Abductor digit minimi opponensplasty: technique, modifications, and measurement of opposition

Satisfactory thumb metacarpophalangeal joint stability after ligament reconstruction with flexor digitorum superficialis in children with radial longitudinal deficiency

We investigated thumb joint stability and patient-reported and functional outcomes a minimum of 1 year after flexor digitorum superficialis opponensplasty and ligament reconstruction in 23 thumbs of 20 consecutive children with radial longitudinal deficiency. In total, 15 thumbs had preoperative multidirectional instability in the metacarpophalangeal joint. We reconstructed 22 ulnar and 16 radial collateral ligaments. At follow-up, all the metacarpophalangeal joints were stable ulnarly. Seven metacarpophalangeal joints were unstable radially despite ligament reconstruction but had no related complaints. We recommend the flexor digitorum superficialis opponensplasty as a safe and reliable procedure in hypoplastic thumbs to create stability and augment thumb strength.Level of evidence: IV.

Outcome After Pollicization for Congenital Thumb Deficiency: A Cohort Study of Cases in a Single Unit, 1987 to 2016

PURPOSE

To investigate the functional and aesthetic outcomes in a cohort with pollicizations performed due to congenital anomalies in our hospital.

METHODS

From 1987 to 2016, we performed pollicizations in 32 hands of children aged 1 to 8 years (median, 2 years). We followed-up on 31 of the hands from 1 to 31 years (median, 10 years) after the procedure. The participants and their caregivers self-assessed their function and appearance with visual analogue scales and patient-reported outcome measures (Patient-Reported Outcomes Measurement Information System Pediatric Upper Extremity; the short version of the Disability of Arm, Shoulder and Hand Outcome Measure; and EQ-5D-3L). We examined the hands with regard to motion, strength, sensitivity, and function.

RESULTS

There were 2 complications and 6 reoperations. Participants with mild anomalies (radial longitudinal deficiency Bayne type N/0 to 2) had better subjective and objective hand function than participants with severe anomalies (radial longitudinal deficiency Bayne type 3-4, ulnar dimelia, 5-finger hand). Hands with preoperatively near-normal index fingers had, in most cases, good thumb opposition and pinch, and hands in both groups benefited from the creation of a cylinder grip. Grip and pinch strength were lower than reported in cohort studies where an additional opponensplasty had been performed.

CONCLUSIONS

Hands with severe congenital anomalies also benefited from the procedure. We recommend a simplified follow-up program to identify cases where additional surgeries to enhance strength should be considered during growth of the child.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Revision of Carpal Tunnel Surgery

Carpal tunnel release is one of the most commonly performed upper extremity procedures. The majority of patients experience significant improvement or resolution of their symptoms. However, a small but important subset of patients will experience the failure of their initial surgery. These patients can be grouped into persistent, recurrent, and new symptom categories. The approach to these patients starts with a thorough clinical examination and is supplemented with electrodiagnostic studies. The step-wise surgical management of revision carpal tunnel surgery consists of the proximal exploration of the median nerve, Guyon’s release with neurolysis, the rerelease of the transverse retinaculum, evaluation of the nerve injury, treatment of secondary sites of compression, and potential ancillary procedures. The approach and management of failed carpal tunnel release are reviewed in this article.

Long-term Outcomes after Toe-To-Thumb Transfers for Burn Reconstruction in Children

Children are one of the most vulnerable populations to burns, and hands are frequently burned anatomical structures. Restoring function in a severely burned pediatric hand is challenging. We present our experience with pediatric toe-to-thumb transfers for burn reconstruction. A retrospective review was conducted of all pediatric toe-to-thumb transfer patients between 2009 and 2014. Children under the age of 18 who underwent secondary reconstruction after electrical or thermal burn injuries with at least 5-year follow-up were included. Functional outcomes were measured with the modified Kapandji score. Complications of the reconstructed hand as well as donor foot were recorded. Four children with 10 toe-to-hand transfers (4 great toes, 2 second toes, and 2 combined second-third toes) met the inclusion criteria. Average follow-up length was 104 months (range 60-144 months) Two children sustained thermal burn injuries and two sustained electrical burn injuries. Three children achieved opposition of the reconstructed toe-to-thumb transfer to the small finger (Kapandji score 5), and one child achieved opposition of the reconstructed toe-to-thumb transfer to the proximal phalanx of the middle finger, the only remaining finger (Kapandji score 3). No donor foot morbidities were noted postoperatively. Toe-to-thumb transfers should be considered the gold standard for thumb reconstruction in children with severe burn injuries of their hands and provide restoration of sensation, pinch, grasp and opposition with minimal morbidity of the donor foot.

Modified Camitz versus BRAND Procedures for the Treatment of Severe Carpal Tunnel Syndrome: A Comparative Trial Study

BACKGROUND

Carpal tunnel syndrome (CTS) is characterized by complications such as pain, paresthesia, and numbness in the fingers. There are some surgical therapies for the management of severe carpal tunnel, but differences exist between the treatments available for creating the opposition. The current study was conducted to compare the effect of modified Camitz and BRAND techniques on thumb opposition in patients with severe CTS.

METHODS

A total of 40 patients with severe CTS who were candidates for opponensplasty were enrolled in this clinical trial study at Alzahra and Kashani hospitals, Isfahan, Iran, from 2014 to 2018. The patients were divided into two groups of modified Camitz and BRAND. Quick DASH-9 and Kapandji scores as well as pulp and side pinch and pronation angle were assessed before and after the surgeries.

