SCIENTIFIC ARTICLE

Flexor Pollicis Longus Rebalancing: A Modified

Technique for Wassel IV-D Thumb Duplication
Xu Yun-lan, MD, Shen Kai-ying, MD, Chen Ji, MD, Wang Zhi-gang, MD

Purpose To report a modified reconstructive technique for Wassel type IV-D thumb dupli-
cation that preserves and transfers the flexor pollicis longus (FPL) from the removed radial
portion.
Methods We analyzed the hands of 16 patients (average age, 2 y) with Wassel IV-D thumb
duplication. Patients were treated with ablation of the radial thumb and reconstruction of the
ulnar thumb by a series of soft tissue procedures, including FPL rebalancing. The post-
operative range of motion and the alignment at the metacarpophalangeal and interphalangeal
joints of the affected thumbs were compared with the preoperative measurements.
Results Of 16 cases, 14 were observed for an average of 29 months. Motion at the inter-
phalangeal joint and alignment at metacarpophalangeal and interphalangeal joints showed
improvement after surgery. According to the Japanese Society for Surgery of the Hand
scoring system, the results were excellent in 2 cases, good in 11, and fair in 1. A disadvantage
of this technique proved to be restricted interphalangeal joint motion with an extension lag
that averaged 14 .
Conclusions The FPL rebalancing technique with soft tissue stabilization of the meta-
carpophalangeal and interphalangeal joints can establish dynamic rebalance of the bifurcated
FPL tendon in Wassel IV-D duplicated thumb. It shows excellent results in alignment and joint
stability. The long-term results are under evaluation. (J Hand Surg Am. 2014;39(1):75e82.
Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Therapeutic IV.
Key words Duplicated thumb, flexor pollicis longus, polydactyly, reconstruction, Wassel.

difficult to treat because of its complex anomalies.1e3

W
a subtype
ASSEL IV-D THUMB DUPLICATION,
of Wassel IV that includes divergence Frequently, the result of surgical treatment is unsatis-
of the metacarpophalangeal (MCP) joint factory because of a residual z-deformity, so a double
and convergence of the interphalangeal (IP) joint, is osteotomy is recommended to gain the best cosmetic
and functional outcome4e8; however, it is difficult to
From the Department of Pediatric Orthopedics, Shanghai Children’s Medical Center, affil- perform in young children.4 The Bilhaut procedure9 is a
iated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
well-known technique for these cases. Technically, the
Received for publication June 14, 2013; accepted in revised form October 11, 2013.
procedure is challenging and carries some risks.6,8,10,11
No benefits in any form have been received or will be received related directly or Tien et al12 noted that the bifurcated flexor pollicis
indirectly to the subject of this article.
longus (FPL) ran obliquely and inserted eccentrically
Corresponding author: Wang Zhi-gang, MD, Department of Pediatric Orthopedics,
Shanghai Children’s Medical Center, affiliated to Shanghai Jiao Tong University School of
onto the margin rather than midpoint of the distal
Medicine, 1678 Dongfang Road, Pudong New District, Shanghai 200127, Peoples Republic phalangeal bases. This may be an important contributing
of China; e-mail: WZGProSCMC@163.com. factor for convergent alignment of the duplicated
0363-5023/14/3901-0012$36.00/0 distal phalanges. They reported a series of soft tis-
http://dx.doi.org/10.1016/j.jhsa.2013.10.003
sue procedure including FPL centralization, which was

