Bilobed Flap in Hand Clinodactyly Reconstruction: Technique Description and Result Appraisal

Abstract

Objective Clinodactyly is a congenital hand deformity that is characterized by coronal angular deviation and may occur in thumbs or fingers. Surgical treatment is indicated for severe angulations. Among the described techniques, one of the options consists of bone alignment by wedge-shaped addition osteotomy of the anomalous phalanx. Such alignment maneuver creates a problem in skin cover, along with soft-tissue tension at the concave aspect of the deformity. Hence, some sort of skin flap is required for the adequate operative wound closure. We aim to demonstrate the aforementioned technique and to assess the results of bilobed flap in the treatment of hand clinodactyly. Methods Retrospective study conducted between January 2008 and January 2015. Five patients were included in the study, including nine operated digits. Surgical indication consisted of angular deviations ˃ 30 ^o . Neither patients with thumb deformities nor those with deformities associated to syndromes were excluded from the study. We assessed the functional and cosmetic outcomes of the technique, as well as complications and the satisfaction rates of the family. Results All patients had satisfactory functional and cosmetic results, with a mean skin healing of 18.6 days. Among nine operated digits, only one of the patients presented vascular compromise at the distal portion of the first flap lobe, albeit without necrosis or the need for any additional procedure. Patients were followed up on a minimum of 12-month interval. No deformity recurred during the observation period. Conclusion Bilobed flap for the treatment of hand clinodactyly is a good option for skin cover after the osteotomy.

Keywords: clinodactyly; figers/abnormalities; osteotomy; surgical flaps.

Fig. 1

Schematic of surgical treatment for clinodactyly using bilobed flap. It starts with a transverse line at the digit concave border, which is the point of maximum deformity. The dorsal lobe shall be the size of the space created at the concave border with the digit aligned. The secondary lobe should be performed toward the palm on the convex side of deformity and must have a similar height to that of the first lobe, although not as wide.

Fig. 2

Patient with Pfeiffer syndrome presenting bilateral hand changes, with the typical hitchhiker thumb deformity associated with third- and fourth-digit syndactyly (A). Radiograph showing a delta proximal phalanx of the thumb, and hypoplasia of middle phalanges of long fingers (B). Thumb radiograph details clinodactyly and delta phalanx (C). Surgical planning with bilobed skin flap (D). Elevation and rotation of bilobed flap with complete skin cover (E and F).

Fig. 3

Patient with index finger clinodactyly. An isolated deformity not associated to any syndrome (A). Radiograph proves the abnormal development of middle phalanx. Delta phalanx (B). Surgical planning with bilobed skin flap (C and D).

Fig. 4

Same patient of the previous figure. Elevation and rotation of bilobed flap, with complete skin cover (A, B, and C). Delta phalanx osteotomy and K-wire fixation (D). Skin healing after 2 weeks postoperatively (E and F).

Fig. 1

Esquema do tratamento cirúrgico da clinodactilia com retalho bilobado. Começa com uma linha transversal na borda côncava do dedo, que é o ponto de deformidade máxima. O lobo dorsal deve ser do tamanho do espaço criado na borda côncava com o dedo alinhado. O lobo secundário deve ser executado em direção à palma da mão no lado convexo da deformidade, devendo ter uma altura semelhante à do primeiro lobo, embora menos largo.

Fig. 2

Paciente com síndrome de Pfeiffer apresentando alterações bilaterais nas mãos, com deformidade típica do polegar do carona, associada à sindactilia do terceiro e quarto dedos (A). Radiografia mostrando falange proximal em delta do polegar e hipoplasia das falanges médias dos dedos longos (B). A radiografia do polegar detalha clinodactilia e a falange em delta (C). Planejamento cirúrgico com retalho cutâneo bilobado (D). Elevação e rotação de retalho bilobado com cobertura cutânea completa (E e F).

Fig. 3

Paciente com clinodactilia do dedo indicador. Deformidade isolada não associada a nenhuma síndrome (A). A radiografia prova o desenvolvimento anormal da falange média. Falange em delta (B). Planejamento cirúrgico com retalho cutâneo bilobado (C e D).

Fig. 4

Mesmo paciente da figura anterior. Elevação e rotação do retalho bilobado, com cobertura cutânea completa (A, B e C). Osteotomia da falange em delta e a fixação com fios de Kirschner (D). Cicatrização da pele após duas semanas de pós-operatório (E e F).