| Background and objectiveThumb polydactyly,also known as radial polydactyly and preaxial polydactyly,is a common congenital malformation of the hand.The general incidence of newborns is 0.08-1.4/1000,which is higher in Asian and Caucasian than in other people.Although many articles refer to thumb polydactyly as repetitive thumbs,in fact,the length and volume of the two thumbs are not the same,and there are also great differences in function.Usually,the development of one thumb is better than that of the other,so some scholars named the thumb polydactyly as split thumb in communication.No matter how it is named,the function of the thumb is very important.The function of the thumb accounts for about 40-50%of the whole hand function.Although part of the thumb polydactyly can meet the daily life,but there are also serious polydactyly,which will affect the normal work and life.Multiple thumbs can also affect the appearance of the hand,bringing psychological impact to patients.Studies have shown that patients with thumb polydactyly differ from normal people in learning,employment,mate selection and fertility.Therefore,whether from the perspective of function or aesthetics,surgery and reconstruction are recommended.Thumb polydactyly varies in appearance and imaging data.Observed from the appearance,the thumb has the following situations:a simple floating thumb is connected to thumb that is close to normal development by only relying on a skin pedicle;One thumb is well developed and close to normal,the other is bifurcated from the backbone or joint,and both fingers have mobility;triploid or polyploid,skewed fingers,and severely dysplastic thumb coexist with a floating finger,etc.Imaging observation is more complex,because bone development matures with age,so it is difficult to judge and deal with some deformities when the bone is not mature.Because the cartilage is not mature and cannot be imaged,it is difficult to distinguish the floating finger from the cartilage.There are also some phalangeal epiphysis that are not mature and cannot be imaged,which can only be known during the operation.These factors have a great influence on the choice of operation.The operation itself is also very complicated,because there are many factors that cause the deformity.This article will not repeat the reasons for the occurrence of congenital deformities,but only describe the specific anatomical abnormalities.The deflection of the thumbs includes skeletal deflection and or joint deformity and dislocation,and also with or without abnormality of the anchor point of the tendon;some also have abnormality of the nail width.These need to be handled carefully during the operation.Is the effect of each operation process and postoperative rehabilitation achieved by doctors of different technical levels according to the standard operation the same?A lot of literature reports have clearly defined the standard of the specific operation doctors.Different levels of doctors use the same surgical method to treat the same type of deformity surgery,the surgical effect is different.In order to better improve the therapeutic effect of thumb polydactyl and promote learning and communication among colleagues,many scholars have classified the thumb polydactyly.The earliest classification began in the 20th century,until the first more systematic and currently used Wassel classification was proposed.This classification divides the thumb polydactyly into seven types.The bifurcations from the distal phalanx to the metacarpal bones are represented by Roman numbers.The odd numbers indicate the bifurcation from the backbone,and the even numbers indicate the bifurcation from the joints.Type VII is refers to duplications involved with triphalagism.Later,other classification methods were proposed.The Rotterdam classification is the most used.This classification is supplemented and improved on the basis of the Wassel classification.The purpose is to include more cases that cannot be used in the Wassel classification.Polydactyly deformities of the thumb,such as triploid,symphalangism,etc.Although these classifications are widely used,they are not based on clinical treatment and have some limitations on the significance of clinical treatment.The surgical approach of the same type may be different,and the surgical approach of different types may be the same.For example,Wassel type Ⅱ and type Ⅳ,which are basically equal in size,length and volume,can be combined in surgery.Wassel Ⅳ has two types:primary thumb plus secondary thumb and crab claw type.The surgical methods are different.One is resection and the other is combined.The Wassel classification relies on the data on the X-ray.There is a misunderstanding.If the child’s bones are not mature and the cartilage cannot be imaged,the interconnected substrates will be mistaken for separation before surgery.Based on the experience of clinical practice,we propose a classification for surgical treatment plans,and the expected purposes are:1.Provide suggestions on the clinical practice;2.The level of the surgeon is recommended;3.Make prevention and rehabilitation plans in advance;4.Provide convenience for learning and communication among peers.Therefore,in order to explore the problems mentioned above,we have carried out the following two aspects of work in this research.Methods and ResultsPart One A radial polydactyly classification system used for surgical planningBased on the case data of the thumb multi