Leprosy and thumb reconstruction by opponensplasty or phalangizing the first metacarpal.

Two relatively simple procedures and can improve thumb function in leprosy (Hansen's disease): one provides opposition for the thumb by an indicis proprius transfer; the other provides grasp for the hand lacking digits by phalangizing the first metacarpal.     

胸小肌移植重建拇对掌功能的解剖与临床研究

目的研究选择性胸小肌移植重建拇对掌功能术式的临床解剖基础及临床治疗的效果。方法在20侧成人尸体胸部及上肢标本上，观测和比较胸小肌及拇对掌肌的解剖数据，行移植模拟试验以评估新术式的可行性；依据解剖研究结果，按新的手术方式施行临床手术治疗5例，术后随访拇对掌功能恢复情况。结果解剖研究结果显示：胸小肌位置恒定，具备独立的动、静脉和神经支配；移植肌与受区对掌肌匹配；临床手术治疗5例，术后随访6～12个月，拇对掌功能恢复，肌力均达到4级以上，大鱼际部外形满意。结论胸小肌移植重建拇对掌功能这一术式有其临床解剖基础，移植手术能达到恢复对掌功能的要求，是一种新的对掌功能重建方法。     

Traumatized index finger pollicization for thumb reconstruction

PURPOSE: When the index finger is injured or severed in conjunction with a traumatic amputation of the thumb, transfer of the injured index finger can restore the important function of the thumb. The purpose of this study is to evaluate the results of the transfer of an injured index finger for traumatic loss of the thumb. METHODS: Seven patients treated by pedicled transfer of a traumatized index finger after amputation to the ipsilateral thumb were reviewed retrospectively. Postoperative evaluations included thumb range of motion, opposition and pinch function, grasp and pinch strength, sensation, a pick-up test, and a patient-rated appearance of the thumb and hand. Vascular patency of the traumatized index finger and thumb was evaluated in each patient prior to thumb reconstruction. RESULTS: After an average of 4 years of follow-up for surviving patients, all had excellent postoperative function and satisfactory results. The period between injury and thumb reconstruction ranged from 5 months to 4 years. All patients were men with a mean age of 43 years. Amputation levels included the metacarpophalangeal joint in 2 patients, the first metacarpal in 2 patients, and the proximal phalanx in 3 patients. All transferred traumatic index fingers survived without complications. CONCLUSIONS: Transfer of the injured index finger to the amputated thumb serves as an excellent adjunct for treatment of traumatic thumb amputations/crush injuries. Consistent results can be obtained while maintaining opposition and protective sensation after this procedure. However, technical demands are great, and initial injuries to the thumb and index finger ultimately determine the final outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

采用掌骨部分移位重建改良Blauth 3B及3C型发育不良拇指的疗效观察

目的 观察第2掌骨纵向半侧骨干移位和二期拇对掌功能重建治疗改良Blauth 3B和3C型拇指发育不良的疗效.方法 2013年12月至2018年6月,复旦大学附属华山医院手外科收治的改良Blauth3B和3C型患儿资料12例.将第2掌骨纵向半侧移位延长第1掌骨,稳定第一腕掌关节.确认骨折愈合后,二期行肌腱移位拇对掌功能重...     

Treatment of a type 3B hypoplastic thumb using extra phalanges from the contralateral duplicated thumb: case report

A boy was born with a right duplicated thumb (Wassel type 6) and a left radial club hand (type 3) associated with a hypoplastic thumb (type 3B). He underwent surgical centralization of the left wrist when he was 13 months old. At age 38 months, he underwent reconstruction of the carpometacarpal joint of the hypoplastic left thumb. This procedure involved transplantation of the radial ray of the right duplicated thumb to the base of the left thumb. When he was 6 years old, the patient underwent an abductor digiti minimi muscle transfer to create opposition for the left thumb and deepening of the first web. At the final follow-up, he could grasp items in the first web space and pick up small items between the thumb and other digits of the left hand. The treatment represents a method of using otherwise discarded tissues for effective reconstruction.     

