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Staged opposition transfer
Staged Opposition Transfer John A. I. Grossman, MD, FACS, Miami, FL, Jay Pomerance, MD, Chicago, IL Six patients sustained extensive hand and upper limb trauma, including median nerve and/or thenar muscle loss. Initial treatment consisted of various median nerve and/or soft tissue reconstructions. Because of extensive palmar scarring and lack of useful opposition (Kapandji stage 3), a 2-stage opposition transfer was performed. In stage 1, a silicone rod was placed along the path of the intended tendon transfer. In stage 2, the rod was removed and the donor tendon was passed through the pseudosheath to the point of insertion at the thumb. All patients were monitored for a minimum of 1 year and all achieved significant functional improvement, documented by Kapandji stage 6 opposition in 1 patient and by at least stage 7 or 8 opposition in the other 5 patients. (J Hand Surg 1998;23A:290-295. Copyright 9 1998 by the American Society for Surgery of the Hand.)
Restoration of t h u m b opposition by tendon transfer following median nerve injury or thenar muscle loss is often of great functional benefit. In c o m p l e x t r a u m a cases, these transfers can be difficult or risky to p e r f o r m because the tendon must pass through a scarred zone of injury in close p r o x i m i t y to p r e v i o u s l y repaired nerves and vessels, leading to a generally poor functional outcome. W e report our experience in 6 patients in w h o m opposition was restored using a 2-stage procedure to o v e r c o m e these p r o b l e m s . The procedure involves initial p l a c e m e n t of a silicone rod and subsequent tendon transfer.
Materials and Methods We used this technique over a 4-year period (1991-1995) in 6 male patients ranging in age from 19 to 52 years. The extensor indicis proprius is the
From the Hand and Peripheral Nerve Surgery Unit, Miami Children's Hospital, Miami, FL; and the Peripheral Nerve Unit, Healthsouth Doctors' Hospital, Miami, FL. Received for publication February 19, 1997; accepted in revised form January 5, 1998. No benefits in any form have been receivedor will be received from a commercialparty related directly or indirectly to the subject of this article. Reprint requests: John A. I. Grossman,MD, FACS, 8940 N Kendall Dr, Miami, FL 33176. Copyright 9 1998 by the AmericanSociety for Surgeryof the Hand. 0363-5023/98/23A02-001753.00/0 290
The Journal of Hand Surgery
preferred donor tendon. The extensor carpi radialis longus may be used if it is elongated by a tendon graft. Stage 1 is performed at the time of either a major soft tissue coverage procedure or median (or other nerve) reconstruction. A 4 . 0 - m m flat silicone rod is placed in the path of the usual extensor indicis proprius transfer from the dorsum of the hand proximal to the extensor retinaculum along a subcutaneous course around the ulna and across the palm. The distal end is sutured securely under the abductor pollicis brevis tendon. When indicated, thumb metacarpophalangeal joint fusion or first web space release is also performed. The proximal end of the rod is left deep in the subcutaneous tissue on the dorsum of the forearm. Stage 2 is p e r f o r m e d when the soft tissues and joints of the hand are m a x i m a l l y supple, which, in our experience, requires a m i n i m u m of 4 months. The donor tendon is elevated through multiple short incisions with c o m p l e t e m o b i l i z a t i o n of the m u s c u l o t e n d i n o u s junction, j The silicone rod is e x p o s e d p r o x i m a l l y and distally (Fig. 1). The p r o x i m a l end of the rod is secured to the tendon to be transferred, and the tendon is then a d v a n c e d through the p s e u d o s h e a t h to the point of insertion at the thumb. The location of the distal insertion is individualized depending on the stability of the m e t a c a r p o p h a l a n g e a l joint. 2
The Journal of Hand Surgery / Vol. 23A No. 2 March 1998
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Figure 1. Proximal and distal rod exposure during the second stage of opposition transfer (case 1).
