JBJS Classics: Pollicization of the Index Finger

OrthoBuzz regularly brings you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation by clicking on the “Leave a Comment” button in the box to the left.

Even before hand surgery became a specialty, the characteristics of the thumb that enabled pad-to-pad opposition (and therefore fine motor function) were well-recognized:  shorter length, fewer bony segments, and pronated position relative to the fingers; a wide first web space; and intrinsic muscle control of abduction, rotation, and pinch.  Although these principles were used to devise surgical procedures to restore thumb function prior to Buck-Gramcko’s landmark JBJS article in 1971, most were used for a small number of patients, with limited information available about outcomes.  Thumb absence is uncommon, and no hand surgeon was able to gain sufficient experience with index pollicization to refine and enhance the technique until the confluence of Buck-Gramcko’s exceptional skill and one of the major medical catastrophes of the 20^th century.

Dieter Buck-Gramcko was born in Hamburg, Germany in 1927.  Following World War II, he trained in general and trauma surgery and became one of the first hand surgeons in Germany.¹  Between 1957 and 1962, thalidomide was marketed in Germany as a sedative, but it also inhibited angiogenesis, causing limb malformations, including thumb deficiency, when fetuses were exposed to the drug during limb development.²  The resulting large number of German infants with thumb deficiency provided Buck-Gramcko with the opportunity to modify the technique of index pollicization and study the outcomes of his modifications to improve results. He described his findings and results in this landmark article.

His careful description of index pollicization includes the principles and techniques that remain the hallmarks of this operation.  His diagram of reduction of bones and joints (Figure 3 of his classic article, shown below) is a simple and elegant depiction of the principles of this complex operation.  His rigorous follow-up, measurement of outcomes, and propensity to criticize his own work to improve results are all apparent in this article, which provides an excellent example of applying the scientific method. Not surprisingly, Buck-Gramcko remained rigorous and objective throughout his long career; 20 years later, he published another article focused on complications and poor outcomes after index-finger pollicization.³

Index pollicization is one of the paramount operations of hand surgery, largely because Buck-Gramcko applied theoretical principles of thumb function, methodically and meticulously refined the technique of pollicization, studied the outcomes of his work, and passed this valuable information along in this classic article.  It remains a useful guide to the performance of this operation almost half a century later.  The thalidomide tragedy had a silver lining, thanks to Buck-Gramcko’s surgical skills, methodologic rigor, and scientific objectivity.

Michelle A. James, MD
JBJS Deputy Editor

References

1. Hoffmann R, Lubahn JD. First Hand: Dieter Buck-Gramcko. Journal of Hand Surgery. 2013;38(5):988-90.
2. Stephens T, Brynner R. Dark remedy: the impact of thalidomide and its revival as a vital medicine. Basic Books, N.Y.; 2009.
3. Buck-Gramcko D. Complications and bad results in pollicization of the index finger (in congenital cases). Annales de Chirurgie de la Main et du Membre Supérieur 1991;10 (6):506-512).