Early dynamic motion versus postoperative immobilization in patients with extensor indicis proprius transfer to restore thumb extension: a prospective randomized study

Wide-Awake Approach for Flexor Digitorum Superficialis Tendon Transfer Followed by Early Active Mobilization

Background The standard clinical practice to treat closed ruptures of the flexor digitorum profundus (FDP) tendons includes free tendon grafting; however, it is not suitable when the muscle amplitude of the ruptured FDP is not sufficient. We report outcomes of six patients who underwent flexor digitorum superficialis (FDS) tendon transfer of the ring finger using the wide-awake approach to repair the closed rupture of the FDP tendon of the little finger in zone 3 or 4. Methods The patients were identified by reviewing our institutional billing records from January 2012 to October 2019 for the International Classification of Disease 10 code M66.3 that describes the diagnosis as "spontaneous rupture of flexor tendons." Results The patients comprised two men and four women with an average age of 72.2 years (standard deviation [SD], 8.4 years). All patients were hospitalized after surgery to undergo early active mobilization. The average total active motion at the final evaluation was 201.8° (range: 85-248°). According to Strickland's criteria, outcomes were excellent for two, good for three, and poor for one patient. No patients complained about the ring finger. Conclusion These results suggest that FDS tendon transfer is recommended when the muscle amplitude of the ruptured FDP is insufficient. We believe that the wide-awake approach and early active mobilization may contribute to satisfactory outcomes.

Supernumerary extensor pollicis longus tendon masking an extensor pollicis longus rupture following non-surgical treatment of a distal radius fracture

Extensor pollicis longus tendon pathology is a recognised complication following non-surgical treatment of non-displaced distal radius fractures. Tendon entrapment typically presents with pain, but preservation of thumb retropulsion during complete rupture results in loss of active thumb retropulsion and tenodesis effect. We present the case of a 52-year-old woman who developed extensor pollicis longus tendon entrapment with full active thumb extension following a non-displaced distal radius fracture. During her elective third dorsal compartment release, the extensor pollicis longus tendon was found to be completely ruptured and a rare supernumerary extensor pollicis longus tendon was found emerging from the fourth dorsal compartment. Gentle traction of this tendon resulted in thumb interphalangeal joint extension and simultaneous index finger metacarpophalangeal joint extension. An extensor indicis proprius to extensor pollicis longus tendon transfer was performed. At her final 6-month follow-up, she had painless full active thumb motion comparable to her contralateral side.

[Simplified active motion protocol following Extensor indicis to Extensor pollicis longus tendon transfer using a side-to-side suture]

BACKGROUND

Ruptures of the Extensor pollicis longus tendon are commonly treated by Extensor indicis transfer using Pulvertaft suture technique. Current literature does not yet give evidence for a preferable post-operative therapy protocol. A side-to-side suture technique is significantly stronger than the Pulvertaft repair technique and therefore allows an immediate active postoperative treatment. We present a new postoperative protocol, which is simple, fast and safe, and should make treatment easier for patients and therapists.

PATIENTS AND METHODS

We treated 10 patients with a transfer of the extensor indicis tendon between 07/2016 and 08/2017 according to the new active protocol. Patients were seen for follow-up at 2, 4 and 8 weeks. Thumb range of motion, pinch and grip strength as well as subjective parameters like pain and general satisfaction were measured.

RESULTS

All patients regained full function of their thumbs with retropulsion over the level of the palm at 4 weeks. Median pinch strength was 89 % and grip strength 74 % of the contralateral side at week 4. There was no secondary rupture of the reconstructed tendon over a one-year period. All patients were satisfied with the result of the operation and the protocol.

CONCLUSION

Our new active postoperative protocol for extensor indicis transfer using a side-to-side suture has proven to be safe and less strenuous for patients and therapists and has been established as standard treatment in our clinic.

Feedback-guided exercises performed on a tablet touchscreen improve return to work, function, strength and healthcare usage more than an exercise program prescribed on paper for people with wrist, hand or finger injuries: a randomised trial

QUESTION

In people with bone and soft tissue injuries of the wrist, hand and/or fingers, do feedback-guided exercises performed on a tablet touchscreen hasten return to work, reduce healthcare usage and improve clinical recovery more than a home exercise program prescribed on paper?