Functional evaluation of early tendon transfer for thumb opposition in median nerve palsy

BackgroundThere is paucity of literature on early tendon transfer in surgical rehabilitation of hands with median nerve injuries. Since the single most important functional deficit in median nerve palsy is the loss of thumb opposition, we evaluated the results of early tendon transfer in restoration of thumb opposition.MethodsThis prospective study involved 10 cases of isolated median nerve paralysis (axonotmesis or neurotmesis) that underwent early tendon transfer for restoration of thumb opposition. A pre- and post-operative evaluation in terms of power and precision grip strength and range of opposition of thumb was done. Median nerve exploration was performed in 4 cases and was supplemented by a tendon transfer for thumb opposition. The extensor indicis proprius (EIP) opponensplasty was performed in nine out of ten cases. In one case where the patient had scarring over the EIP tendon, palmaris longus (PL) opponensplasty was performed.ResultsThe median age at injury was 29 years (range; 8 years–57 years). Minimum period of follow-up was 6 months. Six patients who underwent EIP transfer had excellent opposition while 3 had good opposition. The patient, in whom PL opponensplasty was done, had an excellent opposition. The median time for return to work was 2.75 months.There was significant improvement in the power grip and all three types of precision grip at 6 months follow-up. The percentage deficit in the affected hand compared to the normal hand was significantly reduced. There was no case of tendon pull out in our study, nor did any of our patients have an extensor lag following EIP transfer.ConclusionEarly tendon transfer has a unique role in the management of median nerve palsy hand and we suggest this procedure should be considered in both high and low lesions.     

拇外展功能重建不同术式的比较

目的 通过对128例拇外展功能受损患的病例统计，列出常用手术方法，并通过比较得出不同方法的使用频率及结果优劣。方法按动力、伤因、神经损伤部位、神经损伤数及有无肌腱移植，进行列表统计，以找出规律。并强调了转移肌腱的方向应与拇短展肌轴线方向一致。结果术后经长期随访，环指屈指浅肌、掌长肌、尺侧伸腕肌等应用最多，平均优良率为87．2％，小指外展肌、屈拇短肌等例数较少，但效果很好，值得推广。结论各种伤因所致正中神经损伤及大鱼际肌损伤，均可导致拇指外展功能障碍，只要腕关节及腕掌关节被动活动良好，有良好的动力来源，就应考虑肌腱移位手术，修复拇指外展功能。     

Tendon transfer for median nerve palsy

A large number of tendon transfers have been described that restore opposition to the thumb and provide thumb and finger flexion. To provide optimal results following tendon transfers, one needs to follow the principles of tendon transfer: normal tissue equilibrium, movable joints, and a scar-free bed. Once these are present, we must look to available tables to determine an appropriate tendon transfer, matching up the lost muscle mass, fiber length, and cross-sectional area and then pick out muscle-tendon units of similar size, strength, and potential excursion. For low median nerve palsy (Table 4), we have found from our experimental and clinical studies that the FDS of the long and ring fingers or the wrist extensors (ECR or ECRL) best approximate the force and motion required for full thumb opposition and strength. These transfers are preferred in median nerve palsy or combined median ulnar nerve palsy when both strength and motion are required. In circumstances where only thumb mobility is desired, the EIP is an ideal transfer. Also, the extensor digitorum quinti (EDQ) and ADQ have sufficient mean fiber length (muscle excursion) to provide full thumb opposition. The palmaris longus transfer (Camitz transfer) is an abduction rather than an opposition transfer and should be reserved for selected cases of long-term carpal tunnel syndrome. For high median nerve palsy (Table 5), transfers of the brachioradialis or ECRL to restore lost thumb flexion (FPL) and side-to-side transfer of the FDP of the index finger are generally sufficient. A separate transfer to restore independent flexion of the index finger could be performed by utilizing the pronator teres or extensor carpi radialis ulnaris tendon muscle units. As they combine a proper direction of action, pulley location, and tendon insertion, tendon transfers for median nerve palsy are usually quite successful. In considering any of these elective procedures, however, it is important to remember that tendon transfers are muscle balance operations. The effect of transfer on restoring function must be carefully studied to assess the loss of function that such a transfer may endure.     