In 1 patient (case 1), the indication was extensive palmar scarring following thenar muscle avulsion. In the other 5 patients, the silicone rod was placed under direct vision at the time of neurovascular repair with associated extensive soft tissue trauma. These repairs were in the path of the intended transfer. In 5 patients, the extensor indicis proprius was the donor tendon and in 1 patient, the extensor carpi radialis longus was used. The case using the extensor carpi radialis longus and 1 case using the extensor indicus proprius required elongation of the donor tendon with a palmaris longus graft. All surgeries were performed by the senior author (J.A.I.G.). The clinical details of these cases are summarized in Table 1. Before the procedure, all patients had Kapandji stage 3 opposition. The final clinical evaluation focused on restoration of functional opposition as measured using the system of Kapandji (Table 2). 3 All patients were monitored for a minimum of 1 year.
Results The overall reconstruction was evaluated in all patients at least 1 year after surgery (range, 1 to 3 years). All patients reported a significant subjective improvement in hand function. One hand therapist used the Kapandji method to objectively
measure thumb opposition (Table 2). 3 Five patients achieved Kapandji stage 7 or higher; the sixth patient achieved stage 6. No patients experienced any related complications. Figure 2 shows the progression of case 2 from the initial injury (Fig. 2A) through restoration of functional opposition (Fig. 2E).
Discussion Successful use of a silicone tendon implant to create a smooth path for subsequent placement of a tendon graft is well established. Popularized by Hunter et al., 4 this technique has allowed flexor tendon reconstruction in severely injured digits. The use of this technique for opposition tendon transfer was suggested in 1991 by Eversmann 5 and in 1995 by Dr. Peter J. Stern in a contribution to the Members' Correspondence Newsletter of the American Society for Surgery of the Hand. It is ideally suited for cases of extensive soft tissue injury to the volar wrist and palm where the gliding of the tendon transfer would be severely compromised. We use this technique in cases in which placement of a transfer is not feasible without blind tunneling through a previously operated area with extensive scarring due to nerve and vascular graft reconstruction. 6 The advantages of increased
292
Grossman and Pomerance
Staged Opposition Transfer T a b l e 1. Clinical Case S u m m a r y
Case No.
Age at Time of Surgery O'r)
1
3O
2
52
3
29
4
19
Kapandji Stage Injury
Major Procedures
Crush of hand and avulsion of thenar muscles and median motor branch Avulsion median nerve (6 cm), first dorsal compartment tendons, radial artery, and overlying skin Median nerve and multiple flexor tendon lacerations Open fractures of the radius and ulna, laceration of all flexor tendons, median nerve and soft tissue avulsion
First web release and Z-plasty
35
Amputation through the distal humerus with successful replantation
45
Avulsion of palmar skin, thenar muscles and common digital nerve to fourth web space
Lateral arm flap/median nerve reconstruction with sural nerve grafts/first web release and Z-plasty Median nerve reconstruction with sural nerve grafts Multiple flexor tenolyses, skin graft and resection, and soft tissue flaps; first web space release with Z-plasty; reconstruction of the median nerve with sural nerve grafts Metacarpophalangeal joint fusion/median neurolysis
Temporoparietal free flap with split skin graft; release of the first web space and Zplasty; nerve graft reconstruction of the multiple digital nerves
Donor T e n d o n Extensor indicis proprius with palmaris longus graft Extensor indicis proprius
Before After S u r g e r y SurgeO, 3
6
3
7
Extensor indicis proprius Extensor indicis proprius
3
7
3
8
Extensor carpi radialis longus with palmaris longus graft Extensor indicis proprius
3
8
3
7
T a b l e 2, Kapandji Classification for Evaluation of T h u m b Opposition 3 Stage O: Stage 1: Stage 2: Stage 3: Stage Stage Stage Stage Stage Stage
4: 5: 6: 7: 8: 9:
Stage lO:
The tip of the thumb is located on the lateral aspect of the first phalanx of the index finger. The beginning opposition corresponds to the position of the tip of the thumb in contact with the lateral side of the second phalanx of the index finger. The tip of the thumb comes in contact with the lateral side of the third phalanx of the index finger; in this position, longitudinal rotation does not occur. The tip of the thumb touches the tip of the index finger; this position realizes the minimal opposition with a tip-to-tip pinch. The tip of the thumb touches the tip of the middle finger. The tip of the thumb comes in contact with the tip of the ring finger. The tip of the thumb reaches the tip of the little finger. The tip of the thumb crosses the distal interphalangeal joint crease of the little finger. The tip of the thumb crosses the proximal interphalangeal joint crease of the little finger. The tip of the thumb touches the proximal crease of the little finger corresponding to the base of its first phalanx. The tip of the thumb reaches the distal palmar crease of the little finger corresponding to the metacarpophalangeal joint.
