Wassel Type Research Articles

Surgical correction of radially deviated Wassel type III thumb polydactyly: a prospective case series.

We report our experience with correction of radially deviated Wassel type III thumb polydactyly. After comprehensive assessments from preoperative radiographs, physical examinations and intraoperative reports, we corrected the metacarpophalangeal joint in 34 cases of radially deviated Wassel type III thumb polydactyly. Opening-wedge osteotomies combining bone graft and soft tissue reconstruction were used in 28 cases and soft tissue reconstruction only in six cases. Absorbable sutures were used instead of traditional Kirschner (K)-wires to fix the bone grafts. Patients were followed up for 12-78 months (mean 47 months). According to the Tada scoring system, 25 patients achieved good results, seven fair results and two poor results. Our modified technique for correcting radially deviated Wassel type III thumb polydactyly yielded satisfactory results. Continued follow-up and further studies will contribute to a better understanding of the long-term efficacy and potential refinements of this technique.Level of evidence: IV.

Doubling Down on Maximizing Functional and Aesthetic Outcomes: Modified Technique for Pediatric Wassel Type I Thumb Duplication: A Case Report

Background: Given the rare occurrence, there is a paucity of literature characterizing surgical management of Wassel Type I thumb duplications, especially at an older age where psychosocial factors become a more significant consideration. Case Presentation: We present a 5-year-old girl with right Wassel Type I thumb duplication with delayed initial presentation for treatment. We performed a modified Wassel Type I radial thumb ablation, percutaneous pinning, and nail reconstruction preserving radial nail fold and transferring to ulnar nail plate and fold. Conclusions: This modified approach maximizes functional and aesthetic outcomes and highlights the significance of considering surgical management to improve quality of life in delayed presentations of Wassel Type I thumb duplication.

Modified Bilhaut–Cloquet procedure for Wassel type III–IV polydactyly

BackgroundTo investigate the functional and aesthetic results of a new modified Bilhaut–Cloquet procedure for the treatment of Wassel type III–IV thumb polydactyly.MethodsThirteen patients with Wassel type III–IV thumb polydactyly who visited the Department of Orthopedics of Hebei Provincial Children's Hospital from 2019 to 2022 were selected. The surgical procedure involved a modified Bilhaut–Cloquet surgery, where two-thirds of the distal part of the dominant finger was retained as the p body of the reconstructed thumb. The triangular bone block of the ablated distal thumb that did not contain the epiphysis and articular cartilage was sutured and fixed, and the neurovascular flap of the ablated distal thumb was used as an augmenting segment of the reconstructed thumb, with the nail bed and nail matrix exquisitely sutured. The evaluation performed according to the Japanese Society for Surgery of the Hand (JSSH) system.ResultsAll 13 children showed bone healing, no wound infection, nonunion, or deformity healing. None of the children showed a significant reduction in the active and passive mobility of the thumb postoperatively compared with preoperatively. Postoperative evaluation was performed based on the JSSH score, with a mean of 17.15 points (14–19 points), with 11 children rated as excellent and two as good. No severe nail ridges, nail gaps, or nail split deformities of the thumb were observed postoperatively. Postoperative metacarpophalangeal and interphalangeal joint movements were not reduced compared with preoperative movements. All parents were satisfied with the appearance and function of the reconstructed thumb.ConclusionThe modified Bilhaut–Cloquet procedure designed in this study was satisfactory for Wassel type III–IV thumb polydactyly without affecting the stability of the interphalangeal joints and preserving joint mobility. The postoperative thumb has a comparable circumference and nail width and was cosmetically and functionally satisfactory, especially for the asymmetric two thumbs, which achieved favorable results.

Experience with Management of Radial Polydactyly: The Multicenter Analysis of 28 Surgical Procedures with Follow-Up

Radial polydactyly or thumb duplication is a relatively common congenital malformation of the hand, whereby the surgical techniques can be broadly divided into simple excisions, reconstructions and a Bilhaut-Cloquet procedure. The aim of this study was to identify the appropriate surgical procedures and to present the clinical outcomes that can be achieved. We performed a multicenter analysis of cases of radial polydactyly surgically treated with reconstruction or a Bilhaut-Cloquet procedure between 2015 and 2022. The clinical outcome was assessed using a modification of the Tada score. A total of 28 cases of 27 patients with radial polydactyly were included in the study. The most common Wassel type was type IV (13 cases), and the most common surgical procedure was reconstruction (24 cases). Our study validates an algorithm from the literature as a helpful tool for decision making in selecting a surgical technique for radial polydactyly, although individual surgical experience should also be considered.