拇指对掌功能重建的临床应用

目的 评价尺侧腕伸肌-拇短伸肌腱移位术的临床疗效。方法 通过对20侧新鲜成人尸体上肢标本的应用解剖学研究，建立以尺侧腕伸肌为动力肌，拇短伸肌腱移位术的解剖模型，并观察到该肌腱移位后的走行和拇短展肌的走行基本一致，并有旋前功能。2004年2月-2005年1月，对6例拇指对掌功能丧失者，实施肌腱移位术重建拇指对掌功能。结果 术后随访3～12个月，拇指对掌功能满意。6例中优5例，良1例，优良率为100％。结论 尺侧腕伸肌-拇短伸肌腱移位术，手术方式简单，重建拇指对掌功能效果满意。     

Opposition of the thumb: an anatomic and biomechanical study of tendon transfers

Tendon transfers for opposition of the thumb were anatomically and biomechanically studied to help determine the optimal criteria for selecting the best motor unit for a transfer. Forearm and hand muscle volume, mean fiber length, and cross-sectional area were measured in eight fresh specimens of the upper extremity to determine which muscles best replace lost thenar muscle strength. In a separate group of 18 specimens, the effective moment arms for abduction and flexion of the first metacarpal were calculated in vitro and from biplanar radiographic techniques to determine the effect of eight different opposition transfers on thumb abduction, rotation, and strength. Results of these studies demonstrate that the transfers of flexor digitorum superficialis (FDS) of the long finger and extensor carpi ulnaris best replaced lost thenar muscle strength and provided maximal abduction and near full thumb rotation. The transfers of the extensor carpi radialis longus and the FDS of the ring finger replaced 60% and 40% of required thenar muscle strength, respectively. The palmaris longus was the least effective transfer, having good abduction but weak flexion and opposition. Motion, balance, and strength of tendon transfers must be considered for effective thumb opposition.     

Transfer of extensor carpi radialis longus or brevis for opponensplasty

For the restoration of thumb opposition many types of tendon transfer techniques have been described. The flexor digitorum superficialis (FDS) of the ring finger is commonly selected as a motor. On occasion, however, the quality of the flexor muscles of the fingers or wrist is not good enough for tendon transfer and another available muscle must be selected. In this situation, we have preferred to use an extensor carpi radialis longus (ECRL) or brevis (ECRB) transfer to restore opposition of the thumb. Follow-up examination, at an average 5 years and 10 months after operation, showed that the results of ten of 11 transfers were excellent and the other was good.     

拇对掌功能重建的新方法

目的 介绍一种简单、有效的拇对掌功能重建新方法。方法 对8例拇对掌功能丧失的患者，采用尺侧腕伸肌为动力肌，拇长伸肌腱改道后(沿拇短展肌方向作一皮下隧道，将拇长伸肌腱沿皮下隧道引至腕上1cm处掌尺侧直切口内)，牵拉改道后之拇长伸肌腱，使拇指呈对掌旋前伸拇位时，将拇长伸肌腱与尺侧腕伸肌腱作编结缝合重建拇对掌功能。结果 术后随访4～11个月，平均8．5个月，8例的拇对掌功能均恢复，达100％的有效率。除1例伸拇功能有轻微影响外，余7例均无明显障碍。结论 该术式是一种简单、有效而可靠的重建拇对掌功能的新方法。     

Unusual complication of an opposition tendon transfer at the wrist: ulnar nerve compression syndrome

Restoration of thumb opposition by tendon transfer may be necessary in cases of severe thenar atrophy caused by long-standing carpal tunnel syndrome. Routing the extensor indicis proprius transfer subcutaneously around the ulna to reanimate thumb opposition is an accepted procedure and is considered safe. Ulnar nerve compression leading to palsy is possible, however, as shown in the patient presented. Neurolysis failed to improve the palsy. Rerouting of the transfer deep to the ulnar nerve was necessary to treat the iatrogenic condition. Possible nerve compression should be kept in mind when planning a tendon transfer around the ulnar side of the forearm or carpus and when following up with the patient. Early intervention is necessary to prevent permanent sequelae.     

