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Two-staged Reconstruction of the Flexor Pollicis Longus Tendon
ARTICLE IN PRESS TWO-STAGED RECONSTRUCTION OF THE FLEXOR POLLICIS LONGUS TENDON F. UNGLAUB, C. BULTMANN, A. REITER and P. HAHN From Handsurgery, Vulpiusklinik, Bad Rappenau, Germany and Handsurgery, Rhon-Klinikum, Bad Neustadt, Germany
The purpose of this study was to evaluate the results of two-stage reconstruction of the flexor pollicis longus (FPL) tendon. Sixteen patients who underwent reconstructive surgery of the FPL tendon were assessed retrospectively. Eight weeks after implantation of a silastic spacer, a tendon graft was used for reconstruction (thirteen palmaris longus tendons, two plantaris tendons, one half of the flexor carpi radialis tendon). Power grip, active range of motion, passive range of motion, the Buck-Gramcko assessment, the ASSH assessment and the DASH score were used to evaluate the results. Adequate function in 75% of the cases and a median of 11 on the DASH score was achieved. The results showed that two-stage reconstruction of the FPL tendon can produce satisfactory results, even if primary repair is the ideal. Journal of Hand Surgery (British and European Volume, 2006) 31B: 4: 432–435 Keywords: flexor pollicis longus tendon, two-staged reconstruction, arthrodesis, functional outcome
Most flexor pollicis longus (FPL) divisions nowadays are repaired primarily and recent studies achieved excellent results (Baer et al., 2003; Sirotakova and Elliot, 1999, 2004; Kasashima et al., 2002). If primary repair is neglected or is impossible, only two alternatives are possible: interphalangeal (IP) joint arthrodesis or tendon reconstruction. Although arthrodesis of the IP joint of the thumb is sufficient for most daily activities, precise function of the thumb tip is required for special tasks. This requires IP joint mobility and a functional FPL musculotendinous unit. Due to its anatomical site and the course of the FPL tendon, which runs at 901 to the line of pull of the muscle when the thumb is in maximal abduction, reconstruction of this tendon is difficult. Although there has been a large experience of one-stage FPL reconstruction before 1970 (Boyes, 1950; Pulvertaft, 1956), there is only one, recent, study of twostage reconstruction of the FPL tendon (Frakking et al., 2000). The purpose of this study was to evaluate the final outcome of a series of 16 two-stage reconstructions of the FPL tendon.
cases, the primary suture, done elsewhere, had ruptured and the patients were send to our hospital after a long delay. These seven patients had undergone a total of 18 operations elsewhere, including primary or secondary repair, tenolysis, pulley reconstruction, nerve suture or grafting and Z-plasty. The seven patients were treated by two-stage reconstruction as no functional gliding channel could be found at exploration. The first part of the reconstruction in our hospital was performed 26 (range 0.5–156) months after the injuries took place. A full passive range of motion is often not present after previous surgery, but at least 75% of the full passive range of motion in comparison to the healthy IP joint is an ideal . Furthermore, no signs of arthritis on X-ray of the IP joint were a prerequisite. As described by Hunter and Schneider (1975), tendon grafting was carried out in two stages. At a first operation, the area of the injury was explored and the FPL tendon and scarred sheath were excised, with preservation of the annular pulleys. A silastic spacer was implanted from the IP joint to the forearm and fixed to the distal tendon stump using non-absorbable sutures. Additional procedures included reconstruction of the A2 pulley in three cases, neurolysis in one case, excision of a neuroma in one case, nerve suture in two cases and nerve grafting in two cases. One arthrolysis of the metacarpophalangeal (MCP) joint was performed, with a rotation flap reconstruction of a skin defect on the thenar area, after release of a severe flexion contracture of the MCP joint and the overlying palmar skin following previous postoperative infection. After 8 weeks, the second stage of the tendon graft was performed using a palmaris longus tendon in 13 cases, a plantaris tendon in two cases and half of the flexor carpi radialis tendon in one case. The latter donor tendon was used because the palmaris longus tendon was absent. The tendon graft was anchored to the end of
