Extensor indicis proprius opponensplasty

Opposition Transfer Using the Extensor Indicis Muscle and the Extensor Pollicis Brevis Tendon

Purpose

This study aimed to introduce a novel technique using the extensor pollicis brevis and extensor indicis proprius tendons as power sources for thumb opposition reconstruction in cases of severe carpal tunnel syndrome (CTS) associated with thenar muscle atrophy. Furthermore, the efficacy of this novel method and the traditional Camitz technique was compared.

Methods

Patients with severe CTS and thumb opposition dysfunction who underwent surgery using the novel technique (n = 7 and 9 surgeries) or the Camitz technique (n = 8 and 8 surgeries) were included in the analysis. The pre- and postoperative palmar abduction angle, thumb-ring finger opposition angle, and Kapandji score were assessed. The repeated measures analysis of variance and the Mann-Whitney U test were used for statistical analysis.

Results

The novel technique was associated with a significant postoperative improvement in palmar abduction angle, thumb-ring finger opposition angle, and Kapandji score. In particular, the thumb-ring finger opposition angle of patients who underwent surgery using this technique was superior to that of patients who underwent surgery using the Camitz technique. Therefore, the novel technique was highly effective in improving thumb pronation.

Conclusion

The novel technique using the extensor pollicis brevis and extensor indicis proprius tendons is promising for thumb opposition reconstruction in severe CTS cases. Unlike the traditional Camitz technique, this approach promotes stable thumb opposition function without requiring a pulley, thereby yielding satisfactory outcomes. Nevertheless, further studies with a larger sample size should be conducted to validate these findings.

Type of study/level of evidence

Therapeutic 4; Surgical technique.

Transfer of the palmaris brevis motor branch to the thenar motor branch: A cadaveric preliminary study

OBJECTIVE

High median nerve injuries can lead to poor distal recovery, especially poor functioning of median innervated thenar muscles involved in thumb opposition and palmar abduction. The palmaris brevis (PB) is a small subcutaneous muscle innervated by ulnar nerve. Innervation of the PB is in most of cases provided by the ulnar digital nerve to the little finger. The purpose of this study is to assess the feasibility of transferring the PB motor branch (PBMB) to the median nerve thenar motor branch (TMB), in order to allow for early restoration of thumb palmar abduction and opposition, through a preliminary cadaveric study.

METHODS

Twenty-five cadaver upper limbs were dissected under magnification. The length of the PBMB and TMB, and their origin were recorded. Nerve transfer from PBMB to TMB was conducted, and evaluated on 2 parameters: surgical feasibility, and distance from the coaptation site to the recipient nerve muscle entry point. The PBMB and TMB were harvested, fixated in formalin, then embedded in paraffin. They were sectioned transversely, and stained with a combination of hematoxylin-eosin and Luxol fast blue. Myelinated axons were counted in each specimen and the donor-to-recipient axon ratio was recorded.

RESULTS

The PBMB was constant and originated from the ulnar digital nerve of the little finger in all cases. The transfer from PBMB to TMB was feasible in all cases. Mean myelinated axon counts of PBMB and TMB were 253±142 and 356±198, respectively (p=0.06). The donor-to-recipient axon ratio was 1:1.41. The mean distance from coaptation of the PBMB to the recipient thenar muscles was 23.1±3.0mm.

CONCLUSIONS

Based on our results, PBMB to TMB transfer is feasible. The PBMB has the advantage over other distal nerve transfer donors to be constant and superficial, allowing for an easier harvest. Moreover, this procedure does not sacrifice any intrinsic function of the hand, and the proximity of the PBMB with the carpal tunnel allows for a single incision procedure. Therefore, early restoration of the median innervated thenar muscles may be feasible by the PBMB to TMB transfer in cases of high median nerve lesions.

LEVEL OF EVIDENCE

IV.

Biomechanical Evaluation of Opponensplasty for Low Median Palsy: A Cadaver Study

Purpose

Impaired thumb opposition associated with advanced carpal tunnel syndrome may be treated by opponensplasty at the time of open carpal tunnel release. However, it is unclear which opponensplasty technique achieves the greatest functional improvement. This study aimed to compare the biomechanics of thumb opposition after Camitz, modified Camitz, and Burkhalter opponensplasties.