Ó 2014 ASSH r Published by Elsevier, Inc. All rights reserved. r 75

76 RECONSTRUCTION FOR WASSEL IV-D POLYDACTYLY
technically simple and did not potentially interfere with
bone growth. However, it was difficult for us to make a
bony attachment on immature bone. With a better un-
derstanding of the pathoanatomy, a novel technical
modification of FPL rebalancing (FPLR) preserves and
repositions the FPL tendon of the removed radial distal
phalanx to balance the eccentric insertion of the FPL to
the remaining ulnar distal phalanx. Here, we describe
our technique and report the preliminary results.
MATERIALS AND METHODS
We treated 16 Wassel IV-D thumb duplication pa-
tients with ablation of the radial thumb’s bony ele-
ments and reconstruction of the ulnar thumb by a
series of soft tissue procedures, including FPLR.
Informed consent was obtained and institutional re-
view board approval was acquired.
Surgical technique
Under tourniquet control, we made a racquet incision
around the base of the radial duplicated thumb. A soft
tissue flap from component to be deleted was pre-
served for the further augmentation of the retained
thumb. A periosteal and radial collateral ligament flap
was detached from the base of the proximal phalanx
of the radial component and retained along with the
abductor pollicis brevis tendon. Next, the radial
duplicated thumb was removed completely. In all
patients we contoured by chondroplasty the base of
the proximal phalanx and on the metacarpal head.
We then performed the FPLR technique as follows.
The insertion of the radial thumb’s FPL tendon was
carefully detached and preserved (Fig. 1A). The
conjoined A2 pulley was opened by a longitudinal cut
along the radial attachment, and a small longitudinal
incision was made in the ulnar thumb’s FPL tendon,
just distal to the bifurcation. The preserved radial
thumb’s FPL tendon was passed through the incision
(Fig. 1B) and then transferred to the ulnar side of
reconstructed thumb (Fig. 1C). The transferred FPL
tendon was tensioned, and the insertion was reposi-
tioned by periosteal suture at the ulnar side of the distal
phalangeal base (Fig. 1D). The A2 pulley was recon-
structed by reattaching it onto the radial border of the
proximal phalanx. The principle of FPLR was to use
dynamic rebalance of the bifurcated FPL to correct
radial deviation of the reconstructed thumb’s IP joint in
the Wassel IV-D duplicated thumb (Fig. 2).
A routine soft tissue reconstruction procedure fol-
lowed. After we partially resected the metacarpal head,
we tightly sutured the radial capsule of the MCP joint.
The preserved radial collateral ligament and abductor
pollicis brevis tendon were sutured to the radial side of
J Hand Surg Am.
the reconstructed thumb’s proximal phalanx, which
could stabilize the MCP joint and restore abduction.
The radial collateral ligament and capsule of the
thumb’s IP joint were released, and the ulnar side was
tightened (Fig. 2D). A diamond-shaped skin flap was
resected on unlar side of the retained thumb’s IP joint
(Fig. 1C), which allowed us to improve alignment of
the reconstructed thumb by tightening the suture. We
performed soft tissue augmentation using the flap from
the radial thumb. It was trimmed to cover the paro-
nychium and part of the pulp of the reconstructed
thumb. The incision was closed with absorbable suture
and a long-arm thumb spica cast was applied. All
procedures were performed by the same surgeon.
The cast was removed 3 to 4 weeks after surgery.
A short arm thumb spica orthosis was fabricated and
applied, but was removed for therapy and gentle ac-
tivities. The orthosis was discontinued 8 weeks after
surgery.
Patient study
Sixteen cases of Wassel type IV-D duplicated thumb
were reviewed. There were 9 boys and 7 girls, with an
average age at surgical procedure of 2 years (range,
1e5 y). Preoperative x-ray demonstrated a Wassel
IV-D duplicated thumb (Fig. 3A). We examined the
stability of the MCP and IP joints by manual stress
compared with the other side. Range of motion (ROM)
was measured with a goniometer and reassessed at the
final follow-up. For patients 9, 15, and 16, who were
older than 3 years before surgery, ROM was measured
actively; the others were measured passively. At the
final follow-up, all were measured actively. Alignment
at the MCP and IP joints was measured on the preop-
erative and postoperative x-ray films. Both the
maximum width of the nail and the circumference at IP
joint were measured and expressed compared with the
other side. We recorded parents’ subjective regarding
the appearance and function of the reconstructed
thumb. The Japanese Society for Surgery of the Hand13
evaluation form was adopted to assess functional and
cosmetic outcomes of the reconstructed thumbs.
RESULTS
The mean follow-up evaluation was 29 months (range,
12e43 mo). Two patients (patients 2 and 13), who were
under age 3 years at the final follow-up, were not
included in the final assessment. Table 1 lists surgical
outcomes.
The functional point score averaged 13 points.
Stability and alignment of the MCP joint were good
in all cases, and average active palmar abduction of
the MCP and carpometacarpal joints was 68 .
r Vol. 39, January 2014
 RECONSTRUCTION FOR WASSEL IV-D POLYDACTYLY 77

