Instability Of Metacarpophalangeal Joint Research Articles

Novel figure-of-eight reconstruction with free tendon graft for unrepairable collateral ligament of the thumb metacarpophalangeal joint

ObjectivesThis study aimed to report surgical technique and clinical outcomes for a novel figure-of-eight collateral ligament reconstruction technique using palmaris longus autograft for chronic irreparable collateral ligament injury of the thumb metacarpophalangeal joint. Material and methodsThe Jobe elbow collateral ligament reconstruction method was adapted for thumb metacarpophalangeal joint collateral ligament reconstruction. Sixteen reconstructions (7 ulnar collateral ligament, 9 radial collateral ligament) using palmaris longus autograft were reviewed retrospectively. Surgery was performed at a mean 12 months post-injury. All 16 patients were followed up for more than 1 year. Metacarpophalangeal joint radial and ulnar deviation, metacarpophalangeal and interphalangeal joint range of motion, key pinch and grip strength, Glickel functional grade and QuickDASH score were evaluated. ResultsPreoperative radial or ulnar deviation improved from 19.3° to 5.3° postoperatively. Metacarpophalangeal range of motion improved from 31.5° to 46.6°, and interphalangeal range of motion from 48.4° to 65.6°. Preoperative key pinch and grip strength were respectively 49% and 81% of contralateral values and improved to 82% and 87%. On Glickel grade, 9 cases were excellent and 7 good. ConclusionThe novel Jobe-like figure-of-eight reconstruction technique using palmaris longus graft was useful for reconstructing irreparable thumb metacarpophalangeal joint instability without an incision on the opposite side or an additional implant. Level of evidenceTherapeutic study, level IV.

Thumb hypoplasia in children: A case report

Thumb hypoplasia is a component of radial longitudinal deficiency. The severity of hypoplasia can range from a slightly smaller thumb to a complete absence. They are often categorised using Blauth classification to recommend appropriate treatment. Type II is characterised by the first web-space narrowing, underdeveloped or absence of thenar muscles, thumb extrinsic and metacarpophalangeal joint instability. The author reviews a 7-year-old male patient who visits the hospital due to a small thumb, narrowing web I-II and limiting to flexing the interphalangeal joint. He underwent a first web-space release using flap Z-plasty, stabilised the metatarsal joint and opponensplasty transfer of the flexor digitorum superficialis of the IV finger to increase the opposition of the thumb. Results were assessed according to subject and object criteria. The author proposed that this technique could be reliable for treating other cases with thumb hypoplasia type II and IIIB.

Radial Collateral Ligament Injuries of the Thumb Metacarpophalangeal Joint.

Injuries to the radial collateral ligament (RCL) of the thumb are thought to be relatively uncommon, especially when compared to the ulnar collateral ligament. However, the radial collateral ligament is increasingly recognized as critical for the overall stability of the thumb metacarpophalangeal joint. This article sets out to provide a comprehensive review of RCL injuries of the thumb MCP joint, including epidemiology, biomechanics, diagnosis, and treatment. Although traditionally thought to respond well to conservative management, especially when compared to injuries to the ulnar collateral ligament, there is mounting evidence that chronic RCL injury leads to thumb metacarpophalangeal joint instability and can accelerate post-traumatic joint degeneration. Thus, much of the recent literature details surgical treatment options for radial collateral ligament injury, including repair and reconstruction. While incomplete tears of the thumb RCL respond well to immobilization, complete tears should generally be treated with operative management, either direct repair or anatomic reconstruction, depending on tissue quality. Even subacute and chronic injuries may be amenable to direct repair, with good to excellent outcomes, including in high-demand patient populations, such as professional athletes.

Improving Metacarpophalangeal Joint Instability by Joint Implantation in Parallel From a Supernumerary Thumb in Severely Hypoplastic Duplicated Thumbs.