DESIGN

Randomised, parallel-group trial with concealed allocation, assessor blinding and intention-to-treat analysis.

PARTICIPANTS

Seventy-four workers with limited functional ability due to bone and soft tissue injuries of the wrist, hand and/or fingers.

INTERVENTION

Participants in the experimental and control groups received the same in-patient physiotherapy and occupational therapy. Participants in the experimental group received a home exercise program using the ReHand tablet application, which guides exercises performed on a tablet touchscreen with feedback, monitoring and progression. Participants in the control group were prescribed an evidence-based home exercise program on paper.

OUTCOME MEASURES

The primary outcome was the time taken to return to work. Secondary outcomes included: healthcare usage (number of clinical appointments); and functional ability, pain intensity, and grip and pinch strength 2 and 4 weeks after randomisation.

RESULTS

Compared with the control group, the experimental group: returned to work sooner (MD -18 days, 95% CI -33 to -3); required fewer physiotherapy sessions (MD -7.4, 95% CI -13.1 to -1.6), rehabilitation consultations (MD -1.9, 95% CI -3.6 to 0.3) and plastic surgery consultations (MD -3.6, 95% CI -6.3 to -0.9); and had better short-term recovery of functional ability and pinch strength.

CONCLUSION

In people with bone and soft-tissue injuries of the wrist, hand and/or fingers, prescribing a feedback-guided home exercise program using a tablet-based application instead of a conventional program on paper hastened return to work and improved the short-term recovery of functional ability and pinch strength, while reducing the number of required healthcare appointments.

TRIAL REGISTRATION

ACTRN12619000344190.

Extensor indicis transfer versus palmaris longus transplantation in reconstruction of extensor pollicis longus tendon: a protocol for a systematic review

This review will provide an overview of published data comparing transposition of the extensor indicis pollicis (EIP) tendon and palmaris longus (PL) tendon grafting in thumb extension reconstruction following loss of the extensor pollicis longus (EPL) tendon function. We will consider all studies comparing EIP and PL utilized to reconstruct thumb extension after injury/rupture of the EPL tendon. Only studies published in the English and German literature will be included. A systematic literature research will be performed across relevant health databases including the Cochrane Library, MEDLINE, and Google Scholar using the following keywords: ((extensor pollicis longus) OR EPL) AND ((extensor indicis) OR EIP OR (tendon transposition)) AND ((palmaris longus) OR (free tendon graft) OR (tendon transplantation)). Central tendencies will be reported in terms of means and standard deviations where necessary. If not reported, the standard deviation will be calculated from the standard error of the mean. Risk ratios will be calculated where possible. All calculations will be performed with a 95% confidence interval. Statistical significance will be set at P < 0.05. Adjusted effect estimates will be analyzed in preference to the unadjusted estimates, using inverse-variance weighted average. Pooled estimates will only be presented after consideration of both clinical and methodological heterogeneity of included studies. The review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. SYSTEMATIC REVIEW REGISTRATION: The protocol was registered on PROSPERO CRD42019135735: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=135735.

A new technique to determine the tension in extensor pollicis longus reconstruction

We present an original technique for determining the tension of the extensor pollicis longus tendon after reconstruction. We treated 20 patients using this technique for an extensor pollicis longus tendon graft or extensor indicis tendon transfer and reviewed the results. The tension of the reconstructed extensor pollicis longus was adjusted so that the centre of the distal edge of the thumbnail was elevated 2 cm above the operation table. The mean retropositional distance of the treated thumbs was 1.2 cm less than the contralateral thumbs. The mean total active motion of the thumb was 90%. This technique resulted in satisfactory thumb function. Level of evidence: IV.

The Relationships Between Surface Measurements and Underlying Tendon Autograft Length for Upper Extremity Reconstructive Surgery

PURPOSE

The availability of tendon grafts is an important consideration for successful upper extremity reconstructive surgery, including flexor or extensor tendon reconstructions, tendon transfers, and ligament reconstructions. Graft selection is based on availability, expendability, ease of harvest, and length. Given variations in patient height and extremity length, existing average values may provide suboptimal insight into actual tendon lengths available. The purpose of this study is, therefore, to pursue a method of estimating available donor tendon lengths based on easily measured anatomical surface landmarks.