PATIENTS AND METHODS Between 1993 and 2000, 22 patients underwent reconstruction of the FPL tendon. Sixteen patients, 10 male and six female, of mean age 38 (range 12–66) years were available for assessment after a mean of 52 (range 15–101) months from final reconstruction. The dominant hand was affected in four cases and the nondominant hand in 12 cases. The FPL tendon was divided by cutting incidents (13 cases), subcutaneous rupture (one case), a circular saw (one case) and by a dog bite (one case). All cases came from outside of our hospital. Two FPL divisions had been neglected entirely. In seven 432
ARTICLE IN PRESS TWO-STAGED RECONSTRUCTION OF THE FLEXOR POLLICIS LONGUS TENDON
the silastic spacer proximally and pulled into the new tendon bed. Distally, bony fixation to the distal phalanx was achieved using the ‘‘button-on-the-nail’’ technique with an absorbable suture (Polydioxone 3-0) (Hunter and Schneider, 1975; Iwuagwu et al., 2003; Kleinert and Verdan, 1983). Proximally, a Pulvertaft weave was used to unite the tendon graft to the FPL musculotendinous unit in the distal forearm. Correct tension was achieved by observation of the IP joint during the wrist tenodesis effect of passive flexion and extension of the wrist. This procedure was followed by intensive physiotherapy for 8 weeks, according to the Kleinert regime (Kleinert and Cash, 1985). Clinical assessment comprised measurement of the range of palmar and radial thumb abduction; passive and active ranges of motion (AROM) of the IP and the MCP joints; opposition to the little finger tip; opposition to the digital palmar crease of the little finger; static power grip at Jamar setting 2 (Jamar, Sammons Preston Inc., Bollingbrook, Illinois, USA); static pinch strength to the pulp of the index finger and to the pulp of the middle finger separately (Baseline Hydraulic Pinch Gauge, Fabrication Enterprises Inc., Irvington, New York, USA); static key pinch grip (Baseline Hydraulic Pinch Gauge, Fabrication Enterprises Inc., Irvington, New York, USA); two-point discrimination and the Moberg pick-up test (Moberg, 1958). The active range of motion results were assessed by the Buck-Gramcko (Buck-Gramcko et al., 1976) and ASSH (Kleinert and Verdan, 1983) techniques. Hand function was assessed using the DASH score (Germann et al., 1999). Subjective function of the thumb pre- and postoperatively was assessed by the patients on a scale of 0 to 10, where 10 is normal and 0 indicates no thumb function possible. The final result of overall hand function was assessed by the patient on a scale of 0 (no function) to 10 (normal function). The numbers in both subjective assessments were later summarised as excellent (9,10), good (6,7,8), fair (3,4,5) and poor (0,1,2).
433
Statistical analysis was performed using Student’s t-test for paired observations. The level of significance was considered to be Po0:05:
RESULTS The results of the 16 two-stage FPL reconstructions are shown in Tables 1–3 and in Fig 1. The mean active range of motion of the IP joint was 751 (range 60–851) for the healthy thumb and 321 (range 10–701) for the operated thumb after reconstruction. This is a significant decrease in IP joint AROM (Po0:05). Thirteen patients could oppose the thumb tip to the tip of the little finger. Only three patients were unable to oppose the thumb to the tip of the little finger. The mean distance between the thumb tip and the little finger tip was 0.5 (range 0–3) cm. The same measurement on the healthy side was mean 0.2 (range 0–2.5) cm. Opposition to the palmar digital crease of the little finger was impossible in 10 patients. The mean distance between the thumb tip and the palmar digital crease was 1.9 (range 0–5) cm. The same measurement on the healthy side was mean 0.2 (range 0–1.5) cm. The power grip of the operated hand (mean 31.8 kg, range 13–60.3 kg), as compared to the healthy hand (mean 36.2, range 14.3–62.7 kg), was significantly decreased ðP ¼ 0:035Þ: Pinch grip strength to the index finger (mean reconstructed thumb 4.9, range 1.2–8.3 kg; mean contralateral thumb 6.7, range 2.7–13 kg) ðP ¼ 0:019Þ and key pinch (mean reconstructed thumb 7.3, range 3.3–11 kg; mean contralateral thumb 9.8, range 5.7–17) ðP ¼ 0:0018Þ were also significantly reduced (Table 3). The results of assessment by the Buck-Gramcko and ASSH methods are shown in Table 4. The median of the DASH score was 11, the mean value was 17.2 (range 0.83–65) points. Based on the findings of Jester et al. (2005) the mean value of 17.2 indicates an only moderately higher DASH score than that found in a non-clinical population ðn ¼ 716Þ; with a DASH score of 13.0. Table 4 also shows the subjective grading and