Biomechanical evaluation of thumb opposition transfer insertion sites

The optimal location for insertion of the transferred tendon in opposition transfer is controversial. The purpose of this study was to examine 4 commonly used insertion sites into the thumb and determine which maximizes thumb opposition. The flexor digitorum superficialis of the ring finger was used as a donor tendon and was attached in random order to the abductor pollicis brevis (APB) tendon, the APB and extensor pollicis longus, the flexor pollicis brevis (FPB) and dorsal radial extensor hood, and the ulnar extensor hood at the base of the proximal phalanx. As normal opposition was simulated, the minimum distance between the thumb and little finger and the pinch force were measured. The FPB and radial dorsal extensor hood site resulted in the statistically highest pinch force. The FPB and radial dorsal extensor hood and the APB sites had statistically smaller minimum distances between the thumb and little finger than the ulnar extensor hood site. A subjective evaluation of the 3-dimensional thumb path of motion revealed that the FPB and radial dorsal extensor hood site and the APB insertion site allowed the closest approximation of normal thumb opposition. This biomechanical study supports the use of the FPB and radial dorsal extensor hood insertion site or APB insertion site for opposition transfers.     

Immediate active mobilization versus immobilization for opposition tendon transfer in the hand

PURPOSE: To test the hypothesis that immediate postoperative active mobilization of the hand after opposition tendon transfer will achieve outcomes similar to those of the standard practice of cast immobilization. METHODS: Five hands with isolated lower median nerve paralysis prospectively had opposition tendon transfer followed by immediate postoperative active mobilization for rehabilitation of the transfer. Historical records of 7 identical paralyses with opposition tendon transfers immobilized after surgery in a cast for 3 weeks were used for comparison. Outcomes were assessed by (1) the status of tendon transfer attachment to the thumb during immediate mobilization to detect tendon pullout, (2) the results of the opposition transfers for both groups using identical outcome measures (range of postoperative active abduction of the thumb, pinch pattern, pinch strength), and (3) comparison of the results from both groups. RESULTS: There were no incidences of tendon pullout during immediate active mobilization of opposition tendon transfer. There were no differences in outcome between the 2 groups at late follow-up evaluations, with all opposition transfers achieving good results. Immediate postoperative active mobilization reduced rehabilitation time by an average of 19 days. An earlier return to activities of daily living was a further benefit to patients. CONCLUSIONS: This study supports the hypothesis and suggests that similar outcomes can be achieved in reduced time by immediate active mobilization of opposition tendon transfer. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.     

Blauth II thumb hypoplasia: a management algorithm for the unstable metacarpophalangeal joint

Blauth Type II thumb hypoplasia is defined by first web space narrowing, deficiency of thenar musculature, and instability of the metacarpophalangeal joint (MCPJ). This instability can be uni-axial (type IIA) or multi-axial (type IIB). The aim of this study was to assess the results of treating type II thumb hypoplasia using an algorithm based on the type of instability present. Cases of uni-axial MCPJ laxity (type IIA) underwent stabilization as part of a flexor digitorum superficialis opposition transfer. Type IIB cases with multi-axial instability were treated with an MCPJ chondrodesis and an abductor digit minimi transfer for opposition. First web space release was achieved using a z-plasty approach in all patients. An analysis was carried out of all cases of type II thumb hypoplasia treated by the senior author within the setting of a tertiary referral children's hospital over a 9 year period. Using our management algorithm, equivalent functional results were seen in each subgroup in terms of first web space release, MCPJ stabilization, and opposition.     