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293
B
C Figure 2. (A) Initial injury (case 2). (B) Result following soft tissue coverage with lateral arm flap. (C) Distal insertion of rod. (Figure continues)
294
Grossman and Pomerance / Staged Opposition Transfer
D
E Figure 2. (Continued) (D) Final result following completion of 2-stage tendon opposition transfer. (E) Final resul demonstrating functional opposition.
The Journal of Hand Surgery / Vol. 23A No. 2 March 1998
safety and a consistently good functional outcome warrant adding this technique to the armamentarium of the reconstructive hand surgeon.
References l. Burkhalter W, Christensen RC, Brown P. Extensor indicis proprius opponensplasty. J Bone Joint Surg Am 1973;55: 725-732. 2. Smith RJ. Tendon transfers of the hand and forearm. Boston: Little Brown, 1987: 67.
295
3. Kapandji AI. Clinical evaluation of the thumb's opposition. J Hand Ther 1992;5:102-108. 4. Hunter JM, Jaeger SH, Matsui T, Miyaji N. The pseudosynovial sheath--its characteristics in a primate model. J Hand Surg Am 1983;8:461-470. 5. Eversmann WW. Median nerve palsy. In: Gelberman RH, ed. Operative nerve repair and reconstruction. Philadelphia: JB Lippincott, 1991: 726. 6. Wood VE. Nerve compression following opponensplasty as a result of wrist anomalies: report of a case. J Hand Surg Am 1980;5:279-281.
Restoration of t h u m b opposition by tendon transfer following median nerve injury or thenar muscle loss is often of great functional benefit. In c o m p l e x t r a u m a cases, these transfers can be difficult or risky to p e r f o r m because the tendon must pass through a scarred zone of injury in close p r o x i m i t y to p r e v i o u s l y repaired nerves and vessels, leading to a generally poor functional outcome. W e report our experience in 6 patients in w h o m opposition was restored using a 2-stage procedure to o v e r c o m e these p r o b l e m s . The procedure involves initial p l a c e m e n t of a silicone rod and subsequent tendon transfer.