Table 1—Active ranges of motion of the IP and MCP joints Reconstructed thumb ROM in degrees mean (range) ðn ¼ 16Þ
Contralateral thumb ROM in degrees mean (range) ðn ¼ 16Þ
Maximum IP flexion IP extension deficit Active range of motion IP joint
50 (20–80) 18 (0–55) 32 (10–70)
76 (60–85) 1 (0–10) 75 (60–85)
Maximum MCP flexion MCP extension deficit Active range of motion MCP joint
50 (30–80) 6 (0–40) 44 (5–75)
54 (25–85) 0 54 (25–85)
100 (55–150) 24 (0–75) 76 (20–120)
130 (110–160) 0.6 (0–10) 129 (105–160)
Maximum IP þ MCP flexion IP þ MCP extension deficit Active range of motion IP and MCP joints
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THE JOURNAL OF HAND SURGERY VOL. 31B No. 4 AUGUST 2006
Table 2—Passive and active radial and palmar abduction measurements Reconstructed thumb ROM (degrees) ðn ¼ 16Þ Passive radial abduction Active radial abduction Passive palmar abduction Active palmar abduction
54 49 52 47
(30–75) (30–70) (30–65) (20–60)
Contralateral thumb ROM (degrees) ðn ¼ 16Þ 54 52 53 50
(30–70) (30–65) (30–65) (30–60)
Table 3—Grip and pinch strengths
Mean Mean Mean Mean
Reconstructed thumb (kg) mean (range) ðn ¼ 16Þ
Contralateral thumb (kg) mean (range) ðn ¼ 16Þ
31.8 (13–60.3) 4.9 (1.2–8.3) 4 (1.8–8.3) 7.3 (3.3–11)
36.2 (14.3–62.7) 6.7 (2.7–13) 4.8 (2.7–8.5) 9.8 (5.7–17)
grip strength pinch strength to the index finger pinch strength to the middle finger key pinch strength
Comparison operated and healthy hand (degrees) 140 120
*
100 *
80 60 40 *
refused further surgery. One patient had pulley insufficiency which was evident at follow-up examination, but this did not require operative treatment. One patient developed carpal tunnel syndrome after 6 months, one developed Complex Regional Pain Syndrome Type 1 (Algodystrophy/Reflex Sympathetic Dystrophy), one developed a neuroma and one developed arthritis of the IP joint 36 months after reconstruction. The latter was treated by arthrodesis of the IP joint. Three patients were forced to change their occupations.
20 0 Flexion total IP and MCP
Extension Deficit IP and MCP
operated hand
AROM total IP and MCP
healthy hand
Fig 1 Ranges of motion in comparison to the contralateral side ð ¼ Po0:05Þ (AROM—active range of motion).
the subjective function of the thumb. The pre-topostoperative difference of the subjective function of the thumb indicated a mean improvement of 4.8 points on the Visual Analogue Scale (scale of 0 to 10, where 10 is normal). All patients said they would undergo the operation again. Two patients had to undergo re-operation early because of complications. In one case, the silastic spacer became exposed because of poor skin cover. This was treated by performing the second operation 3 weeks earlier than planned. At this operation, the tendon was covered by use of a local rotational flap. In another case, detachment of the distal bone fixation of the tendon graft occurred 4 days after the second stage reconstruction. This was re-attached successfully 1 day later. Two of the 16 FPL grafts developed adhesions required tenolysis and reconstruction of the pulleys. Another patient had a scar contracture and FPL adhesion. Because the functional deficit was small, the patient
