The Camitz transfer and its modifications: a review

Modified Extensor Indicis Proprius Opponensplasty

Extensor indicis proprius (EIP) opponensplasty is one of the commonly used techniques to restore thumb abduction and opposition in patients with thenar muscle dysfunction from various causes of median nerve palsy. However, its subcutaneous route around the distal ulna may not represent a straight line of pull, and part of the extensor hood sometimes has to be harvested along with the EIP tendon to gain adequate length to reach the insertion. The purpose of the study is to present the alternative method of EIP opponensplasty and report the clinical outcomes. The modified EIP opponensplasty was performed on 16 patients with severe carpal tunnel syndrome. At the final follow-up examination, all patients were able to regain their desired level of activities. The Kapandji score, abduction angle, and the disabilities of the arm, shoulder, and hand score improved in all patients. There were no complications related to harvesting the EIP tendon. Two patients developed finger stiffness, which improved after rehabilitation. This technique is safe and effective for restoring thumb function and can solve the insufficient tendon length problem of the original EIP opponensplasty.

Pedicled Pronator Quadratus Transposition for Functional Opponensplasty: A Cadaveric Anatomical Study for Feasibility

BACKGROUND

Techniques on opponensplasty for chronic carpal tunnel syndrome have been described previously. A novel pronator quadratus (PQ) transposition for chronic carpal tunnel syndrome is described. In addition, the relationship of the distal perforating branch of the radial artery to the surrounding tissue is detailed to optimize further use of the PQ flap for clinical applications.

METHODS

Ten cadaver hands underwent PQ dissection, and the perforating branch of the radial artery was identified. Measurements were taken from the radiocarpal joint and the radial styloid to the distal perforating branch. Finally, a proposed surgical technique of PQ transposition with proximal radius periosteum to the first metacarpophalangeal joint and anterior interosseous nerve transfer was performed.

RESULTS

The average distance of the perforating branch from the radiocarpal joint was 10 ± 1.05 mm, and the average distance from the radial styloid was 17.1 ± 1.6 mm. Pronator quadratus transposed with a layer of radius periosteum demonstrated anatomical feasibility.

CONCLUSIONS

The distal perforating branch of the radial artery predictably perfuses the PQ muscle, which may be used in the future as a means of opponensplasty for chronic carpal tunnel syndrome.

Thumb pronation efficacy of Camitz tendon transfer with insertion on the ulnar capsule of the metacarpophalangeal joint: a cadaver study

Several studies have indicated that Camitz transfer for severe carpal tunnel does not adequately restore thumb opposition. The aim of this study was to determine whether modification of the distal insertion of the transferred palmaris longus tendon could provide more effective opposition. We used 12 fresh-frozen upper extremity specimens. For spatial analysis, we used a three-dimensional motion-tracking device. At 0 N and 5 N of traction force, the pronation angle was significantly larger for the modified procedure than for the conventional procedure. There was no significant difference in the palmar abduction angle between the two groups. The modified palmaris longus tendon insertion on the ulnar side of the thumb metacarpophalangeal joint provides more effective thumb pronation than conventional Camitz opponensplasty in a cadaver model.    .

Distal nerve transfers for peripheral nerve injuries: indications and outcomes

Distal nerve transfer is a refined surgical technique involving the redirection of healthy sacrificable nerves from one part of the body to reinstate function in another area afflicted by paralysis or injury. This approach is particularly valuable when the original nerves are extensively damaged and standard repair methods, such as direct suturing or grafting, may be insufficient. As the nerve coaptation is close to the recipient muscles or skin, distal nerve transfers reduce the time to reinnervation. The harvesting of nerves for transfer should usually result in minimal or no donor morbidity, as any anticipated loss of function is compensated for by adjacent muscles or overlapping cutaneous territory. Recent years have witnessed notable progress in nerve transfer procedures, markedly enhancing the outcomes of upper limb reconstruction for conditions encompassing peripheral nerve, brachial plexus and spinal cord injuries.