METHODS

Thirty cadaveric upper and lower extremity limbs were dissected and the length of commonly harvested tendon grafts including the palmaris longus, extensor indicis proprius, extensor digiti minimi, plantaris, and second long toe extensor was measured. Surface forearm length (from finger tip to cubital fossa) and surface fibular length (from lateral malleolus to fibular head) were also measured. Correlations between surface measurements and underlying tendon lengths were analyzed, and linear models were generated that predicted tendon length as a function of surface measurements.

RESULTS

Surface measurements were correlated with underlying tendon length (R = 0.46 - 0.66). Linear models could predict tendon lengths based on surface measurements. A ratio of donor tendon length compared with the limb segment measured was established for each tendon and can be applied to estimate donor tendon length. For the upper extremity tendons, the multipliers for the palmaris longus, extensor indicis proprius, and extensor digiti minimi were 0.51, 0.20, and 0.18, respectively. Lower extremity tendon ratios for the plantaris and extensor digitorum longus were 0.69 and 0.60, respectively.

CONCLUSIONS

Although length of available donor tendon can be a limiting variable at the time of surgery, surgeons may be better able to estimate underlying tendon lengths using easily obtained superficial measurements.

CLINICAL RELEVANCE

Information obtained from these cadaveric measurements may aid in preoperative planning in hand and upper extremity surgery.

Functional Recovery Following an L-Lengthening Local Tendon Flap for Extensor Pollicis Longus Chronic Ruptures

PURPOSE

Extensor indicis proprius tendon transfer has been considered the reference standard technique for extensor pollicis longus (EPL) chronic ruptures, but relevant complications have been reported. We describe a new reconstructive technique for chronic EPL ruptures and assess functional recovery after this procedure.

METHODS

We observed 31 patients who fulfilled inclusion criteria an average of 6.8 months after treatment. An L-shaped local tendon flap was prepared by making a transverse incision to the middle of the tendon and then longitudinally toward the end of one of the tendon stumps. Absorbable suture was used to coapt the free ends and as a reinforcement suture. We used the total active motion scale to classify results.

RESULTS

Total active motion in patients who completed the follow-up period was 89% of the normal side; 97% of patients returned to their previous employment. Surgical complications were infrequent and only one patient (3%) required surgery for extensor tendon adhesions.

CONCLUSIONS

This technique permits reconstruction of the EPL tendon without the need for a tendon graft or tendon transfer.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Transfer of either index finger extensor tendon to the extensor pollicis longus tendon

BACKGROUND

Extensor pollicis longus (EPL) tendon ruptures have been treated succesfully with the transfer of the extensor indicis proprius (EIP) tendon. Situations exist in which, due to intraoperative observations, another tendon transfer may be considered preferable to the standard EIP transfer method.

OBJECTIVES

To determine whether transfer of the extensor digitorum communis II (EDC II) tendon from the index finger to the EPL tendon, leaving the EIP tendon to the index finger intact, would serve as an equally efficient transfer and not adversely affect the function of the hand.

METHODS

Two patients who had the EDC II tendon transferred to the ruptured EPL tendon, and two patients who had the EIP tendon transferred, were retrospectively reviewed. In each transfer type, one patient had suffered an EPL tendon rupture after a Colles' fracture, and the other had rheumatoid arthritis. The rupture occurred on the non-dominant side in one patient in each transfer type. Each patient was examined and subjected to range of motion and power testing at least one year following surgery.

RESULTS

All four patients showed a minimal extension lag with the lift off test, but there was no noticeable difference in range of motion, pinch grip and hand grip strength between the transfer types. Both EDC II transfer patients demonstrated an 8° to 15° loss of thumb interphalangeal joint flexion compared with the unoperated side; EIP transfer patients demonstrated less than a 5° loss. Three patients demonstrated a minor extension lag in the index finger and middle finger. Extension power of the thumb and index finger in all patients varied with wrist flexion and extension and ranged from 50% to 150% of the unoperated side.

CONCLUSIONS

These case reports suggest that either index finger tendon may be successfully transferred in EPL tendon ruptures.

