C

Figure 21—5. (A,B) Artwork of volar and dorsal incisions of the hand and forearm closed once the tension ofthe transfer is secured and tested with the tenodesis effect. (C) Clinical photo of EIP transfer complete with all skin wounds closed.

dressing is applied to maintain the positional thumb opposition, and the index finger is splinted in extension to avoid an extensor lag at the MP joint.

Alternative Techniques

Brand's technique involves splitting the EIP tendon into two slips. One slip is woven through the APB, passed distal to the MP joint, and then attached to the extensor pollicis longus tendon (Fig. 21—6). The second slip passes subcuta-neously across the extensor mechanism dorsally and is attached to the adductor pollicis on the ulnar side of the MP joint. This technique is useful in those patients with complete loss of thenar musculature function and an unstable MP joint.

The Royle-Thompson method also splits the EIP tendon into two slips. One is passed through a drill hole in the metacarpal neck from radial to ulnar with the metacarpal pulled to the highest degree of opposition as possible. The other half is passed dorsally over the extensor hood at the MP joint and through a small tunnel in the fascia and periosteum at the base of the proximal phalanx. The two slips are tied together. The proximal insertion into the head of the metacarpal serves to assist in the rotation of the thumb while the distal insertion achieves slight rotation of the MP joint without causing flexion.

Bunnell Opponensplasty
Figure 21—6. With a severe median and ulnar paralysis, the EIP tendon is split and the Royle-Thompson SP modification is used.
Fds Opponensplasty
Figure 21—7. An alternative transfer such as a Riordan or Sterling Bunnell seen in this clinical photo with the flexor digitorum superficialis (FDS) ring as the donor tendon.

Use of the flexor digitorum superficialis (FDS) ring as an alternative technique was popularized by Sterling Bunnell (Fig. 21-7).

Postoperative Management

The bulky hand dressing with splints is maintained until the sutures are removed at 10 to 14 days after surgery. Hand therapy is initiated to maintain motion in the fingers. An Orthoplast splint is custom fit to maintain wrist flexion and full thumb opposition for a total of 4 weeks. Range of motion, tendon gliding, and retraining exercises are begun at 4 weeks.

Complications

Complications with poor results after the opposition tendon transfers often are due to an adduction contracture of the first metacarpal. This problem may be avoided by release ofthe contracture prior to the tendon transfer, whether it is by a surgical or conservative fashion.

Flexion or extension contractures of the MP joint of the thumb often reflect the position of the transfer relative to the MP joint axis. The transfer should be sutured more dorsally if there is a flexion contracture and reattached more volarly if there is an extension contracture.

Other common complications with any transfer are placing the donor tendons under inadequate tension, or placing a repair in a poorly vascularized soft tissue bed. These complications, along with a web contracture, or inappropriate splinting can often be avoided if precision handling of all tendons is done along with understanding the important general principles of tendon transfers.

Suggested Readings

Anderson GA, Lee V, Sundaraej GD. Opponensplasty by Extensor Indicis and Flexor Digitorum Superficialis Tendon Transfer.

Brand PW. Biomechanics of tendon transfers. Orthop Clin North Am 1974;5:205. Burkhalter WE. Tendon transfer in median nerve palsy. Orthop Clin North Am 1974;

5:271-281.

Conney WP. Tendon transfer for median nerve palsy. Hand Clin 1998;4:155-165.

Hollister A. Giurintano, DJ. Thumb movements, motions and moments. J Hand Ther 1995;8(2):106-114.

Thompson CF. Fusion of the metacarpals of the thumb and index finger to maintain functional positions of the thumb. J Bone Joint Surg [Am] 1942;24:907.

Thomson TC. A modified operation for opponens paralysis. J Bone Joint Surg [Am] 1942;24:632.

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