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Extensor pollicis longus opposition transfer
Vol. 17A, No. 5 September 1992
3.
4. 5.
6.
7.
8.
Architecture
wrist flexor and extensor muscles. J HAND SURG 1990;15:244-50. Lieber RL. Jacobson MD, Fazeli BS, Abrams RA, Botte MJ. Architecture of selected muscles of the arm and forearm: anatomy and implications for tendon transfer. J HAND SURC 1992;(in press). Long C. Intrinsic-extrinsic muscle control of the fingers. J Bone Joint Surg 1968;50A:973-84. Backhouse KM, Catton WT. An experimental study of the functions of the lumbrical muscles in the human hand. J Anat 1954;88:133-41. Brand PW, Beach RB, Thompson DE. Relative tension and potential excursion of muscles in the forearm and hand. J HAND SURG 1981;6:209-13. Jacobson MD, Raab RW, Fazeli BM, Lieber RL. Architecture of the intrinsic muscles of the hand: implications for normal function and tendon transfer. Trans ORS Societies of Canada, Japan and USA. 1991;l: 330. Sacks RD. Roy RR. Architecture of hindlimb muscles
9.
10.
11.
12.
13. 14. 15.
of intrinsic hand muscles
of cats: functional significance. J Morph01 1982; 173: 18595. Lieber RL, Baskin RJ, Yeh Y. Sarcomere length determination using laser diffraction: the effect of beam and fiber diameter. Biophys J 1984;45: 1009- 17. Ikebuchi Y, Murakami T, Ohtsuka A. The interosseous and lumbrical muscles in the human hand, with special reference to the insertions of the interosseous muscles. Acta Med Okayama 1988:42:327-34. Goldberg S. The origin of the lumbrical muscles in the hand of the South African native. Hand 1970;2: 16871. Lieber RL, Blevins FT. Skeletal muscle architecture of the rabbit hindlimb: functional implications of muscle design. J Morph01 1989;199:93-101. Boyes JH, ed. Bunnell’s surgery of the hand. 5th ed. Philadelphia: JB Lippincott. 1970. Steindler A. Kinesiology of the human body. Springfield. Illinois: Charles C Thomas, 1955. Smith RJ, Hastings H. Principles of tendon transfers to the hand. Instr Course Lect 1980;29: 129-49.
Extensor pollicis longus opposition transfer A new technique of opposition transfer uses the extensor pollicis longus tendon, which is sectioned just proximal to the metacarpophahmgeal membrane,
advanced subcutaneously
joint of the thumb, routed through the interosseous
across the anterior surface of the forearm but deep to the
extensor pollicis brevis tendon, and sutured to its distal stump with a 1 cm overlap. This technique differs from that of Riley et al.” in several significant ways, although the same motor is used. Experience
in 35 cases has yielded good or excellent results in 31 instances.
(J HAND SURG
1992;17A:809-11.)
Ulrich Mennen, MBChB (Pret), FRCS(Edin), FFXS(Glasg), MMed(Orth), MD(Orth), MEDUNSA, South Africa
From the Department of Hand and Microsurgery, Medical University of Southern Africa/Ga-Rankuwa Hospital, Medunsa, South Africa. Received for publication Nov. 21, 1991.
June 21, 1991; accepted
in revised form
FCS(SA)(Orth),
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Ulrich Mennen, 0204, South Africa.
MD, P. 0. Box 186, Medunsa
3/l/36898
THE JOURNALOF HAND SURGERY
809
810
The Journal of HAND SURGERY
Mennen
Fig. 1. Extensor pollicis longus is tunneled subcutaneously skin to incision over dorsum of thumb metacaxpophalangeal
along junction of palmar and dorsal joint.
Fig. 2. Extensor pollicis longus is tunneled under extensor pollicis brevis, overlapped to distal stump with nonabsorbable
suture material overlapping
0
pposition of the thumb is a complex motion that combines extension, abduction, and rotation. Many techniques for attempting to accomplish this when the median innervated thenar muscles are paralyzed have been described. l-9This article describes what I believe is a new technique, which seems to restore this complex motion.
Materials and methods I have operated on 35 patients with paralysis of the thenar muscles caused by either high or low median nerve lesions. There were 26 males (average age, 33 years; range, 9 to 64) and nine females (average age, 38 years; range, 16 to 60) in the group. The prime pathologic causes of the median nerve palsy were as follows: Hansen’s disease 15 Wrist injuries 9 (laceration, crush, gunshot) High median nerve laceration 8 Guillain-Barre syndrome 1 2 Tetraplegia (C6-7)
1 cm.