Methods

We used 6 fresh-frozen cadaveric arms. Each procedure was reproduced on each arm: Camitz opponensplasty, modified Camitz opponensplasty involving palmaris longus transfer routed around the flexor carpi ulnaris pulley, and Burkhalter opponensplasty. Arms were fixed with the wrist in 0° flexion and the forearm in neutral pronosupination, and sensors were placed on the thumbnail, radial styloid, and dorsal aspect of the second metacarpal head. The donor tendon was pulled using a mechanical testing machine with a maximum force of 25 N, and the locations of the sensors in thumb opposition were recorded. The first web space and thumb pronation angles were measured for each procedure and compared.

Results

The mean first web space and pronation angles produced using 25 N were 55° and 20°, 57° and 26°, and 53° and 29° for the Camitz, modified Camitz, and Burkhalter opponensplasties, respectively. The first web space angle was significantly larger after modified Camitz opponensplasty compared with Burkhalter opponensplasty with 25 N loading. Camitz opponensplasty resulted in a significantly smaller pronation angle compared with modified Camitz and Burkhalter opponensplasties with 25 N loading.

Conclusions

The modified Camitz opponensplasty produces a relatively balanced biomechanical outcome in terms of the first web space and pronation angles. Conversely, Burkhalter opponensplasty has been shown to be a favorable technique for improving pronation.

Clinical relevance

Modified Camitz opponensplasty with a pulley offers effective restoration of thumb opposition, including pronation. On the other hand, Burkhalter opponensplasty represents a suitable option not only for patients with high median palsy and injury to the palmar aponeurosis but also for those who require improved pronation.

Upper Extremity Tendon Transfers: A Brief Review of History, Common Applications, and Technical Tips

Background  Tendon transfer in the upper extremity represents a powerful tool in the armamentarium of a reconstructive surgeon in the setting of irreparable nerve injury or the anatomic loss of key portions of the muscle-tendon unit. The concept uses the redundancy/expendability of tendons by utilizing a nonessential tendon to restore the function of a lost or nonfunctional muscle-tendon unit of the upper extremity. This article does not aim to perform a comprehensive review of tendon transfers. Instead it is meant to familiarize the reader with salient historical features, common applications in the upper limb, and provide the reader with some technical tips, which may facilitate a successful tendon transfer.

Learning Objectives  (1) Familiarize the reader with some aspects of tendon transfer history. (2) Identify principles of tendon transfers. (3) Identify important preoperative considerations. (4) Understand the physiology of the muscle-tendon unit and the Blix curve. (5) Identify strategies for setting tension during a tendon transfer and rehabilitation strategies.

Design  This study was designed to review the relevant current literature and provide an expert opinion.

Conclusions  Tendon transfers have evolved from polio to tetraplegia to war and represent an extremely powerful technique to correct neurologic and musculotendinous deficits in a variety of patients affected by trauma, peripheral nerve palsies, cerebral palsy, stroke, and inflammatory arthritis. In the contemporary setting, these very same principles have also been very successfully applied to vascularized composite allotransplantation in the upper limb.

Functional evaluation of early tendon transfer for thumb opposition in median nerve palsy

BACKGROUND

There is paucity of literature on early tendon transfer in surgical rehabilitation of hands with median nerve injuries. Since the single most important functional deficit in median nerve palsy is the loss of thumb opposition, we evaluated the results of early tendon transfer in restoration of thumb opposition.

METHODS

This prospective study involved 10 cases of isolated median nerve paralysis (axonotmesis or neurotmesis) that underwent early tendon transfer for restoration of thumb opposition. A pre- and post-operative evaluation in terms of power and precision grip strength and range of opposition of thumb was done. Median nerve exploration was performed in 4 cases and was supplemented by a tendon transfer for thumb opposition. The extensor indicis proprius (EIP) opponensplasty was performed in nine out of ten cases. In one case where the patient had scarring over the EIP tendon, palmaris longus (PL) opponensplasty was performed.