FIGURE 1: A 3-year-old boy (patient 15) with left Wassel IV-D thumb duplication. Intraoperative photographs of the FPLR technique.
A Insertion of the radial thumb’s FPL tendon was carefully detached and preserved. B The radial thumb’s FPL tendon was drawn and
passed through the ulnar thumb’s FPL. C The radial thumb’s FPL tendon was transferred to the ulnar side of the retained thumb.
A diamond-shaped skin flap was resected on the ulnar side of the IP joint. D The transferred FPL was reattached to the ulnar side of the
reconstructed thumb’s distal phalangeal base.

Stability of the IP joint was good overall; (patients 1, 3, 4, 6e10, and 14) had an exten-
however, we observed more than 5 of residual sion lag ranging from 5 to 25 at the IP joint
radial deviation at the IP joint in 8 patients (patients 1, (Appendix A, available on the Journal’s Web site at
4, 5, 7, 9, 10, 11, and 16). Nine of 14 patients www.jhandsurg.org), which was unchanged from

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78 RECONSTRUCTION FOR WASSEL IV-D POLYDACTYLY

FIGURE 2: Surgical techniques (FPLR). A, B The FPL tendon ran obliquely rather than along the longitudinal axis of proximal
phalanx and showed an eccentric tendon insertion. C The FPL tendon of the radial thumb was drawn and passed through the small
incision on the ulnar thumb’s FPL. D The radial thumb’s FPL tendon was reattached to the ulnar side of reconstructed thumb’s distal
phalangeal base. The lateral collateral ligament of the MCP joint and the medial collateral ligament of the IP joint were tightened to
correct the alignment.

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 RECONSTRUCTION FOR WASSEL IV-D POLYDACTYLY 79

FIGURE 3: A 1-year-old boy (patient 4) with right Wassel IV-D thumb duplication. A Preoperative x-ray. B, C When the boy was
3 years of age, his parents were satisfied with both the cosmetic and functional outcomes. Good pinch function was present. D At 21
months after the operation, the x-ray showed no recurrent angular deformity at the IP or MCP joints.

preoperative measurements (Table 2). Limited www.jhandsurg.org). No patients reported pain or

active flexion of IP and MCP joints (60 to 90 ) difficulties in daily living.
was observed in 2 patients (patients 1 and 16; The ROM of the IP joints and alignment of the
Appendix A, available on the Journal’s Web site at affected thumbs were improved at final follow-up

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80 RECONSTRUCTION FOR WASSEL IV-D POLYDACTYLY

TABLE 1. Patient Data

Age at Follow-Up Functional Cosmetic Pain and
Surgery Evaluation Points Points Satisfaction Total Circumference
Patient Sex (y) (mo) (14 Points) (4 points) (2 points) (20 Points) at IP (%)

1 F 1 39 11 3 2 16 82
2* F 2
3 M 1 43 13 3 2 18 96
4 M 1 21 12 4 2 18 97
5 F 1 33 13 4 2 19 91
6 F 1 30 13 3 2 18 86
7 M 1 39 12 3 2 17 89
8 M 2 28 13 3 2 18 90
9 F 3 27 12 4 2 18 95
10 M 1 36 12 3 2 17 89
11 M 2 27 13 4 2 19 94
12 F 2 21 14 4 2 20 95
13* M 2
14 M 1 24 13 3 2 18 84
15 M 3 21 14 4 2 20 95
16 F 5 12 12 4 2 18 92

*Patients 2 and 13 were under age 3 years at the final follow-up evaluation and were not included in the final assessment.

