Surgical Reconstruction of Unstable Hypoplastic Finger "Nubbins" using Allograft and BMP-2 Augmentation: Surgical Technique and Case Series
Zachary C. Hanson, MD1; Gary M. Lourie, MD2
1Wellstar Atlanta Medical Center, Atlanta, GA; 2The Hand and Upper Extremity Center of Georgia, Atlanta, GA
Introduction: Congenital hand anomalies such as symbrachydactyly and amniotic band syndrome (ABS) are associated with rudimentary hypoplastic digits often referred to as “nubbins”. Unstable hypoplastic digits can lead to poor function due to instability with pinch and manipulation of objects, particularly in those with adactylous or monodactylous hands. The primary goals of surgical reconstruction in these patients are to create 2 stable digits for pinch and improve finger opposition, pinch strength and digit mobility. A number of treatment options have been proposed, including vascularized and non-vascularized toe phalangeal transfer; the primary drawbacks of these procedures include ubiquitous donor site morbidity and high rates of cosmetic, emotional and functional (e.g., shoe-wear fit) concerns. Common drawbacks of allograft lengthening procedures include nonunion, pseudoarthrosis, and bony resorption postoperatively.
In this paper, we present a surgical technique and case series of pediatric patients who underwent surgical reconstruction of unstable/telescoping hypoplastic fingertips using bony allograft augmented with BMP-2.
Materials & Methods: A surgical technique for reconstruction of unstable, hypoplastic fingertips was performed using Plexur ® allograft (Medtronic, Dublin, Ireland) augmented with BMP-2 , Infuse ® (Medtronic, Dublin, Ireland). The series included pediatric patients hypoplastic digits with instability affecting grip-pinch strength and hand prehension. All patients required a robust soft tissue envelopes capable of receiving the bony allograft for lengthening.
Results: 10 patients between the ages of 2 and 4 years were included, with 8 thumbs and 2 index fingers being reconstructed. No major complications were reported; 1 patient developed a transient inflammatory reaction which resolved without intervention. All 10 patients developed clinically stable digits with parent-reported improvements in pinch-grip function including using a switch, opening a bag and putting on clothes. Postoperative radiographic outcomes did not show any cases of bony overgrowth; 2 patients had evidence of bony resorption though this did not correspond to significant change in finger length postoperatively.
Conclusion: Hypoplastic fingertip reconstruction using bony allograft augmented with BMP-2 is a surgical option for stabilization of unstable hypoplastic fingertips in congenital hand anomalies. The use of allograft augmented with BMP-2 eliminates donor site morbidity seen with autograft reconstructive options and may limit the concerns with healing/incorporation traditionally reported with allograft use in the literature.
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