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Functional outcome of upper limp tendon transfers performed in children with spastic hemiplegia
FUNCTIONAL OUTCOME OF UPPER LIM TRANSFERS PERFORMED IN CHILDREN WIT HEMIPLE J. H. ROTH, S. E. O’GRADY, R. S. RICHARDS and A. M. PORTE From the Hand and Upper Limb Centre, St. Joseph’s Hospital, London, Ontario, Canada
Children with spastic hemiplegia often present with upper limb muscle imbalance. Tbe purpose of this paper was to determine whether reconstructive surgery improved their functional ability. 17 children under the age of 16 years with spastic hemiplegia underwent reconstruction that included tendon transfers, tendon lengthenings and thumb metacarpophalangeal fusion. They were assessed pre-operatively and at an average follow-up period of 2.6 years. Children’s abilities were classified according to House’s functional rating scale. Tendon transfers improved functional grading by two grades, from good passive assist to fair active assist. Improvement in the arc of wrist motion and forearm rotation was also seen. Parental satisfaction was high. Reconstructive surgery improved the functional abilities in this group of children with spastic hemiplegia. Journal of Hand Surgery (British and European Volume, 1993) 18B: 299-303
function cannot be restored. Improved cosmetic appearance is a secondary goal. The emphasis of previous papers has been on the surgical procedures proposed. Although positive gains have been reported, few authors have reliably measured outcome. Thus quantitative comparisons are lacking. This study set out to collect data regarding the physical and functional outcome of surgery. A secondary objective was to assess parental perceptions about the surgery.
Cerebral palsy is defined as a congenital, non-progressive disorder of movement and posture characterized by altered motor, sensory, and intellectual function (Hoffer, 1988). Although the cerebral lesion remains static, the limb deformity changes with growth and does not stabilize until skeletal maturation occurs. Recognizable patterns of deformity occur in the upper limb (Goldner, 1987). The most common pattern is a flexion-pronation pattern of deformity. In this group, the forearm is pronated and the wrist flexed and ulnar-deviated. In the hand, the fingers are flexed, and the thumb flexed and adducted. In Goldner’s series, this pattern is present in 70% of patients. Smaller subgroups include those with extension deformity and those with a supination deformity. In addition to the postural deformity, the extremity movement pattern is classified into spastic, athetoid, ataxic or mixed. Differentiation must be made between athetoid and spastic limbs, as the results in athetoid limbs are much less predictable than in spastic hemiplegia. Initial therapy of the upper limb deformity is nonoperative. Neuro-developmental and assistive play therapies are used to develop bimanual use of the hands. Splinting may also be used to reduce the spastic effects. These therapies may not prevent the development of deformities that limit functional hand use. It is in these children that operative intervention has been felt to have good results (Chait et al, 1980; Hoffer et al, 1986; Zancolli et al, 1983). Surgical correction is indicated in childhood rather than waiting for a fixed deformity to occur. Operative goals include release of contractures, augmentation of weak muscles and skeletal stabilization (House et al, 1981). Functionally, the goal is to improve gross hand function, especially in bimanual activities. Specific goals include correction of the wrist to a more functional position, improvement of grasp and release, release of the pronation contracture and correction of the thumb-in-palm deformity. However, normal hand
METHODS
Our study sample was drawn from those children with a diagnosis of spastic hemiplegia followed at Thames Valley Children’s centre. Between 1983-1988, 25 children underwent upper limb reconstruction for spastic hemiplegia. 17 patients were available for follow-up. Surgery
Criteria for surgery included: 1. The ability to position the hand in voluntarily. 2. A lack of athetosis in movement. 3. Cognitive ability in the trainable range.
space
All procedures were performed by a single surgeon and each patient underwent similar surgical procedures (Table 1). The children underwent simultaneous correction of forearm wrist and thumb deformities. In 15 out of 17 subjects the forearm deformity was corrected by the pronator to supinator transfer (Sakellarides et al, 1981). The pronator teres is detached from its insertion and transferred through the interosseous membrane from volar to dorsal. It is then reinserted onto the volar radial aspect of the radius. This changes its function from a pronator of the forearm to an active supinator. In all patients, wrist extension was achieved by transferring flexor carpi ulnaris to extensor carpi radialis 299
300
Table l-Surgical
THE JOURNAL
OF HAND
SURGERY
VOL. 18B No. 3 JUNE
1993
procedures performed in each patient
Prosupimator transfer
FCU to ECRB
BR to APL, EPB
MP fusion
1. 2. 3. 4.
