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Toe-to-finger free flexor tendon transfer for digital flexion reconstruction
SD
THE JOURNAL OF HAND SURGERY VOL. 28R SUPPLEMENT I
at the base of the proximal phalanx and the overprojection of the adjacent phalanges. In the event of tendon adhesion, rupture or noticeable crepitation of the flexor tendon during digital movements after osteosynthesis of proximal phalangeal fractures, tendon attritiominitation by the imphanted material has to be considered.
lot). TWO-STAGE FLEXOR TENDON RECONSTRUCTION IN ZONE II USING A SILICONE ROD AND A PEDICLED INTRASYNOVIAL GRAFT (THE MODIFIED PANEVA TECHNIQUE)
Nickolaos Darlis, A.E. Beris, A.V. Korompilias, M.D. Vekris, G.I. Mitsionis, PN. Soucacos. University ofloannina, School of Medicine, Depurtment of Orthopaedic Surgev, Greece
Ioannina,
Two-stage flexor tendon reconstruction with silicone rods and a free graft (Hunter technique) is the most widely accepted treatment for a scarred flexor tendon system in zone II (Boyes grade 2 to 5). Nevertheless this procedure presents technical difficulties some of which can be overcome by its combination with the long known Paneva technique. This modified Paneva technique includes creating a loop between the proximal stumps of Flexor Digitorum Profundus and Superfmialis in the first stage and reflecting the latter as a “pedicled” graft through the pseudosheath created around the silicone rod, in the second stage. We present 21 patients (23 digits) with zone II injuries, a mean age of 24 years and a mean follow up of 50 months (minimum 1 year). At follow-up examination the range of motion, grip and pinch strength and the effect of concomitant injuries were assessed. The rate of good and excellent results was 82% in the Buck-Gramco scale and 73% in the modified Strickland scale. The results compare favorably to those of conventional two stage flexor tendon grafts. Apart from technical versatility, additional advantages of the technique include using a local intrasynovial graft, the absence of donor site morbidity and a low rate of post- reconstruction tendon rupture or tendon adhesion.
101. TOE-TO-FINGER FREE FLEXOR TENDON TRANSFER FOR DIGITAL FLEXION RECONSTRUCTION
Joseph Bakhacht. E. Demiri2, J. Sentucq-Riga13, R. Boileau3, B. Panconi’, J.C. Guimberteau”. ‘Institut Aquifain de la Main, Clinique Tourny, 54 Rue Huguerie, 33000 Bordeaux, France; 2Plastic Surgery Department, Aristote University of Thessaloniki, Greece; 31nstitutAquitain de la Main, Bordeaux, France
Flexor tendon repair has always been a challenge for hand surgeons, particularly, when injuries are situated on zone Il. Posttraumatic adhesions usually require secondary operations and may often result in compromised digital motion and hand function. As the disadvantages of the two-staged reconstruction are known, vascularised tendon transfer has already been proposed; the superficialis flexor tendon of the ring finger, based on the uhrar vascular pedicle, has been used to reconstruct digital flexion. Based on this “idea” of pedicled tendon transfer, which however may not be use-
ful in cases with extended injury of the entire flexion mechanism, we transferred the flexor mechanism of the second toe as a free composite flap and repaired “en bloc” and as a single operation, the flexor tendons, digital theta and palmar plates of a long finger. This composite flap is based on the medial plantar vessels and contains both flexor tendons of the second toe. with their digital sheath and pulleys. An anatomical study carried out previously, describes the different types of vascular basis of the flap and confirm the safety of the transfer. We report six clinical cases, where this technique was performed with satisfactory functional results. Problems with donor site morbidity were not recorded. Indications and advantages of this free tendon transfer are also discussed.