Materials and Methods We used this technique over a 4-year period (1991-1995) in 6 male patients ranging in age from 19 to 52 years. The extensor indicis proprius is the
From the Hand and Peripheral Nerve Surgery Unit, Miami Children's Hospital, Miami, FL; and the Peripheral Nerve Unit, Healthsouth Doctors' Hospital, Miami, FL. Received for publication February 19, 1997; accepted in revised form January 5, 1998. No benefits in any form have been receivedor will be received from a commercialparty related directly or indirectly to the subject of this article. Reprint requests: John A. I. Grossman,MD, FACS, 8940 N Kendall Dr, Miami, FL 33176. Copyright 9 1998 by the AmericanSociety for Surgeryof the Hand. 0363-5023/98/23A02-001753.00/0 290
The Journal of Hand Surgery
preferred donor tendon. The extensor carpi radialis longus may be used if it is elongated by a tendon graft. Stage 1 is performed at the time of either a major soft tissue coverage procedure or median (or other nerve) reconstruction. A 4 . 0 - m m flat silicone rod is placed in the path of the usual extensor indicis proprius transfer from the dorsum of the hand proximal to the extensor retinaculum along a subcutaneous course around the ulna and across the palm. The distal end is sutured securely under the abductor pollicis brevis tendon. When indicated, thumb metacarpophalangeal joint fusion or first web space release is also performed. The proximal end of the rod is left deep in the subcutaneous tissue on the dorsum of the forearm. Stage 2 is p e r f o r m e d when the soft tissues and joints of the hand are m a x i m a l l y supple, which, in our experience, requires a m i n i m u m of 4 months. The donor tendon is elevated through multiple short incisions with c o m p l e t e m o b i l i z a t i o n of the m u s c u l o t e n d i n o u s junction, j The silicone rod is e x p o s e d p r o x i m a l l y and distally (Fig. 1). The p r o x i m a l end of the rod is secured to the tendon to be transferred, and the tendon is then a d v a n c e d through the p s e u d o s h e a t h to the point of insertion at the thumb. The location of the distal insertion is individualized depending on the stability of the m e t a c a r p o p h a l a n g e a l joint. 2
The Journal of Hand Surgery / Vol. 23A No. 2 March 1998
291
Figure 1. Proximal and distal rod exposure during the second stage of opposition transfer (case 1).
In 1 patient (case 1), the indication was extensive palmar scarring following thenar muscle avulsion. In the other 5 patients, the silicone rod was placed under direct vision at the time of neurovascular repair with associated extensive soft tissue trauma. These repairs were in the path of the intended transfer. In 5 patients, the extensor indicis proprius was the donor tendon and in 1 patient, the extensor carpi radialis longus was used. The case using the extensor carpi radialis longus and 1 case using the extensor indicus proprius required elongation of the donor tendon with a palmaris longus graft. All surgeries were performed by the senior author (J.A.I.G.). The clinical details of these cases are summarized in Table 1. Before the procedure, all patients had Kapandji stage 3 opposition. The final clinical evaluation focused on restoration of functional opposition as measured using the system of Kapandji (Table 2). 3 All patients were monitored for a minimum of 1 year.
Results The overall reconstruction was evaluated in all patients at least 1 year after surgery (range, 1 to 3 years). All patients reported a significant subjective improvement in hand function. One hand therapist used the Kapandji method to objectively
measure thumb opposition (Table 2). 3 Five patients achieved Kapandji stage 7 or higher; the sixth patient achieved stage 6. No patients experienced any related complications. Figure 2 shows the progression of case 2 from the initial injury (Fig. 2A) through restoration of functional opposition (Fig. 2E).
Discussion Successful use of a silicone tendon implant to create a smooth path for subsequent placement of a tendon graft is well established. Popularized by Hunter et al., 4 this technique has allowed flexor tendon reconstruction in severely injured digits. The use of this technique for opposition tendon transfer was suggested in 1991 by Eversmann 5 and in 1995 by Dr. Peter J. Stern in a contribution to the Members' Correspondence Newsletter of the American Society for Surgery of the Hand. It is ideally suited for cases of extensive soft tissue injury to the volar wrist and palm where the gliding of the tendon transfer would be severely compromised. We use this technique in cases in which placement of a transfer is not feasible without blind tunneling through a previously operated area with extensive scarring due to nerve and vascular graft reconstruction. 6 The advantages of increased
292
Grossman and Pomerance
Staged Opposition Transfer T a b l e 1. Clinical Case S u m m a r y
Case No.