_ + + +
+ + + t
+ + + t
_ + + _
5. 6.
t +
+ t
t +
+ t
I. 8. 9. 10.
+ + + +
+ + + +
+ + t +
+ + + -
11.
t
+
+
+
12. 13. 14. 15. 16. 17.
_ t + + + t
t
t
+ + + + +
+ + + + t
+ t
-
+ + t t
_ Lengthen FPL _
brevis through the interosseous membrane. Care is taken to free the muscle belly proximally without damaging the major neurovascular pedicle in the proximal third. The interosseous membrane is exposed to the proximal aspect of pronator quadratus and is incised longitudinally, preserving the anterior interosseous artery. The transfer is routed just proximal to pronator quadratus. By not routing the transfer around the ulnar border of the forearm, an ulnar-deviating force is avoided. Surgery for the thumb in palm deformity varied. All patients had transfer of brachioradialis to abductor pollicis longus and extensor pollicis brevis in an attempt to gain active abduction. Fusion of the thumb metacarpophalangeal joint in extension was performed in 14 patients. Adductor pollicis release and release of the first dorsal interosseous was performed in four patients. Post-operatively, the patient was immobilized in an above elbow cast for 5 weeks. Hand therapy was then initiated and continued twice weekly for 6 months. After this time a home program was instituted with monthly checks for the first year after surgery. Assessment A pre-test and post-test study design was used. Preoperative data was gathered retrospectively from the patients’ records and reviewed by two observers, an occupational therapist and a hand surgeon. This information included active and passive range of motion, strength, type of grasp, release patterns and bimanual use of the hands. This information was used to assign a functional class to each child. A modified version of House’s nine point functional rating scale was used
Other procedures Repeat MP fusion
_ Release adductor pollicis i Release 1st dorsal interosseous Release adductor pollicis Release 1st dorsal interosseous 1 Lengthen FCR Release adductor pollicis i Release 1st dorsal interosseous Release adductor pollicis Release 1st dorsal interosseous
(House et al, 1981). To assess the validity of the rating scale a second occupational therapist independently reviewed the patients and an inter-rater reliability score was determined to compare the assessments. At follow-up, similar information was obtained. A detailed assessment of specific hand functions was also performed. Grasp and release were scored separately to assess both fine pincer grasp and voluntary release without additional stabilization. Grasp was scored on an eight-point scale from none (1) to fine pincer grasp (8). Release was graded on a 6 point scale from no release (1) to release of objects without stabilization (6). This information was used to assign a post-operative functional class to each child. Precision and fine object manipulation were also assessed. Sensory examination was performed for light touch, stereognosis, two point discrimination, pain and proprioception. Finally, a questionnaire was completed by the parents regarding their perceptions of surgery. Statistical analysis Statistical analysis of data was performed using t-tests for continuous data and Chi-square analysis for categorical data. Due to the large number of variables tested, the P value was set at P < 0.01 to minimize error. Interobserver reliability for the modified House functional classification was 0.89-0.92, indicating that our modifications produced a reliable scale. RESULTS 17 children were reviewed. The average age at surgery was 8.3 years with a range from 3.3 to 15.5 years. 11
TENDON TRAKSFERS
IN SPASTIC HEMIPLEGIA
were male and six female. The right upper limb was involved in nine patients and the left in eight. Average follow-up was 2.6 years with a range of 0.9 to 4.6 years. No early complications related to the surgery were noted. Three children required subsequent surgery. One child required a repeat metacarpophalangeal fusion of the thumb. Two children underwent secondary retensioning of their FCU to ECRB transfers with one transfer tightened and the other released. One child who did not undergo primary thumb MP fusion required fusion at a second operation to correct the thumb-inpalm deformity. 