Radial polydactyly: towards a unifying approach for surgical management.

Abstract

Radial polydactyly is often underestimated in its complexity. While many cases can be managed by excision and reconstruction of a dominant thumb, suboptimal outcomes persist when soft-tissue imbalance or bony deviation is not fully addressed. Expectations for aesthetic symmetry have also increased, placing greater demands on surgical precision and judgement.Limitations of current approaches and classifications:In cases where both duplicates are small (typically <70% of the contralateral thumb), achieving adequate thumb girth and a satisfactory nail complex frequently requires augmentation or combined procedures. Traditional techniques such as the Bilhaut-Cloquet procedure, although conceptually elegant, may result in split nail deformity, joint stiffness, and excessive bulk. Likewise, the Wassel-Flatt classification, despite its widespread use, does not adequately capture soft-tissue anomalies, axial deviation, or triphalangeal components, limiting its value for operative planning.A proposed classification and surgical philosophy:We present a simplified, two-group classification derived from decades of cumulative clinical experience. This framework integrates key anatomical and morphological factors, including size discrepancy, axis deviation, soft-tissue quality and nail deformity, to guide surgical strategy. It incorporates both transverse (modified Bilhaut-Cloquet) and longitudinal (on-top plasty) reconstructive concepts, as well as combinations of these techniques where required. This approach also recogizes the need for a comprehensive surgical skillset, including paediatric orthoplastic and microsurgical expertise for optimal refinement. This pragmatic classification aims to address at least 95% of cases with radial polydactyly configurations, while remaining intuitive for clinical use. It provides a structured approach to surgical planning, communication, and outcome assessment, and should be applicable. By aligning anatomical complexity with tailored reconstruction, it supports more consistent functional and aesthetic outcomes. V.