsic muscle and tendon abnormalities
Type III A: Stable CMC joint
Type III B: Unstable CMC joint
Type IIIC: Buck Gramcko has added this variation in which thumb has only metacarpal with no musculotendinous unit and a wider skin bridge
Type IV: Pouce floutant (French Floating thumb)
Thumb is small and has rudimentary skeletal elements. It is an unstable digit, connected to the hand by only a skin bridge containing the neurovascular bundle.
Type V: Aplasia i.e.Absence of all thumb structures and radial carpal bones

Figure 1: Preoperative picture of Type IV thumb hypoplasia (volar view)

Figure 2: Preoperative picture of Type IV thumb hypoplasia (dorsal view)

Figure 3: Preoperative xray showing rudimentary skeletal elements

Evaluation
Thumb hypoplasia can be the only presentation of radial longitudinal deficiency or it may be associated with other anomalies. Plain bilateral radiographs will help to assess thumb phalanges, metacarpal and carpometacarpal joint. One should assess wrist and forearm to rule out radial longitudinal deficiency.
As thumb hypoplasia can be associated with other syndromes, thorough cardiac, renal, haematological and musculoskeletal evaluation is essential. Common investigations include a complete blood count, 2D Echo Cardiogram and sonography abdomen for solid organs. This is important as the treatment of these conditions may take priority over thumb hypoplasia management. [12]Any positive findings may also impact anaesthesia for surgery.

Figure 4: Buck Gramcko type markings for dorsal side

Figure 5: Buck Gramcko type markings for palmar side

Figure 6: Dorsal flaps raised preserving dorsal venous network

Treatment
Aim of thumb reconstruction is to provide a functional and stable thumb which will improve the grip and aesthetic appearance of hand.
Typically Type I is more or less a functional thumb,hence no treatment is required.
Type II: depending on findings; first web space release, opponensplasty using Abductor Digiti Minimi (ADM) or other suitable donors and/or UCL reconstruction
Type III A: same procedures like type II and in addition may require further additional extrinsic tendon transfers to improve the function, which transfers and how needs to be decided on a case by case basis, depending on need.
Type IIIB,IIIC, IV and V: Pollicisation

Timing of surgery:
Surgery at an early age is recommended for better functional results as it will allow cognitive development and physiological adaptation of the reconstructed thumb before corticalisation which happens around 18 months of age. [13]
We are basically going to discuss about pollicisation in advanced hypoplasia IIIB onwards or Aplasia in this paper.
Pollicisation is a Latin word; Pollex means thumb and Pollicisation is defined as reconstruction of thumb using the adjacent radial finger.

History of pollicisation
In 1885,Guermonprez seems to be the first person to report a case of pollicisation. Before the second world war, many surgeons Dunlop (1923), Bunnell (1931) have reported doing pollicisation. However, follow up study of these cases had unsatisfactory results.
The major modification in the procedure was seen after the Second World War. Gosset (1949) [14] described index finger and ring finger pollicisation on neurovascular pedicle without skin attachments. Middle finger pollicisation was described by Hilgenfeldt (1950) [15]. Further contributions were by Bunnell (1952), Littler (1953). [16.17]
In 1971, Buck Gramcko published an article about pollicisation [18] which is the landmark article in establishing the technique of pollicisation in our opinion. Buck Gramcko’s major work on pollicisation evolved after the thalidomide tragedy in Europe which had led to many congenital hand and upper limb anomalies. Manske, Foucher et all have modified the technique but Buck Gramcko’s technique is the gold standard method still commonly used. The authors use the Buck Gramcko technique.

Principles of Pollicisation:
In 1990 Littler had said:
“It is not the full length of the thumb, nor its great strength and movement, but rather its strategic position relative to the fingers and the integrity of the specialized terminal pulp tissue which determines the prehensile status.”