Case Series: Wide-Awake Local Anaesthesia Without Tourniquet (WALANT) for Camitz Transfer

Background: Wide-Awake Local Anaesthesia Without Tourniquet (WALANT), with the benefit of simplicity and a low complication rate, is a well-recognised procedure in orthopaedic surgery. To date, there is no report using WALANT technique with the Camitz transfer procedure. The aim of this study is to determine the early outcomes of using WALANT for Camitz transfer and compare these with outcomes of similar procedures in literature. Methods: Between January 2012 and January 2018, all patients with severe carpal tunnel syndrome (CTS) with thenar muscle atrophy who underwent the Camitz transfer procedure as day surgery under the WALANT technique at the Thammasat University Hospital were included. With the WALANT technique, the 10 mL of prepared anaesthesia was injected into the area around the palmaris longus tendon from 5-cm proximal to the distal wrist crease to the distal palmar crease, while an additional 10 mL was injected from the radial side of the metacarpophalangeal joint of the thumb to the distal wrist crease before the operation. Upon completion of the operation, the patients' hand was placed in a thumb spica splint. Patient demographic data, visual analogue scale (VAS) during injection and during procedure, operative time, blood lost and complications were recorded. Results: Thirty-six patients (8 males and 28 females) were included. The average age of the patients was 65.9 (37-87) years old. The average VAS score during the anaesthetic injection was 6.22 (5-8). The average VAS pain score during the operation was 0.52 (0-3). The average operative time was 27.06 (17-47) minutes. The mean intraoperative blood loss was 3 (2.4-6.8) mL. All patients underwent the procedure without any complications. Conclusions: The WALANT technique is safe and can be used as alternative anaesthesia for the Camitz transfer. Level of Evidence: Level IV (Therapeutic).

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.

Opponensplasty by the Palmaris Longus Tendon to the Rerouted Extensor Pollicis Brevis Transfer With Endoscopic Carpal Tunnel Release in Severe Carpal Tunnel Syndrome

In patients with severe carpal tunnel syndrome (CTS), restoring thumb opposition is critical because this function is essential for proper pinching, grasping, and other complex hand movements. Opponensplasty is an effective procedure to preserve thumb function, with several methods reported. Camitz opponensplasty, using the palmaris longus (PL), is an option for patients with severe CTS. Recently, several modified Camitz procedures have been proposed to overcome the shortcomings of the original description. This article describes the surgical technique of the opponensplasty using the PL tendon to the rerouted extensor pollicis brevis transfer. The procedure provides satisfactory outcomes for early functional recovery of the hand in patients with severe CTS.

Three-dimensional analysis of thumb motion recovery after carpal tunnel release

This study quantified recovery of thumb motion in patients with carpal tunnel syndrome after carpal tunnel release using three-dimensional motion analysis with a retroreflective surface-based marker method. Eighteen hands from 14 patients who underwent carpal tunnel release for idiopathic carpal tunnel syndrome were included. The angular movements of the three joints of the thumb, the path length of the thumb tip and the area enclosed by the perimeter path of the thumb tip were measured during circumduction. The range of joint movement, including abduction/adduction of the trapeziometacarpal joint, and flexion/extension of the interphalangeal and metacarpophalangeal joints and the path length of the thumb tips, improved significantly 1 year after surgery. The quantification of thumb kinematics helps to better understand motor dysfunction in carpal tunnel syndrome, assess the severity of the condition and decide on treatment.Level of evidence: IV.

Single incision thenar muscle reconstruction using the free functional pronator quadratus flap

Background

Injuries to the thenar muscle mass or the thenar branch of the median nerve and resulting loss of thumb opposition lead to a massive impairment of hand function. For decades, reconstructive approaches were based on tendon transfers. To broaden the reconstructive repertoire, we present the free functional pronator quadratus flap as a viable alternative for functional reconstruction and provide a specification for its indication. We demonstrate our surgical technique to a single incision reconstruction using the free functional pronator quadratus flap. Based on a series of three patients, which were analyzed for hand function using Kapandji’s score and the angle of Bourrel, grip strength and nerve conduction velocity in a two year follow up, we present an indication algorithm.

