Ricardo Navarro

Metacarpal synostosis: a simple classification and a new treatment technique.

&NA; The current classification of metacarpal synostosis is based on the extent of the synostosis. The authors propose a new classification that takes into account the shape of the metacarpal bones, the curvature of the epiphysis, and the discrepancy in length between the two bones. This classification provides better guidelines for the correction of all components of the deformity. The classification is based on the authors’ observations of and experience with 36 cases of metacarpal synostosis; 13 of the deformities were surgically corrected. The I‐shaped deformity, whether with distinct (type d) or fused (type f) metacarpophalangeal joints, does not require surgical correction. The U‐shaped deformity has parallel epiphysis and does not require surgery unless the two metacarpals are asymmetrical in length (type a) or tightly fused (type t); in these cases, simple lengthening or widening of the space with a bone graft is sufficient. Y‐shaped synostosis should be separated whether the branches are symmetrical or asymmetrical, the latter having one branch shorter than the other. Because the epiphyses are already divergent, simple separation does not effectively correct Y‐shaped synostosis. The authors propose an osteotomy to isolate a trapezoidal segment of bone from the bifurcation. The isolated bone segment is then reversed in the proximal‐distal direction to provide a “plateau” upon which the two distal metacarpals can be realigned. Two cases of Ys (symmetrical) synostosis were successfully treated with this technique; one case of Ya (asymmetrical) synostosis also required distraction lengthening of the shorter metacarpal to achieve an excellent result. One of the most difficult types of metacarpal synostosis to treat is k‐shaped synostosis, observed only between the fourth and fifth metacarpals; in this type, the head of the short fifth metacarpal abuts the metaphysis of the fourth. Osteotomy and distraction lengthening provide predictable results for correction of this deformity. The authors suggest that k‐shaped synostosis might represent a late evolution of untreated Ua synostosis. (Plast. Reconstr. Surg. 108: 1225, 2001.)

Apport d’une nouvelle plastie à la reconstruction de la première commissure dans les malformations congénitales. À propos d’une série de 54 patients

Resume Introduction Peu de travaux ont ete consacres au probleme specifique de l’absence ou de l’insuffisance de la premiere commissure dans les malformations congenitales. Materiel et methodes Soixante-sept plasties de premiere commissure ont ete revues chez 54 patients comportant 44 cas de plasties classiques (Z, lambeau dorsal de l’index, du pouce ou de la main) et 16 cas de lambeaux dits « pseudo-cerf-volant ». Les resultats ont ete difficiles a juger mais ont centres sur l’allongement du repli et une composante de creusement commissural, non toujours desire. Resultats Le « pseudo-cerf-volant » a entraine un allongement du repli commissural de 3,2 cm sans effet de creusement. Discussion Aucune methode d’evaluation classique n’est applicable a l’appreciation des resultats de plastie commissurale dans le cadre des malformations du fait de la grande variabilite des tableaux cliniques, de l’absence de cooperation dans le jeune âge, de la possibilite d’instabilite articulaire metacarpophalangienne (MP) du pouce et de la croissance. Si la plastie en Z a quatre lambeaux s’avere suffisante pour les commissures moderement limitees, le lambeau « pseudo-cerf-volant » est utile dans les formes severes. Conclusion Il ne semble pas logique d’avoir une plastie « preferee » mais toutes les techniques trouvent une place en fonction de l’âge, de la malformation, de l’etat du pouce et de la presence ou de l’absence de commissure.

Correction of first web space deficiency in congenital deformities of the hand with the pseudokite flap.

The authors describe a new flap to enlarge or create a first web in patients with congenital deficiencies of the hand. This lozenge‐shaped flap is harvested from the dorsoradial aspect of the index finger based on a narrow proximal skin bridge protecting its axial vascularization. A dorsal skin graft of the donor site is avoided by closure using a rhomboid flap. Procedures in 16 patients were performed and reviewed; the only complication was insertion of a small split‐thickness graft in five patients to avoid tension at the metacarpophalangeal joint level. The flap lengthened the web fold an average of 3.2 cm without “pseudolengthening” the thumb. (Plast. Reconstr. Surg. 107: 1458, 2001.)

La symbrachydactylie, classification et traitement. À propos d’une série de 117 cas

Resume Afin de faciliter les indications chirurgicales, nous proposons une modification de la classification des symbrachydactylies (Blauth). Sur 120 symbrachydactylies (117 patients), 86 mains ont ete operees. La liberation commissurale a ete le geste le plus frequent (81 espaces). Le transfert d’orteil a ete reserve aux formes severes monodactyles ou adactyles (51 transferts chez 49 patients operes a un âge moyen de 12 mois). Le type I necessite la separation de doigts courts et parfois raides. Le type II, « pseudo-fourche », doit etre divise en trois sous-groupes. Si le groupe IIC, avec main en cuillere est rare, le type IIA, avec plus de deux doigts longs, souvent hypoplasiques et instables, doit faire choisir entre le sacrifice de doigts rudimentaires et leur stabilisation. Le type IIB necessite rarement une intervention car la prise est souvent excellente. Le type III monodactyle merite d’etre separe en type IIIA avec pouce normal et IIIB avec instabilite et hypoplasie. Enfin le type peromelique est accessible a un transfert d’orteil en position antebrachiale, a condition que la mobilite du poignet (type IVA) compense l’insuffisance de celle du transfert. En cas d’indication de transfert d’orteil, l’intervention pratiquee avant l’âge d’un an permet une integration excellente. Si la mobilite active a ete decevante (en moyenne 35°), la croissance a ete bonne et la sensibilite excellente(discrimination moyenne de 5 mm). La symbrachydactylie est une entite qui est integree au groupe I (classification de l’IFSSH). La variete de presentation necessite une classification precise afin d’affiner les indications chirurgicales.

Pollicization of damaged fingers.

The history of thumb reconstruction was thoroughly reviewed by a major contributor in the field, J.W. Littler (37). Guermonprez in 1887 (23) seems to have been the first to report on pollicization of a finger. Then other cases were successively reported by Noesske (1919) (37), Dunlop (1923) (lo), and Bunnell ( 5 ) (1931-1952). Gosset (22) was the first to get rid of a skin bridge, entirely isolating a finger on its pedicles. Hilgenfeldt (27) and mainly Littler (35) standardized the technique and stressed the possibility of transfcrring a damaged finger on only one vascular pedicle (36). Since then, few series have been published (3,~8,12,33,34,47,48,51), most of them being case reports (1,2,9,10,17,25,26,3234,43,45,50). Acute pollicization has been infrequently mentioned in the literature (12,24,30,31,46). In 1996, we reported on 27 cases performed at two institutions and reviewed with a mean follow-up of 9.5 years (18).