14 children had thumb-in-palm deformity prior to surgery and all maintained the thumb out of the palm after surgery. Five children showed active thumb abduction postoperatively. As two children had active thumb abduction prior to surgery, only three gained active abduction as a result of surgery. This was not a statistically significant improvement. The forearm pronation deformity was significantly reduced postoperatively. The arc of motion prior to surgery was from 90” to 38” pronation. After surgery the arc of motion was from 56” pronation to 11” supination. Thus the mean position of forearm range was improved from 64” pronation prior to surgery to 22” pronation after surgery (Figs la and b, PcO.01). In spite of the improvement in position, no change was noted in the total active range of motion. The mean active range was 52” before and 66” after surgery (P= n.s.). Wrist position was significantly improved (Fig 2). The mean position was 41” flexion preoperatively and improved to 11” flexion (PC 0.0001). The arc of motion was 36” flexion to 7” flexion prior to surgery. After surgery the arc of motion was from 19” flexion to 42” extension. Again, the total active range of motion was not improved by surgery. Active range of wrist motion was 69” prior to surgery and 61” post-operatively. Functional findings using the modified House scale showed significant improvement. Mean functional classification scores moved from 3.7 to 5.5 post-operatively. Functionally, the involved hand moved from being used as a passive assist to being used a fair active assist. This indicates more voluntary control over the limb. Overall, ten out of the 17 children were rated as having fine pincer grasp, voluntary release and spontaneous use of the involved hand post-operatively. Children with intact stereognosis did not score higher in functional classification than those with impaired stereognosis. Parents’ perceptions of the surgery were uniformly positive, with 65% indicating definite improvement and 35% some improvement. Only one parent would not repeat the surgery. Parental satisfaction was not related to functional classification post surgery. No relationship could be demonstrated between high scores or low scores and satisfaction. Also, the degree of improvement did not correlate with satisfaction.
30 1
DISCUSSION Although cerebral palsy is a diverse condition, a subgroup of similar patients with spastic hemiplegia can benefit from the series of tendon transfers described. The findings presented here support previous reports of positive outcome of upper limb surgery in spastic hemiplegia (Zancolli et al, 1983; House et al, 1981; Tonkin and Gschwind, 1992). Physical improvements obtained from surgery were improved wrist position, decreased pronation deformity of the forearm and po.sitioning the thumb out of the palm. Performance of the surgery in childhood eliminated the need for proximal row carpectomy necessary in the adult spastic hemiplegic limb. The transfer used for correction of the pronated forearm is the pro-supinator transfer (Sakellarides et al, 1981; Gschwind and Tonkin, 1992). This theoretically removes a pronating force and converts it into a supinating force. Assessment of muscle transfer function in these patients is very difficult. Our data. show that although the mean range of motion did not increase, it was significantly changed. Effectively, a gain of 51” supination was achieved (Fig lb). Similarly, at the wrist, an effective gain of 53” extension at the wrist was gained (Fig 2). Our results for range of motion are similar to others (Wanner and Johnson, 1988). This corresponds to moving the wrist into a functional range of motion with good extension. The ability to extend the wrist improves grasp function. Thumb MP fusion in extension maintained correction of the thumb-in-palm deformity even in those children who did not gain active abduction of the thumb after tendon transfer. Functionally, after surgery there was a significant increase in grasp and release function of the hand. This allowed the band to be used as an active assist or for bimanual activities rather than as a passive helper. The improvement in functional use of the hand appears to be due to improved upper limb position rather than increased range of motion, as range was not improved by our transfers. Interestingly, no correlation between hand sensibility and outcome of surgery was seen in this study. This may be due to the fact that sensibility measurements were not sensitive enough to discriminate. A second explanation is that visual cues may compensate during bimanual functions. Currently, poor sensation is not a contraindication to surgery in our patients. Impaired vision and poor sensation together are contraindications to surgery. A high level of parental satisfaction was seen with 15/17 parents indicating that they would consent to surgery again Parental satisfaction was not related to functional improvement after surgery. Our results show that range of motion does not improve after surgery. However, both postural improvement and gains in functional abilities can be expected. This does underscore the necessity for careful functional evaluation by experienced therapists. Functional
THE JOURNAL OF HAND SURGERY VOL. 18B No. 3 JUNE 1993
302 Before Surgery
Pronation
Mean Arc of Motion = 90” pronation to 36O pronation Mean Arc of Motion = 56” pronation to 1 lo supination
Mean Active Range = 52’
Mean Active Range = 66O
b
/J
;r
Key -
mean forearm position before surgery
------mean
forearm position after surgery
Fig l(a) The active forearm motion Correction of the pronation deformity
present before and after has been achieved.