Results

After successful reinnervation of all flaps, we found an improvement of Kapandji’s score from 4.3 ± 0.94 preoperatively, to 8.7 ± 0.47 after two years. Accordingly, the angle of Bourrel decreased from 75.75 ± 3.45 degrees to 36.96 ± 3.68 degree. Grip strength also improved from 14 ± 2.2 kg to 26.2 ± 1.2 kg. No impairment of wrist pronation was observed.

Conclusion

We found excellent functional recovery of thumb opposition and strength, showing similar or even superior results compared to results from tendon transfers. With the benefit of a single incision surgery and therefore minimal donor site morbidity, this free functional muscle transfer is a viable alternative to classic tendon transfers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01308-x.

Novel Surgical Procedure for Half Palmaris Longus Transfer during Opponensplasty of the Thumb for Patients with Carpal Tunnel Syndrome: A Technical Note

Thumb opposition is an essential movement for daily use of the hand, including precise pinching/grasping and fine and complicated hand movement. Although studies have reported use of several donor tendons for opponensplasty, opponensplasty using the palmaris longus (i.e., Camitz opponensplasty) has been used in patients with loss of opposition function due to longstanding carpal tunnel syndrome. The procedure involves a simple, useful tendon transfer and does not cause functional deficits. To obtain enough length to transfer the tendon to the metacarpophalangeal joint of the thumb, the PL tendon should be obtained with the palmar aponeurosis. However, the palmar aponeurosis is not always available for opponensplasty, as it is occasionally thin and insufficient for elongation of the palmaris longus. An extended skin incision over the palm can cause painful scar formation and postoperative residual pain. This procedure restores the palmar abduction function of the thumb but not opposition function. In the present article, we describe a modification of Camitz opponensplasty that uses a half-split palmaris longus, which is long enough to anchor to the insertion of the adductor pollicis at the metacarpophalangeal joint of the thumb.

Biomechanical Evaluation of Opponensplasty for Low Median Palsy: A Cadaver Study

Purpose

Impaired thumb opposition associated with advanced carpal tunnel syndrome may be treated by opponensplasty at the time of open carpal tunnel release. However, it is unclear which opponensplasty technique achieves the greatest functional improvement. This study aimed to compare the biomechanics of thumb opposition after Camitz, modified Camitz, and Burkhalter opponensplasties.

Methods

We used 6 fresh-frozen cadaveric arms. Each procedure was reproduced on each arm: Camitz opponensplasty, modified Camitz opponensplasty involving palmaris longus transfer routed around the flexor carpi ulnaris pulley, and Burkhalter opponensplasty. Arms were fixed with the wrist in 0° flexion and the forearm in neutral pronosupination, and sensors were placed on the thumbnail, radial styloid, and dorsal aspect of the second metacarpal head. The donor tendon was pulled using a mechanical testing machine with a maximum force of 25 N, and the locations of the sensors in thumb opposition were recorded. The first web space and thumb pronation angles were measured for each procedure and compared.

Results

The mean first web space and pronation angles produced using 25 N were 55° and 20°, 57° and 26°, and 53° and 29° for the Camitz, modified Camitz, and Burkhalter opponensplasties, respectively. The first web space angle was significantly larger after modified Camitz opponensplasty compared with Burkhalter opponensplasty with 25 N loading. Camitz opponensplasty resulted in a significantly smaller pronation angle compared with modified Camitz and Burkhalter opponensplasties with 25 N loading.

Conclusions

The modified Camitz opponensplasty produces a relatively balanced biomechanical outcome in terms of the first web space and pronation angles. Conversely, Burkhalter opponensplasty has been shown to be a favorable technique for improving pronation.

Clinical relevance

Modified Camitz opponensplasty with a pulley offers effective restoration of thumb opposition, including pronation. On the other hand, Burkhalter opponensplasty represents a suitable option not only for patients with high median palsy and injury to the palmar aponeurosis but also for those who require improved pronation.

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.

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.