Here, we present 2 cases of a severely hypoplastic duplicated thumb classified as Wassel types 5 and 6 and discuss whole-joint implantation from a supernumerary thumb as an alternative to stabilize the hypoplastic metacarpophalangeal (MCP) joint. The aim of the surgical treatment of thumb polydactyly is to reconstruct a functional and aesthetically pleasing thumb. Hypoplasia of joint components and abnormal tendon alignment lead to unpleasing results with angular deformity of the reconstructed thumb. In 2 cases, the MCP joint of the dominant digit was hypoplastic and unstable in all directions. The main problem was underdevelopment of the affected MCP joint, and it was reasonable to attempt to stabilize the unstable joint by adding another redundant joint in parallel. Whole-joint implantation with a flap on a vascular pedicle is useful to repair both joint instability and soft tissue hypoplasia, as in case 1. The vascularized joint can maintain balanced growth potential. However, nonvascularized interphalangeal (IP) joint implantation is a simple solution for repairing MCP joint instability, as in case 2. These joints have no tendon insertions, so we believe they are acting as a splint supporting the hypoplastic joint for a long period. The transfer of composite tissues from the foot has been reported for reconstruction of finger and thumb hypoplasia. Duplicated thumb operation is usually recommended at 1 year old. Similarly, nonvascularized joint implantation in parallel may be a promising choice to overcome MCP joint instability and to maintain range of motion in hypoplastic cases with a duplicated thumb.In conclusion, joint implantation in parallel from a supernumerary thumb could prevent angular deformity and is an alternative to overcome MCP joint instability in cases of a severely hypoplastic duplicated thumb without any donor morbidity.

Pediatric Trigger Thumb with Metacarpophalangeal Joint Hyperextension or Instability.

BackgroundThe aim of this study was to provide the first on report on the mechanism and the different treatment measures of metacarpophalangeal joint hyperextension (MCPH) or metacarpophalangeal joint instability (MCPI) in cases of pediatric trigger thumb. Some pediatric trigger thumb patients have disease combined with excessive extension of metacarpophalangeal (MCP) joint or instability of MCP joint.Material/MethodsA total of 1083 children with trigger thumb surgery were divided into 2 groups (the MCPH group and the MCPI group) by the extension degree of the MCP joint. After tendon sheath released, the MCPH group was treated by a cast and the MCPI group was treated by a cast and a brace. We compared the differences in baseline data and the further functional activities of interphalangeal (IP) and MCP joint between the 2 groups.ResultsAmong the 1083 cases, 154 cases (185 thumbs) were trigger thumb with MCPH or MCPI, of which 167 thumbs were placed in the MCPH group and 18 thumbs were placed in the MCPI group. The average age of the MCPH group was 2.8 years, with an average duration of disease of 13 months. The average age of the MCPI group was 6.6 years, with an average duration of disease of 33 months. MCPH still existed after cast removal. In the MCPI group, 12 out of 18 thumbs recovered; 6 thumbs relapsed at 2–4 months after brace removal.ConclusionsTrigger thumb with MCPH and MCPI in children is significantly associated with multi-joint laxity. While there was still MCPH after cast treatment, there was no need for further treatment during the short-term follow-up. Cast and brace treatment after surgery was a simple, easy method for treatment of MCPI and had a good effect.

Poster 234: Treatment of First Metacarpophalangeal Joint Instability and Snapping Thumb Using Ultrasound-guided Prolotherapy and Hydrodissection: A Case Report

Poster 234: Treatment of First Metacarpophalangeal Joint Instability and Snapping Thumb Using Ultrasound-guided Prolotherapy and Hydrodissection: A Case Report

Treatment of instability of the metacarpophalangeal and trapeziometacarpal joints of the thumb

Restoration of stability of the thumb represents an enormous gain of function for the patient and can be achieved by arthrodesis or ligament reconstruction. Ligament reconstruction should only be performed if good stability and mobility and apain-free grip can also be achieved. In every case surgery must protect the delicate soft tissues and should be based on aprofound knowledge of the anatomical and biomechanical circumstances. Instability of the trapeziometacarpal joint is rare but metacarpophalangeal joint instability (ulnar, palmar and radial) is relatively frequent. For both conditions arthrodesis is the most frequently used and easier surgical procedure. Ligament reconstruction is more difficult to perform but can maintain the mobility of these joints.

Extensor Digiti Minimi Transfer for the Treatment of an Unstable Metacarpophalangeal Joint in Thumb Polydactyly Without Thenar Atrophy.

