Scandinavian Journal of Plastic and Reconstructive Surgery and Hand ...

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Split distal flexor pollicis longus tenodesis: long-term results Arvid Ejeskär; Annika Dahlgren; Jan Fridén Online Publication Date: 01 March 2002 To cite this Article: Ejeskär, Arvid, Dahlgren, Annika and Fridén, Jan (2002) 'Split distal flexor pollicis longus tenodesis: long-term results', Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, 36:2, 96 - 99 To link to this article: DOI: 10.1080/028443102753575248 URL: http://dx.doi.org/10.1080/028443102753575248

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SPLIT DISTAL FLEXOR POLLICIS LONGUS TENODESIS: LONG-TERM RESULTS Arvid Ejeska¨r,1 Annika Dahlgren2 and Jan Fride´n1 From the 1Department of Hand Surgery, 2Spinal Unit, Sahlgrenska University Hospital, Go¨teborg University, Go¨teborg, Sweden

Scand J Plast Reconstr Surg Hand Surg 2002; 36: 96–99 Abstract. A thumb lacking intrinsic muscle function but having extrinsic exion will hyper ex in the interphalangeal joint giving a positive Froment’s sign. This can effectively be prevented with split exor pollicis longus tenodesis. The mean postoperative range of motion in the IP joint of 39 hands was 28 (18)° and 23 (20)° six and 12 months postoperatively. The procedure makes arthrodesis (temporary or permanent) super uous. This procedure can be recommended strongly. Key words: flexor pollicis longus, tenodesis, intrinsic paralysis, tetraplegia, reconstructive hand surgery. Correspondenc e to: Arvid Ejeska¨r, MD, PhD, Department of Hand Surgery, Sahlgrenska University Hospital, SE 413 45 Go¨teborg, Sweden. (Tel: ‡46 31 3423072. Fax: ‡46 31 820589. E-mail: [email protected] ) Accepted 23 March 2001

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Successful reconstruction of active thumb exion in a paralysed hand results in full exion of the interphalangeal (IP) joint. This procedure will provide the patient with a functioning lateral pinch grasp despite absence of active thenar muscle control. Characteristically, this grip includes a exion force applied from the tip of the thumb to the radial aspect of the middle phalanx of the index nger rather than from the pulp of the thumb to the index nger as is normal. The reduced area of contact between digits consequently causes an increased need for substantial grip strength, a need that seldom can be met in this category of patients. Moberg, who invented the key grip reconstruction for tetraplegic hands, solved this intriguing problem with a temporary arthrodesis of the IP joint using a 2 mm Kirschner (K) wire (3). However, he considered the ideal to be a limited movement in the joint of 20°– 30° but could not nd the solution to the problem. In 1992 Mohammed et al. (4) described the split exor pollicis longus (FPL) tenodesis. This technique met all the necessary demands in that it not only positioned the pulp of thumb optimally but also provided limited active exion of the IP joint. Since then Van Heest et al. (5) have published their results in a small series of patients, but long-term results have yet to be reported to our knowledge. The objective of this study, therefore, was to evaluate the long-term clinical results of the split FPL tenodesis in a de ned group of patients. 2002 Taylor & Francis. ISSN 0284–4311

PATIENTS AND METHOD Operative technique The distal part of the FPL is exposed either by a volar or midlateral incision. The tendon sheath is opened from the insertion of the tendon on the distal phalanx to the annular ligament volar to the metacarpophalangeal (MCP) joint. The tendon is divided longitudinally and the radial half is detached from the distal phalanx (Fig. 1). An incision is made on the extensor side of the thumb and the detached tendon is re-routed radially and dorsally. It is sutured to the long extensor tendon of the thumb. It is important to check the degree of tension by pulling in the exor pollicis longus at wrist level. This test should result preferably in 20°–30° of exion in the IP joint. To ensure that the thumb is immobilised in an optimal position, the IP joint may be trans xed with a K-wire in the desired degree of exion. After this the reconstruction of the thumb grip is completed and the hand is immobilised in a cast. Four weeks later the cast is removed. If the joint has been trans xed the K-wire is also removed. The patient is tted with a small plastic orthosis (Or tÓ ) which supports the IP-joint in 20° of exion but leaves part of the pulp of the thumb free for contact with the index nger during gripping (Fig. 2). After a total of 6–8 weeks the patient is free to use the hand without the orthosis. However, personal transfers are prohibited until three months postoperatively. Scand J Plast Reconstr Surg Hand Surg 36


Split distal flexor pollicis longus tenodesis

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Fig. 1. Operative technique. (a) The FPL tendon is split longitudinally and the radial half is detached from its insertion and rerouted dorsally. (b) The attachment into the extensor pollicis longus tendon.

