Salvage Reconstruction of Failed Pollicization by Distraction Lengthening

Abstract

Hypoplasia of the thumb can present as an isolated deformity or as part of a systemic process such as thrombocytopenia-absent-radius syndrome, Holt–Oram syndrome, Fanconi’s anemia, and VACTERL syndrome (vertebral abnormality, anal atresia, cardiac abnormality, tracheoesophageal fistula, esophageal atresia, renal abnormality, lower extremity abnormalities). If the hypoplastic thumb is not functional, pollicization of the index finger is the treatment of choice for Blauth type IIIB, IV (floating thumb), and obviously if the thumb is absent (type V). Successful pollicization of the index finger requires meticulous surgical technique, but good long-term results have been reported as high as 81% [23]. Functional limitations have been reported by many studies [1, 2, 5–7, 10–12, 16, 21, 22], but other reports of complications, including failures, are scarce. Reported complications include iatrogenic neurovascular injury, web space contracture, malrotation, functional deficits (decreased pinch and grip strength, lack of opposition), and stiffness [4]. To our knowledge, there is limited literature concerning treatment for a failed pollicization. This could be due to reluctance of surgeons to report their complications and/or small patient numbers. This case report describes a child with left radial longitudinal deficiency and complete thumb aplasia that underwent pollicization of the index finger by another hand surgeon. Unfortunately, the pollicization failed either due to resorption of the proximal phalanx of the index finger (metacarpal of the new thumb) due to infection or ischemia or due to the surgeon inadvertently resecting the proximal phalanx of the index finger, mistaking it for the metacarpal. This resulted in a pollicized index finger that was too short and consequently had limited opposition and tip-to-tip pinch. The objective of this case report is to make the hand surgeons aware of this previously unreported complication of pollicization and describe a method of reconstruction to provide a functional thumb. Informed consent and permission for publication was given by the child and parents.