102. THE DROP THUMB: PALSY OR KUPYUKE? Gareth Stables, L. Benyon, ES. Fahmy. Countess #Chester Hospital, Countess qf Chester Health Park, Liverpool Road Local. CH2 Chestel; UK A case of non-traumatic isolated extensor pollicis longus, extensor pollicis brevis and abductor pollicis longus dysfunction is reported, highlighting the dilemma faced by the surgeon in the diagnosis and treatment of such cases. Acute isolated total loss of the function of the thumb extensors in the absence of penetrating injuries is rare. Closed rupture of the Extensor Pollicis Longus (EPL) is the most likely diagnosis in such presentations. This is usually secondary to fracture of the distal radius or arthritis. The incidence of spontaneous rupture following fracture radius is less than 0.2% of all Colle’s fracture and of these 93% are undisplaced. Repeated minor trauma, as described in the Prussian army as an occupational hazard of drummer boys, can also precipitate closed ruptures. In this paper an isolated non-traumatic paralysis of all the thumb extensors is presented. This could be easily mistaken for, closed EPL rupture. Also the exclusion of malingering is very difficult. This is a very local&d variation of PIN palsy. Four patterns of PIN Palsy have been previously described. In our patient EPL, EPB and APL are affected. This is a very rare presentation that has not been described to in the past. Diagnosis is difficult. Plain hand X-rays did not reveal any underlying pathology. Initial exploratory procedure showed an intact EPL tendon. Further physical exemination, MRI, EMG and histology of the EPL muscle indicated that the loss of function of the thumb extensors is possibly secondary to palsy of one of the PIN branches. As the PIN supplies the thumb extensors and other muscles available for tendon transfer, the management of this localised nerve palsy presents a dilemma to the surgeon. Preoperative assessment of the function of the Extensor Tndicis muscle is also difficult. To our knowledge, total isolated paralytic loss of function of the thumb extensors was rarely reported. The key features to establish diagnosis of such uncommon condition will be discussed. The “0 degree - Extension Lag test” to preoperatively assess the independent function of El tendon will be described. The different surgical approaches and the choice 01 the most suitable procedure will be referred to. The anatomical variation of the patterns of nerve supply to the extensor muscles from the PIN branches will be covered. Awareness of such a rare presentation is essential to establish early accurate diagnosis and eliminate unnecessary surgical procedures.
THE JOURNAL OF HAND SURGERY VOL. 28R SUPPLEMENT I
at the base of the proximal phalanx and the overprojection of the adjacent phalanges. In the event of tendon adhesion, rupture or noticeable crepitation of the flexor tendon during digital movements after osteosynthesis of proximal phalangeal fractures, tendon attritiominitation by the imphanted material has to be considered.
lot). TWO-STAGE FLEXOR TENDON RECONSTRUCTION IN ZONE II USING A SILICONE ROD AND A PEDICLED INTRASYNOVIAL GRAFT (THE MODIFIED PANEVA TECHNIQUE)
Nickolaos Darlis, A.E. Beris, A.V. Korompilias, M.D. Vekris, G.I. Mitsionis, PN. Soucacos. University ofloannina, School of Medicine, Depurtment of Orthopaedic Surgev, Greece
Ioannina,
Two-stage flexor tendon reconstruction with silicone rods and a free graft (Hunter technique) is the most widely accepted treatment for a scarred flexor tendon system in zone II (Boyes grade 2 to 5). Nevertheless this procedure presents technical difficulties some of which can be overcome by its combination with the long known Paneva technique. This modified Paneva technique includes creating a loop between the proximal stumps of Flexor Digitorum Profundus and Superfmialis in the first stage and reflecting the latter as a “pedicled” graft through the pseudosheath created around the silicone rod, in the second stage. We present 21 patients (23 digits) with zone II injuries, a mean age of 24 years and a mean follow up of 50 months (minimum 1 year). At follow-up examination the range of motion, grip and pinch strength and the effect of concomitant injuries were assessed. The rate of good and excellent results was 82% in the Buck-Gramco scale and 73% in the modified Strickland scale. The results compare favorably to those of conventional two stage flexor tendon grafts. Apart from technical versatility, additional advantages of the technique include using a local intrasynovial graft, the absence of donor site morbidity and a low rate of post- reconstruction tendon rupture or tendon adhesion.