Patients We have used this method since April 1995 and the present report includes operations on 40 hands in 33 tetraplegic patients and a minimum follow-up of six months. Thirty-two patients had sustained a cervical cord lesion and one had a severe form of Guillain-Barre´ paralysis. The international classi cation of the patients’ arms (Table I) ranged from O:0 to OCu8 (2) of which ve belonged to the group X (Table II). For various reasons three hands were not followed up at six months and were only followed up at 12 months, so data at six months are available for 37 hands, and at 12 months for 25 hands.

Complications One patient had previously been operated on at another centre and given a key grip procedure as described by Moberg including division of the annular ligament at the level of the metacarpophalangeal joint of the thumb. After the split thumb tenodesis he had a postoperative rupture of the remaining part of the exor tendon sheath resulting in bow stringing of the exor tendon and dehiscence of the wound which required a Z-plasty to heal. Before the split FPL tenodesis one patient had a transfer of the exor carpi radialis to exor pollicis longus. This procedure gave him a strong thumb exion and a moderate exion

Fig. 2. The thumb splint. (a) Radial view. (b) Volar view showing the free part of the pulp of the thumb. Scand J Plast Reconstr Surg Hand Surg 36


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A. Ejeska¨r et al.

Table I. International classi cation for surgery of the hand in tetraplegia (Modi ed Giens 1984) (2). Group denotes the number of muscles in the forearm minimum strength grade 4 (MRC scale: 0–5), which means that the muscle can perform movements against some manual resistance. O = ocular afferent impulses and OCu = oculocutaneous impulses-that is both vision and tactile gnosis Sensibility O or OCu Group

Description Function

Motor characteristics

0 1 2 3 4 5 6 7 8 9 X

No muscle below elbow grade 4 Brachioradialis Ext. carpi radialis longus Ext. carpi radialis brevis Pronator teres Flexor carpi radialis Finger extensors Thumb extensor Partial nger exors Lacks only intrinsics Exceptions

Flexion and supination of elbow Extension of wrist (weak) Extension of wrist (strong) Pronation of forearm Flexion of wrist Extrinsic extension of digits Extrinsic extension of thumb Extrinsic exion of ngers (weak) Extrinsic exion of ngers

Table II. Classi cation of the arms. The ve cases in group X have been subdivided into the most similar standard group. Group denotes the number of muscles minimum grade 4 in the forearm. O = ocular sensory impulses and OCu = oculo-cutaneous impulses-that is both vision and tactile gnosis Group

O OCu OX OCuX Total

0

1

2

3

4

5

6

7

8

Total n

1 2 0 0 3

4 1 0 1 6

2 2 0 1 5

0 3 0 1 4

3 9 0 0 12

0 2 0 0 2

0 0 1 0 1

0 3 0 0 3

0 3 0 1 4

10 25 1 4 40

contracture of the IP joint. Soon after the split tenodesis he developed pain in the thumb and too much exion in the joint. He had to be reoperated on and the transposed tendon strip reattached with careful postoperative splinting of the IP joint.

RESULTS The mean (SD) active range of movement (ROM) in the IP joint six months after the procedure was 28 (18)° (Table III). Mean extension was ¡4° and mean active exion was 32°. At 12 months, the ROM of 25 hands was 23 (20)°, extension ¡8° and exion 31°. One year postoperatively, 20 out of 22 hands had active exion in the IP joint ranging from 15°–60°. One patient with a weak wrist extensor (grade 3–) only reached 0 position and the patient with previous key grip procedure had a xed angle of 10° of extension. Data on passive IP joint exion were available in 22 hands at six months postoperatively. The results show that the passive exion in the IP joint exceeded the active exion by roughly 23°. Scand J Plast Reconstr Surg Hand Surg 36

DISCUSSION The split FPL tenodesis has solved a great problem in reconstruction of a thumb grip in a severely paralysed hand. The range of motion in the IP joint is almost 30° after six months, which seems to be close to the ideal. From 6 to 12 months there was an average loss of ROM and extension of 4°. In one patient the tenodesis stretched so that the active exion in the IP joint was 60°. That patient had the other hand operated on within less than three months after the rst operation and was Table III. Extension, exion, and range of movement in the interphalangeal joint 6 and 12 months postoperatively Data are median (range)°.