Before surgery steps should be taken to make the thumb as mobile as possible by the usual means. The operative technique has been standardized as follows. The extensor pollicis longus (EPL) is approached through an incision dorsal to the metacarpophalangeal joint of the thumb and divided 1 cm proximal to the joint. The proximal tendon is then retrieved through a second incision on the dorsal forearm at the junction of its distal and middle thirds. A palmar incision is made 3 cm proximal to the wrist crease and just radial to the ulnar artery. A tunneling forceps is then advanced from ventral to dorsal between the ulnar artery, ulnar nerve, and flexor carpi ulnaris tendon and the remaining flexor tendons. The tunneling forceps is pushed through the interosseous membrane in an oblique line to exit through the proximal dorsal wound. The proximal EPL stump is then grasped and puiled from dorsal to ventral. It is important that the opening in the interosseous membrane be large enough to comfortably accommodate the EPL, including the distal portion of its muscle belly.
Vol. 17A, No. 5
September 1992
Extensor
The tunneling forceps is now pushed subcutaneously from the dorsal hand incision to the anterior forearm (ventral) incision. This line should follow along the base of the thenar eminence at its palmar-dorsal junction (Fig. 1). The proximal EPL stump is now grasped and pulled out of the wound at the dorsal hand incision. It is important that the EPL be routed deep to the extensor pollicis brevis (EPB) tendon. The two stumps are sutured to one another with a nonabsorbable suture and a 1 cm overlap (Fig. 2) to ensure the correct tension for opposition. The thumb is immobilized in a short arm thumb spica for 4 weeks. After this a dynamic opposition splint is used for an additional 4 weeks, and during this time the patient is encouraged thumb in activities of daily living.
to use the
Results The following criteria have been used to evaluate the results: Excellent-Normal opposition function (i.e., thumb pulp meets little finger pulp) Good-Functional (i.e., full circumduction but not full internal rotation of thumb ray). Fair-Minimal function with only some circumducI tion present. Poor-Failure with no opposition function. The results in the thirty five patients were as follows: Excellent Good Fair Poor
26 5 2 2
The two poor results were due to palmar subluxation of the transferred EPL so that it acted as a thumb MCP joint flexor. In these two cases the EPL was not passed deep to the EPB; I believe that this step would have obviated this complication. In these two cases metacarpophalangeal joint arthrodesis resulted in greatly improved function. The two fair results were in patients with an inadequate opening in the interosseous membrane which resulted in diminished glide of the transferred tendon; this technical point has been observed in subsequent cases. I have found thumb extension to be well preserved.
pollicis
longus opposition
transfer
811
Discussion
The advantages of this operation are its relative ease and simplicity with predictably good results if the technical steps outlined here are carefully followed. There are only three small incisions, and no tendon function is lost with this transfer. I do not think there is any loss of muscle power in the transferred EPL, although that is a possibility. I do not agree with the contention that thumb extension and opposition are contradictory movements. ’ ’ The other opposition transfer that uses the EPL is that of Riley et al.” There are some technical differences between their procedure and mine. My procedure avoids disturbing the extensor hood over the MCP joint, moves the tendon to the anterior surface in a more direct line (via the interosseous membrane rather than around the ulnar border of the forearm), and avoids MCP joint fusion. REFERENCES 1. Royle ND. An operation for paralysis of the intrinsic 2.
muscles of the thumb. JAMA 1938;111:612. Thompson TC. A modified operation for opponens paralysis. J Bone Joint Surg 1942;24:632-40.
3. Phalen GS, Miller RC. Transfer of wrist extensor muscles
to restore or reinforce flexion power of the fingers and opposition of the thumb. J Bone Joint Surg 1947;29: 993-7. 4. Chouhy-Aguirre S, Caplan S. Sobre secuelas de lesion alta e irreparable di nervio meidano y cubital y su tratamiento. Prensa Med Argent 1956;43:2341-6. 5. Burkhalter WE. Tendon transfer in median nerve paralysis. Orthop Clin North Am 1974;5:271. 6. Taylor TR. Reconstruction 7. 8. 9.
10. 11.
of the hand; a new technique in tenoplasty. Surg Gynecol Obstet 1921;32:237-48. Camitz H. Dber die de Handlung der Opposition-slahmung. Acta Chir Stand 1929;65:77. Huber E. Hilfsoperation bei Medianusltimung. Dtsch Arch Klin Med 1921;136:271. Mangus DJ. Flexor pollicis longus tendon transfer for restoration of opposition of the thumb. Plast Reconstr Surg 1973;52: 155. Riley WB, Mann RJ, Burkhalter WE. Extensor pollicis longus opponensplasty. J Hand Surg 1980;5:217-20. Burkhalter WE. Intrinsic replacement in median nerve paralysis (restoration of opposition). In: Green DP, ed. Operative hand surgery. 2nd ed. New York. Churchill Livingstone, 1988:1499-1534.