Postoperative deviation in Wassel types II and III radial polydactyly: a retrospective analysis of 73 thumbs.

This study examined the relationship between osteochondral stability and postoperative deviation at the interphalangeal (IP) joint in Wassel types II and III radial polydactyly. Cases with cartilaginous fusion between the radial distal phalanx and the proximal phalanx were classified as type IIB, while the remaining cases were categorized as type IIA. In conventional surgery, the cartilage was routinely resected on the radial aspect of the proximal phalangeal head, while in the modified procedure, this was preserved to avoid postoperative radial deviation. Postoperatively, there was no significant difference between both procedures in type IIA thumbs regarding IP joint deviation, whereas in type IIB/III thumbs, IP joint deviation was significantly higher in the conventional group (mean 19° [SD 16°]) compared to the modified group (mean 0.8° [SD 4.9°]). Surgeons should exercise caution against excessive cartilage excision to preserve osteochondral stability during procedures, especially for type IIB and III radial polydactylies.Level of evidence: IV.

Aesthetic outcomes of and anatomic reconstruction for Wassel type IV-D radial polydactyly using a modified Bilhaut-Cloquet procedure.

Wassel type IV-D thumb duplication is the most complex form and anatomic reconstruction is difficult. The aim of this study was to create an aesthetically satisfactory anatomical reconstruction for Wassel type IV-D radial polydactyly thumbs using the modified Bilhaut-Cloquet procedure. Surgery was performed on 24 thumbs with Wassel type IV-D radial polydactyly. To align the joint surfaces, the proximal phalanxes were unequally joined, primarily on the ulnar, and the distal phalanx was either symmetrically joined or unequally joined via curvature osteotomy. The patients were followed up for 12-91 months. The interphalangeal joint remained stable in all cases. The average functional score was 13.5 points (maximum 14 points). The overall average cosmetic score was 3.3 (maximum 4 points). Our modification of the Bihaut-Cloquet procedure produced good functional results for patients with Wassel type IV-D radial polydactyly. This method is used to correct the alignment and to stabilize the interphalangeal joint in both hypoplastic thumbs.

A minimally invasive technique for residual zigzag deformities of the thumb.

This study aimed to introduce a minimally invasive technique in correcting residual zigzag deformities after early treatment of thumb duplication followed by fixation with a cemented frame. Nineteen patients (14 males, 5 females; mean age, 12 years; age range, 8-14 years) with residual zigzag thumb deformities were treated with the minimally invasive technique from 2017 to 2019. The function and cosmesis of the thumbs were assessed using the Japanese Society for Surgery of the Hand. The mean period between the first and the second operations was 35 months (range, 12-84 months). There were Wassel types III (n=4), IV (n=13), and V (n=2) residual zigzag thumb deformities. Preoperatively, the mean alignment deformities of the interphalangeal and metacarpophalangeal joints were 23° (12-42°) and 18° (11-33°), respectively. The mean function and cosmesis of the thumbs were 12 points (range, 8-14 points). There were 1 fair and 18 poor scores. At the final follow-up (mean, 28 months; range, 24-33 months), the mean alignment deformities of the interphalangeal and metacarpophalangeal joints were 1° (0-4°) and 18° (0-4°), respectively. The mean function and cosmesis of the thumbs were 18 points (range, 16-20 points). There were 5 excellent results, 13 good results, and 1 fair result. Residual zigzag thumb deformities can be successfully corrected with the minimally invasive technique, resulting in good functional and cosmetic outcomes. The technique can be used as an alternative in selected cases. Level IV, Therapeutic Study.

Midterm Surgical Outcomes of Duplicated Thumbs According to New Classification.

Surgical outcomes of duplicated thumbs differ depending on the branching type. The authors developed a new classification system and report surgical outcomes with an average 10.2-year follow-up. A total of 529 patients with 562 duplicated thumbs were reviewed. Surgical anatomies were compared with radiographs, and then a new classification system was developed based on branching level and bone shape observed on the radiograph: distal type (D-type), including Wassel types I and II; proximal type (P-type), including Wassel types Ⅲ and Ⅳ, and four subdivisions (Po, Pa, Pb, and Pc) according to bone structure; and metacarpal type (MC-type), including Wassel types V and VI. All hands were assessed using the Japanese Society for Surgery of the Hand evaluation form, and factors causing poor outcomes were analyzed. There were 25% D-type, 59% P-type, and 14% MC-type hands; 2% of hands were not classified. Overall, 351 hands (63%) were directly assessed when patients reached 5 years of age. Seventeen percent of hands had fair results. Good results were achieved in 90% of D- and Po-type hands. Pa-, Pb-, Pc-, and MC-type hands had lower Japanese Society for Surgery of the Hand scores than did D- or Po-type hands. Pa- and Pb-type hands tended to develop interphalangeal joint malalignment and instability, whereas Pc- and MC-type hands developed disorders in the metacarpophalangeal joint with growth. The authors' new classification system clarifies the potential pitfalls for each type of duplicated thumb. More than 90% of D- and Po-type hands obtained good results. Care should be taken with interphalangeal joint reconstruction for Pa- and Pb-type hands. Meticulous reconstruction of the metacarpophalangeal joint is essential for Pc- and MC-type hands. This analysis provides important information for surgeons and patients. Risk, IV.