surgery,
outcome rather than measurements of range of motion are essential to assess the value of upper limb surgery in spastic hemiplegia. The functional result is the key and should replace isolated assessments of range of motion in assessing the results of tendon transfers.
(b)
The mean
position
of the forearm
before
and after
surgery.
In conclusion, a review of upper limb tendon transfers in spastic hemiplegia has indicated positive outcomes. Total active range of forearm and wrist motion was not improved. Consistent correction of the pronation and wrist flexion deformities was obtained with single stage
TENDON
TRANSFERS
IN SPASTIC
HEMIPLEGIA
Extension
Flexion
Flexion
Mean Arc of Motion = 76” flexion to 7” flexion
Mean Arc of Motion = 19” flexion to 42” ~~~~~~~~
Mean Active Range = 69”
Mean Active Range = 62”
Fig 2
The active wrist motion
before and after surgery.
surgery. Few patients required secondary surgery. Improved hand position and functional performance as well as high parental satisfaction were demonstrated. References CHAIT, L. A., KAPLAN, I., STEWART-LORD B. and GOODMAN, M. (1980). Early surgical correction in the cerebral palsied hand. Journal of Hand Surgery, 5: 3: 122-126. GOLDNER, J. L. Upper Extremity Reconstruction in Cerebral Palsy. In: Hunter, J, Schneider, L. and Mackin, E. (Eds.): Tendon Surgery in the Hand. St. Louis, C. V. Mosby, 1987: 454-492. GSCHWIND, C. and TONKIN, M. (1992). Surgery for cerebral palsy: Part 1. Classification and operative procedures for pronation deformity. Journal of Hand Surgery, 178: 4: 391-395. HOFFER, M. M. Cerebral Palsy. In: Green, D. P. (Ed.): Operative Hand Surgery. 2nd Edn. New York, Churchill Livingstone, 1988: Vol 1: 215-226. HOFFER. M. M., LEHMAN, M. and MITANI, M. (1986). Long term followup on tendon transfers to the extensors of the wrist and fingers in patients with cerebral palsy. Journal of Hand Surgery,: 11A: 6: 836-840. HOUSE, J. H., GWATHMEY, F. W. and FIDLER, M. 0. (1981). A dynamic
approach to the thumb-in-palm deformity m cerebral palsy. Journal of Bone and Joint Surgery. 63A: 2: 216-225. SAKELLARIDES, H. T., MITEL, M. A. and LENZI, W. D. (1981). Treatment of pronation contractures of the forearm in cerebral palsy by changing of the insertion of the pronator radii teres. Journal of Bone and Joint Surgery, 63A: 4: 645-652. TONKIN, M. and GSCHWIND, C. (1992). Surgery for cerebral palsy: Part 2. Flexion deformities of the wrist and fingers. Journal of Hand Surgery, 17B: 4: 396-400. WENNER, S. M. and JOHNSON, K. A. (1988). Transfer of the flexor carpi ulnaris to the radial wrist extensors in cerebral palsy. Journal of Hand Surgery, 13A: 2: 231-233. ZANCOLLI, E. A., GOLDNER, L. J. and SWANSON, A. B. (1983). Surgery of the spastic hand in cerebral palsy: Report of the committee on spastic hand evaluation. Journal of Hand Surgery, 8: 5(2): 766-?72.