Dear Sir, As treatments for the laxity of metacarpophalangeal (MCP) joint in hypoplastic thumb, joint capsular plication, free tendon graft or MCP arthrodesis have been performed [1]. In addition, transfer of abductor digiti minimi [2] or ring finger flexor digitorum superficialis [3] have been used to provide thumb opposition and restore MCP joint stability. In the present case, we used extensor digiti minimi (EDM) transfer to treat MCP joint instability due to ulnar collateral ligament laxity in a patient with thumb polydactyly without thenar muscle atrophy. An 11-year-old girl who was naturally right thumb polydactyly with floating ulnar thumb had a thumb plasty at the age of five. But she was bothered by an unstable MCP joint due to ulnar collateral hypoplasia (Fig. 1a). Six years later from primary operation, she underwent a second surgery to improve joint instability and outer appearance of the thumb. The MCP joint instability was corrected by an EDM transfer, which involved fasting the end of the transferred tendon to the ulnar side of the MCP joint at the bottom of proximal phalanx and at the metacarpal head (Fig. 2). At 10 months postoperatively, the appearance of the thumb was improved and the MCP joint was stable (Fig. 1b). The EDM transfer procedure was initially reported for restoration of thumb adduction in ulnar nerve paralysis [4], but MCP joint stability could be achieved by changing the distal tendon insertion as this case. We consider there are some advantages to this procedure: 1) the MCP joint achieves maximum stability in the opposite position, because the tension of the transferred EDM tendon increases with the increase in the angle of opposition, 2) the mobility of the MCP joint is not impaired, 3) the strength of side pinch could be increased by increasing the thumb adduction force. On the other hand, the disadvantages of this procedure include that this transfer would position thumb in extension and adduction, and a decrease in the extension force of the little finger. The former demerit barely mattered in actuality, because we think the tension of transferred EDM is not strong in the rest position.

Which Technique for Treatment of Chronic Thumb MCP Joint Instability? Comparison of 3 Techniques With a Mean Follow-up of 84 Months

Objective: Injuries to the thumb collateral ligament are common whose acute surgery gives good functional results. But they are often unrecognized and surgical procedures for chronic instability are still being discussed. The aim of this study was to compare retrospectively the clinical and radiological results of the 3 main treatments for chronic instability of the metacarpophalangeal (MCP) joint of the thumb to identify trends and optimize outcome. Materials and Methods: In this retrospective and monocentric study, we included all the patients operated between 2000 and 2012 from a chronic posttraumatic instability of the MCP joint of the thumb by 1 of 3 techniques: primary repair (37 cases), ligament reconstruction (14 cases), and arthrodesis (43 cases). Patients with hyperextension instability, degenerative instability, and a follow-up less than 2 years were excluded from this study. Subjective and objective results and rates of complications and recurrence were compared at end of the follow-up. Results: Sixty-seven patients were included, 55 followed up for a mean 84 months (range, 24-164 months). Whichever the procedure, all patients considered themselves improved or healed. Forty-eight patients (87.3%) were satisfied or very satisfied. The relief of pain was significantly better in the arthrodesis group. The mean Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) for primary repair group were 17.4 (0-89.5), for ligament reconstruction group 25.7 (0-58.3), and for the arthrodesis group 17.8 (0-50). Pinch strength, on average of the value on the unoperated side, was 89% for primary repair group, 84% for ligament reconstruction group, and 94% for the arthrodesis group. Six of 10 ligament reconstructions had MCP joint laxity at end of follow-up. There were significantly fewer patients who considered themselves cured in the ligament reconstruction group. There were 4 failures by end of follow-up: 1 associated with primary repair, 1 with arthrodesis, and 2 with ligament reconstruction. Discussion and Conclusion: Surgery in treating chronic instability of the MCP joint of the thumb gives generally good results. Primary repair should be considered as much as possible. In contrast to literature report, ligament reconstruction does not give better results than arthrodesis.

Gamekeeper’s thumb

Gamekeeper’s thumb is a condition resulting from low-grade repeated force through the ulnar collateral ligament of the thumb metacarpophalangeal joint. In its acute form, it is sometimes known as Skier’s thumb and can be associated with tears, ruptures and fractures. Prompt assessment of the thumb’s structural integrity is therefore important in preventing long-term morbidity of metacarpophalangeal joint instability. Diagnosis is usually made clinically, although radiological imaging can act as a helpful adjunct. Unstable injuries tend to have a better functional outcome if repaired surgically. This article will outline relevant clinical anatomy, injury mechanism, clinical assessment and management of ulnar collateral injuries including Gamekeeper’s thumb.