compared with preoperative measurements (Table 2).
Preoperative flexion of IP joints averaged 16 ; the mean
value was 46 at the final follow-up. The angulations
were 39 at the MCP joints and 43 at the IP joints; their
mean values decreased to 3 and 7 postoperatively
(Fig. 3B, patient 4). Although the ROM of the MCP
joint was not improved and there was an average of
14 active extension-deficit at the IP joints, we observed
active pinch motion in all patients (Fig. 3C, patient 4).
x-rays showed no recurrent angular deformity at the IP
or MCP joints (Fig. 3D, patient 4 ).
The cosmetic point score averaged 3.5 points and
the surgical scar was acceptable to the family. No nail
or pulp deformity was observed. The average
circumference at the IP joint was 91% of the other
side, but a small nail was present; the average width
of the nail was 77% of the other side.
The total assessments score of the Japanese Society
for Surgery of the Hand averaged 18 points. Accord-
ing to the scoring system, the results were excellent in
2 cases, good in 11, and fair in 1. Interphalangeal joint
motion with extension lag was not perfect.
DISCUSSION
Wassel IV radial polydactyly is the most common
form and is subdivided into 4 types.3 Reconstruction
of the Wassel IV-D is the most challenging. The
surgeon has 2 alternatives for reconstruction.
First, the surgeon may choose 1 of the smaller
thumbs to reconstruct. Frequently, although the ulnar
thumb is preserved to retain the ulnar collateral liga-
ment for pinch, it is not simple ablation of an extra
thumb, but thumb reconstruction.2,4,5,11,12,14e16 This
approach is straightforward and avoids the complex-
ities and complications of the reconstructive pro-
cedures below but does yield a notable difference in
thumb size.11 Occasionally, single or multiple closing
wedge osteotomies may be required and can be stabi-
lized with a longitudinal pink-wire to correct bony
angulation.4e8 Wedge osteotomies may have to be
postponed because of the immature bone of young
children. In 2007, Tien et al12 proposed a series of soft
tissue procedures as an alternative surgical technique
to the double osteotomy procedure in very young
children. The reconstruction techniques included A2
pulley reconstruction, FPL centralization, and liga-
ment reconstruction. The intramedullary pin main-
tained postoperative immobilization. With 3.3 years of
follow-up evaluation, the results were good in 3 cases
and fair in 1.
The second option for thumb reconstruction is
to increase the size of the thumb. In this procedure,
both small digits may be combined in the Bilhaut