The effectiveness of early mobilization after tendon transfers in the hand: a systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION

Over the past decade, early mobilization (initiated within a week) has become an increasing trend in postoperative rehabilitation after tendon transfer surgery in the hand. However, there are no published reviews summarizing the effectiveness of early mobilization protocols in comparison with conventional immobilization in tendon transfer rehabilitation.

PURPOSE

To systematically review available evidence on the effectiveness of early mobilization protocols to conventional immobilization protocol after tendon transfers in the hand.

METHODS

A literature search of the Cochrane Library, PubMed, PEDro, EMBASE, and CINAHL databases was conducted (1980 to date). Randomized controlled trials (RCTs), case-control, and other study designs were included. Six articles were eligible for inclusion in the analysis (five RCTs and one retrospective study) and 260 articles that did not meet inclusion criteria were excluded. Level of evidence (Center for Evidence-based Medicine) and methodological quality (Structured Effectiveness Quality Evaluation Scale [SEQES] score) of each study were assessed by two independent reviewers.

RESULTS

This review found three high quality trials (SEQES score: 35-43 of 48), with level 1b and 2b evidence, supporting early mobilization of tendon transfers. The literature reports reduced total cost, total rehabilitation time, and demonstrates that early mobilization is a safe approach with no incidence of tendon ruptures or insertion pull out. In the initial phase of rehabilitation, outcomes like range of motion, grip strength, pinch strength, total active motion of digits, deformity correction, and tendon transfer integration were significantly superior with early mobilization compared with immobilization. However, in the long term, these outcomes were similar in both the groups, suggesting that early mobilization protocol improves hand function in the initial phase of rehabilitation (four weeks) and the long-term results (two months to one year) are equivalent to immobilization.

CONCLUSIONS

Based on a limited number of small studies, there is evidence of short-term benefit for early mobilization, but inconclusive findings for longer-term outcomes. Until the body of evidence increases, clinicians should consider the clinical context, their experience in optimizing patient outcomes after surgery, and the patient's preferences when selecting between early and late mobilization after tendon transfer.

LEVEL OF EVIDENCE

2a.

A systematic review of rehabilitation protocols following surgical repair of the extensor pollicis longus

Introduction

The goal of this systematic review was to determine which rehabilitation protocol (static, dynamic or early active) yields the best outcomes following repair of the extensor pollicis longus (EPL) tendon in the following domains: total active motion (TAM), grip strength and range of motion.

Methods

A comprehensive and systematic literature search was run. The retrieved abstracts and titles were screened by two independent reviewers. Rehabilitation protocols were classified as static, dynamic or early active. Methodological quality of included randomized controlled trials and cohort studies were assessed using the SIGN50 scale.

Results

Fifteen articles were included in the final analysis ( κ = 0.8). From this total, five studies employed static splinting, 12 dynamic splinting and two early active splinting. Static splinting yielded ‘excellent’/‘good’ results ranging from 50% (minimum) to 60% (maximum) on the TAM classification system and a weighted mean TAM of 73.0 ± 24.0° (range 58.75–85°). Dynamic splinting studies demonstrated ‘excellent’/‘good’ results ranging from 64.4% (minimum) to 98% (maximum) and a weighted mean TAM of 111.2 ± 11.7° (range 89–134°) ( P < 0.001 and mean difference of 38.2 (95% confidence interval: 32.2–44.2). In one study, early active motion resulted in 83% of patients having ‘excellent’/‘good’ ratings.

Discussion

The available level II–IV evidence suggests better outcomes when using dynamic splinting over static splinting for rehabilitation of the EPL tendon repair. Further evidence is required to clinically confirm the differences between early active and dynamic rehabilitation protocols.

Economic impact of hand and wrist injuries: health-care costs and productivity costs in a population-based study

BACKGROUND

Injuries to the hand and wrist account for approximately 20% of patient visits to emergency departments and may impose a large economic burden. The purpose of this study was to estimate the total health-care costs and productivity costs of injuries to the hand and wrist and to compare them with other important injury groups in a nationwide study.

METHODS

Data were retrieved from the Dutch Injury Surveillance System, from the National Hospital Discharge Registry, and from a patient follow-up survey conducted between 2007 and 2008. Injury incidence, health-care costs, and productivity costs (due to absenteeism) were calculated by age group, sex, and different subgroups of injuries. An incidence-based cost model was used to estimate the health-care costs of injuries. Follow-up data on return to work rates were incorporated into the absenteeism model for estimating the productivity costs.