4ccepred: 6 January 1993 Dr .I. Roth. Hand and Upper Limb Centre. St. Josephs’ Health Centre, 268 Grcsvenor St. London, 0
Ontario,
1993 The British
Canada, Society
N6A 4L6. for Surgery
of the Hand
Children with spastic hemiplegia often present with upper limb muscle imbalance. Tbe purpose of this paper was to determine whether reconstructive surgery improved their functional ability. 17 children under the age of 16 years with spastic hemiplegia underwent reconstruction that included tendon transfers, tendon lengthenings and thumb metacarpophalangeal fusion. They were assessed pre-operatively and at an average follow-up period of 2.6 years. Children’s abilities were classified according to House’s functional rating scale. Tendon transfers improved functional grading by two grades, from good passive assist to fair active assist. Improvement in the arc of wrist motion and forearm rotation was also seen. Parental satisfaction was high. Reconstructive surgery improved the functional abilities in this group of children with spastic hemiplegia. Journal of Hand Surgery (British and European Volume, 1993) 18B: 299-303
function cannot be restored. Improved cosmetic appearance is a secondary goal. The emphasis of previous papers has been on the surgical procedures proposed. Although positive gains have been reported, few authors have reliably measured outcome. Thus quantitative comparisons are lacking. This study set out to collect data regarding the physical and functional outcome of surgery. A secondary objective was to assess parental perceptions about the surgery.
Cerebral palsy is defined as a congenital, non-progressive disorder of movement and posture characterized by altered motor, sensory, and intellectual function (Hoffer, 1988). Although the cerebral lesion remains static, the limb deformity changes with growth and does not stabilize until skeletal maturation occurs. Recognizable patterns of deformity occur in the upper limb (Goldner, 1987). The most common pattern is a flexion-pronation pattern of deformity. In this group, the forearm is pronated and the wrist flexed and ulnar-deviated. In the hand, the fingers are flexed, and the thumb flexed and adducted. In Goldner’s series, this pattern is present in 70% of patients. Smaller subgroups include those with extension deformity and those with a supination deformity. In addition to the postural deformity, the extremity movement pattern is classified into spastic, athetoid, ataxic or mixed. Differentiation must be made between athetoid and spastic limbs, as the results in athetoid limbs are much less predictable than in spastic hemiplegia. Initial therapy of the upper limb deformity is nonoperative. Neuro-developmental and assistive play therapies are used to develop bimanual use of the hands. Splinting may also be used to reduce the spastic effects. These therapies may not prevent the development of deformities that limit functional hand use. It is in these children that operative intervention has been felt to have good results (Chait et al, 1980; Hoffer et al, 1986; Zancolli et al, 1983). Surgical correction is indicated in childhood rather than waiting for a fixed deformity to occur. Operative goals include release of contractures, augmentation of weak muscles and skeletal stabilization (House et al, 1981). Functionally, the goal is to improve gross hand function, especially in bimanual activities. Specific goals include correction of the wrist to a more functional position, improvement of grasp and release, release of the pronation contracture and correction of the thumb-in-palm deformity. However, normal hand
METHODS
Our study sample was drawn from those children with a diagnosis of spastic hemiplegia followed at Thames Valley Children’s centre. Between 1983-1988, 25 children underwent upper limb reconstruction for spastic hemiplegia. 17 patients were available for follow-up. Surgery
Criteria for surgery included: 1. The ability to position the hand in voluntarily. 2. A lack of athetosis in movement. 3. Cognitive ability in the trainable range.
space
All procedures were performed by a single surgeon and each patient underwent similar surgical procedures (Table 1). The children underwent simultaneous correction of forearm wrist and thumb deformities. In 15 out of 17 subjects the forearm deformity was corrected by the pronator to supinator transfer (Sakellarides et al, 1981). The pronator teres is detached from its insertion and transferred through the interosseous membrane from volar to dorsal. It is then reinserted onto the volar radial aspect of the radius. This changes its function from a pronator of the forearm to an active supinator. In all patients, wrist extension was achieved by transferring flexor carpi ulnaris to extensor carpi radialis 299
300
Table l-Surgical
THE JOURNAL
OF HAND
SURGERY
VOL. 18B No. 3 JUNE
1993
procedures performed in each patient
Prosupimator transfer
FCU to ECRB
BR to APL, EPB
MP fusion
1. 2. 3. 4.
