Thumb Function and Electromyography Result after Modified Camitz Tendon Transfer

Endoscopic carpal tunnel release with opponensplasty using ring finger flexor digitorum superficialis under WALANT with ultrasound assistance

In patients with severe, long-standing carpal tunnel syndrome and thenar muscle atrophy, nerve decompression alone is unlikely to restore thumb opposition. A multitude of tendon transfer techniques have been described to restore thumb opposition. We describe the technique of an endoscopic carpal tunnel release with opponensplasty using ring finger flexor digitorum superficialis (FDS) tendon under Wide Awake Local Anaesthesia No Tourniquet (WALANT) and ultrasound assistance.

Opponensplasty for Nerve Palsy: A Systematic Review

Opposition is an essential function of the human thumb to enable fine pinch and grip strength. Loss of opposition can be caused by both congenital and acquired pathology resulting in significant disability. This systematic review aims to compare the different techniques available to restore opposition. A systematic review of opponensplasty techniques was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines using PubMed, Embase, Medline, and Web of Science. Studies published in English before April 2021 and that reported on original outcomes of opponensplasty techniques used in the context of neurologic dysfunction were eligible for inclusion. A total of 641 articles were included, of which 42 texts were eligible for inclusion with a total cohort of 873 patients. The most commonly used transfers were palmaris longus (PL), extensor indicis proprius (EIP), and flexor digitorum superficialis (FDS). These transfers all demonstrated an improvement in range of motion, pinch strength, and Kapandji scores. Complication rates of 19% and 12% were reported with FDS and EIP transfers, respectively, predominantly related to donor site morbidity. A complication rate of 6% was observed with PL transfers, which was most commonly related to bowstringing. Heterogeneity of outcomes precluded a direct statistical comparison. There is significant heterogeneity in the literature reporting on opponensplasty techniques. There is limited capacity of direct comparison; however, FDS and EIP appear to demonstrate better functional outcomes, at the cost of higher complication rates. Each technique has specific complications and advantages and importance in patient counseling and discussion. Further prospective comparative studies are warranted.

Thumb Pronation Angle in Thumb Opposition Evaluated by the Nail Tip Angle of Thumb-Ring Finger Opposition

BACKGROUND

This study aimed to devise the method for the evaluation of the thumb pronation angle and calculate its reference value.

METHODS

The study was conducted from October 2021 to March 2022, and 600 hands of 300 healthy volunteers were included in this study. The participants were divided into 6 age groups with 50 participants each. In study 1, 12 participants from group 1 were randomly selected, which included 6 male and 6 female participants. We measured the thumb pronation angle using FASTRAK system and the nail tip angle of thumb-ring finger opposition (T-R angle) and also evaluated the relation between them. In study 2, we measured the T-R angle of 600 hands of 300 healthy volunteers. The T-R angle mean (SD) and 95% confidence interval (CI) of each age group were calculated as reference values.

RESULTS

The thumb pronation angle was correlated with the T-R angle. The T-R angle mean (SD) and 95% CI of the 6 groups were as follows: group 1, 142.5° (12.4) and 117.7 to 167.3; group 2, 139.9° (10.1) and 119.7 to 160.1; group 3, 142.3° (9.7) and 122.9 to 160.5; group 4, 140.2° (12.6) and 115.0 to 165.4; group 5, 138.3° (11.9) and 114.5 to 162.1; and group 6, 135.4° (13.0) and 109.4 to 161.4. The 95% CI tended to decrease with an increasing age.

CONCLUSIONS

The T-R angle was a suitable evaluation method for the thumb pronation angle, and it should be evaluated by age groups.

The Influence of the Tissue Adhesive Material as a Surgical Wound-Closure Technique Following Carpal Tunnel Decompression on Neurological and Functional Outcomes: A Single-Center Randomized Controlled Trial

Background Carpal tunnel syndrome (CTS) is caused by compression of the median nerve in the carpal tunnel. The effect of tissue adhesives as a material for wound closure following CTS decompression has been insufficiently investigated. This study aimed to evaluate outcomes by comparing two modalities of wound closure following carpal surgery in patients randomly assigned to either tissue adhesives or sutures. Methodology This randomized, prospective study was conducted in April 2022 at the University Hospital of Split in Croatia. Patients aged 61.56 ± 12.03 years were randomized to either tissue adhesive Glubran Tiss 2®-based (n = 50) or suture-based (n = 50) wound-closure techniques. The following outcomes were assessed before surgery and six months postoperatively: hand strength, electroneurographic characteristics of the median nerve, and the Boston Carpal Tunnel Questionnaire. Results Significant differences between glue-based and suture-based wound-closure techniques were found in the six-month postoperative hand grip strength (25.06 ± 6.69 vs. 21.41 ± 5.62 kg; p = 0.002), postoperative sensory amplitude (10.08 ± 5.50 vs. 7.54 ± 5.41 mV; p = 0.012), and postoperative sensory velocity (42.22 ± 11.04 vs. 35.23 ± 16.40 m/s; p = 0.008). In the glue-based group, significantly more patients achieved a postoperative sensory velocity greater than 45 m/s (47.9% vs. 22.0%; p= 0.006), postoperative distal sensory latency less than 3.5 ms (89.6% vs. 84.0%; p = 0.304), and postoperative motor latency of less than 4.2 ms (60.42% vs. 38.00%; p = 0.022). Conclusions This trial demonstrated that cyanoacrylate-based adhesion material for wound closure after open CTS decompression compared with sutures showed a significant six-month postoperative increment in hand grip strength and median nerve sensory conduction.

