when the ligation is done inappropriately it can give a residual nubbin. also, a neuroma can develop in the area of the scar. an excision can prevent the development of a residual nubbin and the sensitivity due to a neuroma. for infants with ulnar type b polydactyly the recommended treatment is ligation in the neonatal nursery. a 2011 study opined that excision of an extra digit in the neonatal nursery was a safe and simple procedure with a good clinical and cosmetic outcome. as of 2022, for infants with ulnar type b polydactyly the recommended treatment is surgical excision or suture ligation, when no bony structures exist. complications of ligation include infection, neuroma or cyst formation. radial polydactyly because neither of the two thumb components is normal, a decision should be taken on combining which elements to create the best possible composite digit. instead of amputating the most hypoplastic thumb, preservation of skin, nail, collateral ligaments and tendons is needed to augment the residual thumb. surgery is recommended in the first year of life, generally between 9 and 15 months of age. surgical options depend on type of polydactyly. bilhaut-cloquet procedure this type of procedure is recommended for wassel types 1 and 2 (in which both thumbs are severely hypoplastic) by some congenital hand surgeons. the technique contains a composite wedge resection of the central bone and soft-tissue. this will be achieved with approach of the lateral tissue of each thumb. the goal is to achieve a normal thumb, what concerns the size, which is possible. if the width of the nail bed is greater than 70% of the contralateral thumb, it may be split. ablation with collateral ligament reconstruction this type of procedure is used for all wassel types of polydactyly and is the most commonly used technique. it is recommended in all cases of thumb duplication with a hypoplastic, less-functional thumb. otherwise, one could consider the bilhaut-cloquet. the ulnar thumb is preferably preserved as it is the more developed one in most cases. by detaching the radial collateral ligament from distal to proximal, a periosteal sleeve can be preserved. in this way, the radial collateral band of the radial digit, will function as the absent radial collateral ligament of the preserved ulnar thumb. elevation of the apb and fpb is performed in wassel type 4 duplication; this can be accomplished via the periosteum or separately. as the tendons insert proximally, the elevation is performed proximally too to potentially rebalance the ulnar thumb. after the radial thumb is amputated, the ulnar elements are centralized and fixed with a kirschner wire. in most cases, a longitudinal and sagittal osteotomy is needed to centralize the bony parts of the ulnar thumb. while the soft-tissue of the radial thumb was preserved, it is now attached to the radial side of the ulnar thumb together with the periosteal sleeve. the apb and fpb of the ablated radial thumb are attached to the distal phalanx for more stability. if necessary, the extensor pollicis longus and the flexor pollicis longus are reattached to centralize their course. in wassel type 5 and 6 the opponens pollicis muscle must be transferred to the ulnar metacarpal. soft tissue with collateral ligament reconstruction is used to avoid any angular deformity in the preserved thumb. tendon centralization is also often used for correction. still, cases with osseous deformities may happen. to provide alignment, osteotomies are necessary to be done. this operation may need bone grafting, which is obtained from the amputated thumb. on top plasty procedure this type is indicated when one thumb is larger proximally and the other thumb has a larger distal component. (the procedure is initially described as a way to lengthen amputated digits.) the goal is to create a functional thumb by combining less-hypoplastic components. on top plasty procedure is rarely employed in the treatment of congenital thumb duplication. it might be necessary for wassel types 4, 5, 6. at the level of the mid-proximal phalanx or mid-metacarpal, the distal component is transferred to the proximal component. the tendons of the distal component are preserved as the rest of the distal component is amputated. the neurovascular bundle which supplies the distal component is reserved and transferred proximally. central polydactyly early osteotomy and ligament reconstructions should be done to prevent deformities, such as angular growth deformities. the surgical treatment of central polydactyly is highly variable. after the surgery the hand must be functional and stable, but also aesthetically pleasing. this requires intraoperative creativity and flexibility. the surgeon must also consider whether retention of a fully functional supranumerary digit is preferable to surgical intervention. in contrast, a functional, four-fingered hand achieved via ray amputation may be preferable to a five-fingered hand with a deformed or stiff reconstructed finger. cases of polysyndactyly are approached through a standard opposing zig-zag incision. the incision is favored toward the accessory digit, preserving extra skin for subsequent closure. depending on the level and extent of duplication, the flexor and extensor tendons may require centralization or rebalancing. also, the collateral ligaments must be preserved or reconstructed. wide articular surfaces should be narrowed and phalangeal wedge osteotomies may be required to provide an axial alignment. attention must also be given to reconstruct the intermetacarpal ligament. furthermore, one should take in mind the provision for adequate web-space soft tissue. complications complications include: painful scarring, infection, joint instability, residual deformity, angulated growth, growth arrest, joint stiffness, and nail bed deformities. a 2014 study reported a 19% revision rate for preaxial polydactyly for pain or instability. prognosis type a ulnar polydactyly there are no substantive outcome studies regarding the function of these hands following surgical intervention. this is mainly caused by the fact that there is a generally normal function of these patients’ hands following ablation with collateral ligament reconstruction. in a study on 27 patients undergoing surgical excision for type a ulnar polydactyly, only one complication was noted in the form of an infection. however, no investigators have objectively reviewed functional range of motion or articular stability. type b ulnar polydactyly in a study on 21 