_ + + +
+ + + t
+ + + t
_ + + _
5. 6.
t +
+ t
t +
+ t
I. 8. 9. 10.
+ + + +
+ + + +
+ + t +
+ + + -
11.
t
+
+
+
12. 13. 14. 15. 16. 17.
_ t + + + t
t
t
+ + + + +
+ + + + t
+ t
-
+ + t t
_ Lengthen FPL _
brevis through the interosseous membrane. Care is taken to free the muscle belly proximally without damaging the major neurovascular pedicle in the proximal third. The interosseous membrane is exposed to the proximal aspect of pronator quadratus and is incised longitudinally, preserving the anterior interosseous artery. The transfer is routed just proximal to pronator quadratus. By not routing the transfer around the ulnar border of the forearm, an ulnar-deviating force is avoided. Surgery for the thumb in palm deformity varied. All patients had transfer of brachioradialis to abductor pollicis longus and extensor pollicis brevis in an attempt to gain active abduction. Fusion of the thumb metacarpophalangeal joint in extension was performed in 14 patients. Adductor pollicis release and release of the first dorsal interosseous was performed in four patients. Post-operatively, the patient was immobilized in an above elbow cast for 5 weeks. Hand therapy was then initiated and continued twice weekly for 6 months. After this time a home program was instituted with monthly checks for the first year after surgery. Assessment A pre-test and post-test study design was used. Preoperative data was gathered retrospectively from the patients’ records and reviewed by two observers, an occupational therapist and a hand surgeon. This information included active and passive range of motion, strength, type of grasp, release patterns and bimanual use of the hands. This information was used to assign a functional class to each child. A modified version of House’s nine point functional rating scale was used
Other procedures Repeat MP fusion
_ Release adductor pollicis i Release 1st dorsal interosseous Release adductor pollicis Release 1st dorsal interosseous 1 Lengthen FCR Release adductor pollicis i Release 1st dorsal interosseous Release adductor pollicis Release 1st dorsal interosseous
(House et al, 1981). To assess the validity of the rating scale a second occupational therapist independently reviewed the patients and an inter-rater reliability score was determined to compare the assessments. At follow-up, similar information was obtained. A detailed assessment of specific hand functions was also performed. Grasp and release were scored separately to assess both fine pincer grasp and voluntary release without additional stabilization. Grasp was scored on an eight-point scale from none (1) to fine pincer grasp (8). Release was graded on a 6 point scale from no release (1) to release of objects without stabilization (6). This information was used to assign a post-operative functional class to each child. Precision and fine object manipulation were also assessed. Sensory examination was performed for light touch, stereognosis, two point discrimination, pain and proprioception. Finally, a questionnaire was completed by the parents regarding their perceptions of surgery. Statistical analysis Statistical analysis of data was performed using t-tests for continuous data and Chi-square analysis for categorical data. Due to the large number of variables tested, the P value was set at P < 0.01 to minimize error. Interobserver reliability for the modified House functional classification was 0.89-0.92, indicating that our modifications produced a reliable scale. RESULTS 17 children were reviewed. The average age at surgery was 8.3 years with a range from 3.3 to 15.5 years. 11
TENDON TRAKSFERS
IN SPASTIC HEMIPLEGIA
were male and six female. The right upper limb was involved in nine patients and the left in eight. Average follow-up was 2.6 years with a range of 0.9 to 4.6 years. No early complications related to the surgery were noted. Three children required subsequent surgery. One child required a repeat metacarpophalangeal fusion of the thumb. Two children underwent secondary retensioning of their FCU to ECRB transfers with one transfer tightened and the other released. One child who did not undergo primary thumb MP fusion required fusion at a second operation to correct the thumb-inpalm deformity. 