RESULTS

Hand and wrist injuries annually account for $740 million (in U.S. dollars) and rank first in the order of most expensive injury types, before knee and lower limb fractures ($562 million), hip fractures ($532 million), and skull-brain injury ($355 million). Productivity costs contributed more to the total costs of hand and wrist injuries (56%) than did direct health-care costs. Within the overall group of hand and wrist injuries, hand and finger fractures are the most expensive group ($278 million), largely due to high productivity costs in the age group of twenty to sixty-four years ($192 million).

CONCLUSIONS

Hand and wrist injuries not only constitute a substantial part of all treated injuries but also represent a considerable economic burden, with both high health-care and productivity costs. Hand and wrist injuries should be a priority area for research in trauma care, and further research could help to reduce the cost of these injuries, both to the health-care system and to society.

Retrospective review of hand-based splinting for zone II extensor pollicis longus tendon repairs using an early active motion rehabilitation regimen

Introduction

Forearm-based splints have been traditionally used for extensor pollicis longus (EPL) tendon repairs for zones T II–T V (T is used to represent thumb extensor tendon zones). Limited literature exists on hand-based splinting in the rehabilitation of zone T II EPL tendon repairs. This retrospective review of five case studies highlights the anatomical justification and the outcome of rehabilitation of zone T II EPL surgical repairs using a static hand-based thumb extension splint.

Methods

In this study, five patients were retrospectively reviewed. All patients attended hand therapy for initial treatment within three days postoperatively. The postoperative interphalangeal joint mobilization regimen utilized in this study was early active motion (EAM). Outcomes measured in the study were reliable and valid, including goniometry measurement at week 4, week 6 and week 8 postoperatively for range of motion, total active motion (TAM), Dargan's criteria assessing extensor lag and White's assessment of interphalangeal joint range of motion.

Results

The results demonstrated that a hand-based splint did not create undue stress on the EPL tendon repair, as there was no incidence of rupture. Hyperextension of EPL was within 8° compared with the non-injured thumb. ‘Excellent’ and ‘good’ categories were achieved when applying TAM criteria, White's assessment and Dargan's criteria.

Conclusion

A hand-based splint with an EAM regimen is a viable treatment option for zone T II EPL surgical repairs instead of a long forearm-based splint. Further research is warranted with a larger sample and using a control group.

Early active motion versus immobilization after tendon transfer for foot drop deformity: a randomized clinical trial

BACKGROUND

Immobilization after tendon transfers has been the conventional postoperative management. Several recent studies suggest early mobilization does not increase tendon pullout.

QUESTIONS/PURPOSES

To confirm those studies we determined whether when compared with immobilization early active mobilization after a tendon transfer for foot-drop correction would (1) have a similar low rate of tendon insertion pullout, (2) reduce rehabilitation time, and (3) result in similar functional outcomes (active ankle dorsiflexion, plantar flexion, ROM, walking ability, Stanmore score, and resolution of functional problems.

METHODS

We randomized 24 patients with surgically corrected foot-drop deformities to postoperative treatment with early mobilization with active motion at 5 days (n = 13) or 4 weeks of immobilization with active motion at 29 days (n = 11). In both groups, the tibialis posterior tendon was transferred to the extensor hallucis longus and extensors digitorum communis for foot-drop correction. Rehabilitation time was defined as the time from surgery until discharge from rehabilitation with independent walking. The minimum followup was 16 months (mean, 19 months; range, 16-38 months) in both groups.

RESULTS

We observed no case of tendon pullout in either group. Rehabilitation time in the mobilized group was reduced by an average of 15 days. The various functional outcomes were similar in the two groups.

CONCLUSION

In patients with Hansen's disease, an early active mobilization protocol for foot-drop correction has no added risk of tendon pullout and provides similar functional outcomes compared with immobilization. Early mobilization had the advantage of earlier restoration of independent walking.