3.
4. 5.
6.
7.
8.
Architecture
wrist flexor and extensor muscles. J HAND SURG 1990;15:244-50. Lieber RL. Jacobson MD, Fazeli BS, Abrams RA, Botte MJ. Architecture of selected muscles of the arm and forearm: anatomy and implications for tendon transfer. J HAND SURC 1992;(in press). Long C. Intrinsic-extrinsic muscle control of the fingers. J Bone Joint Surg 1968;50A:973-84. Backhouse KM, Catton WT. An experimental study of the functions of the lumbrical muscles in the human hand. J Anat 1954;88:133-41. Brand PW, Beach RB, Thompson DE. Relative tension and potential excursion of muscles in the forearm and hand. J HAND SURG 1981;6:209-13. Jacobson MD, Raab RW, Fazeli BM, Lieber RL. Architecture of the intrinsic muscles of the hand: implications for normal function and tendon transfer. Trans ORS Societies of Canada, Japan and USA. 1991;l: 330. Sacks RD. Roy RR. Architecture of hindlimb muscles
9.
10.
11.
12.
13. 14. 15.
of intrinsic hand muscles
of cats: functional significance. J Morph01 1982; 173: 18595. Lieber RL, Baskin RJ, Yeh Y. Sarcomere length determination using laser diffraction: the effect of beam and fiber diameter. Biophys J 1984;45: 1009- 17. Ikebuchi Y, Murakami T, Ohtsuka A. The interosseous and lumbrical muscles in the human hand, with special reference to the insertions of the interosseous muscles. Acta Med Okayama 1988:42:327-34. Goldberg S. The origin of the lumbrical muscles in the hand of the South African native. Hand 1970;2: 16871. Lieber RL, Blevins FT. Skeletal muscle architecture of the rabbit hindlimb: functional implications of muscle design. J Morph01 1989;199:93-101. Boyes JH, ed. Bunnell’s surgery of the hand. 5th ed. Philadelphia: JB Lippincott. 1970. Steindler A. Kinesiology of the human body. Springfield. Illinois: Charles C Thomas, 1955. Smith RJ, Hastings H. Principles of tendon transfers to the hand. Instr Course Lect 1980;29: 129-49.
Extensor pollicis longus opposition transfer A new technique of opposition transfer uses the extensor pollicis longus tendon, which is sectioned just proximal to the metacarpophahmgeal membrane,
advanced subcutaneously
joint of the thumb, routed through the interosseous
across the anterior surface of the forearm but deep to the
extensor pollicis brevis tendon, and sutured to its distal stump with a 1 cm overlap. This technique differs from that of Riley et al.” in several significant ways, although the same motor is used. Experience
in 35 cases has yielded good or excellent results in 31 instances.
(J HAND SURG
1992;17A:809-11.)
Ulrich Mennen, MBChB (Pret), FRCS(Edin), FFXS(Glasg), MMed(Orth), MD(Orth), MEDUNSA, South Africa
From the Department of Hand and Microsurgery, Medical University of Southern Africa/Ga-Rankuwa Hospital, Medunsa, South Africa. Received for publication Nov. 21, 1991.
June 21, 1991; accepted
in revised form
FCS(SA)(Orth),
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Ulrich Mennen, 0204, South Africa.
MD, P. 0. Box 186, Medunsa
3/l/36898
THE JOURNALOF HAND SURGERY
809
810
The Journal of HAND SURGERY
Mennen
Fig. 1. Extensor pollicis longus is tunneled subcutaneously skin to incision over dorsum of thumb metacaxpophalangeal
along junction of palmar and dorsal joint.
Fig. 2. Extensor pollicis longus is tunneled under extensor pollicis brevis, overlapped to distal stump with nonabsorbable
suture material overlapping
0
pposition of the thumb is a complex motion that combines extension, abduction, and rotation. Many techniques for attempting to accomplish this when the median innervated thenar muscles are paralyzed have been described. l-9This article describes what I believe is a new technique, which seems to restore this complex motion.
Materials and methods I have operated on 35 patients with paralysis of the thenar muscles caused by either high or low median nerve lesions. There were 26 males (average age, 33 years; range, 9 to 64) and nine females (average age, 38 years; range, 16 to 60) in the group. The prime pathologic causes of the median nerve palsy were as follows: Hansen’s disease 15 Wrist injuries 9 (laceration, crush, gunshot) High median nerve laceration 8 Guillain-Barre syndrome 1 2 Tetraplegia (C6-7)
1 cm.