RESULTS

The median age at injury was 29 years (range; 8 years-57 years). Minimum period of follow-up was 6 months. Six patients who underwent EIP transfer had excellent opposition while 3 had good opposition. The patient, in whom PL opponensplasty was done, had an excellent opposition. The median time for return to work was 2.75 months.There was significant improvement in the power grip and all three types of precision grip at 6 months follow-up. The percentage deficit in the affected hand compared to the normal hand was significantly reduced. There was no case of tendon pull out in our study, nor did any of our patients have an extensor lag following EIP transfer.

CONCLUSION

Early tendon transfer has a unique role in the management of median nerve palsy hand and we suggest this procedure should be considered in both high and low lesions.

Outcomes of Endoscopic Carpal Tunnel Release With Ring Finger Flexor Digitorum Superficialis Opponensplasty in Severe Carpal Tunnel Syndrome

PURPOSE

To evaluate the outcomes of endoscopic CTR with ring finger flexor digitorum superficialis (FDS) opponensplasty for the treatment of patients with severe carpal tunnel syndrome (CTS).

METHODS

We prospectively studied 52 patients who were graded as having severe CTS by physical examination and electrodiagnostic studies and who underwent endoscopic CTR-ring finger FDS opponensplasty. Preoperative and postoperative data were collected for active perpendicular thumb abduction; Kapandji score for thumb opposition; grip, key, and tip pinch strength; Medical Research Council score on sensory and motor recovery; Semmes-Weinstein monofilament testing; thenar muscle bulk recovery; and work status.

RESULTS

Follow-up was 17.5 months on average (range, 7-34 months). Thumb abduction improved significantly from 13.2° (±4.6°) before surgery to 61.7° (±6.4°) afterward. Mean thumb opposition (as measured by Kapandji score) improved significantly from grade 1.5 to 8.7. Tip pinch strength significantly improved from 38.9% to 72.9% of the contralateral side. Medical Research Council scores improved to S3+ and S4 in 85% of patients and to M4 and M5 in 96% of patients. Sensory threshold recovery to 3.61 and 4.31 monofilament occurred in 85% of patients. We observed thenar muscle bulk recovery in 51.9% of patients. Time to return to work was 5 weeks after surgery, on average. Two patients reported scar pain, 2 reported pillar pain, and we found ring finger proximal interphalangeal joint contracture in 3.

CONCLUSIONS

Endoscopic CTR with FDS opponensplasty provides satisfactory outcomes of improved thumb abduction and opposition, sensory and motor recovery, and early return to work in patients with severe CTS.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Tendon Transfers for Peripheral Nerve Palsies

Recovery after an upper extremity peripheral nerve injury varies depending on multiple factors. In patients with poor functional recovery, tendon transfers may be indicated. The decision to perform an early tendon transfer at the time of nerve repair or before expected reinnervation is considered on a case-by-case basis. There are a multitude of potential tendon transfer options, the choices of which depend on remaining function, specific deficits, and surgeon experience and preferences. A thoughtful approach to reconstruction can lead to a substantial functional improvement with minimal donor site morbidity.

Functional pectoralis minor myocutaneous flap transplantation for reconstruction of thumb opposition: An anatomic study with clinical applications

OBJECTIVE

To develop a myocutaneous flap for reconstruction of thumb opposition function in patients with loss of the thenar muscles and skin.

METHODS

An anatomic experiment on the dimensions of the pectoralis minor muscle and its neurovascular supply in 10 adult human cadavers was conducted to evaluate the feasibility of microsurgical transplantation using part of the muscle for thumb opposition reconstruction. Based on these results, we performed surgical thenar reconstruction with a pectoralis minor myocutaneous flap in seven patients (34.7 ± 9.8 years of age) from December 2007 to October 2010.

RESULTS

The transferred muscle was reinnervated with the third lumbrical branch of the ulnar nerve. Six to twelve months after the surgery, follow-up assessment showed that all patients had recovered functional opposition of the carpometacarpal joint with survival of the skin and a muscle power of M4 to M5.

CONCLUSION

Our results support the use of this new technique for thenar and opposition reconstruction in patients with severe loss of the thenar muscles and skin and damage to the median nerve and who wish to improve the appearance of the thenar eminence.

Pronator teres opposition transfer through Guyon's canal: a technique

Restoration of thumb opposition in the setting of peripheral nerve or brachial plexus injury is critical to upper limb function. When commonly utilized opposition donors are unavailable for clinical use, the pronator teres represents a good and reliable tendon for restoration of thumb opposition. Here we describe our rational and technique for pronator teres opposition transfer using Guyon's canal as a pulley.