fingers in the hand and foot surgery affiliated to Shandong Provincial Hospital Affiliated to Shandong University and the second hospital of Shandong University,we found that there are many kinds of thumb multi finger operation methods,which are summarized as follows:the first is to remove the redundant fingers,reconstruct the bone joint,tendon,nail and the extension function;the second is to combine the operation method with the other The third method is to use different fingers or other parts of tissue to splice a normal or close to normal thumb.According to the research of thumb polydactyly operation,we put forward a new classification.The difficulty of operation is from easy to difficult.Type Ⅰ has a main well-developed main finger.The criterion is that the width of the main finger is greater than or equal to 70%of the contralateral thumb nail.According to whether the deviation of interphalangeal joint or metacarpophalangeal joint is more than 200,this type can be divided into two subtypes:type Ⅰ-A is less than 200,and the operation method is simple resection;type Ⅰ-B is greater than or equal to 200;the operation method is reconstruction after resection,including osteotomy to correct the force line or tendon transposition,joint capsule repair,etc;Type Ⅱ:the development of the two fingers of this type is poor,and there is no difference between the primary and secondary.The judgment standard is that the width of the fingernails of the two fingers is less than 70%of that of the healthy thumb.According to whether the two fingers are equal in length,they can be divided into two subtypes:type Ⅱ-A with equal length,the traditional Bilhaut Cloquet combination;type Ⅱ-B with unequal length,the modified Bilhaut Cloquet(osteotomy or advancement flap,etc.);type Ⅱ-A with equal length,the modified Bilhaut Cloquet(osteotomy or advancement flap,etc.);Type Ⅲ requires microsurgical repair and reconstruction.Each finger is disassembled and a new thumb is spliced.When necessary,tissue is transplanted from other parts of the body for repair.A separate operation plan is required for each case.This type can be divided into two subtypes:type Ⅲ-A,each finger has a well-developed segment,the surgical method is the top shift;type Ⅲ-B is floating finger,polyploidy,ulnar limb and other serious deformities.According to the actual situation of hand and foot surgery of Shandong provincial hospital and hand and foot surgery of the second hospital of Shandong University,surgeons can be divided into five different grades according to their professional and technical level.Doctors with level-1 and level-2 can treat type Ⅰ-A polydactyly;doctors with level-3 can treat type Ⅰ-B and Ⅱ-A polydactyly,Level-4 doctors can treat type Ⅲand all types of thumb polydactyly.If the professional team does not have level-4 professional doctors,we suggest that level-3 should operate carefully after consulting with the superior doctors,or invite high-level doctors from other institutions to operate on the patients.Part Two Detection of Classification CredibilityAfter the classification criteria and clinical treatment guidelines were formulated,the clinical information of patients with thumb polydactyly treated from August 2015 to January 2020 was extracted from the hand and foot surgery department of Shandong Provincial Hospital Affiliated to Shandong University and the hand and foot surgery department of the second hospital of Shandong University.A total of 327 hands were collected from 308 patients,including 129 female patients and 179 male patients,with an average age of 13.4 months(3 months to 8 years).The photos and imaging data of the patients were collected and sorted out and made into PPT for storage.In the hand and foot surgery department of two hospitals,5 doctors with technical level from level-1 to level-5 were randomly selected.Five doctors were trained and explained the classification standard.After confirming the understanding of the classification,the photos and imaging data of thumb polydactyly were classified according to the new classification.The case data were submitted to five doctors separately.They did not participate in the discussion,and the classification was repeated 2 weeks later.After the data were returned for statistical analysis,5 doctors were called to discuss the results of classification.When the opinions of classification were different,they were classified according to the highest vote.If necessary,the opinions of level-5 professional doctors were referred.Statistical analysis of the credibility between doctors and the credibility before and after the same doctor showed that the credibility between doctors was 0.937 for the first time,0.957 after two weeks,and the lowest credibility among single doctors was 0.840.The guidelines recommended by Landis and Koch are used to explain the reliability level:0=poor,0 to 0.20=slight,0.21 to 0.40=average,0.41 to 0.60=medium,0.61 to 0.80=significant,0.81 to 1.0=almost perfect.The new classification is easy to understand and master by doctors of different technical levels in the clinical practice,and the classification of actual cases is highly repeatable.Through the classification and the corresponding technical level classification,it provides a feasible scheme for us to control the operation quality,and also strengthens the improvement of doctors’ professional skills and promotes the communication between doctors. |
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