A Matched Comparative Study of the Bilhaut Procedure Versus Resection and Reconstruction for Treatment of Radial Polydactyly Types II and IV

To compare outcomes of the Bilhaut procedure with outcomes of conventional resection and reconstruction in radial polydactyly types II and IV. Patients treated with the Bilhaut procedure were radiologically matched with patients treated with reconstruction. Evaluated outcomes included the Rotterdam assessment system, pinch strength, and thumb size measurements. To determine objectively which aesthetic outcome scores truly depended on surgical technique rather than observer opinion, we analyzed evaluations by a panel of 22 individuals with varying clinical experience who were blinded to the study protocol, using a linear mixed regression model. The Bilhaut procedure reduced the risk of suboptimal outcome for metacarpophalangeal joint instability in type IV radial polydactyly. Conversely, the Bilhaut procedure increased the risk of suboptimal scar appearance, residual prominence at amputation site, thumb size, and nail appearance. Tip pinch strength was more significantly reduced after the Bilhaut compared with reconstruction, whereas pulp circumference and nail width exceeded 100% of the unaffected contralateral hand after the Bilhaut reconstruction. There was no significant difference in active range of motion between procedures. Nail appearance proved the only aesthetic drawback of the Bilhaut procedure after adjustment for clinical experience. There was superior metacarpophalangeal joint stability after the Bilhaut procedure for radial polydactyly type IV, but this did not result in the presumed benefit to thumb strength. For experienced surgeons, both procedures resulted in comparable thumb active range of motion. However, aesthetic results were more likely perceived as pleasing after conventional reconstruction, even after adjusting for observer experience with regard to nail appearance. Despite possible benefits of modified Bilhaut procedures that preserve the nail, conventional reconstruction is the preferred procedure until otherwise proven. Therapeutic III.

Defining postoperative stability in children with radial polydactyly.

There is little fundamental data on paediatric metacarpophalangeal joint instability in radial polydactyly following surgical reconstruction. We evaluated 27 thumbs in a healthy paediatric population (Group A: eight girls and 19 boys with a mean age of 9.7 years (range 2.7-14.2)) and 12 thumbs following Wassel-IV reconstruction (Group B: eight girls and four boys with a mean age at follow-up of 10.6 years (range 2.7-13.2)). Metacarpophalangeal joint radial deviation, ulnar deviation on stress testing, interphalangeal joint and metacarpophalangeal joint alignment on posterior-anterior radiographs were measured and scored according to parameters defining joint instability. The aim of our study was to provide fundamental data on thumb metacarpophalangeal joint mobility patterns and alignment for further postoperative evaluations in children. The average ulnar deviation and radial deviation on stress testing of the healthy (Group A) metacarpophalangeal joints was 25° (10°-45°) and 30° (10°-55°), respectively. In the operated (Group B) thumbs, the ulnar deviation and radial deviation was greater at 35° (10°-55°) and 30° (10°-70°). Ulnar deviation (UD) of the proximal phalanx at the metacarpophalangeal joint on posterior-anterior radiographs was a mean of 10° (range -10°-30°) in Group B; this was significantly greater than in Group A at a mean of 5° (range -5-20°) (p = 0.029). The mean radial alignment of the interphalangeal joint (distal phalanx relative to the proximal phalanx) was significantly higher in Group B (15°) than Group A (0°) (p = 0.221). In the literature on radial polydactyly, cut off values defining metacarpophalangeal joint instability in children range from 5° to 20°. According to our results, high but physiological metacarpophalangeal joint mobility of the thumb needs to be taken into consideration when evaluating children following reconstruction. Ulnar or radial deviation greater than 30°, in combination with the lack of a definite end point on metacarpophalangeal joint stress testing, may be regarded as unstable. Based on our study on healthy paediatric and reconstructed thumbs, comparison of joint stability with the healthy contralateral hand is recommended in order to define pathological instability. II.