Littler has classified requirements of the procedure as follows [19]
Mechanical
1. Correct length
2. Strategic position
3. Stability

Physiological
1. Movement
2. Sensibility
3. Absence of pain
4. Integration

Satisfactory appearance
In the opinion of the authors, pollicisation is one of the finest and most difficult operations in reconstructive hand surgery. Patient’s parents have a tough time deciding about amputing the useless thumb and using index finger for thumb reconstruction. Authors feel it is simultaneously rewarding to and taxing on the surgeon performing it. [20]

TECHNIQUE Figs. 1- 17
Fig. 1,2 and 3 represent pre operative photos and X-Ray.
Markings as per Buck-Gramcko (Fig. 4,5) Senior author (MRT) starts the surgery by raising the dorsal flaps taking care to preserve dorsal venous network. (Fig. 6)
Once the dorsal flaps are raised preserving dorsal venous network, palmar incisions are made and pedicles are dissected on the palmar side. Sometimes it may be required to open the neural ring on the ulnar side pedicle,if it is present.(Fig.7)

Figure 7: Dissection of vascular pedicles of Index finger

After dissecting and safeguarding the pedicle, first dorsal interosseous and first palmar interosseous with lateral band extension is identified and cut. To identify the distal lateral band at the time of final suturing, a 6-0 nylon suture is used for tagging the remaining lateral band (Fig. 8,9,10)

Figure 8: First dorsal interroseous raised with tendon

Figure 9: Lateral band on finger tagged with 6/0 nylon loose stitch for later identification

Figure 10: First palmar interroseous raised with tendon

Next step is to identify the two extensors – extensor indicis proprius and extensor digitorum communis of index finger and cut them. In more severe variants of Radial dysplasia only one tendon is present.(Fig. 11)

Figure 11: Extensor digitorum communis and Extensor Indicis proprious seen

Figure 12: Extensor Indicis proprious (EIP) cut and raised off MP joint so as to act on distal interphalangeal as future extensor pollicis longus

For setting the index completely free, the deep transverse metacarpal ligament between index and middle finger has to be divided. (Fig. 13)

Figure 13: Dividing deep transverse metacarpal ligament between index and middle finger

The line of division of metacarpal is through the epiphysis at the level of the head. The shaft is disarticulated at the CMC joint and is excised extra-periosteally.(Fig. 14,15)

Figure 14: Division of index finger metacarpal at the level of head of metacarpal

Figure 15: Metacarpal shaft disarticulated at carpometacarpal joint

At every step, one has to be careful about the neurovascular pedicle of the index finger.
The metacarpal head has to be rotated by 900 in extension and fixed with 4-0 nylon to prevent hyperextension of the new CMC joint.(Fig 16)

Figure 16: Rotating metacarpal head dorsally by 900

Index finger is now rotated 150 degrees, abducted 40-50 degrees and fixed at the CMC level with a 4-0 nylon suture which goes thru the CMC joint- head of metacarpal-CMC other lip.(Fig 17)

Figure 17: Index finger is fixed at CMC level

The Extensor/s are sutured first. The EIP becomes the EPL and the EDC becomes the APL
The Metacarpal level attachment of the EIP is dissected off; this enables the EIP to act on the DIP as an extensor. (Fig 12)
The EDC is kept attached at the base of the PPx of the IF so that once the tendon is reattached it acts as the APL.
The First dorsal interosseous is attached next to the lateral band to become the new abductor – opponens complex.(Fig. 18)

Figure 18: Suturing first dorsal interosseous to lateral band as the new abductor opponens complex

Dorsal flaps are sown.
The Palmar Interosseous is now attached to the other lateral band to become the Adductor Pollicis.
Skin flaps are now adjusted and closed to get the new thumb(Pollex) in opposition and pronation to achieve pulp to pulp pinch.(Fig. 19)
Fig. 20,21 show two views of the completed operation

Figure 19: Adjusting skin flaps to get new thumb in opposition and pronation

Figure 20: Final position palmar view

Figure 21: Final position dorsal view

A bulky padded dressing is given to protect the new thumb and tourniquet released and vascularity of both arteries and veins is checked.(Fig. 22)
Fig. 19 shows a long term result

Figure 22: Final dressing

Figure 23: showing 7 years follow up results

Complications of procedure
Losing the finger—very rare but possible
Skin necrosis
Hyperextension at CMC joint
Too long length
Functional Result may not be as good in severe radial longitudinal deficiency. There are chances of abnormalities of muscles of index finger and stiffness of index finger PIP joint in these cases (Symphalangism) which leads to relative functional impairment following pollicisation.
In our opinion it is still better than a four fingered hand at all times

Conclusion
Pollicisation is the optimum method of thumb reconstruction in thumb hypoplasia/aplasia