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 RECONSTRUCTION FOR WASSEL IV-D POLYDACTYLY
TABLE 2. Preoperative and Postoperative ROM Plus Alignment Data
MCP
ROM
Extension Flexion
Preoperative 0 49  7 (40 to 60) 39  4 (31 to 48) 12  8 (0 to 25) 16  5 (10 to 25)
Postoperative 0 47  6 (35 to 55)
Data are presented as degrees. All patients’ individual measurements are listed in Appendix A (available on the Journal’s Web site at www.
jhandsurg.org).
procedure.6,8,9e11 The central aspect of both thumbs is
excised, allowing the outer components of each thumb
to join into a larger one. However, it is technically
challenging; disadvantages include an inevitable central
ridge in the nail, potential growth plate problems, and
poor motion of the joints.8,10,11
Abid and colleagues15 used a modified Bilhaut
technique for Wassel IV-D thumbs, which combines
excision of the central part of the proximal phalanx
and partial excision of the base of the distal phalanx.
This provides axis correction and stabilization of the
IP joint while avoiding subsequent nail dystrophy,
because a single nail is preserved. Results were good
in all 4 cases.
Before 2008, we used soft tissue reconstruction in
Wassel IV-D thumb duplications with good func-
tional results, but parents complained of less than
perfect alignment of the thumb and a relative smaller
size thumb compared with the collateral thumb. We
then modified the technique of FPL reconstruction,
ligament reconstruction, and the flap design.
As noted above, an eccentric tendon insertion can
contribute to deformity on either the extensor or
flexor side. Ogino et al17 preserved and transferred
the extensor tendon of the removed digit to correct
the deviation, but we found that the distal phalanges
typically converge mainly because of the pull of the
extrinsic flexor tendons. Initially, we doubted the
reliability of the attachment by periosteal suture when
the FPL is centralized, because we cannot make a
bony attachment on an immature skeleton owing to
its potential growth plate problems. We proposed the
FPLR technique, preserving the eccentric tendon
insertion of the ulnar thumb’s FPL, simultaneously
transferring the radial thumb’s FPL tendon to the
ulnar side of ulnar thumb’s distal phalangeal base.
With this technique, the FPL of the reconstructed
thumb has 2 insertions at the base of distal phalanx.
One is on the radial side and the other is on the ulnar
side. The FPLR rebalances eccentric tendon insertion
J Hand Surg Am.
81
IP
ROM (degrees)
Alignment Extension Flexion Alignment
43  6 (35 to 52)
3  2 (0 to 5) 14  12 (0 to 25) 46  9 (30 to 65) 7  5 (0 to 13)
of the FPL and maintains the alignment of the thumb
during IP joint flexion.
Because we noted that there was dislocation or
subluxation at the IP joint of the ulnar thumb in all
16 cases, we feel it important to reduce the joint in the
reconstruction. Fortunately, in most cases, the IP joint
was reduced after we released the radial collateral
ligament and capsule and tightened the ulnar por-
tions. Furthermore, partial skin resection and tight-
ening suture on convex ulnar side of IP joint
improved the alignment of the reconstructed thumb.
Finally, management of the skin is an important
step. In our technique, a soft tissue flap from the
deleted component is preserved to supplement the
retained thumb. This allowed us to augment the girth
and width of the retained thumb and made it com-
parable to the uninvolved side.
Kemnitz and De5 concluded that functional results
seemed to correlate with stability of the IP and MCP
joints and less with mobility of the IP and MCP
joints. In particular, the IP joint seemed to get stiffer
with age, with no consequence for function. In the
follow-up evaluations, stability of the MCP and IP
joints was well maintained in all patients, although 9
of 14 still had extension lags between 5 and 25 .
Fortunately, mild flexion of the IP joint is a functional
position, our patients had no restriction in their daily
lives, and all parents were satisfied with no reports.
No patient required revision surgery. Long-term re-
sults are being evaluated.
Limitations of our technique are slightly restricted
IP joint motion and a dysplastic nail.
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3. Hung LK, Cheng JC, Bundoc R, et al. Thumb duplication at the
metacarpophalangeal joint: management and a new classification.
Clin Orthop Relat Res. 1996;(323):31e41.
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82 RECONSTRUCTION FOR WASSEL IV-D POLYDACTYLY
4. Horii E, Nakamura R, Sakuma M, et al. Duplicated thumb bifurcation
at the metacarpophalangeal joint level: factors affecting surgical
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treatment. J Pediatr Orthop B. 2002;11(1):79e84.
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800e804.
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Am. 1994;19(6):973e976.
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11. Goldfarb CA. Reconstruction of radial polydactyly. Tech Hand Up
Extrem Surg. 2006;10(4):265e270.
12. Tien YC, Chih TT, Wang TL, et al. Soft tissue reconstruction for type
IV-D duplicated thumb: a new surgical technique. J Pediatr Orthop.
2007;27(4):462e466.
13. Congenital Hand Committee, Japanese Society for Surgery of the
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Hand. 2007;24:422 [in Japanese].
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metacarpal condyle for reconstructing Wassel type IV thumb dupli-
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669e675.
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 APPENDIX A. Patients’ Individual Measurement Data
MCP (degrees) IP (degrees)

Extension Flexion Alignment Extension Flexion Alignment

Patient Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative

RECONSTRUCTION FOR WASSEL IV-D POLYDACTYLY

J Hand Surg Am.

1 0 0 55 50 48 3 15 25 10 30 48 13

3 0 0 60 55 31 5 20 20 15 40 37 5
4 0 0 50 50 42 0 15 25 15 45 42 12

5 0 0 50 50 35 5 5 0 15 50 50 9
6 0 0 45 45 40 0 20 25 20 50 42 4
r
Vol. 39, January 2014

7 0 0 50 50 38 4 15 25 15 45 44 9

8 0 0 40 40 35 5 25 25 15 55 35 0
9 0 0 40 35 36 5 15 5 25 65 39 12

10 0 0 60 55 39 4 15 15 10 45 50 13

11 0 0 45 50 37 0 5 0 15 45 36 9
12 0 0 55 50 41 0 0 0 25 45 35 0

14 0 0 50 50 44 5 15 25 15 45 47 0

15 0 0 40 40 38 0 5 0 15 55 47 0
16 0 0 45 40 40 0 0 0 10 30 52 10

x  SD 48.93  6.84 47.14  6.11 38.86  4.22 2.57  2.38 12.14  7.77 13.57  11.84 15.71  4.75 46.07  9.24 43.14  6.00 6.86  5.20

82.e1