LEVEL OF EVIDENCE

Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

A randomized clinical trial comparing immediate active motion with immobilization after tendon transfer for claw deformity

PURPOSE

Immobilization after tendon transfers has been the conventional postoperative management. A recent study indicated beneficial effects of an immediate active motion protocol (IAMP) after tendon transfer for claw deformity correction compared with effects in a historical cohort. In this study, we further tested this hypothesis in a randomized clinical trial comparing the effectiveness of the IAMP with that of conventional immobilization.

METHODS

Fifty supple claw hand deformities were randomized postoperatively into 2 equal groups for IAMP and immobilization. Therapy began on the second postoperative day for the IAMP group and on the twenty-second postoperative day for the immobilization group. The primary outcome measures were deformity correction, active range of motion of digits, tendon transfer insertion pullout, and time until discharge from rehabilitation. Secondary outcome measures were swelling, pain, hand strength, and dexterity. Both groups were compared at discharge from rehabilitation and at the last clinical follow-up (at least 1 year postoperatively).

RESULTS

Assessments were available for all 50 patients at discharge and for 23 patients in each group at follow-up. The average follow-up was 18 months for the IAMP group and 17 months for the immobilization group. Deformity correction, range of motion, swelling, dexterity, and hand strength were similar for both groups at discharge and a follow-up. There was no evidence of tendon insertion pullout in any patient of either group. Relief of pain was achieved significantly earlier with IAMP. Morbidity was reduced by, on average, 22 days with IAMP.

CONCLUSIONS

We found that the immediate active motion protocol is safe and has similar outcomes compared with those of immobilization, with the added advantage of earlier pain relief and quicker restoration of hand function. Immediate motion after tendon transfer can significantly reduce morbidity and speed up the rehabilitation of paralytic limbs, and it may save expense for the patients.

Early free active versus dynamic extension splinting after extensor indicis proprius tendon transfer to restore thumb extension: a prospective randomized study

PURPOSE

Transfer of the extensor indicis proprius tendon to the distal extensor pollicis longus (EPL) tendon is a standard operation to restore thumb extension. However, several postoperative hand therapy regimens exist. The previously described early dynamic extension splinting protocol has become our standard, and we now compare it with an early active protocol in a prospective randomized study.

METHODS

Twenty-one patients with a closed EPL tendon rupture in zones T4 and T5 were treated with an extensor indicis proprius tendon transfer and were randomly divided into 2 postoperative physical therapy regimens: one group (DY) was treated with a dynamic protocol using a rubber-band system, and the other group (AC) was allowed an early active thumb extension with limited flexion. All patients were evaluated for active range of motion (ROM) of the thumb and for grip and tip-pinch strength 3, 4, 6, and 8 weeks postoperatively. Long-term outcomes were not evaluated.

RESULTS

Three weeks postoperatively, DY group patients demonstrated a significantly better active ROM in the interphalangeal joint than that of the AC group patients. DY group patients achieved 72% of contralateral joint active ROM compared with 49% of contralateral joint active ROM achieved in the AC group. However, no significant difference was found during further course of study resulting in a final mean interphalangeal joint active ROM of 69 degrees (range, 45 degrees to 110 degrees) in group DY and of 58 degrees (range, 40 degrees to 75 degrees) in group AC. The mean grip strength and tip-pinch strength did not differ significantly after 8 weeks with patients achieving 66% and 73%, respectively, of the contralateral side in group DY and 63% and 71%, respectively, of the contralateral side in group AC. Three complications--one due to rupture (DY group), one due to adhesion, and one due to inadequate joint motion secondary to poor tendon tensioning at the time of initial surgery (both AC group)--occurred during a 1-year follow-up.

CONCLUSIONS

Considering the small group sizes, both regimens (dynamic vs early active) achieved comparable clinical results. The early active protocol does not have a notably higher complication rate but fails to accelerate rehabilitation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Extensor-tendons reconstruction using autogenous palmaris longus tendon grafting for rheumatoid arthritis patients

Background

The purpose of the study is to retrospectively review the clinical outcome of our study population of middle-aged RA patients who had suffered extensor-tendon rupture. We reported the outcome of autogenous palmaris tendon grafting of multiple extensor tendons at wrist level in 14 middle-aged rheumatoid patients.