RESULTS

Quick DASH-9 score, Kapandji score, pulp and side pinch and pronation angle significantly improved post-operatively (P=0.0XXX, P=0.0XXX, P=0.0XXX, P=0.0XXX, and P=0.0XXX, respectively). But, no significant differences were seen in the mentioned variables between both groups pre and post-operative (P>0.05, for all the studied variables). No postsurgical complications were seen in any of the groups.

CONCLUSION

The findings of the present study demonstrated that, both Modified Camitz and BRAND techniques are effective and safe techniques, yielding high improvements, but no serious complications. Both techniques can be considered for treatment of patients with severe CTS.

The Relationships Between Surface Measurements and Underlying Tendon Autograft Length for Upper Extremity Reconstructive Surgery

PURPOSE

The availability of tendon grafts is an important consideration for successful upper extremity reconstructive surgery, including flexor or extensor tendon reconstructions, tendon transfers, and ligament reconstructions. Graft selection is based on availability, expendability, ease of harvest, and length. Given variations in patient height and extremity length, existing average values may provide suboptimal insight into actual tendon lengths available. The purpose of this study is, therefore, to pursue a method of estimating available donor tendon lengths based on easily measured anatomical surface landmarks.

METHODS

Thirty cadaveric upper and lower extremity limbs were dissected and the length of commonly harvested tendon grafts including the palmaris longus, extensor indicis proprius, extensor digiti minimi, plantaris, and second long toe extensor was measured. Surface forearm length (from finger tip to cubital fossa) and surface fibular length (from lateral malleolus to fibular head) were also measured. Correlations between surface measurements and underlying tendon lengths were analyzed, and linear models were generated that predicted tendon length as a function of surface measurements.

RESULTS

Surface measurements were correlated with underlying tendon length (R = 0.46 - 0.66). Linear models could predict tendon lengths based on surface measurements. A ratio of donor tendon length compared with the limb segment measured was established for each tendon and can be applied to estimate donor tendon length. For the upper extremity tendons, the multipliers for the palmaris longus, extensor indicis proprius, and extensor digiti minimi were 0.51, 0.20, and 0.18, respectively. Lower extremity tendon ratios for the plantaris and extensor digitorum longus were 0.69 and 0.60, respectively.

CONCLUSIONS

Although length of available donor tendon can be a limiting variable at the time of surgery, surgeons may be better able to estimate underlying tendon lengths using easily obtained superficial measurements.

CLINICAL RELEVANCE

Information obtained from these cadaveric measurements may aid in preoperative planning in hand and upper extremity surgery.

Tendon Transfers for the Hypoplastic Thumb

Thumb hypoplasia is a component of radial longitudinal deficiency. The severity of hypoplasia can range from a slightly smaller thumb to a complete absence. Types II and IIIA hypoplastic thumbs are candidates for reconstruction to improve function, stability, and strength. There are 2 commonly used tendon transfers that can augment thumb opposition strength: the Huber abductor digiti minimi muscle transfer and the flexor digitorum superficialis opposition transfer. Both transfers use ulnar-sided structures to augment the thenar musculature. The Huber opposition transfer increases thenar bulk, but does not provide additional tissue for metacarpophalangeal stability.

The Snow-Fink technique as an opposition tendon transfer for children born with a hypoplastic or absent thumb

BACKGROUND

A novel opposition tendon transfer, previously described by Snow and Fink in adults but not in children, can provide better functional results and cosmetic appearance than the currently preferred Huber transfer.

METHODS

Thirty-one children were born either without a thumb (17) or with a hypoplastic thumb (14). Thirty-eight thumbs were classified according to the Blauth classification as stages II, IIIA, IIIB, IV, and V respectively. The opposition tendon transfer was performed between the ages of 4 and 10, using the expendable flexor digitorum superficialis (FDS) tendon from the ring finger which was passed through a 3-mm-diameter window in the transverse carpal ligament, routed subcutaneously across the palm and attached to the insertion of the abductor pollicis brevis on the base of the proximal phalanx of the thumb. This creates a vector of pull from the ulnar side of the hand which both abducts and pronates the thumb. Twenty-one hands underwent additional procedures such as four-flap Z-plasty (11), ulnar collateral ligament reconstruction (6), joint transfer, full-thickness skin grafting, and distraction lengthening.

RESULTS

The ability of each child to oppose their thumb to the index finger (score 2), middle finger (score 3), ring finger (score 4), or small finger (score 5) was assessed preoperatively and postoperatively by their Kapandji score. Thirty-one children (81.6 %) achieved a postoperative Kapandji score of 5, while 7 children (18.4 %) had a postoperative Kapandji score of 4. No deformities were observed, and the metacarpophalangeal (MCP) joint was stabilized with the other slip of the FDS when necessary.

CONCLUSIONS

An opposition transfer using the FDS tendon of the ring finger through a window in the transverse carpal ligament is a simple and reliable technique for improving thumb function in children born with an absent or hypoplastic thumb. This transfer does not produce a concave deformity in the hypothenar eminence like the Huber transfer, provides better pronation, and affords concurrent stabilization of the MCP joint.

Thumb hypoplasia

Thumb hypoplasia, congenital underdevelopment of the thumb, can range from a slight decrease in thumb size to complete absence of the thumb. As part of the radial longitudinal deficiency spectrum, other organ systems may be affected as well. Hence, the global health of the child should be addressed before focusing on the thumb. The decision of whether to reconstruct the existing thumb or to ablate the thumb and perform a pollicization of the index finger hinges primarily on the examination of trapeziometacarpal joint stability. Ultrasound imaging may play a role in decision making in borderline cases. The ultimate goal of surgical treatment is to provide a stable and functional thumb.