Pathological anatomy, classification and treatment of the atypical Wassel Type VI thumb duplication.

We studied the pathological anatomical structures of atypical Wassel Type VI thumb duplication to provide a theoretical basis for surgical treatment. Forty-seven patients with atypical Wassel Type VI thumb duplication were treated. We found that some of cases had an ulnar thumb without an extensor tendon, or without a flexor tendon, or without both. All the ulnar metacarpal bones were abnormal to variable degrees. On-top-plasty is currently the best procedure for the treatment of this type of anomaly. Flexor tendon reconstruction is an important factor in functional reconstruction of the thumb, and keeping the pulley and sheath intact is a key step in flexor tendon reconstruction. Placing the on-top-plasty level at the distal end of the metacarpal or at the proximal phalanx depends on the presence of the flexor tendon. According to the condition of the flexor tendon, the atypical Wassel Type IV duplication can be divided into two types: the absent type and the intact type.Level of evidence: VI.

Prediction of Surgical Outcomes of Radial Polydactyly From the Wassel-Flatt Type and Symmetry of Duplication.

The Wassel classification is commonly used for cases of radial polydactyly but has not been used to predict surgical outcomes. This study aimed to investigate the predictive factors of surgical outcomes using the Wassel type and symmetry of duplication. Forty-five patients with 47 radial polydactylies were reviewed using the Japanese Society for Surgery of the Hand (JSSH) scores 4.6 years after minor thumb excision and reconstructive surgery. The symmetry index was defined as the metaphyseal width ratio of the minor thumb to the dominant thumb. The relationships between the JSSH scores and operation age, sex, side, follow-up duration, Wassel type, symmetric index, divergent angle, and joint angulation were analyzed by linear regression. The mean JSSH score of the 47 thumbs was 18.3 points (range, 15-20). Five thumbs had fair or poor outcomes (scores <17), all of which were Wassel type IV. The hypoplastic type had a better JSSH score (19.4) than other Wassel types. The symmetric index had a negative relationship with JSSH scores, especially for Wassel type IV (r=-0.68, P =0.001). Linear regression revealed that the symmetric index was the only independent factor significantly associated with JSSH scores among Wassel type IV polydactylies ( P <0.05). The receiver operating characteristic curve suggested a symmetric index <0.74 could predict good or excellent outcomes. The symmetry of the 2 duplicated thumbs is an important factor for surgical outcomes. The Wassel type IV polydactylies with a symmetric index >0.74 are at greater risk of fair or poor outcomes after excision and reconstruction, and further studies are warranted to confirm whether the Bilhaut-Cloquet procedure is a good choice. Level IV-Case-control study.

Reoperation after primary operation for pre-axial polydactyly of the hand: A 12-year experience at a single institute

This study aimed to evaluate and describe the rate, reasons, and detailed procedures of reoperations for pre-axial polydactyly of the hand at our institute conducted within 12 years. We retrospectively reviewed the medical records and radiographs of 268 patients (292 digits) with pre-axial polydactyly of the hand, who were treated surgically at our institute from November 2006 to May 2018 and followed up for >12 months. Fifty-two thumbs of 47 patients underwent reoperations, yielding a 17.8% reoperation rate. According to the initial deformity type, the highest reoperation rate was observed in the cases classified under modified Wassel type VIIA (60.9%, 14/23 thumbs), followed by those under type VIIB (44.4%, 8/18 thumbs). Scheduled reoperations were performed in seven type VIIA and four type VIIB cases with a triphalangeal thumb and eight with triangular epiphysis of the distal phalanx. Unexpected reoperations were conducted in 33 cases, 31 (93.9%) of which had deviated thumbs. Various surgical treatments, including corrective osteotomy, collateral ligament plication, and flexor pollicis longus tendon relocation, were performed to correct deviations. A total of 23 cases (74.2% of 31 thumbs) received a corrective osteotomy at the second or third operation. The reoperation rate after primary operation for pre-axial polydactyly of the hand was 17.8%. It was higher in the cases initially classified under modified Wassel type VII; however, a considerable number of cases received scheduled reoperations. A deviated thumb was the most common cause of unexpected reoperation, and corrective osteotomy was the most commonly performed procedure. The rate and details of reoperation should be routinely mentioned for preoperative planning and patient education in pre-axial polydactyly. Therapeutic level IV.