101. TOE-TO-FINGER FREE FLEXOR TENDON TRANSFER FOR DIGITAL FLEXION RECONSTRUCTION
Joseph Bakhacht. E. Demiri2, J. Sentucq-Riga13, R. Boileau3, B. Panconi’, J.C. Guimberteau”. ‘Institut Aquifain de la Main, Clinique Tourny, 54 Rue Huguerie, 33000 Bordeaux, France; 2Plastic Surgery Department, Aristote University of Thessaloniki, Greece; 31nstitutAquitain de la Main, Bordeaux, France
Flexor tendon repair has always been a challenge for hand surgeons, particularly, when injuries are situated on zone Il. Posttraumatic adhesions usually require secondary operations and may often result in compromised digital motion and hand function. As the disadvantages of the two-staged reconstruction are known, vascularised tendon transfer has already been proposed; the superficialis flexor tendon of the ring finger, based on the uhrar vascular pedicle, has been used to reconstruct digital flexion. Based on this “idea” of pedicled tendon transfer, which however may not be use-
ful in cases with extended injury of the entire flexion mechanism, we transferred the flexor mechanism of the second toe as a free composite flap and repaired “en bloc” and as a single operation, the flexor tendons, digital theta and palmar plates of a long finger. This composite flap is based on the medial plantar vessels and contains both flexor tendons of the second toe. with their digital sheath and pulleys. An anatomical study carried out previously, describes the different types of vascular basis of the flap and confirm the safety of the transfer. We report six clinical cases, where this technique was performed with satisfactory functional results. Problems with donor site morbidity were not recorded. Indications and advantages of this free tendon transfer are also discussed.
102. THE DROP THUMB: PALSY OR KUPYUKE? Gareth Stables, L. Benyon, ES. Fahmy. Countess #Chester Hospital, Countess qf Chester Health Park, Liverpool Road Local. CH2 Chestel; UK A case of non-traumatic isolated extensor pollicis longus, extensor pollicis brevis and abductor pollicis longus dysfunction is reported, highlighting the dilemma faced by the surgeon in the diagnosis and treatment of such cases. Acute isolated total loss of the function of the thumb extensors in the absence of penetrating injuries is rare. Closed rupture of the Extensor Pollicis Longus (EPL) is the most likely diagnosis in such presentations. This is usually secondary to fracture of the distal radius or arthritis. The incidence of spontaneous rupture following fracture radius is less than 0.2% of all Colle’s fracture and of these 93% are undisplaced. Repeated minor trauma, as described in the Prussian army as an occupational hazard of drummer boys, can also precipitate closed ruptures. In this paper an isolated non-traumatic paralysis of all the thumb extensors is presented. This could be easily mistaken for, closed EPL rupture. Also the exclusion of malingering is very difficult. This is a very local&d variation of PIN palsy. Four patterns of PIN Palsy have been previously described. In our patient EPL, EPB and APL are affected. This is a very rare presentation that has not been described to in the past. Diagnosis is difficult. Plain hand X-rays did not reveal any underlying pathology. Initial exploratory procedure showed an intact EPL tendon. Further physical exemination, MRI, EMG and histology of the EPL muscle indicated that the loss of function of the thumb extensors is possibly secondary to palsy of one of the PIN branches. As the PIN supplies the thumb extensors and other muscles available for tendon transfer, the management of this localised nerve palsy presents a dilemma to the surgeon. Preoperative assessment of the function of the Extensor Tndicis muscle is also difficult. To our knowledge, total isolated paralytic loss of function of the thumb extensors was rarely reported. The key features to establish diagnosis of such uncommon condition will be discussed. The “0 degree - Extension Lag test” to preoperatively assess the independent function of El tendon will be described. The different surgical approaches and the choice 01 the most suitable procedure will be referred to. The anatomical variation of the patterns of nerve supply to the extensor muscles from the PIN branches will be covered. Awareness of such a rare presentation is essential to establish early accurate diagnosis and eliminate unnecessary surgical procedures.