Extensor indicis proprius transfer for loss of extensor pollicis longus function

In the period 1969–1991, 46 extensor indicis proprius tendon transfers were performed for functional loss of extensor pollicis longus. The long-term function of the thumb was reviewed in 22 patients with an average follow-up of 7 years. Based on Geldmacher's evaluation scheme for assessment of the results of extensor tendon reconstruction, we report 5 excellent (23%), 4 good (18%), 12 satisfactory (55%) and 1 poor (4%) result. The mean loss of pinch strength was 8% compared with the contralateral, non-operated thumb. Subjectively, the majority of the patients (86%) described no limitations in their daily life activities. It is recommended that the transfer be tight enough to give full thumb extension and that the hand be immobilized with the thumb in this position for 4 weeks.     

Effects of extensor pollicis longus transposition and extensor indicis proprius transfer to extensor pollicis longus on thumb mechanics

PURPOSE: The spatial relationship of the extensor pollicis longus (EPL) to the thumb carpometacarpal (CMC) joint may be altered by its transposition from the third dorsal wrist compartment and by subcutaneous extensor indicis proprius (EIP) to EPL tendon transfer. Changes in tendon position could alter thumb function. This study examined changes in the EPL adduction moment arm after EPL tendon transposition from its extensor compartment or EIP transfer. METHODS: The EPL adduction moment arm at the thumb carpometacarpal joint was determined under 4 tendon conditions: (1) intact extensor pollicis longus, (2) transposed extensor pollicis longus, (3) extensor indicis proprius to extensor pollicis longus tendon transfer through an extensor retinacular pulley, and (4) extensor indicis proprius tendon transfer through a subcutaneous route. Each tendon condition was tested in 2 wrist positions: neutral and 40 degrees of flexion. RESULTS: The wrist neutral/flexion moment arms for the 4 tendon conditions, in millimeters, were 9.2/7.3, 3.6/1.2, 8.3/5.1, and 4.8/1.0. CONCLUSIONS: EPL transposition produces a significant decrease of its adduction moment arm at the thumb CMC joint, an effect exacerbated by wrist flexion. The moment arm mechanics of the pulley and subcutaneous EIP tendon transfer resemble those of the intact and transposed EPL, respectively. Diminution of the adduction moment arm could impair thumb function, especially adduction.     

A new modification of extensor indicis proprius transfer to extensor pollicis longus using a retinacular pulley

A new modification of the extensor indicis proprius transfer to the extensor pollicis longus tendon through a fourth dorsal compartment retinacular pulley is described. This new modification has been assessed in cadavers biomechanically via computer simulation and in a limited number of patients with success. It affords the benefit over the standard subcutaneous extensor indicis proprius to the extensor pollicis longus tendon transfer of maintaining the adduction moment arm of the thumb. The moment arm mechanics of the pulley transfer resemble those of the intact extensor pollicis longus. Therefore this new modification offers better thumb function in both adduction and circumduction motions.     

改良法修复拇长伸肌腱自发性断裂的临床疗效

目的 探讨改良的示指固有伸肌腱修复拇长伸肌腱自发性断裂的手术方法及临床疗效.方法 对20例拇长伸肌腱自发性断裂且示指固有伸肌功能存在、动力正常的患者采取改良法重建拇长伸肌腱功能.结果 20例均获随访,时间8个月~3年1个月.拇指背伸抬高丢失0~1.8 cm,拇指屈曲丢失0~2.3 cm;示指背伸丢失角度0°~10°.根据SEEM评分标准评价疗效:优15例,良5例.结论 采用改良的示指固有伸肌腱重建拇长伸肌腱功能,手术操作简单,转位肌力量足够强大,疗效满意.     

Traumatic rupture of the extensor pollicis longus tendon

Rupture of the extensor pollicis longus tendon is rather rare, attributable in about half of all cases to rheumatoid arthritis affecting the wrist or to a Colles' fracture. In the remainder of cases, either a direct closed injury to the wrist or a hyperextension injury of the wrist is most often responsible. Far more unusual is a rotational injury which can cause complete avulsion of the EPL tendon at the musculotendinous junction. A delayed rupture is most probably caused by an avascular necrosis secondary to traumatic disruption of the mesotendon. Surgical correction of the injury is best accomplished by tendon transfer, using the extensor indicis proprius. Postoperative immobilization, hyperextension of the thumb, and adequate resting tension are all necessary to assure good return of function. Postoperatively, the patient may experience a slight decrease in extensor strength of the index finger which may or may not be accompanied by a minimal loss in extensor range.     

Optimum tensioning position for extensor indicis to extensor pollicis longus transfer.