DISCUSSION Whether, or not, it is necessary for the IP joint of the thumb to be mobile is controversial (Frakking et al., 2000; Boyes, 1955; Urbaniak and Goldner, 1973; Van’t Hoff and Heiple, 1958). Results of thumb replantation show that adequate function can be achieved with arthrodesis of the IP joint. However, for precise function, a mobile IP joint and a working FPL are necessary. Most FPL divisions nowadays are repaired primarily (Sirotakova and Elliot, 1999). However, a proportion of patients with divided FPL tendons either are not seen quickly enough for primary, or delayed, primary repair or run into problems after primary repair. In recent times, there has only been one study reporting secondary FPL reconstruction in 10 patients using two-stage tendon grafting (Frakking et al. 2000). The outcome in this study was very disappointing. None of the 10 FPL reconstructions could be graded as excellent, only four were good, two satisfied, and four poor using the BuckGramcko criteria of assessment (Buck-Gramcko et al., 1976). In comparison to the results of primary repair (Baer et al., 2003; Sirotakova and Elliot, 1999, 2004; Kasashima et al., 2002) the results in our study are also poor. A mean active range of motion of the IP joint of 321 is far from normal, the complication rate was high,
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Table 4—Buck-Gramcko, ASSH and subjective assessments
Excellent Good Fair Poor
Buck-Gramcko assessment ðn ¼ 16Þ
ASSH assessment ðn ¼ 16Þ
Subjective assessment of function of the thumb1 ðn ¼ 16Þ
Subjective assessment of overall hand function2 ðn ¼ 16Þ
4 3 5 4
0 4 9 3
3 6 3 4
4 7 4 1
1 Subjective function of the thumb pre- and postoperatively was assessed by the patients on a scale of 0 to 10, where 10 is normal and 0 indicates no thumb function possible. These numbers were summarised as excellent (9,10), good (6,7,8), fair (3,4,5) and poor (0,1,2). 2 The final result of overall hand function was assessed by the patient on a scale of 0 (no function) to 10 (normal function). These numbers were summarised as excellent (9,10), good (6,7,8), fair (3,4,5) and poor (0,1,2).
the time of treatment long and grip strength was reduced. The results from the subjective assessments and the DASH assessment also support this conclusion. The results of two-stage FPL reconstruction do not leave room for complacency and need improvement. They also emphasize the need to attempt primary repair whenever possible. Nevertheless, a reconstructed FPL tendon with, albeit, limited mobility of the IP joint results in better function than an IP joint fusion and patients need only 20–301 of IP joint rapid movement to manipulate fine objects, such as screws, between the thumb tip and the index tip (Khandwala et al., 2004). This goal of active flexion of the IP joint within a range of 201 to 301, was achieved in most of our cases. The decision to reconstruct the FPL when the window of opportunity for immediate primary reconstruction has passed depends on the patient’s personal circumstances, manual and intellectual capabilities. Given the inadequacies of two-stage graft reconstruction of the FPL tendon, the alternative of IP arthrodesis, which is a reliable and quick procedure resulting in fewer complications, should always be considered and will be more suitable for certain patients. However, our results show that a thumb with an IP joint which moves actively through an adequate range of motion to be useful can be achieved by two-stage FPL tendon grafting, even if only with large effort.
References Baer W, Jungwirth N, Wulle C, Schaller P (2003). Die Beugesehnennacht nach Mantero eine Alternative. Handchirurgie Mikrochirurgie Plastiche Chirurgie, 35: 363–367. Boyes JH (1950). Flexor tendon grafts in fingers and thumb. Journal of Bone and Joint Surgery, 32A: 489–499. Boyes JH (1955). Evaluation of results of digital flexor tendon grafts. Journal of Surgery, 89A: 1116–1119. Buck-Gramcko D, Dietrich FE, Gogge S (1976). Evaluation criteria in follow-up studies of flexor tendon repair. Handchirurgie, 8: 65–69. Frakking TG, Depuydt KP, Kon M, Werker PMN (2000). Retrospective outcome analysis of staged flexor tendon reconstruction. Journal of Hand Surgery, 25B: 168–174. Germann G, Wind G, Harth A (1999). The DASH (Disability of ArmShoulder-Hand) Questionnaire—a new instrument for evaluating