Minimally invasive modified Camitz opponensplasty for severe carpal tunnel syndrome

PURPOSE

We aimed to compare the clinical results and the complications between the minimally invasive modified Camitz opponensplasty and the conventional Camitz opponensplasty for severe carpal tunnel syndrome (CTS), and to evaluate the efficacy of the modified technique for CTS.

METHODS

Twenty-eight hands in 24 patients with severe CTS who had disorder of the thumb opposition with thenar muscle atrophy (group 1) were treated by minimally invasive modified Camitz opponensplasty, passing the transferred palmaris longus (PL) tendon under the abductor pollicis brevis (APB) fascia using only palm and thumb incision, and no incision to either wrist crease or forearm. Ten hands in 10 patients (group 2) were treated by the conventional Camitz opponensplasty. Clinical evaluation was made by comparing the results before and after surgery for the angle of the thumb palmar abduction, pinch power, and grip strength.

RESULTS

All clinical findings significantly improved after surgery compared with before surgery in all patients. In group 1, there were no complications including transferred tendon bowstring, painful wrist scar, or injury to the palmar cutaneous branch of the median nerve in all hands. Conversely, patients in group 2 had four painful wrist scars and nine bowstrings of the transferred tendon.

CONCLUSIONS

Several complications have been considered to attribute to the long incision and an extensive dissection crossing the wrist crease from the palm to the wrist in the conventional Camitz procedure. The current modified Camitz opponensplasty by minimally invasive incision without straddling the wrist crease is a simple and effective procedure that can decrease the risk of painful scar around the wrist crease in severe CTS patients with disorder of thumb opposition. Additionally, this technique, by passing the transferred PL tendon under the APB fascia, is useful in restoring the thumb opposition immediately, and in preventing the bowstringing of the transferred tendon.

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.

Transfer of the Motor Branch of the Abductor Digiti Quinti for Thenar Muscle Reinnervation in High Median Nerve Injuries

PURPOSE

In high median nerve repairs, thenar muscle reinnervation is impossible because of the long distances over which axons must regenerate. To overcome this obstacle, we propose transferring the abductor digiti quinti motor branch (ADQMB) to the thenar branch of the median nerve (TBMN).

METHODS

We used 10 embalmed hands for anatomical and histological studies. Thereafter, 5 patients with a high median nerve injury underwent surgical reconstruction within 8 months of their accident and were followed for at least 10 months after surgery (mean, 13.2 months). We transferred the ADQMB to the TBMN. The median nerve was grafted in 4 patients and the motor branch of the extensor carpi radialis brevis was transferred to the anterior interosseous nerve in 3. Patients had pre- and postoperative evaluations of thumb range of motion and strength.

RESULTS

In cadaveric hands, the ADQMB was the first branch of the ulnar nerve to arise near the pisiform bone. The TBMN arose from the anterior surface of the median nerve, underneath the flexor retinaculum. Retrograde dissection of the TBMN allowed tension-free coaptation with the ADQMB. Both branches contained approximately 650 myelinated fibers. After surgery, all our patients improved thumb pronation, thenar eminence bulk, and abductor pollicis brevis British Medical Research Council score. They recovered approximately 75% of their normal-side grasp and pinch strength. No patient lost little finger abduction.

CONCLUSIONS

Transfer of the ADQMB to the TBMN reinnervated the thenar muscles, which improved thumb range of motion and strength.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Minimally Invasive Palmaris Longus Abductorplasty for Severe Carpal Tunnel Syndrome

Camitz abductorplasty is the most commonly used tendon transfer in patients with severe carpal tunnel syndrome with significant muscle wasting and loss of opposition. This procedure requires a long incision in the palm to harvest a strip of palmar aponeurosis to lengthen the palmaris longus tendon, allowing it to reach the abductor pollicis brevis insertion. Several complications have been attributed to this extensive dissection in the palm. We describe a minimally invasive palmaris longus abductorplasty using a strip of free flexor carpi radialis tendon graft to achieve the necessary length. This can be done together with carpal tunnel release in patients with severe carpal tunnel syndrome.