Modified Bilhaut-Cloquet Procedure for the Reconstruction of Wassel Type III Radial Polydactyly.

The purpose of this research is to study the modified surgical effect of Wassel type III radial polydactyly thumbs of equal or nearly equal size treated. The study sample consisted of 12 reconstructed cases of Wassel type III radial polydactyly. The proximal phalanx was unequally combined by the curvature osteotomy and aligned the articular surface, and the distal phalanx was symmetrically combined. A fragment bone was filled in the depression of the distal phalanx to correct nail curvature and prevent seagull deformities. Twelve cases were available for assessment using an evaluation form on the Japanese Society for Surgery of the Hand. An average functional point was 13.75 points (maximum 14 points). The interphalangeal joint motion was reduced, but this joint was stable in all cases. The cosmetic score was averaged 3.6 (maximum 4 points), and most parents were satisfied with the postoperative appearance and functional results. Our modification of Bihaut-Cloquet procedure is an effective way to provide a well-functioning thumb for Wassel type III radial polydactyly thumbs. Level IV.

A modified Bilhaut-Cloquet procedure for thumb duplication: Reconstruction of functionality and appearance

The Bilhaut-Cloquet technique is the preferred surgical method for thumb polydactyly with symmetrical caliber and osseous components. However, the traditional Bilhaut-Cloquet technique has many esthetic and functional complications. In this study, we aimed to investigate an effective modified Bilhaut-Cloquet procedure for Wassel type IV thumb duplication. The dorsal scar of the thumb was hidden on the ulnar side of the thumb through the flap design. The nail bed was sutured flat by combining the phalangeal bone and nail bed on different planes. The sensory function of the thumb was restored by keeping the ulnar skin of the thumb intact. Our modified Bilhaut-Cloquet procedure did not reduce the mobility of the joints. All patients had relatively rounded fingernails, and no seagull deformity was present. The ulnar side of the palm skin of the thumb remained intact with no scars, maximizing the preservation of the sensory function of the thumb. All the operated children and their parents were satisfied with the esthetic result. We hid the surgical scar by improving the surgical method and reducing the thumb seagull nail deformity, and the influencing of the finger sensation caused by the scar on the finger abdomen. The procedure improved not only the appearance of the reconstructed thumbs but also the sensory function of the thumbs.

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.

Surgical correction of wassel type 3 radial polydactyly: A case report

Radial or preaxial polydactyly is a common congenital anomaly occurring sporadically that must be treated early. Thumb duplications are a failure of formation and/or differentiation affecting the radial-ulnar axis of the hand plate in which Wassel has described seven types. The aim of surgical reconstruction is to obtain a stable and mobile thumb of adequate size and appropriate shape with preservation the function of pinch and opposition, and reconstruction of all components in one procedure. The most common form of reconstruction is removal of the lesser digit and reconstruction of the dominant digit. Here, we present a case of a Wassel Type 3 thumb duplication which was surgically corrected.

Polydactyly presentations: A case report

Polydactyly is a duplication of the digits of the hands or feet. It is a congenital anomaly and can manifest as a single disorder or as a component of a syndrome. It is typically an autosomal dominant inherited condition with variable expression and incomplete penetrance. It is genetically heterogenic being caused by mutations in different genes. It manifests in different forms, based on the position of occurrence of the extra digit. It can occur as a single disorder as a component of a syndrome. Its presentation ranges from just a skin tag to a complete digit with the accompanying metatarsal or metacarpal bone. It can result in functional impairment or it may just be a cosmetically unacceptable digit with no functional impairment. Treatment depends on the nature of the extra digit as well as any functional impairment it may be causing. Surgical excision is employed and various reconstruction procedures are also employed in treatment, and must be well planned out to avoid a worsening of function. We present two cases; a 3-month-old baby girl presenting with a hereditary preaxial polydactyly (PPD) (Wassel type V) of both feet and a 29-year-old man with isolated postaxial polydactyly of the right foot with which was symptomatic.