Fiber type composition of contiguous palmaris longus and abductor pollicis brevis muscles: Morphological evidence of a functional synergy

The palmaris longus (PL) tendon is used in surgical opponensplasty to restore functional hand movements in thenar paralysis. Although successful PL autologous tendon transfer has been attributed to an established synergistic relationship between the PL and abductor pollicis brevis (APB) muscles in vivo, this functional relationship may be dependent on the quality of their spatial relationship and properties of their constituent muscle fibers. The purpose was to compare the proportion of type I and type II muscle fibers in the APB based on its contiguous morphological relationship with the PL tendon for indirect insight into their functional synergy, contractile capacity, and digastric arrangement. Twenty-four contiguous PL and APB specimens were harvested from the upper limbs (12 right and 12 left) of twelve formalin-embalmed cadavers (mean age: 74 ± 10 years). The fiber type composition of these muscles was determined by labeling serial cross sections with myosin heavy chain (MyHC) type I and type II monoclonal antibodies. The PL consisted of a relatively heterogeneous fiber type composition irrespective of the presence of a discrete (type I: 41 ± 11%; type II: 55 ± 12%; hybrid: 4 ± 3%) or rudimentary (type I: 49 ± 10%; type II: 45 ± 9%; hybrid: 6 ± 4%) tendinous connection with the APB. The APB fascicles arranged contiguously with the PL through a discrete tendon had significantly greater proportions of type II fibers (41 ± 19%) compared to those with rudimentary PL connections (type II: 15 ± 8%). Therefore, the APB fascicles arranged in a digastric relationship with the PL may have the capacity to produce more powerful contractions than those with rudimentary PL tendons based on the known contractile properties of type II muscle fibers. Knowledge of the spatial relationship between the PL and thenar musculature prior to PL autologous tendon transfer may be a useful indicator of the quality of established synergy in vivo.

Thumb Opposition Recovery Following Surgery for Severe Carpal Tunnel Syndrome: A Clinical, Radiological, and Electrophysiological Pilot Study

PURPOSE

To objectively assess recovery of thumb opposition in patients with carpal tunnel syndrome (CTS) after open carpal tunnel release and to evaluate electrophysiological and magnetic resonance (MR) neurography findings as predictors of thumb opposition recovery.

METHODS

A total of 22 patients with severe CTS and thenar atrophy were included in this study. A detailed clinical, electrophysiological, and MR neurography evaluation was done both before and after surgery at 6 months to assess thumb opposition recovery.

RESULTS

The median duration of symptoms was 12 months (interquartile range, 12-20 months). The compound muscle action potential of the abductor pollisis brevis (CMAP-APB) also showed statistically significant improvement of 0.5 + 0.2 mV after surgery. Tip-tip pulp pinch strength increased from 1.2 ± 0.4 to 2.0 ± 0.4 kg at 6-month follow-up, lateral pulp pinch strength increased from 1.9 ± 0.6 to 2.8 ± 0.9 kg at 6-month follow-up, and 3-point pulp pinch also improved from 1.9 ± 0.5 to 2.8 ± 0.9 at final follow-up. On MR neurogram, the proportion of patients with abnormal median nerve morphology decreased from 81.8% to 68.2%, abnormal thenar branch morphology decreased from 63.6% to 36.4% and denervation edema deceased from 59.1% to 13.6%.

CONCLUSIONS

Patients suffering from severe CTS with thenar atrophy and detectable CMAP-APB showed promising improvement following open carpal tunnel release.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

A new method of measuring the thumb pronation and palmar abduction angles during opposition movement using a three-axis gyroscope

Background

Thumb opposition is vital for hand function and involves pronation and palmar abduction. The improvement of pronation is often used as one of the evaluation items of the opponensplasty method for severe carpal tunnel syndrome. However, most of the studies used substitution evaluation methods for measurement of the pronation angle. Thus, there is still no appropriate method for measuring thumb pronation angle accurately in carpal tunnel syndrome patients.

In recent reports, a wearable gyroscope was used to evaluate upper extremity motions and it can be possibly used for accurate measurement of the thumb pronation angle along the three-dimensionally moving bone axis.

Thus, we investigated the reliability of measuring thumb pronation using a gyroscope and evaluated whether this method can be used to detect opposition impairment.

Methods

The participants were volunteers with unaffected upper limbs (32 hands) and patients with carpal tunnel syndrome (27 hands). The pronation and palmar abduction angles during opposition movements were measured using a three-axis gyroscope that included a three-axis accelerometer. The gyroscope was fixed onto the first metacarpal bone and the thumb phalanx.

Results

The pronation and palmar abduction angles of the metacarpal bone and the palmar abduction angles of the phalanx significantly decreased in the carpal tunnel syndrome group. The pronation angle of the metacarpal bone during opposition movement peaked later than the palmar abduction angle in all hands.

Conclusions

We were able to measure the thumb pronation and palmar abduction angles using the three-axis gyroscope, and this tool was able to detect impairments of thumb opposition due to carpal tunnel syndrome. This could be a tool for measuring thumb and finger angles and for detecting impairments caused by various diseases.