Age at Time of Surgery O'r)
1
3O
2
52
3
29
4
19
Kapandji Stage Injury
Major Procedures
Crush of hand and avulsion of thenar muscles and median motor branch Avulsion median nerve (6 cm), first dorsal compartment tendons, radial artery, and overlying skin Median nerve and multiple flexor tendon lacerations Open fractures of the radius and ulna, laceration of all flexor tendons, median nerve and soft tissue avulsion
First web release and Z-plasty
35
Amputation through the distal humerus with successful replantation
45
Avulsion of palmar skin, thenar muscles and common digital nerve to fourth web space
Lateral arm flap/median nerve reconstruction with sural nerve grafts/first web release and Z-plasty Median nerve reconstruction with sural nerve grafts Multiple flexor tenolyses, skin graft and resection, and soft tissue flaps; first web space release with Z-plasty; reconstruction of the median nerve with sural nerve grafts Metacarpophalangeal joint fusion/median neurolysis
Temporoparietal free flap with split skin graft; release of the first web space and Zplasty; nerve graft reconstruction of the multiple digital nerves
Donor T e n d o n Extensor indicis proprius with palmaris longus graft Extensor indicis proprius
Before After S u r g e r y SurgeO, 3
6
3
7
Extensor indicis proprius Extensor indicis proprius
3
7
3
8
Extensor carpi radialis longus with palmaris longus graft Extensor indicis proprius
3
8
3
7
T a b l e 2, Kapandji Classification for Evaluation of T h u m b Opposition 3 Stage O: Stage 1: Stage 2: Stage 3: Stage Stage Stage Stage Stage Stage
4: 5: 6: 7: 8: 9:
Stage lO:
The tip of the thumb is located on the lateral aspect of the first phalanx of the index finger. The beginning opposition corresponds to the position of the tip of the thumb in contact with the lateral side of the second phalanx of the index finger. The tip of the thumb comes in contact with the lateral side of the third phalanx of the index finger; in this position, longitudinal rotation does not occur. The tip of the thumb touches the tip of the index finger; this position realizes the minimal opposition with a tip-to-tip pinch. The tip of the thumb touches the tip of the middle finger. The tip of the thumb comes in contact with the tip of the ring finger. The tip of the thumb reaches the tip of the little finger. The tip of the thumb crosses the distal interphalangeal joint crease of the little finger. The tip of the thumb crosses the proximal interphalangeal joint crease of the little finger. The tip of the thumb touches the proximal crease of the little finger corresponding to the base of its first phalanx. The tip of the thumb reaches the distal palmar crease of the little finger corresponding to the metacarpophalangeal joint.
The Journal of Hand Surgery / Vol. 23A No. 2 March 1998
293
B
C Figure 2. (A) Initial injury (case 2). (B) Result following soft tissue coverage with lateral arm flap. (C) Distal insertion of rod. (Figure continues)
294
Grossman and Pomerance / Staged Opposition Transfer
D
E Figure 2. (Continued) (D) Final result following completion of 2-stage tendon opposition transfer. (E) Final resul demonstrating functional opposition.
The Journal of Hand Surgery / Vol. 23A No. 2 March 1998
safety and a consistently good functional outcome warrant adding this technique to the armamentarium of the reconstructive hand surgeon.
References l. Burkhalter W, Christensen RC, Brown P. Extensor indicis proprius opponensplasty. J Bone Joint Surg Am 1973;55: 725-732. 2. Smith RJ. Tendon transfers of the hand and forearm. Boston: Little Brown, 1987: 67.
295
3. Kapandji AI. Clinical evaluation of the thumb's opposition. J Hand Ther 1992;5:102-108. 4. Hunter JM, Jaeger SH, Matsui T, Miyaji N. The pseudosynovial sheath--its characteristics in a primate model. J Hand Surg Am 1983;8:461-470. 5. Eversmann WW. Median nerve palsy. In: Gelberman RH, ed. Operative nerve repair and reconstruction. Philadelphia: JB Lippincott, 1991: 726. 6. Wood VE. Nerve compression following opponensplasty as a result of wrist anomalies: report of a case. J Hand Surg Am 1980;5:279-281.