upper extremity treatment outcome. Handchirurgie Mikrochirurgie Plastische Chirurgie, 31: 149–152. Hunter JM, Schneider LH. Staged flexor tendon reconstruction: current status. American Academy of Orthopedic Surgeons: Symposium on Tendon Surgery in the Hand. St. Louis, Mosby, 1975: 134–144. Iwuagwu FC, Shaaban H, Lees VC (2003). A biomechanical study of reattachment versus distal multistrand repair in distal division of the flexor digitorum profundus. Journal of Hand Surgery, 28B: 369–372. Jester A, Harth A, Germann G (2005). Measuring levels of upperextremity disability in employed adults using the DASH questionnaire. Journal of Hand Surgery, 30A: 1074.e1–1074.e10. Kasashima T, Kato H, Minami A (2002). Factors influencing prognosis after direct repair of the flexor pollicis longus tendon: multivariate regression model analysis. Hand Surgery, 7: 171–176. Khandwala AR, Blair J, Harris SB, Foster AJ, Elliot D (2004). Immediate repair and early mobilisation of the extensor pollicis longus tendon in zones 1–4. Journal of Hand Surgery, 29B: 250–258. Kleinert HE, Cash SL (1985). Management of acute flexor tendon injuries in the hand. Instructional Course Lectures, 34: 361–372. Kleinert HE, Verdan C (1983). Report of the committee on tendon injuries. Journal of Hand Surgery, 8: 794–798. Moberg E (1958). Objective methods for determining the functional value of the sensibility in the hand. Journal of Bone and Joint Surgery, 40B: 454–476. Pulvertaft GR (1956). Tendon grafts for flexor tendon injuries in the fingers and thumb. Journal of Bone and Joint Surgery, 38B: 175–194. Sirotakova M, Elliot D (1999). Early active mobilization of primary repairs of the flexor pollicis longus tendon. Journal of Hand Surgery, 24B: 647–653. Sirotakova M, Elliot D (2004). Early active mobilization of primary repairs of the flexor pollicis longus tendon with two Kessler twostrand core sutures and a strengthened circumferential suture. Journal of Hand Surgery, 29B: 531–535. Urbaniak JR, Goldner JL (1973). Laceration of the flexor pollicis longus tendon: delayed repair by advancement, free graft or direct suture. Journal of Bone and Joint Surgery, 55A: 1123–1148. Van’t Hoff A, Heiple KG (1958). Flexor tendon injuries of the fingers and thumb. Journal of Bone and Joint Surgery, 40A: 256–262. Received: 29 March 2005 Accepted after revision: 23 February 2006 P. Hahn MD, PhD, Handsurgery, Vulpiusklinik, VulpiusstraXe 29, 74906 Bad Rappenau, Germany. Tel.: +49 7264 60133; fax: +49 7264 60267. E-mail: [email protected]
r 2006 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2006.02.014 available online at http://www.sciencedirect.com
The purpose of this study was to evaluate the results of two-stage reconstruction of the flexor pollicis longus (FPL) tendon. Sixteen patients who underwent reconstructive surgery of the FPL tendon were assessed retrospectively. Eight weeks after implantation of a silastic spacer, a tendon graft was used for reconstruction (thirteen palmaris longus tendons, two plantaris tendons, one half of the flexor carpi radialis tendon). Power grip, active range of motion, passive range of motion, the Buck-Gramcko assessment, the ASSH assessment and the DASH score were used to evaluate the results. Adequate function in 75% of the cases and a median of 11 on the DASH score was achieved. The results showed that two-stage reconstruction of the FPL tendon can produce satisfactory results, even if primary repair is the ideal. Journal of Hand Surgery (British and European Volume, 2006) 31B: 4: 432–435 Keywords: flexor pollicis longus tendon, two-staged reconstruction, arthrodesis, functional outcome
Most flexor pollicis longus (FPL) divisions nowadays are repaired primarily and recent studies achieved excellent results (Baer et al., 2003; Sirotakova and Elliot, 1999, 2004; Kasashima et al., 2002). If primary repair is neglected or is impossible, only two alternatives are possible: interphalangeal (IP) joint arthrodesis or tendon reconstruction. Although arthrodesis of the IP joint of the thumb is sufficient for most daily activities, precise function of the thumb tip is required for special tasks. This requires IP joint mobility and a functional FPL musculotendinous unit. Due to its anatomical site and the course of the FPL tendon, which runs at 901 to the line of pull of the muscle when the thumb is in maximal abduction, reconstruction of this tendon is difficult. Although there has been a large experience of one-stage FPL reconstruction before 1970 (Boyes, 1950; Pulvertaft, 1956), there is only one, recent, study of twostage reconstruction of the FPL tendon (Frakking et al., 2000). The purpose of this study was to evaluate the final outcome of a series of 16 two-stage reconstructions of the FPL tendon.
