Split flexor pollicis longus tendon transfer to A1 pulley for correction of paralytic Z deformity of the thumb.

PURPOSE: To test the hypothesis that split flexor pollicis longus (FPL) transfer to the A1 pulley will correct a thumb paralytic Z deformity and that the transfer can be subjected to early postoperative active mobilization protocol. METHODS: In a prospective trial, 19 consecutive thumbs with ulnar or combined ulnar and median nerve paralysis received split FPL transfer to the thumb A1 pulley and active mobilization of transfer after 48 hours. Outcomes were assessed by correction of Z deformity during pinch, tendon transfer insertion pullout during early active mobilization, range of motion at the thumb metacarpophalangeal and interphalangeal joints, and postoperative treatment time. Data from historical records of 20 thumbs with split FPL to extensor pollicis longus (EPL) and 3 weeks' immobilization, treated before the prospective trial in the same institution, were used for comparison. RESULTS: All 19 thumbs with split FPL to A1 pulley achieved Z deformity correction at discharge from rehabilitation. There was no incidence of transfer insertion pullout during active mobilization, and patients were discharged 22 days earlier than the controls who received transfer of FPL to EPL insertion. Seventeen thumbs were available for follow-up more than 1 year after the index procedure. Fifteen thumbs retained deformity correction, and 2 had recurrence of Z deformity. The interphalangeal joint had considerably greater active motion following split FPL to A1 pulley compared with transfer of split FPL to EPL insertion. CONCLUSIONS: This study supports the hypothesis. Split FPL tendon transfer to thumb A1 pulley can correct paralytic thumb Z deformities and be mobilized early for transfer re-education. Improved interphalangeal joint active motion and reduced treatment time are added advantages over FPL transfer to the EPL insertion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Factors affecting functional outcome of opponens replacement in median nerve paralysis in leprosy.

In this study, the factors affecting functional outcomes of opponens replacement in median nerve paralysis in leprosy, were investigated. Fifty six patients who underwent opponens transfer between 1995 and 2001 were included in the study. The average duration of follow up is 7.3 years with a range of 4-10 years. Functional assessments were done through assessment of grip strength, pinch strengths and fine manipulation and the results were interpreted using Sundararaj (1984) criteria. 76.6% had excellent or good results, 13.3% fair and 10.1% poor results. Pinch strength, grip strength and fine manipulation showed improvement after surgery. Logistic regression analysis showed that duration of paralysis had a significant independent effect on the outcome.

[Flexor digitorum superficialis tendon transfer for intrinsic paralysis in leprosy]. / Transfert tendineux palliatif utilisant le Flexor Superficialis Digitorum dans les paralysies intrinsèques d'origine lépreuse.

A follow up study was performed in the rehabilitation centre for patients with leprosy in Hôchiminhville - Vietnam. All patients had claw-hand deformity due to ulnar and median nerve intrinsic paralysis. Thirty-two affected hands (128 long fingers) were included in the study. A Bunnel-Littler tendon transfer procedure was performed using a four-tailed graft of the flexor digitorum superficialis of the third finger. Clinical evaluation included anatomical measurements of interphalangeal and metacarpal joints in complete extension and in the intrinsic position. In the open hand assessment, 48.5% reported good results, 14.8% medium results and 36.7% poor results. With the hand in the intrinsic position, 53.9% achieved good results, while 33.6% achieved medium results and poor in 12.5%. Poor functional outcome is related to a failure of this procedure and seems to be due to extensor tendon laxity, with or without stiffness of the interphalangeal joints. There were many anatomical deformities (27.3%) found at the time of follow up, notably boutonniere (51.4%) and mallet finger deformities (31.4%) The fourth and fifth fingers had the worst results. We have therefore decided to change our protocol for claw-hand correction and use the Bouvier test in deciding on our surgical indications. Preoperative physiotherapy is absolutely necessary to reduce stiffness of the interphalangeal joints.

Reconstructive surgery in upper limbs in leprosy.

Of all the deformities in leprosy, 80% require minor surgery and the rest major surgery. Upper and lower limbs and face are mainly affected by deformities. Either the median or ulnar nerve and rarely the radial nerve are involved in isolation or in combination. Tendon transfer is the only option available in cases of deformities like simian hand, ulnar claw hand, wrist drop and failure to the metacarpals. The only motor function to be restored in median nerve palsy is opponensplasty. For radial nerve palsy standard FCU transfer, FDS transfer and FCR transfer are the reconstructive methods. For ulnar nerve palsy, an intrinsic minus hand function is restored by the motors PL, ECRL, FDS, EIP or EDM extended by four tail fascia lata graft onto lateral or ulnar bands of fingers. When ulnar nerve is part of much more extensive paralysis, reducing the availability of suitable motors, static mathods of conection of claw hand are done.

Restoration of sensibility in irreparable ulnar and median nerve lesions with use of sensory nerve transfer: long-term follow-up of 20 cases.

A prospective study was conducted to evaluate patient outcomes following sensory nerve transfer. Twenty patients with irreparable ulnar or median nerve lesions underwent the procedure. Nerve involvement was bilateral in 5 cases. The mean age of the patients at the time of surgery was 29 years. The mean paralysis time and the average length of follow-up were 59 and 78 months, respectively. Eighteen of 20 patients attended a sensory re-education program after surgery. Outcome was assessed objectively by functional sensory recovery testing and by the British Medical Research Council standards. Subjective outcome was assessed by a questionnaire. Two-point discrimination of less than 10 mm was achieved in 15 of 25 hands. The mean functional sensory recovery score was 83. Eighteen of 20 patients reported that the function of their hands improved after the procedure. Good or excellent results were associated with immediate transfer of the nerve, young age, and patients' attendance to the sensory re-education program after surgery. No differences were found between the recovery of ulnar and median nerves. Based on these results we suggest that sensory nerve transfer is a simple and reliable way of restoring sensibility to the hand with favorably comparable results over conventional nerve grafting in selected cases.

Notre experience de la chirurgie de la nevrite lepreuse / Our experience with surgery of neuritis in leprosy

The author reports his own experience of the surgery of neuritis in leprosy and specially that of the ulnar nerve. If early applied with good indications and a carefull procedure, the surgical treatment gives a high frequency of sensory and motor recovery, preventing deformities and dehabilitations.