Sesamoid bone transfer for metacarpophalangeal hyperextension instability of the thumb: A CT-osteoabsorptiometry study

Background and aimHyperextension instability of the metacarpophalangeal (MCP) joint of the thumb may result in pain, malfunction, and accelerated osteoarthritis in the carpometacarpal (CMC) joint. One method of treatment is sesamoid arthrodesis. The aim of this study is to investigate if a sesamoid transfer as a treatment of hyperextension instability of the thumb MCP joint leads to an altered distribution of the subchondral mineralisation and a negative clinical outcome. MethodsSesamoid transfer was performed on 12 patients with hyperextension instability of the MCP joint of the thumb. The range of motion (ROM) and radiologic outcome were assessed. Pinch and power grip strength were measured and compared to the nonoperated side.To determine the areas of maximum subchondral mineralisation in the joint, computed tomography (CT)-osteoabsorptiometry was performed to determine the long-term stress distribution within the joint. ResultsThe distributions of the stress zones in the operated and nonoperated thumbs were not statistically different a median of 5 years following the sesamoid transfer procedure. There was no difference in the functional and radiological results between the operated and nonoperated thumbs. ConclusionIf it is assumed that the nonoperated thumb represents the normal condition for each individual, then it may be deduced that the operation achieves good clinical results, and the distribution of the subchondral mineralisation does not change.

Correction of paralytic hand deformities

The ulnar nerve is most commonly involved in leprosy and is affected at or just above the elbow. The outcome of this damage is paralysis of the intrinsic muscles of the hand with the exception of the thenar group, together with paresis of ring and little finger flexor digitorum profundus (FDP). Although the obvious deformity is clawing of the fingers, other deformities are produced: 1. Hollowing of the intermetacarpal and thumb web space. 2. Flattening of the ulnar half of the hand. 3. Loss of abduction and adduction of the fingers. 4. Instability of metacarpophalangeal joint(MCPJ) 5. Flattening of the distal transverse metacarpal arch. The overall effect is poor grip due unstable MCPJ, poor grasp because of inadequate opening of the hand, rolling of finger tips and a poor pinch due unstable MCPJ of the index finger. Loss of function and anatomical defects needs surgical correction .The appearance of the hand is also very important for leprosy patients, because it is the characteristic deformity which is the principal cause of social rejection. For every single deformity, there is an operative answer. But performing such a large number of operations defeats the very purpose for which these are performed. The goal should be to achieve the best for functional and social needs of the patients with the fewest interventions. The choice for surgery involves a consideration of disease status, condition of the hand, age, extent of paralysis, occupational needs and also the socio-economic background.

Intraoperative Periprosthetic Fractures Associated With Metacarpophalangeal Joint Arthroplasty

To assess the incidence of and identify risk factors for intraoperative periprosthetic fractures during primary and revision metacarpophalangeal (MCP) joint arthroplasty. Through our institutional Joint Registry Database, we identified 818 MCP joint arthroplasties performed in 285 patients from 1998 to 2012, including 690 primary arthroplasties and 128 revision arthroplasties. Primary diagnoses included inflammatory arthritis (667), osteoarthritis (75), and posttraumatic arthritis (76). Periprosthetic fractures were identified through review of medical records. Intraoperative periprosthetic fractures occurred in 23 (3%) fingers (21 patients), including 19 primary and 4 revision arthroplasties. Twelve fractures required stabilization, 4 required only bone grafting, and 1 required both. The fractures occurred during broaching (12), implantation (10), or prior implant removal (1). Diabetes mellitus (DM), younger age, pyrocarbon implant insertion, and cementless fixation increased risk for intraoperative fracture. In particular, DM and the use of pyrocarbon implants significantly increased fracture risk. At 4 years (range, 1.3-10.2 y) average follow-up, no patient with intraoperative fracture had developed a subsequent fracture compared with 3 postoperative fractures in patients without intraoperative fractures. All fractures had healed by the time of the last follow-up. The 2- and 5-year implant survival rates were 96% and 80% in those with intraoperative fractures, respectively, which was not significantly different from those without an intraoperative fracture. When comparing patients with an intraoperative fracture with those without, there was an increased risk of postoperative MCP joint instability defined as implant dislocation. Patients with intraoperative fractures still had noteworthy improvements in their postoperative pain levels and pinch strengths. Intraoperative fractures occurred in 3% of MCP joint arthroplasties, including 3% of primary and 3% of revision arthroplasties. Increased risk for fracture was associated with the use of pyrocarbon implants, cementless fixation, and DM. Although these fractures did not appear to adversely affect implant survival, they were associated with increased risk of postoperative instability. Prognostic III.