This study evaluates various wrist and thumb positions for tensioning the extensor indicis proprius when transferred to the extensor pollicis longus tendon to determine which positions provide optimum passive range of flexion and extension of the thumb. In five adult cadaver upper limbs, transfer of the extensor indicis proprius to the extensor pollicis longus was simulated. The limbs were fixed with the elbow in 90 degrees flexion and the forearm and wrist in neutral. Surface bone markers were digitized to determine the thumb and wrist positions in three-dimensional space and their intersegmental joint angles. Twelve combinations of thumb (the interphalangeal and metacarpophalangeal joints) and wrist positions for tensioning were tested. A fixed tension of 80 N was applied to the tendon ends for each of the tensioning positions and during the transfer to ensure that the tendon remained taut. A wrist tenodesis effect was used subsequently to assess the passive range of thumb motion as an indicator of the outcome of the transfer. The results showed that the better tensioning position was with the thumb fully extended and the wrist in neutral. In six patients in whom an extensor indicis proprius to extensor pollicis longus transfer was done, the tendons were tensioned with the thumb in full extension and the wrist in neutral. A prospective review and functional assessment at an average of 18.6 months' followup was done. No significant differences between the surgically treated and normal thumbs were seen for the Jebsen Taylor, 9-peg, and grip and pinch strength tests. The study suggests that in an extensor indicis proprius to extensor pollicis longus transfer, tensioning of the tendons with the thumb in full extension and the wrist in neutral gives good thumb flexion and extension range.     

Spontaneous rupture of the extensor pollicis longus tendon

An extensor pollicis longus tendon, ruptured after treatment of a giant cell tumor of the distal radius by packing the cavity with polymethylmethacrylate cement. The lack of extension was treated successfully with tendon transfer of the extensor indicis proprius to the extensor pollicis longus. Pathophysiology of the rupture is discussed.     

Extensor indicis proprius syndrome secondary to an anomalous extensor indicis proprius muscle belly

The complaint of dorsal hand pain is common among patients seen in a primary care practice. The differential diagnosis includes tenosynovial disease, ganglion, trauma, and soft-tissue tumors. Rarely is an anomalous muscle an etiologic factor. Reported here is an anomalous indicis proprius muscle that was manifested as a painful dorsal hand mass. Also discussed are the anatomic variations of the extensor indicis proprius syndrome.     

EMG-biofeedback therapy for rupture of the extensor pollicis longus tendon

EMG-biofeedback therapy was attempted in five cases of EPL tendon rupture with residual postoperative functional disabilities such as weakness of extension or extension lag of the thumb, and improvement was obtained in muscle strength, range of motion, and performance of daily activities. EMG-biofeedback therapy is a method which, utilizing visual or auditory information, supplements and facilitates the intrinsic feedback mechanism in the human body. This method is applied as a treatment to improve motor dysfunction. The effectiveness of the therapy is elucidated by a neural motor control theory based on the sensory-motor feedback loop.     

EMG-biofeedback therapy for rupture of the extensor pollicis longus tendon

Summary EMG-biofeedback therapy was attempted in five cases of EPL tendon rupture with residual postoperative functional disabilities such as weakness of extension or extension lag of the thumb, and improvement was obtained in muscle strength, range of motion, and performance of daily activities. EMG-biofeedback therapy is a method which, utilizing visual or auditory information, supplements and facilitates the intrinsic feedback mechanism in the human body. This method is applied as a treatment to improve motor dysfunction. The effectiveness of the therapy is elucidated by a neural motor control theory based on the sensory-motor feedback loop.     

Prevention of extensor lag after indicis proprius tendon transfer.

An experiment on fresh cadaver hands showed that a longitudinal incision of the hood did not affect index extension when traction was made on the common extensor tendon, but that excision of a portion of the hood containing the indicis proprius caused an extensor lag. The lag was eliminated by repair of the hood, providing that the closure was not too tight to prevent normal excursion of the hood. These findings were correlated with findings in patients who had undergone indicis proprius tendon transfer. Extensor lag after indicis proprius transfer is not caused by removal of the force of the tendon per se, but by factors which cause either disruption of normal hood function or tethering of its normal excursion.     

Analysis of donor deficit after extensor indicis proprius tendon transfer

From November 1984 to February 1989, 13 extensor indicis proprius tendon transfers were performed for various reasons. Nine patients with a total of ten transfers were available for follow-up, at an average of 29 months. Active range of motion was measured (both dependently and independently) at the metacarpophalangeal joints of both the involved and the uninvolved index finger. There was no extensor lag of the metacarpophalangeal joint during dependent extension, and only an average of 2.1 degrees of extensor lag during independent extension. Measurement of total active motion showed that the dependent and independent range of motion of the involved index finger was 95% of that of the uninvolved index finger. The obvious concerns with using the extensor indicis proprius tendon for transfer is the possible theoretical loss of complete extension and independent extension of the index finger. We found these concerns not to be a problem.     

Spontaneous rupture of the extensor pollicis longus tendon]

A rare case of "spontaneous" rupture of the extensor pollicis longus tendon with primary chronic polyarthritis in the background is reported in this paper. In this case a transposition of the extensor indicis proprius was carried out, with the modification by J. B?hler and Manninger. This method gives a very good functional result.     

Endoscopic single-incision extensor indicis transposition for extensor pollicis longus reconstruction

Traditional methods for harvesting the extensor indicis (EI) tendon for transposition to the extensor pollicis longus (EPL) tendon using direct visualization commonly require 3 incisions. The authors describe an endoscopic EI tendon transposition for EPL tendon reconstruction as an alternative technique for the traditional open technique. This new modification of endoscopic EI transposition to EPL has the benefit over the standard harvesting technique of only 1 incision to accomplish the complete procedure and results in less scarring. To date, the authors have only operated on ruptures after radius fractures without significant synovitis in the area of the extensor compartment.