Suture osteosynthesis in the bony reconstruction of thumb duplication.

Metacarpal osteotomies are done to correct deviation deformity in thumb duplication. We describe a suture-only technique of metacarpal osteosynthesis, without using K-wires. Thirteen Flatt Type IV thumbs and five Wassel Type VII thumbs were reconstructed with this technique. The median follow-up was 23months. After osteotomy, the metacarpal bone fragments were sutured together with 5-0 polyglactin or 4-0 polydioxanone sutures. Metacarpal fragment displacement was not observed on postoperative radiographs obtained at 1 and 2weeks. Bony union was achieved at 6weeks without loss of alignment. The metacarpophalangeal joint alignment was anatomical (≤5° deviation) in eight cases. The mean pre- and postoperative metacarpophalangeal joint alignments were 27° and 9°, respectively. The 11 patients who were available for grading with the Japanese Society for Surgery of the Hand Score were assessed as good. Complete internalization of the bony fixation eliminates infections associated with exposed K-wires without compromising the overall outcome.Level of evidence: IV.

Modified method for reconstruction of thumb abduction function in children undergoing surgical treatment of thumb duplication.

PurposeThis study was performed to evaluate a modified method of reconstructing the thumb abduction function in children undergoing surgical treatment of thumb duplication.MethodsThis retrospective study included 33 children (38 thumbs) with Wassel type III to VII thumb duplication who underwent excision of the polydactylism and osteotomy of the preserved thumb. Among them, 16 children (19 thumbs) underwent reconstruction of the attachment of the articular capsule and collateral ligament of the metacarpophalangeal joint, abductor pollicis brevis and flexor pollicis brevis by the anchor technique (Group A), while 17 children (19 thumbs) underwent suturing the attachment of the above-mentioned soft tissues to the periosteum (Group B). All children were followed up for six years after surgery. The appearance, function and joint stability of the preserved thumb were compared between the two groups; the bone alignment and development were observed.ResultsThe deformity rate of preserved thumbs and the positive rate of lateral stress test were significantly lower in Group A than B (p < 0.05). The modified Tada score and the distance of first web were significantly higher in Group A than B (p < 0.05). Flexion, extension, adduction, abduction and palmar movement of the thumbs were good; bone alignment and development were good and no osteophyte or anchor shadow was left in the preserved thumbs in Group A.ConclusionReconstruction of the abduction function using the anchor technique is effective in children undergoing surgical treatment for Wassel type III to VII thumb duplication and it may be superior to the conventional technique.Level of evidenceIII

Radial Polydactyly

Purpose: The purpose is to propose a modification of Wassel/Flatt classification system for radial polydactyly based on radiological findings and previously described classification systems. Materials and Methods: Thirty-five patients with radial polydactyly were included in the study. There were 47 supernumerary fingers. Patients' clinical and radiological data were evaluated retrospectively. Family history, sex, age, unilateral or bilateral placement, the origin of radial polydactyly, coexisting anomalies, and syndromes of each patient were documented. We classified cases into 13 different subgroups, according to X-rays and clinical findings. Results: One supernumerary digit was rudimentary Type, 2 were hypoplastic type, one was Wassel Type I, 3 were Wassel Type II, and 5 were Wassel Type III, 12 were Wassel Type IV, 5 were Wassel Type V, 7 were Wassel Type VI, 9 were Wassel Type VII, one was symphalangism, one was complicated type. Conclusion: We think it is beneficial to add complicated type (tetraplication, triplication) symphalangism, rudimentary and hypoplastic malformations together as a single comprehensive classification system to better define diagnosis and treatment plans.

Long-term outcomes after corrective cartilaginous joint resection based on arthrographic findings of duplicated thumbs.

We report greater than 10-year outcomes in duplicated thumbs following corrective cartilaginous resection during the growth period. We have undertaken corrective resection of cartilaginous joint connections based on intraoperative arthrographic findings to reconstruct favourable alignment in six Wassel Type II and IV thumb duplication in six patients. The age at surgery was 13 months (range 10-15), and the average post-surgical follow-up was 134 months (range 120-160). We observed five excellent and one good outcome using the Japanese Society for Surgery of the Hand scoring method. Favourable joint congruency and alignment were preserved, and no growth plate arrest or joint space narrowing was present more than 10 years after surgery. We conclude that corrective resection of the cartilaginous joint based on intraoperative arthrographic findings has long-term reliability for duplicated thumbs, especially those of Wassel Type II and IV, which have a cartilaginous joint connection.Levels of evidence: IV.