HYPOPLASTIC THUMB TYPE IIIB: AN ALTERNATIVE METHOD FOR SURGICAL REPAIR

Hypoplastic thumb is the second most common congenital deformity of the thumb. Thumb hypoplasia is characterized by diminished thumb size, metacarpal adduction, metacarpophalangeal joint instability, and thenar muscle hypoplasia. In the literature, different classification types of hypoplastic thumb have been used and different treatment methods described. In this case we presented an alternative palliative treatment method for a ten-year-old patient with modified Blauth’s classification type IIIB hypoplastic thumb and one-year follow-up results.

New and Improved Medical Test Costs Just One Cent

Evaluating a scientific paper often starts with an assessment of the manuscript’s technical construction and the project design; these elements often characterize the reader’s “first impression.” From this perspective, the article by McKeon et al. makes a good first impression. In this cadaver dissection study, stability of the thumb metacarpophalangeal joint is assessed after progressive release of the proper and accessory collateral ligaments. The authors identify radiographic parameters that correlate with metacarpophalangeal joint instability, noting in particular that radial translation of the proximal phalanx relative to the thumb metacarpal head correlates with disruption of both collateral ligament structures. This paper is easy to read, and the technical details of the experimental environment and anatomic dissection are detailed and clear. The radiographic reproductions, which are especially critical to the presentation of the data, are well prepared and simple to understand. The authors wrote a good Discussion section in which they properly frame the practical considerations related to a reliable radiographic finding that correlates with complete ulnar collateral ligament disruption. Furthermore, this project is important because ulnar collateral ligament injuries of the thumb are very …

Radial Collateral Ligament Injuries of the Thumb Metacarpophalangeal Joint: Epidemiology in a Military Population

The reasons for variation in the reported incidence rates between thumb metacarpophalangeal joint radial collateral ligament (RCL) and ulnar collateral ligament (UCL) injuries are unclear. Delay in diagnosis of injury to the RCL leads to greater time of patient disability. The purpose of this study was to define the demographics and presentation of patients with RCL injuries in a military health care system. We performed a retrospective review of electronic medical records over a 5-year period to determine the incidence and epidemiology related to patients with instability of the thumb metacarpophalangeal joint resulting from injury of the radial or ulnar collateral ligaments. A total of 56 patients presented with thumb metacarpophalangeal joint instability. Of these, 18 (32%) had an RCL injury. Patients with an RCL injury were, on average, younger than those with UCL injuries. Those with RCL injuries were more likely to require surgery than were those with UCL injuries (67% vs 40%). With regard to time to presentation, most patients with UCL injuries presented 2 to 10 weeks after injury, whereas nearly all patients with RCL injuries presented greater than 10 weeks after injury. Radial collateral ligament injuries were more likely than UCL injuries to have resulted from an axial load (56% vs 16%), whereas UCL injuries were more likely to have been caused by an abduction-adduction moment (50% vs 22%). In this series, patients sustaining injuries to the RCL were younger and presented later than their counterparts with UCL instability. Close attention to subtle or frank instability presenting as pain in younger patients with axial loading injury mechanisms may allow early diagnosis and appropriate treatment of this injury.

Reconstruction of the Hypoplastic Thumb

Thumb hypoplasia is characterized by diminished thumb size, metacarpal adduction, metacarpophalangeal joint instability, thenar muscle hypoplasia or aplasia, extrinsic tendon dysplasia, and in the most severe cases, carpometacarpal joint instability or thumb aplasia. Severe thumb hypoplasia and aplasia are best treated by thumb ablation and pollicization of the index finger. Less severe thumb hypoplasia can be reconstructed by a combination of soft tissue release, first web space local flap coverage, metacarpophalangeal joint collateral ligament and capsule reconstruction, extrinsic tendon tenolysis, and muscle or tendon transfers.

Reconstruction of the Type IIIA Hypoplastic Thumb

The management of the hypoplastic thumb depends on the degree of bony malformation, soft tissue anomaly, and deficiencies. Type IIIA thumbs have thumb-index web-space narrowing, hypoplasia of the thenar musculature, metacarpophalangeal joint instability, and extrinsic tendon abnormalities. They also have a hypoplastic metacarpal with a stable carpometacarpal joint, differentiating them from type IIIB thumbs which have an unstable carpometacarpal joint due to partial metacarpal aplasia. Whereas type IIIB thumbs are best treated with ablation and index pollicization, type IIIA thumbs are amenable to reconstruction. Many techniques have been described for correction of the variety of deformities found in theses thumbs. The purpose of this article is to present our preferred technique for comprehensive reconstruction of type IIIA thumbs.