Transfer of the flexor carpi radialis to the abductor pollicis brevis tendon for the restoration of tip-pinch in severe carpal tunnel syndrome

In patients with severe thenar atrophy secondary to carpal tunnel syndrome, we hypothesize that following open carpal tunnel release, concomitant transfer of the abductor pollicis brevis (APB) origin to the flexor carpi radialis (FCR) tendon will lead to improved patient function restoring palmar abduction and thumb opposition. We evaluated 14 patients through questionnaires and seven patients through additional physical examination (thumb range of motion, ability to tip pinch, grip/pinch strength) for a mean follow-up of 2.8 years. All patients showed evidence of palmar abduction with 71% demonstrating the ability to oppose the thumb to the tip and base of the small finger. The transfer of the APB origin to the FCR tendon can restore thumb abduction and opposition for thenar paralysis secondary to severe carpal tunnel syndrome. Patients experience good functional outcomes with the majority experiencing restored thumb opposition.

Extensor indicis proprius opponensplasty - the burkhalter revisited

The Extensor Indicis Proprius Opponensplasty although not widely exercised by hand surgeons has previously been shown to produce good results in the restoration of thumb opposition. Over the last 5 years the Extensor Indicis Proprius was selectively used in cases where the Flexor Digitorum Superficialis was unavailable or inappropriate. In a small case series operating on a total of six male patients with an average age of 32 and follow up of 12 months we have been impressed by the functional outcome and lack of donor site morbidity. The Extensor Indicis Proprius is expendable with minimal donor site morbidity, is of sufficient length and has an optimal line of pull to provide a superior mechanical advantage and a favourable torque when compared to Flexor Digitorum Superficialis.

Extensor indicis proprius opponensplasty for isolated traumatic low median nerve palsy: A case series

INTRODUCTION

The standard opponensplasty for isolated low median nerve palsy in nonleprosy patients uses the flexor digitorum superficialis of the ring finger.

OBJECTIVE

To report the results of extensor indicis proprius (EIP) opponensplasty in 15 consecutive nonleprosy patients with isolated traumatic low median nerve palsy.

METHODS

A retrospective study of the author's cases of EIP opponensplasty for isolated traumatic median nerve palsy over the past 15 years was conducted. The author used the EIP to restore thumb opposition in all cases of isolated median nerve palsies when the following conditions were present: protective sensibility in the median nerve distribution; normal power of EIP; supple hands; and full passive range of opposition with no contracture of the first web space. There were a total of 15 patients with a mean age of 30 years (range 20 to 45 years). They all had traumatic isolated low median nerve palsy with recovery of at least protective sensation and no recovery of opposition. The tendon was harvested just proximal to the extensor expansion, the flexor carpi ulnaris was used as a pulley and the insertion was to the tendon of abductor pollicis brevis.

RESULTS

There were no postoperative complications or extension lag of the donor finger. Using previously published criteria, 12 patients experienced excellent results while the remaining three had a good result.

CONCLUSIONS

In nonleprosy patients with isolated traumatic low median nerve palsy, the results of this transfer are consistent and there is no need to harvest the EIP tendon distal to the extensor expansion because a single insertion to the abductor pollicis brevis is sufficient.

Tendon transfers for radial, median, and ulnar nerve palsy

Tendon transfers are used to restore balance and function to a paralyzed, injured, or absent neuromuscular-motor unit. In general, tendon transfer is indicated for restoration of muscle function after peripheral nerve injury, injury to the brachial plexus or spinal cord, or irreparable injury to tendon or muscle. The goal is to improve the balance of a neurologically impaired hand. In the upper extremity, tendon transfers are most commonly used to restore function following injury to the radial, median, and ulnar nerves. An understanding of the general principles of tendon transfer is important to maximize the outcome.

Tendon versus nerve transfers in elbow, wrist, and hand reconstruction: a literature review

Upper extremity reconstruction forces the surgeon to chose between several available procedures, among them tendon and nerve transfer. Few guidelines exist to assist the surgeon in this regard, and the authors, therefore, undertook a retrospective review of case series describing tendon and nerve transfer. The authors discovered a scarcity of robust reporting, particularly in regard to tendon transfer, making an objective comparison between the two techniques difficult. Tendon transfers are popular and familiar. Nerve transfers promise distinct advantages; however, excellent evidence of their superiority is lacking.