Before surgery steps should be taken to make the thumb as mobile as possible by the usual means. The operative technique has been standardized as follows. The extensor pollicis longus (EPL) is approached through an incision dorsal to the metacarpophalangeal joint of the thumb and divided 1 cm proximal to the joint. The proximal tendon is then retrieved through a second incision on the dorsal forearm at the junction of its distal and middle thirds. A palmar incision is made 3 cm proximal to the wrist crease and just radial to the ulnar artery. A tunneling forceps is then advanced from ventral to dorsal between the ulnar artery, ulnar nerve, and flexor carpi ulnaris tendon and the remaining flexor tendons. The tunneling forceps is pushed through the interosseous membrane in an oblique line to exit through the proximal dorsal wound. The proximal EPL stump is then grasped and puiled from dorsal to ventral. It is important that the opening in the interosseous membrane be large enough to comfortably accommodate the EPL, including the distal portion of its muscle belly.
Vol. 17A, No. 5
September 1992
Extensor
The tunneling forceps is now pushed subcutaneously from the dorsal hand incision to the anterior forearm (ventral) incision. This line should follow along the base of the thenar eminence at its palmar-dorsal junction (Fig. 1). The proximal EPL stump is now grasped and pulled out of the wound at the dorsal hand incision. It is important that the EPL be routed deep to the extensor pollicis brevis (EPB) tendon. The two stumps are sutured to one another with a nonabsorbable suture and a 1 cm overlap (Fig. 2) to ensure the correct tension for opposition. The thumb is immobilized in a short arm thumb spica for 4 weeks. After this a dynamic opposition splint is used for an additional 4 weeks, and during this time the patient is encouraged thumb in activities of daily living.
to use the
Results The following criteria have been used to evaluate the results: Excellent-Normal opposition function (i.e., thumb pulp meets little finger pulp) Good-Functional (i.e., full circumduction but not full internal rotation of thumb ray). Fair-Minimal function with only some circumducI tion present. Poor-Failure with no opposition function. The results in the thirty five patients were as follows: Excellent Good Fair Poor
26 5 2 2
The two poor results were due to palmar subluxation of the transferred EPL so that it acted as a thumb MCP joint flexor. In these two cases the EPL was not passed deep to the EPB; I believe that this step would have obviated this complication. In these two cases metacarpophalangeal joint arthrodesis resulted in greatly improved function. The two fair results were in patients with an inadequate opening in the interosseous membrane which resulted in diminished glide of the transferred tendon; this technical point has been observed in subsequent cases. I have found thumb extension to be well preserved.
pollicis
longus opposition
transfer
811
Discussion
The advantages of this operation are its relative ease and simplicity with predictably good results if the technical steps outlined here are carefully followed. There are only three small incisions, and no tendon function is lost with this transfer. I do not think there is any loss of muscle power in the transferred EPL, although that is a possibility. I do not agree with the contention that thumb extension and opposition are contradictory movements. ’ ’ The other opposition transfer that uses the EPL is that of Riley et al.” There are some technical differences between their procedure and mine. My procedure avoids disturbing the extensor hood over the MCP joint, moves the tendon to the anterior surface in a more direct line (via the interosseous membrane rather than around the ulnar border of the forearm), and avoids MCP joint fusion. REFERENCES 1. Royle ND. An operation for paralysis of the intrinsic 2.
muscles of the thumb. JAMA 1938;111:612. Thompson TC. A modified operation for opponens paralysis. J Bone Joint Surg 1942;24:632-40.
3. Phalen GS, Miller RC. Transfer of wrist extensor muscles
to restore or reinforce flexion power of the fingers and opposition of the thumb. J Bone Joint Surg 1947;29: 993-7. 4. Chouhy-Aguirre S, Caplan S. Sobre secuelas de lesion alta e irreparable di nervio meidano y cubital y su tratamiento. Prensa Med Argent 1956;43:2341-6. 5. Burkhalter WE. Tendon transfer in median nerve paralysis. Orthop Clin North Am 1974;5:271. 6. Taylor TR. Reconstruction 7. 8. 9.
10. 11.
of the hand; a new technique in tenoplasty. Surg Gynecol Obstet 1921;32:237-48. Camitz H. Dber die de Handlung der Opposition-slahmung. Acta Chir Stand 1929;65:77. Huber E. Hilfsoperation bei Medianusltimung. Dtsch Arch Klin Med 1921;136:271. Mangus DJ. Flexor pollicis longus tendon transfer for restoration of opposition of the thumb. Plast Reconstr Surg 1973;52: 155. Riley WB, Mann RJ, Burkhalter WE. Extensor pollicis longus opponensplasty. J Hand Surg 1980;5:217-20. Burkhalter WE. Intrinsic replacement in median nerve paralysis (restoration of opposition). In: Green DP, ed. Operative hand surgery. 2nd ed. New York. Churchill Livingstone, 1988:1499-1534.