Methods

Between Feb. 2000 to Feb. 2004, thirty-six ruptured wrist level extensor tendons were reconstructed in fourteen rheumatoid patients (11 women and three men) using autogenous palmaris longus tendon as a free interposition graft. In each case, the evaluation was based on both subjective and objective criteria, including the range of MCP joint flexion after surgery, the extension lag at the metacarpophalangeal joint before and after surgery, and the ability of the patient to work.

Results and Discussion

The average of follow-up was 54.1 months (range, 40 to 72 months). The average range of MCP joint flexion after reconstruction was 66°. The extension lag at the metacarpophalangeal joint significantly improved from a preoperative mean of 38° (range, 25°–60°) to a postoperative mean of 16° (range, 0°–30°). Subjectively all patients were satisfied with the clinical results, and achieved a return to their level of ability before tendon rupture. We found good functional results in our series of interposition grafting using palmaris longus to reconstruct extensor tendon defects in the rheumatoid patients.

Conclusion

Reconstruction for multiple tendon ruptures is a salvage procedure that is often associated with extensor lag and impairment of overall function. Early aggressive treatment of extensor tendon reconstruction using autogenous palmaris longus tendon as a free interposition graft in the rheumatoid wrist is another viable option to achieve good clinical functional result.

Immediate postoperative active mobilization versus immobilization following tendon transfer for claw deformity correction in the hand

PURPOSE

To test the hypothesis that immediate postoperative active mobilization of tendon transfer following claw correction with flexor digitorum superficialis 4-tail pulley insertion will achieve similar outcomes to immobilization in a cast for 3 weeks.

METHODS

In a prospective study, 32 hands with complete ulnar nerve paralysis had flexor digitorum superficialis middle finger 4-tail pulley insertions for 4-digit claw deformity correction and mobilization for tendon transfer rehabilitation on the second day after surgery. Surgical technique was modified to increase the strength of transfer slip insertion. Historical records of 32 mobile claw deformities treated prior to the prospective trial in the same institution with a similar procedure and immobilized in a cast for 3 weeks was used for comparison. Outcomes were assessed by (1) the status of tendon transfer attachment to flexor pulley during immediate mobilization to detect tendon transfer insertion pullout; (2) results of the claw correction in open hand position and intrinsic plus position, and range of digit flexion using identical outcome measures (3) morbidity following surgery; and (4) comparing results of immediate mobilization with immobilization.

RESULTS

There was no incidence of transfer insertion pullout during immediate postoperative mobilization. There was no clinically relevant difference in results of claw correction of both groups in open hand and intrinsic plus position. Total active motion of digit flexion was considerably better with immediate mobilization at late result. A reduction of morbidity by 21 days and an earlier return to daily living activities were benefits to the patient with immediate postoperative mobilization of tendon transfer for claw correction.

CONCLUSIONS

This study supports the hypothesis. Immediate postoperative active mobilization is safe and has similar outcomes of deformity correction compared to immobilization. Immediate mobilization has the added benefits of reduced morbidity and improved total active range of digit flexion compared to immobilization.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Reconstruction after chronic extensor pollicis longus ruptures: a new technique

Different types of secondary reconstruction of extensor pollicis longus tendon injuries have been reported, with repair using the extensor indicis proprius being the gold standard. This technique, however, may decrease extension strength and independent extension of the index finger. We presumed repair with the accessory abductor pollicis longus would achieve functional motion of the thumb and avoid donor site morbidity. We retrospectively report the results for 11 consecutive patients who had repair with the accessory abductor pollicis longus and were followed prospectively for a minimum of 2 years. Study-specific outcome measures were used to assess function in activities of daily living, pain, and patient satisfaction. According to the score described by Geld-macher et al, good or excellent results were achieved in all cases. Mean abduction deficit of the thumb was 10 degrees compared with the uninjured side. Using a 0- to 10-point visual analog scale self-reporting questionnaire, patients obtained mean results of 7.9 points for pain, 7.5 points for activities of daily living, and 7.6 points for patient satisfaction. We recommend the accessory abductor pollicis longus as an alternative for extensor pollicis longus tendon repair.

