Author’s experience in surgical treatment of aplasia of the thumb according to the Buck-Gramcko procedure introduced by this author in 1971 is reported. Inidcation of the pollicization of the index finger according to Buck-Gramcko is aplasia of the thumb in the 3rd, 4th and 5th stages (Blauth’s classification). The surgical technique is particulary complex because of knowledge of microsurgery and soft-tissue reconstruction necessary. The different surgical phases may be schematically divided into a cutaneous stage which calls for the reconstruction of the web space, a vacular stage, a skeletal stage in which the reduction of the trapezium radial I metacarpal is reduced and a miotendinous stage. Surgery is carried out on patients of at least one year of age as it is necessary their cardial-pulmonary system be adequately mature, development of the endostal circle, thicker vascular walls and a suitably developed bimanual grasp, as well. The revision of these cases treated is especially significant because an average follow-up of the 17 years puts in good light the functionality of the hand, both from the points of view of strength and movement (Percival’s classification). After a revision of the case studies with a long term f.-u. we may affirm that the pollicization of the index finger according Buck-Gramcko, to achieve the development of the first finger in opposition, is the best-choice surgery in the reconstruction of the aplasial thumb and owes its effectiveness to the association of microsurgical techniques for preparing an island pedicle composite-tissue flap to the cardinal principles of articular reconstruction and of tendon transfers

Purpose: We reviewed a series of pollicizations in children with congenital thumb malformations. The purpose of this study was to assess the influence of anatomic or technical factors on functional and cosmetic outcome. Material: The series included 33 operations in 26 children. The Blauth classification was: grade IIIA (n=1), grade IIIB (n=8), grade IV (n=8), grade V (n=13), mirror hand (n=8). We noted the type of skin incision, technique used to fix the metacarpal head on the carpus, and tendon shortenings. Results were assessed at mean 4 years follow-up on the basis of the cosmetic aspect (parent satisfaction) and functional outcome measured with the Kapandji index and flexion-extension of inter-phalangeal joint, thumb finger opposition, and sensitivity. Results: Mean age at surgery was 32 months. Fixation was achieved with sutures in 24 cases and pinning in nine. Tendon shortening was performed in 16 cases on the extensor system and in one case on the deep flexor system. Mean follow-up was four years. There was no significant difference between groups A and B for cosmetic outcome. The main factor influencing objective functional outcome was the association of a grade III or IV radial club hand. In these patients, the final outcome was compromised by the stiffness or deformation of the radiocarpal joint and the stiffness of the preoperative Kapandji index which was 7 (mean) in group A and 4.75 in group B. Discussion and conclusion: The following technical aspects did not have a significant effect on the final functional result in our series: type of skin incision, type of carpal fixation, shortening the extensor or flexor system. Technical aspects which must be performed with particular care include reconstruction of the thenar muscles using interosseous muscles, curettage of the growth cartilage of the head of the second metacarpus, and hyper-extension of the head of the second metacarpus during fixation onto the carpus. Careful technique avoids future complications such as excessive growth of the neometa-carpus or Z-thumb