cases, the primary suture, done elsewhere, had ruptured and the patients were send to our hospital after a long delay. These seven patients had undergone a total of 18 operations elsewhere, including primary or secondary repair, tenolysis, pulley reconstruction, nerve suture or grafting and Z-plasty. The seven patients were treated by two-stage reconstruction as no functional gliding channel could be found at exploration. The first part of the reconstruction in our hospital was performed 26 (range 0.5–156) months after the injuries took place. A full passive range of motion is often not present after previous surgery, but at least 75% of the full passive range of motion in comparison to the healthy IP joint is an ideal . Furthermore, no signs of arthritis on X-ray of the IP joint were a prerequisite. As described by Hunter and Schneider (1975), tendon grafting was carried out in two stages. At a first operation, the area of the injury was explored and the FPL tendon and scarred sheath were excised, with preservation of the annular pulleys. A silastic spacer was implanted from the IP joint to the forearm and fixed to the distal tendon stump using non-absorbable sutures. Additional procedures included reconstruction of the A2 pulley in three cases, neurolysis in one case, excision of a neuroma in one case, nerve suture in two cases and nerve grafting in two cases. One arthrolysis of the metacarpophalangeal (MCP) joint was performed, with a rotation flap reconstruction of a skin defect on the thenar area, after release of a severe flexion contracture of the MCP joint and the overlying palmar skin following previous postoperative infection. After 8 weeks, the second stage of the tendon graft was performed using a palmaris longus tendon in 13 cases, a plantaris tendon in two cases and half of the flexor carpi radialis tendon in one case. The latter donor tendon was used because the palmaris longus tendon was absent. The tendon graft was anchored to the end of
PATIENTS AND METHODS Between 1993 and 2000, 22 patients underwent reconstruction of the FPL tendon. Sixteen patients, 10 male and six female, of mean age 38 (range 12–66) years were available for assessment after a mean of 52 (range 15–101) months from final reconstruction. The dominant hand was affected in four cases and the nondominant hand in 12 cases. The FPL tendon was divided by cutting incidents (13 cases), subcutaneous rupture (one case), a circular saw (one case) and by a dog bite (one case). All cases came from outside of our hospital. Two FPL divisions had been neglected entirely. In seven 432
ARTICLE IN PRESS TWO-STAGED RECONSTRUCTION OF THE FLEXOR POLLICIS LONGUS TENDON
the silastic spacer proximally and pulled into the new tendon bed. Distally, bony fixation to the distal phalanx was achieved using the ‘‘button-on-the-nail’’ technique with an absorbable suture (Polydioxone 3-0) (Hunter and Schneider, 1975; Iwuagwu et al., 2003; Kleinert and Verdan, 1983). Proximally, a Pulvertaft weave was used to unite the tendon graft to the FPL musculotendinous unit in the distal forearm. Correct tension was achieved by observation of the IP joint during the wrist tenodesis effect of passive flexion and extension of the wrist. This procedure was followed by intensive physiotherapy for 8 weeks, according to the Kleinert regime (Kleinert and Cash, 1985). Clinical assessment comprised measurement of the range of palmar and radial thumb abduction; passive and active ranges of motion (AROM) of the IP and the MCP joints; opposition to the little finger tip; opposition to the digital palmar crease of the little finger; static power grip at Jamar setting 2 (Jamar, Sammons Preston Inc., Bollingbrook, Illinois, USA); static pinch strength to the pulp of the index finger and to the pulp of the middle finger separately (Baseline Hydraulic Pinch Gauge, Fabrication Enterprises Inc., Irvington, New York, USA); static key pinch grip (Baseline Hydraulic Pinch Gauge, Fabrication Enterprises Inc., Irvington, New York, USA); two-point discrimination and the Moberg pick-up test (Moberg, 1958). The active range of motion results were assessed by the Buck-Gramcko (Buck-Gramcko et al., 1976) and ASSH (Kleinert and Verdan, 1983) techniques. Hand function was assessed using the DASH score (Germann et al., 1999). Subjective function of the thumb pre- and postoperatively was assessed by the patients on a scale of 0 to 10, where 10 is normal and 0 indicates no thumb function possible. The final result of overall hand function was assessed by the patient on a scale of 0 (no function) to 10 (normal function). The numbers in both subjective assessments were later summarised as excellent (9,10), good (6,7,8), fair (3,4,5) and poor (0,1,2).