patients with type b ulnar polydactyly treated with suture ligation it was found that the duplicated digit was typically amputated at an average of 10 days and no complications of infection or bleeding were reported. in a large study on 105 patients treated with suture ligation an overall complication rate of 23.5% was reported, citing a residual tender or unacceptable bump in 16%, infection in 6%, and bleeding in 1% of patients. in general, suture ligation is safe and effective when applied to appropriate cases of type b polydactyly in which no substantial ligamentous or osseous structures are present within the pedicle. parents should be educated as to the progression of necrosis, and that revision of residual tissue or scar may be necessary when the child is six months of age or older. bilhaut procedure advantages: by combining two hypoplastic thumbs a sufficient thumb size is acquired. furthermore, the ip and mcp joints are very stable as the collateral ligaments are not violated during reconstruction. disadvantages: violation during reconstruction can lead to growth arrest or asymmetric growth. nail deformity could also occur after reconstruction. although the joints are stable, restriction of flexion may be possible. the average ip flexion in a reconstructed thumb is 55 degrees less than the contralateral thumb. mcp flexion averaged 55 degrees in reconstructed thumbs, compared to 75 degrees in the contralateral thumb. ablation with collateral ligament reconstruction advantages: the reconstructed joints tend to remain flexible. also, it preserves the nail bed and physis, this increases the prevention of nail deformities over time. disadvantages: although surgeons try to obtain a stable thumb of appropriate size, instability of the ip and mcp joint may occur, as well as a size mismatch. thumbs are defined as unacceptable if ip joint deviation exceeds 15 degrees, mcp joint deviation exceeds 30 degrees, and thumb size is inappropriate based on the examiner's assessment. also, thumb size one-third greater or less than the contralateral thumb is defined as unacceptable. on-top plasty procedure no surgical outcomes studies exist for evaluating the function of the thumbs after an on-top plasty reconstruction. central polydactyly few clinical outcome studies exist regarding the treatment of central polydactyly. tada and colleagues note that satisfactory surgical correction of central polydactyly is difficult to achieve and that outcomes are generally poor. in tada's study, 12 patients were reviewed. all patients required secondary surgical procedures to address flexion contractures and angular deviation at the ip joint level. however, several primary factors contribute to the complexity of central polydactyly reconstruction. hypoplastic joints and soft tissues that predispose the reconstructed finger to joint contracture, and angular deformities as well as complex tendon anomalies, are often difficult to address. therefore, treatment is wholly dependent on the anatomic components present, the degree of syndactyly, and the function of the duplicated finger. epidemiology preaxial polydactyly the condition has an estimated occurrence of 0.3–3.6 per 1000 live births. postaxial hand polydactyly is most frequent in the united states in black males. preaxial polydactyly occurs in 0.08 to 1.4 in 1,000 live births. in the united states, it is more common in white people and also relatively frequent in native american and asian people. a 1994 study by finley et al. combined data from jefferson county, alabama, united states, and uppsala county, sweden. this study found incidence of all types of polydactyly at rates of 2.3 per 1000 live births of white males, 0.6 per 1000 live births of white females, 13.5 per 1000 live births of black males, and 11.1 per 1000 live births of black females. society and culture twelve-fingered man, illustrated in the 1493 nuremberg chronicles people with polydactyly antonio alfonseca, retired mlb professional baseball pitcher known as el pulpo (spanish for "the octopus") for his extra digit on each extremity. endre ady, hungarian poet born with six fingers, but one was removed as a child. the poet later interpreted it as a sign of his selection (according to the ancient hungarian belief, the táltos are born with more bones, such as six fingers). brites de almeida, a legendary portuguese woman who killed seven hiding castilian soldiers in her oven after the battle of aljubarrota, had six fingers on each hand. the actress gemma arterton was born with six fingers on each hand, the additional fingers being removed after birth. anne boleyn, former queen of england, was rumoured to have six fingers on one hand. however, considering that this rumour first emerged in the 1580s from a catholic dissenter, it is generally deemed false. robert chambers, purported author of vestiges of the natural history of creation, and his brother william had six digits on each limb. lucille clifton, an african-american poet and civil rights advocate. zerah colburn, american prodigious math calculating savant. calvin choy, a hong konger singer and actor nicknamed "sir one one" (sir11) as he has six digits on his right hand. several members of a da silva family in são paulo, brazil, have two thumbs on each hand. vicente fox, former president of mexico, has six toes on each foot. danny garcia, boxing champion, has six toes on his right foot. yoandri hernández garrido, nicknamed veinticuatro ("twenty four" in spanish), has six fully formed fingers on both hands and six perfect toes on each foot. hampton hawes, jazz pianist, was born with six fingers on each hand (the extra fingers were surgically removed shortly after birth). henry ii the pious, high duke of poland 1238–1241, had six toes on his left foot. a boy named hong hong born in pingjiang county, hunan province, china, has 31 fingers and toes. kamani hubbard, a boy in california, was born in 2009 with a rare case of polydactyly, with 12 fingers and 12 toes, all fully functional. johann jacob freiherr von moscon (1621–1661), lower styrian baron, is depicted with six fingers at his left hand on a portrait from brežice, slovenia. jiang qing, mao zedong's fourth wife, reportedly had six toes on her right foot. hrithik roshan, a bollywood actor born with a supernumerary thumb on his right hand. nayanthara, an indian actress, has a rudimentary finger on her left hand. akshat saxena from uttar pradesh, india, is the world record holder for highest number of digits. he was born in 2010 with seven