14 children had thumb-in-palm deformity prior to surgery and all maintained the thumb out of the palm after surgery. Five children showed active thumb abduction postoperatively. As two children had active thumb abduction prior to surgery, only three gained active abduction as a result of surgery. This was not a statistically significant improvement. The forearm pronation deformity was significantly reduced postoperatively. The arc of motion prior to surgery was from 90” to 38” pronation. After surgery the arc of motion was from 56” pronation to 11” supination. Thus the mean position of forearm range was improved from 64” pronation prior to surgery to 22” pronation after surgery (Figs la and b, PcO.01). In spite of the improvement in position, no change was noted in the total active range of motion. The mean active range was 52” before and 66” after surgery (P= n.s.). Wrist position was significantly improved (Fig 2). The mean position was 41” flexion preoperatively and improved to 11” flexion (PC 0.0001). The arc of motion was 36” flexion to 7” flexion prior to surgery. After surgery the arc of motion was from 19” flexion to 42” extension. Again, the total active range of motion was not improved by surgery. Active range of wrist motion was 69” prior to surgery and 61” post-operatively. Functional findings using the modified House scale showed significant improvement. Mean functional classification scores moved from 3.7 to 5.5 post-operatively. Functionally, the involved hand moved from being used as a passive assist to being used a fair active assist. This indicates more voluntary control over the limb. Overall, ten out of the 17 children were rated as having fine pincer grasp, voluntary release and spontaneous use of the involved hand post-operatively. Children with intact stereognosis did not score higher in functional classification than those with impaired stereognosis. Parents’ perceptions of the surgery were uniformly positive, with 65% indicating definite improvement and 35% some improvement. Only one parent would not repeat the surgery. Parental satisfaction was not related to functional classification post surgery. No relationship could be demonstrated between high scores or low scores and satisfaction. Also, the degree of improvement did not correlate with satisfaction.
30 1
DISCUSSION Although cerebral palsy is a diverse condition, a subgroup of similar patients with spastic hemiplegia can benefit from the series of tendon transfers described. The findings presented here support previous reports of positive outcome of upper limb surgery in spastic hemiplegia (Zancolli et al, 1983; House et al, 1981; Tonkin and Gschwind, 1992). Physical improvements obtained from surgery were improved wrist position, decreased pronation deformity of the forearm and po.sitioning the thumb out of the palm. Performance of the surgery in childhood eliminated the need for proximal row carpectomy necessary in the adult spastic hemiplegic limb. The transfer used for correction of the pronated forearm is the pro-supinator transfer (Sakellarides et al, 1981; Gschwind and Tonkin, 1992). This theoretically removes a pronating force and converts it into a supinating force. Assessment of muscle transfer function in these patients is very difficult. Our data. show that although the mean range of motion did not increase, it was significantly changed. Effectively, a gain of 51” supination was achieved (Fig lb). Similarly, at the wrist, an effective gain of 53” extension at the wrist was gained (Fig 2). Our results for range of motion are similar to others (Wanner and Johnson, 1988). This corresponds to moving the wrist into a functional range of motion with good extension. The ability to extend the wrist improves grasp function. Thumb MP fusion in extension maintained correction of the thumb-in-palm deformity even in those children who did not gain active abduction of the thumb after tendon transfer. Functionally, after surgery there was a significant increase in grasp and release function of the hand. This allowed the band to be used as an active assist or for bimanual activities rather than as a passive helper. The improvement in functional use of the hand appears to be due to improved upper limb position rather than increased range of motion, as range was not improved by our transfers. Interestingly, no correlation between hand sensibility and outcome of surgery was seen in this study. This may be due to the fact that sensibility measurements were not sensitive enough to discriminate. A second explanation is that visual cues may compensate during bimanual functions. Currently, poor sensation is not a contraindication to surgery in our patients. Impaired vision and poor sensation together are contraindications to surgery. A high level of parental satisfaction was seen with 15/17 parents indicating that they would consent to surgery again Parental satisfaction was not related to functional improvement after surgery. Our results show that range of motion does not improve after surgery. However, both postural improvement and gains in functional abilities can be expected. This does underscore the necessity for careful functional evaluation by experienced therapists. Functional
THE JOURNAL OF HAND SURGERY VOL. 18B No. 3 JUNE 1993
302 Before Surgery
Pronation
Mean Arc of Motion = 90” pronation to 36O pronation Mean Arc of Motion = 56” pronation to 1 lo supination
Mean Active Range = 52’
Mean Active Range = 66O
b
/J
;r
Key -
mean forearm position before surgery
------mean
forearm position after surgery
Fig l(a) The active forearm motion Correction of the pronation deformity
present before and after has been achieved.