Immediate Thumb Extension following Extensor Indicis Proprius???to???Extensor Pollicis Longus Tendon Transfer Using the Wide-Awake Approach

BACKGROUND

The elective use of low-dose epinephrine in hand surgery has allowed for the performance of simple operative procedures with tourniquet-free pure local anesthesia (the wide-awake approach). The absence of general anesthesia or sedation has, in turn, allowed for the observation of how quickly the sensorimotor cortex adapts following procedures such as tendon transfer.

METHODS

Seven patients underwent a wide-awake transfer of the extensor indicis proprius to the extensor pollicis longus between February of 2002 and May of 2005 for restoration of thumb extension using local lidocaine with epinephrine alone. One of the seven patients experienced rupture of the initial transfer, necessitating transfer of the extensor carpi radialis longus to the extensor pollicis longus using the wide-awake approach.

RESULTS

All seven patients were able to extend their thumbs fully by means of extensor indicis proprius intraoperatively immediately following transfer suture placement. Restoration of function was not ablated by loss of proprioception or visual feedback. At a mean follow-up of 15 months, thumb extension was restored to within normal limits in the affected thumb, with a slight decrease in grip and tripod pinch strength.

CONCLUSIONS

The wide-awake approach has allowed the authors to adjust tendon transfer tension with active movement before skin closure without the risks associated with general or regional anesthesia. In addition, it has allowed them to observe immediate cortical adaptation in the context of a simple tendon transfer. The authors hypothesize that the brain's ability to immediately use extensor indicis proprius for thumb extension stems from the activation of preexisting synergistic cortical finger movement programs.

Hand transplantation: the state-of-the-art

The feasibility of hand transplantation has been demonstrated, both surgically and immunologically. Levels of immunosuppression comparable to regimens used in solid organ transplantation are proving sufficient to prevent graft loss. Many patients have achieved discriminative sensibility and recovery of intrinsic muscle function. In addition to restoration of function, hand transplantation offers considerable psychological benefits. The recipient's pre-operative psychological status, his motivation and his compliance with the intense rehabilitation programme are key issues. While the induction of graft specific tolerance represents a hope for the future, immunosuppression currently remains necessary and carries significant risks. Hand transplantation should, therefore, only be considered a therapeutic option for a carefully selected group of patients.

Immediate active mobilization versus immobilization for opposition tendon transfer in the hand

PURPOSE

To test the hypothesis that immediate postoperative active mobilization of the hand after opposition tendon transfer will achieve outcomes similar to those of the standard practice of cast immobilization.

METHODS

Five hands with isolated lower median nerve paralysis prospectively had opposition tendon transfer followed by immediate postoperative active mobilization for rehabilitation of the transfer. Historical records of 7 identical paralyses with opposition tendon transfers immobilized after surgery in a cast for 3 weeks were used for comparison. Outcomes were assessed by (1) the status of tendon transfer attachment to the thumb during immediate mobilization to detect tendon pullout, (2) the results of the opposition transfers for both groups using identical outcome measures (range of postoperative active abduction of the thumb, pinch pattern, pinch strength), and (3) comparison of the results from both groups.

RESULTS

There were no incidences of tendon pullout during immediate active mobilization of opposition tendon transfer. There were no differences in outcome between the 2 groups at late follow-up evaluations, with all opposition transfers achieving good results. Immediate postoperative active mobilization reduced rehabilitation time by an average of 19 days. An earlier return to activities of daily living was a further benefit to patients.

CONCLUSIONS

This study supports the hypothesis and suggests that similar outcomes can be achieved in reduced time by immediate active mobilization of opposition tendon transfer.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level III.

Late extensor pollicis longus rupture following displaced distal radius and ulna fractures in a child

A 12-year-old boy experienced rupture of the extensor pollicis longus 1 month after closed reduction and percutaneous pinning of a markedly volarly displaced fracture of the distal radius and ulna. Late extensor pollicis longus rupture is a rare complication in children, especially following a markedly displaced fracture.

Tendon transfers for failed nerve reconstruction

There are few reconstructive procedures in the upper extremity that are as helpful to patients as a tendon transfer. Successful tendon transfer requires the marriage of anatomic knowledge, surgical judgment, and rehabilitative expertise. Frequently, the improvement in function can be dramatic. By the same token, an unsuccessful tendon transfer wastes a normal muscle-tendon unit in the hand and leaves the patient withless function than what was present preoperatively.