Radial polydactyly: towards a unifying approach for surgical management

INTRODUCTION: 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. CONCLUSION: 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. LEVEL OF EVIDENCE: V.