Extension Flexion Range of movement

At 6 months (n = 37)

At 12 months (n = 25)

¡4 (18)° 32 (14)° 28 (18)°

¡8 (21)° 31 (16)° 23 (20)°


Split distal flexor pollicis longus tenodesis allowed to drive his wheelchair with the rst operated hand having the second one in a cast, which was the probable cause of the stretching. Van Heest et al. (5) published the results of a series of 12 patients who all had “full IP joint extension and between 15 and 30° of exion’’. Their method for measuring the tension in the tenodesis differed slightly from ours. They stated “tension is adjusted so that the thumb pulp can be brought into an effective key pinch position on the radial side of the index nger’’ without giving any exact angle for the position of the IP joint. They might have tightened the tenodesis less that we have done as their patients all had full extension in contrast to ours who lacked 4° and 8° degrees in extension to the zero position. Goloborod’ko (1) described another method of stabilising the IP joint. He split the tendon of exor pollicis longus within the tendon sheath and sutured the released half of the tendon back to its insertion but outside the brous sheath. He noted approximate exion of 27° and lack of extension of 9° in a small series of patients. These results are similar to ours. However, his method seems to be more technically demanding than ours. The presence of an active long thumb extensor in a tetraplegic patient is no indication to refrain from this procedure. A normal extensor pollicis longus cannot prevent hyper exion in the IP joint. The split FPL tenodesis balances the amount of exion to both IP and MCP joints, to some extent replacing the thenar muscles, so it is useful in any patient with loss of the intrinsic muscles of the thumb. The patient who had had exor carpi radialis transferred to exor pollicis longus had a powerful thumb exor. He was the only patient who did not have thumb exion reconstructed together with the tenodesis, so the postoperative treatment differed somewhat from the other patients. He started personal transfer early and probably stretched the tenodesis. We therefore conclude that if the exor pollicis longus is strong

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preoperatively one should protect the tenodesis carefully so as not to overload it. In most cases the method gives a more passive than active range of movement, which gives a pliable thumb. This is a de nite advantage over a temporary or permanent arthrodesis. The complication of postoperative bow stringing should not be a problem providing that the annular ligament is not divided at the base of thumb in reconstructing a key grip. We now regularly use the mediolateral incision by which the secondary wound rupture probably could have been avoided. CONCLUSIONS The split distal thumb tenodesis is the ideal solution for balancing the exion of the thumb in severely paralysed thumbs irrespective of the cause of the paralysis. It gives about 25° of active range of movement one year postoperatively and some further passive exion. It eliminates the need for arthrodesis of the IP joint in paralysed hands. REFERENCES 1. Goloborod’ko SA. Treatment of interphalangeal hyper exion and metacarpophalangeal hyperextension of the thumb in combined low median-ulnar nerve palsy. J Hand Surg 1998; 23A: 1059–1062. 2. McDowell CL, Moberg EA, House JH. The second international conference on surgical rehabilitation of the upper limb in tetraplegia (quadriplegia). J Hand Surg 1986; 11A: 604–607. 3. Moberg E. The upper limb in tetraplegia. Stuttgart: Thieme, 1978: 48–50. 4. Mohammed KD, Rothwell AG, Sinclair SW, Willems SM, Bean AR. Upper-limb surgery for tetraplegia. J Bone Joint Surg 1992; 74B: 873–879. 5. Van Heest A, Hanson D, Lee J, Wentdorf F, House J. Split exor pollicis longus tendon transfer for stabilization of the thumb interphalangeal joint: a cadaveric and clinical study. J Hand Surg 1999; 24A: 1303–1310.

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