433
Statistical analysis was performed using Student’s t-test for paired observations. The level of significance was considered to be Po0:05:
RESULTS The results of the 16 two-stage FPL reconstructions are shown in Tables 1–3 and in Fig 1. The mean active range of motion of the IP joint was 751 (range 60–851) for the healthy thumb and 321 (range 10–701) for the operated thumb after reconstruction. This is a significant decrease in IP joint AROM (Po0:05). Thirteen patients could oppose the thumb tip to the tip of the little finger. Only three patients were unable to oppose the thumb to the tip of the little finger. The mean distance between the thumb tip and the little finger tip was 0.5 (range 0–3) cm. The same measurement on the healthy side was mean 0.2 (range 0–2.5) cm. Opposition to the palmar digital crease of the little finger was impossible in 10 patients. The mean distance between the thumb tip and the palmar digital crease was 1.9 (range 0–5) cm. The same measurement on the healthy side was mean 0.2 (range 0–1.5) cm. The power grip of the operated hand (mean 31.8 kg, range 13–60.3 kg), as compared to the healthy hand (mean 36.2, range 14.3–62.7 kg), was significantly decreased ðP ¼ 0:035Þ: Pinch grip strength to the index finger (mean reconstructed thumb 4.9, range 1.2–8.3 kg; mean contralateral thumb 6.7, range 2.7–13 kg) ðP ¼ 0:019Þ and key pinch (mean reconstructed thumb 7.3, range 3.3–11 kg; mean contralateral thumb 9.8, range 5.7–17) ðP ¼ 0:0018Þ were also significantly reduced (Table 3). The results of assessment by the Buck-Gramcko and ASSH methods are shown in Table 4. The median of the DASH score was 11, the mean value was 17.2 (range 0.83–65) points. Based on the findings of Jester et al. (2005) the mean value of 17.2 indicates an only moderately higher DASH score than that found in a non-clinical population ðn ¼ 716Þ; with a DASH score of 13.0. Table 4 also shows the subjective grading and
Table 1—Active ranges of motion of the IP and MCP joints Reconstructed thumb ROM in degrees mean (range) ðn ¼ 16Þ
Contralateral thumb ROM in degrees mean (range) ðn ¼ 16Þ
Maximum IP flexion IP extension deficit Active range of motion IP joint
50 (20–80) 18 (0–55) 32 (10–70)
76 (60–85) 1 (0–10) 75 (60–85)
Maximum MCP flexion MCP extension deficit Active range of motion MCP joint
50 (30–80) 6 (0–40) 44 (5–75)
54 (25–85) 0 54 (25–85)
100 (55–150) 24 (0–75) 76 (20–120)
130 (110–160) 0.6 (0–10) 129 (105–160)
Maximum IP þ MCP flexion IP þ MCP extension deficit Active range of motion IP and MCP joints
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Table 2—Passive and active radial and palmar abduction measurements Reconstructed thumb ROM (degrees) ðn ¼ 16Þ Passive radial abduction Active radial abduction Passive palmar abduction Active palmar abduction
54 49 52 47
(30–75) (30–70) (30–65) (20–60)
Contralateral thumb ROM (degrees) ðn ¼ 16Þ 54 52 53 50
(30–70) (30–65) (30–65) (30–60)
Table 3—Grip and pinch strengths
Mean Mean Mean Mean
Reconstructed thumb (kg) mean (range) ðn ¼ 16Þ
Contralateral thumb (kg) mean (range) ðn ¼ 16Þ
31.8 (13–60.3) 4.9 (1.2–8.3) 4 (1.8–8.3) 7.3 (3.3–11)
36.2 (14.3–62.7) 6.7 (2.7–13) 4.8 (2.7–8.5) 9.8 (5.7–17)
grip strength pinch strength to the index finger pinch strength to the middle finger key pinch strength
Comparison operated and healthy hand (degrees) 140 120
*
100 *
80 60 40 *
refused further surgery. One patient had pulley insufficiency which was evident at follow-up examination, but this did not require operative treatment. One patient developed carpal tunnel syndrome after 6 months, one developed Complex Regional Pain Syndrome Type 1 (Algodystrophy/Reflex Sympathetic Dystrophy), one developed a neuroma and one developed arthritis of the IP joint 36 months after reconstruction. The latter was treated by arthrodesis of the IP joint. Three patients were forced to change their occupations.