Tendon transfers for thumb opposition: a biomechanical study of pulley location and two insertion sites

PURPOSE:The purpose of this biomechanical study was to test 5 proximal tendon pulley sites or routes of tendon transfer and 2 distal tendon insertion sites that are used commonly for performing a thumb opposition transfer. METHODS: Five fresh-frozen cadaver arms were used to test (1) an around flexor carpi ulnaris (FCU) pulley, (2) an FCU loop pulley, (3) a Guyon's canal pulley, (4) a junction of the distal edge of the transverse carpal ligament and the ulnar border of the palmar aponeurosis (Royle-Thompson pulley), and (5) a palmar thenar subcutaneous transfer (Camitz). Two tendon insertion sites were tested: a palmar radial insertion into the abductor pollicis brevis and a dorsal ulnar insertion into the thumb proximal phalanx. RESULTS: The Guyon's canal and Royle-Thompson pulleys produced the greatest amount of approximation of the thumb pulp to the fifth metacarpal head. The around the FCU pulley, FCU loop pulley, and Camitz transfer produced the greatest palmar abduction. The Guyon's canal and Royle-Thompson pulleys were the most mechanically efficient pulleys, producing the least amount of transmitted force. The palmar radial insertion site produced better thumb opposition, metacarpophalangeal joint abduction, metacarpophalangeal joint flexion, and approximation of the thumb pulp to the fifth metacarpal head. CONCLUSIONS: We conclude that the choice of the proximal pulley used may depend on the needs of the transfer, and a palmar radial thumb insertion is more effective than the dorsal ulnar insertion.     

Thumb reconstruction with an iliac bone graft and a dorsalis pedis flap transplant including the extensor digitorum brevis muscle for restoring opposition: A case report

A method for thumb reconstruction with an iliac bone graft and a dorsalis pedis flap transplant, including the extensor digitorum brevis muscle for restoring opposition, is presented. This case involved a 21-year-old man with a traumatically absent right thumb at the metacarpal base. Thumb reconstruction by means of an iliac bone graft with immediate transfer of a dorsalis pedis neurovascular sensory free flap, including the extensor digitorum brevis muscle to restore the opponens pollicis muscle, was carried out. After a period of six months he had gained satisfactory opposition of his newly reconstructed thumb to the ring finger, with evidence of contraction of the muscle on electromyograms.     

Bilateral carpal tunnel syndrome after abductor digiti minimi opposition transfer: a case report

We present a case of bilateral, delayed-onset, median nerve compression at the wrist after abductor digiti minimi opposition transfer for thumb hypoplasia. The symptoms resolved on each side after transverse carpal ligament release without disruption of the opposition transfers.     

Management of thumb hypoplasia

This chapter emphasizes the dilemma of salvage and reconstruction of the congenitally aplastic or hypoplastic thumb without normal cerebrocortical representation for prehensile grasp and pinch. The philosophy of reconstruction of the congenitally anomalous thumb is clearly divergent from thumb reconstruction following trauma. It is difficult to advise parents who seek surgical correction of the severely deficient thumb ray that amputation is the procedure of choice, to be followed by transfer of an otherwise normal digit to become a functional thumb unit. The psychological impact of these recommendations may be devastating to parents. Informed understanding of the likely progressive development of index-middle finger scissoring, pronation of the index ray with spontaneous broadening of the pulp, and the deteriorating use of an existing hypoplastic thumb may make the decision for ablation easier for parents. It is critical that these decisions be made through careful education and understanding, considering always the overall grasp-and-pinch capability of the hand as a whole. Reconstruction of the aplastic or hypoplastic thumb is an exciting and challenging area of hand surgery. The rewards are improvement in grasp and pinch either by functional integration of the reconstructed part, or by complete replacement of the deficient thumb by tissue from adjacent or distant donor sites. Success is measured not only in terms of cosmetic appearance, but as enhanced capacity of the child's hand in all activities of daily living (Fig. 39A and B).