References

1. The rule of thumb by Tom Tyler JAC 30.3.4(2010) ,711-32.http://www.cyberchimp.co.uk/research/thumb.html
2. Lightdale-Miric N, Mueske NM, Lawrence EL, Loiselle J, Berggren J, Dayanidhi S, Stevanovic M, Valero-Cuevas FJ, Wren TA. Long term functional outcomes after early childhood pollicization. J Hand Ther. 2015 Apr-Jun;28(2):158-65
3. MahmutKömürcü, SerdarYüce et al. Index finger pollicization for treating a congenitally nonfunctioning thumb in patients with radial longitudinal deficiency. Eastern Journal of Medicine 2014;19: 175-181.
4. Tay SC, Moran SL, Shin AY, Cooney WC III. The hypoplastic thumb. J Am AcadOrthopSurg 2006;14: 354 –366.
5. Thumb hypoplasia .Scott A. Riley,Ronald C. Burgess. Hand Surg 2009;34A: 1564–1573.
6. James MA, McCarroll HR Jr, Manske PR. Characteristics of patients with hypoplastic thumbs. J Hand Surg 1996;21A: 104–113.
7. Abdel-Ghani B, Amro S. Characteristics of patients with hypoplastic thumb: a prospective study of 51 patients with the results of surgical treatment. J PediatrOrthop B 2004;13:127–138.
8. James MA, Green HD, McCarroll HR Jr, Manske PR. The association of radial deficiency with thumb hypoplasia. J Bone Joint Surg 2004;86A: 2196–2205.
9. Tickle C. Experimental embryology as applied to the upper limb. J Hand Surg 1987;12B: 294 –300.
10. Kato H, Ogino T, Minami A, Oshio I. Experimental study of radial ray deficiency. J Hand Surg 1990;15B:470–476.
11. Kozin SH. Deformities of the Thumb. Green’s Operative Hand Surgery.6 thed.ScottW.Wolfe, Robert N., William C., Scott K. editors. Philadelphia: Churchill Livingstone, Elsevier: 2011.p 1371.
12. Riley SA. An overview of radial longitudinal deficiency. CurrOrthop Prac2008;9:655–659.
13. Joseph Upton III and Amir Taghinia. Congenital hand III: Disorders of formation- thumb hypoplasia.James Chang and Peter C. Neliganeditors.Plastic Surgery- Hand and Upper Extremity.Elsevier Saunders,2013.p 572-602.
14. Gosset I: La pollicisation de I ‘index . J Chir.1949;65:403.
15. Bhaskaranand Kumar, Ashwath Acharya, and Anil K. Bhat. A relook at pollicization. Indian J Plast Surg. 2011 MayAug;44(2): 266–275.
16. Paul Binhammer and Graham Lister.Pollicization. Reconstructive Surgery in Hand Mutilation. Edited by Guy Foucher, Martin Dunitz: 1997.pg 29-40.
17. J W Littler, The neurovascular pedicle method of digital transposition for reconstruction of the thumb. Plast. Reconstr. Surg. 1953, 12:303-14
18. BuckGramcko D. Pollicization of the index finger. Method and results in aplasia and hypoplasia of the thumb. J Bone Joint Surg Am 1971;53:1605-17.
19. Yves Allieu, Michel Chammas and Jean Luc Roux. Considertions concerning pollicization. Reconstructive Surgery in Hand Mutilation. Edited by Guy Foucher, Martin Dunitz: 1997.pg41-52.
20. Thatte MR, Nehete S, Garude K, Mehta R. Unfavourable results in pollicisation. Indian J Plast Surg. 2013 May;46(2):303-11..

How to Cite this Article: Hiremath AS, Raut BN, Yadav AA, Thatte MR. Pollicisation: Embryology, History, Technique and Results. International Journal of Paediatric Orthopaedics May-Aug 2016;2(2):29-33.

Dr Mukund R. Thatte

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Clinical and Radiological Outcome following Kim’s Step cut Translation Osteotomy for Cubitus Varus and Valgus in Children

Pollicisation: Embryology, History, Technique and Results

Clinical and Radiological Outcome following Kim’s Step cut Translation Osteotomy for Cubitus Varus and Valgus in Children

Pollicisation: Embryology, History, Technique and Results

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Clinical and Radiological Outcome following Kim’s Step cut Translation Osteotomy for Cubitus Varus and Valgus in Children

Authors :Dhurvas Ramlal Ramprasath [1], Vasudevan Thirunarayanan [1], Murugan Shanmuga Sundaram [2]

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Pollicisation: Embryology, History, Technique and Results

Authors :Amita S. Hiremath [2], Binita N. Raut [1], Amit A. Yadav [2], Mukund R. Thatte [3]

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