surgery,
outcome rather than measurements of range of motion are essential to assess the value of upper limb surgery in spastic hemiplegia. The functional result is the key and should replace isolated assessments of range of motion in assessing the results of tendon transfers.
(b)
The mean
position
of the forearm
before
and after
surgery.
In conclusion, a review of upper limb tendon transfers in spastic hemiplegia has indicated positive outcomes. Total active range of forearm and wrist motion was not improved. Consistent correction of the pronation and wrist flexion deformities was obtained with single stage
TENDON
TRANSFERS
IN SPASTIC
HEMIPLEGIA
Extension
Flexion
Flexion
Mean Arc of Motion = 76” flexion to 7” flexion
Mean Arc of Motion = 19” flexion to 42” ~~~~~~~~
Mean Active Range = 69”
Mean Active Range = 62”
Fig 2
The active wrist motion
before and after surgery.
surgery. Few patients required secondary surgery. Improved hand position and functional performance as well as high parental satisfaction were demonstrated. References CHAIT, L. A., KAPLAN, I., STEWART-LORD B. and GOODMAN, M. (1980). Early surgical correction in the cerebral palsied hand. Journal of Hand Surgery, 5: 3: 122-126. GOLDNER, J. L. Upper Extremity Reconstruction in Cerebral Palsy. In: Hunter, J, Schneider, L. and Mackin, E. (Eds.): Tendon Surgery in the Hand. St. Louis, C. V. Mosby, 1987: 454-492. GSCHWIND, C. and TONKIN, M. (1992). Surgery for cerebral palsy: Part 1. Classification and operative procedures for pronation deformity. Journal of Hand Surgery, 178: 4: 391-395. HOFFER, M. M. Cerebral Palsy. In: Green, D. P. (Ed.): Operative Hand Surgery. 2nd Edn. New York, Churchill Livingstone, 1988: Vol 1: 215-226. HOFFER. M. M., LEHMAN, M. and MITANI, M. (1986). Long term followup on tendon transfers to the extensors of the wrist and fingers in patients with cerebral palsy. Journal of Hand Surgery,: 11A: 6: 836-840. HOUSE, J. H., GWATHMEY, F. W. and FIDLER, M. 0. (1981). A dynamic
approach to the thumb-in-palm deformity m cerebral palsy. Journal of Bone and Joint Surgery. 63A: 2: 216-225. SAKELLARIDES, H. T., MITEL, M. A. and LENZI, W. D. (1981). Treatment of pronation contractures of the forearm in cerebral palsy by changing of the insertion of the pronator radii teres. Journal of Bone and Joint Surgery, 63A: 4: 645-652. TONKIN, M. and GSCHWIND, C. (1992). Surgery for cerebral palsy: Part 2. Flexion deformities of the wrist and fingers. Journal of Hand Surgery, 17B: 4: 396-400. WENNER, S. M. and JOHNSON, K. A. (1988). Transfer of the flexor carpi ulnaris to the radial wrist extensors in cerebral palsy. Journal of Hand Surgery, 13A: 2: 231-233. ZANCOLLI, E. A., GOLDNER, L. J. and SWANSON, A. B. (1983). Surgery of the spastic hand in cerebral palsy: Report of the committee on spastic hand evaluation. Journal of Hand Surgery, 8: 5(2): 766-?72.
4ccepred: 6 January 1993 Dr .I. Roth. Hand and Upper Limb Centre. St. Josephs’ Health Centre, 268 Grcsvenor St. London, 0
Ontario,
1993 The British
Canada, Society
N6A 4L6. for Surgery
of the Hand