Functional pectoralis minor muscle flap transplantation for reconstruction of thumb opposition: an anatomic study and clinical applications

In this report, we present the results of an anatomic study on the dimensions of the pectoralis minor muscle and its neurovascular supply in 10 adult human cadavers, in attempt to evaluate the feasibility of microsurgical transplantation of a part of the muscle for thumb opposition reconstruction. A series of five patients consequently underwent thenar reconstruction with the pectoralis minor muscle flap from December 2004 to October 2006. The transferred muscle was reinnervated with the third lumbrical branch of the ulnar nerve. Follow-up assessment showed that the patients recovered functional opposition of carpometacarpal joint with 24 degrees of pronation, and a muscle power with M4 to M5. All patients were satisfied with the appearance of reconstructed thenar eminence. We recommend this new technique for thenar and opposition reconstruction in patients who have severe loss of thenar muscles, injury to the median nerve, and wish to improve the appearance of thenar eminence.

Unusual complication of an opposition tendon transfer at the wrist: ulnar nerve compression syndrome

Restoration of thumb opposition by tendon transfer may be necessary in cases of severe thenar atrophy caused by long-standing carpal tunnel syndrome. Routing the extensor indicis proprius transfer subcutaneously around the ulna to reanimate thumb opposition is an accepted procedure and is considered safe. Ulnar nerve compression leading to palsy is possible, however, as shown in the patient presented. Neurolysis failed to improve the palsy. Rerouting of the transfer deep to the ulnar nerve was necessary to treat the iatrogenic condition. Possible nerve compression should be kept in mind when planning a tendon transfer around the ulnar side of the forearm or carpus and when following up with the patient. Early intervention is necessary to prevent permanent sequelae.

Assessment of results of opponensplasty

One hundred and fifty-six opponensplasties carried out on 115 patients at Anandaban Hospital between 1987 and 1997 were reviewed. In most cases a flexor digitalis superficialis opponensplasty was performed. The outcome was assessed by measuring the finger to which the thumb could obtain a pinch grip, the gap between the thumb and little metacarpophalangeal joints, and the satisfaction of the patient. The objective assessments demonstrated excellent or good results in 89%. Good or fair patient satisfaction was obtained in 93%. Early complications were seen in seven cases (4%). Objective measurements of outcome and patient satisfaction were not always in agreement, indicating that objective measures do not adequately assess the success of surgery from the patient's perspective. We thus conclude that subjective measurements of results are an important measure of success and should be included in the evaluation of surgical results.

Evaluation of the results of opponensplasty

A comprehensive evaluation system for opponensplasties has been described taking into consideration several variables. Each variable has been assigned a score depending upon its significance in the normal hand. The total score of the hand is used for grading the results as good, fair and poor.

Index finger extension and strength after extensor indicis proprius transfer

We reviewed the long-term morbidity of the donor index finger following extensor indicis proprius tendon transfer in 34 patients with an average follow-up period of 8 years. An extension lag of the donor index was found to present in 24 patients. In all patients a reduced extension strength of the donor index finger was noticed, either measured dependently (with concurrent long finger extension) or independently (without long finger extension). Despite these findings, 30 of the patients described no limitations in their daily life activities. In nearly all patients the dependent extension strength was superior to the independent extension strength. To prevent an extension lag, the surgeon should avoid surgical trauma to the dorsal aponeurosis ("hood") by sectioning the index tendon proximal to the hood.

Opponensplasty by extensor indicis and flexor digitorum superficialis tendon transfer

From 1977 to 1988, 166 patients with median nerve paralysis of varied aetiology underwent opponensplasty. In 50 of these the extensor indicis was used, and in 116 the flexor digitorum superficialis of the ring finger. An analysis of these hands showed that the EI opponensplasty was best in supple hands and FDS opponensplasty was more suitable for less pliable hands. There were fewer complications seen after FDS opponensplasty if the detachment of the donor tendon was done through a volar oblique incision rather than the conventional lateral incision.