20 0 Flexion total IP and MCP
Extension Deficit IP and MCP
operated hand
AROM total IP and MCP
healthy hand
Fig 1 Ranges of motion in comparison to the contralateral side ð ¼ Po0:05Þ (AROM—active range of motion).
the subjective function of the thumb. The pre-topostoperative difference of the subjective function of the thumb indicated a mean improvement of 4.8 points on the Visual Analogue Scale (scale of 0 to 10, where 10 is normal). All patients said they would undergo the operation again. Two patients had to undergo re-operation early because of complications. In one case, the silastic spacer became exposed because of poor skin cover. This was treated by performing the second operation 3 weeks earlier than planned. At this operation, the tendon was covered by use of a local rotational flap. In another case, detachment of the distal bone fixation of the tendon graft occurred 4 days after the second stage reconstruction. This was re-attached successfully 1 day later. Two of the 16 FPL grafts developed adhesions required tenolysis and reconstruction of the pulleys. Another patient had a scar contracture and FPL adhesion. Because the functional deficit was small, the patient
DISCUSSION Whether, or not, it is necessary for the IP joint of the thumb to be mobile is controversial (Frakking et al., 2000; Boyes, 1955; Urbaniak and Goldner, 1973; Van’t Hoff and Heiple, 1958). Results of thumb replantation show that adequate function can be achieved with arthrodesis of the IP joint. However, for precise function, a mobile IP joint and a working FPL are necessary. Most FPL divisions nowadays are repaired primarily (Sirotakova and Elliot, 1999). However, a proportion of patients with divided FPL tendons either are not seen quickly enough for primary, or delayed, primary repair or run into problems after primary repair. In recent times, there has only been one study reporting secondary FPL reconstruction in 10 patients using two-stage tendon grafting (Frakking et al. 2000). The outcome in this study was very disappointing. None of the 10 FPL reconstructions could be graded as excellent, only four were good, two satisfied, and four poor using the BuckGramcko criteria of assessment (Buck-Gramcko et al., 1976). In comparison to the results of primary repair (Baer et al., 2003; Sirotakova and Elliot, 1999, 2004; Kasashima et al., 2002) the results in our study are also poor. A mean active range of motion of the IP joint of 321 is far from normal, the complication rate was high,
ARTICLE IN PRESS TWO-STAGED RECONSTRUCTION OF THE FLEXOR POLLICIS LONGUS TENDON
435
Table 4—Buck-Gramcko, ASSH and subjective assessments
Excellent Good Fair Poor
Buck-Gramcko assessment ðn ¼ 16Þ
ASSH assessment ðn ¼ 16Þ
Subjective assessment of function of the thumb1 ðn ¼ 16Þ
Subjective assessment of overall hand function2 ðn ¼ 16Þ
4 3 5 4
0 4 9 3
3 6 3 4
4 7 4 1
1 Subjective function of the thumb pre- and postoperatively was assessed by the patients on a scale of 0 to 10, where 10 is normal and 0 indicates no thumb function possible. These numbers were summarised as excellent (9,10), good (6,7,8), fair (3,4,5) and poor (0,1,2). 2 The final result of overall hand function was assessed by the patient on a scale of 0 (no function) to 10 (normal function). These numbers were summarised as excellent (9,10), good (6,7,8), fair (3,4,5) and poor (0,1,2).
the time of treatment long and grip strength was reduced. The results from the subjective assessments and the DASH assessment also support this conclusion. The results of two-stage FPL reconstruction do not leave room for complacency and need improvement. They also emphasize the need to attempt primary repair whenever possible. Nevertheless, a reconstructed FPL tendon with, albeit, limited mobility of the IP joint results in better function than an IP joint fusion and patients need only 20–301 of IP joint rapid movement to manipulate fine objects, such as screws, between the thumb tip and the index tip (Khandwala et al., 2004). This goal of active flexion of the IP joint within a range of 201 to 301, was achieved in most of our cases. The decision to reconstruct the FPL when the window of opportunity for immediate primary reconstruction has passed depends on the patient’s personal circumstances, manual and intellectual capabilities. Given the inadequacies of two-stage graft reconstruction of the FPL tendon, the alternative of IP arthrodesis, which is a reliable and quick procedure resulting in fewer complications, should always be considered and will be more suitable for certain patients. However, our results show that a thumb with an IP joint which moves actively through an adequate range of motion to be useful can be achieved by two-stage FPL tendon grafting, even if only with large effort.
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r 2006 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2006.02.014 available online at http://www.sciencedirect.com