Functional Surgery ofthe Upper Limb in High-Ievel Tetraplegia: Part II

Transcription

1 J Techmques in Hand and Upper Extremity Surgery 4(1):64--68, Uppincotl Williams & Wilkins, fnc., Philadelphia CHNIQO Functional Surgery ofthe Upper Limb in High-Ievel Tetraplegia: Part II YVES ALLIEU, M.D. BERTRAND COULET, M.D. MICHEL CHAMMAS, M.D. Orthopaedic and Upper Limb Surgery Department, Lapeyronie Hospital, Montpellier, France n...:;"unctional reconstruction of the hand has two stages: 11 1 restoration of wrist extension and constuction of the pollici digital pinch. The first stage is necessary only in group 1 of the international classification; these patients present a weak wrist extension. Pollici digital pinch construction is performed in two steps: restoring motor function of the pinch and positioning the thumb. RESTORATION OF ACTIVE WRIST EXTENSION (LEVEL G1) BY BRACHIORADIALIS TRANSFER TO THE EXTENSOR CARPI RADIALIS (ECR) LONGUS AND BREVIS The originators of this surgical technique emphasized the importance of active wrist extension to maintain the tenodesis effect of the wrist (2). The brachioradialis (BR), the only transferable muscle for these patients, was formerly considered an inappropriate motor muscle, but this notion is wrong if we consider certain principles (3,7). Operative Technique The patient is placed in a dorsal position, with a pneumatic tourniquet at the root of the limb. The forearm is in neutral pronosupination. A lateral incision is made distally, facing the radial styloid, and continues proximally on the anterior side of the forearm, facing the BR muscular body. Its terminai tendon is released from the radius, taking case to protect the sensitive branch of the radial nerve, which was previously identified. The muscle body is largely released from its aponeurotic wrapping. The principal pedicle is very proximal, and there is no risk of injury to it. An accessory pedicle situated at the middle level of the muscle body will be coagulated. The release procedure is very im- Address correspondence and reprint requests to Dr. Yves Allieu, Orthopaedic and Upper Limb Surgery Departinent, Lapeyronie Hospital, Montpellier Cedex 5, France. portant; it is considered sufficient when a traction on the BR tendon allows an excursion of at least 3 cm. The ECR brevis and longus distal tendons are identified above the extensor retinaculum by the same surgical approach. The BR is fixed to the ECR by a transtendinosis type of suture. The tension should be set so that the wrist remains in very slight extension against gravity. Moberg (8) proposed opening the retinaculum of the second groove to increase the strength moment of the ECR. Postoperative Management Immobilization is assured by a splint that maintains the elbow in flexion and the wrist at 30 0 extension. Mobilization starts at week 4. Complications The main complication is stretching and weakness of the transfer. The results depend mainly on the quality of the active extension of the elbow (1), which must be restored before the BR transfer to stabilize the elbow extension. POLLICI DIGITAL PINCH CONSTRUCTION The construction of a pollici digital pinch requires two stages, regardless of the neurologic level of the patient: activation of the pinch and positioning of the thumb. The first is systematic, and the second depends on the spontaneous positioning of the frrst column. For technical reasons, we have separated these two stages, which must be associated and performed simultaneously. Pinch Motorization Procedures We distinguish two types of pollici digital pinches according to the neurologic level: In the passive pinch, the flexor pollicis longus (FPL) fixed to the radius is activated by tenodesis during 64 Techniques in Hand and Upper Extremity Surgery

2 y. Allieu et al. range of motion in the thumb is preserved. The interphalangeai (IF) and metacarpophalangeal (MP) joints must be stabilized. At the IF level, we perform the crossed tenodesis technique by transfening part of the FPL to the EPL, as described by Mohammed et al. (9) (Fig. 4). The MP joint is stabilized by a dorsal capsulodesis of the EPL and EPB at the back of the articulation. IP Stabilization: The New Zealand Procedure (Fig. 4). The procedure is protected postoperatively for 4 weeks with a 1211 O-mm pin that maintains the IF joint at 20 flexion. MP Stability. To avoid hyperflexion of the MP, we perform a dorsal capsulodesis of the EPB and EPL or as soon as the MP flexion exceeds 30. Morever, by shifting and fixing these tendons to the MP radial side of the thumb, a pronation effect of the first column is obtained, which stabilizes the pinch. When MP flexion is very important, we can perform an arthrodesis directly, which will result in a more active pinch. lndex-finger-positioning Procedure. When the lesion segment is long, the flexors are hypotonic and the l\t1p index is not stabilized in flexion. Wrist extension induces a limited flexion of the index frnger. It will be possible to position the index finger correctly by perforrning the lasso surgical procedure of Zancolli (11) on the finger by using the flexor digitorum superficialis. Sorne patients prefer to preserve the flexibility of the hand, and they may passively position the l\t1p index finger rather than use the key grip by using the rolling technique described by Moberg (8). The aim of this procedure is to obtain a strong and stable key grip, with a good opening (Figs. 5, 6). Complications After Key-Grip Construction (10) Surgery causes pain by irritating the sensitive branch of the radial nerve, as does arthrodesis of the CM. In both cases, the pain very often regresses after a few weeks. Weakening due to stretching of the FPL tenodesis, which necessitates a surgical tightening. Opening defect due to stretching of the EPL tenodesis and flexion contracture of the MP joint of the thumb. This complication is particularly frequent after pinch activation by the transfer of the BR to the FPL. in this case, an arthrodesis of the MP joint has to be associated to a secondary tenodesis. REFERENCES 1) Brys D, Waters RL. Effect of triceps function on the brachioradialis transfer in quadraplegia. J Hand Surg 1987; 12A: ) Freehafer AA, Mast WA. Transfer of brachioradialis to improve wrist extension in high spinal-cord injury. J Bane Joint Surg 1967;49A: ) Freehafer AA, Peckham PH, Keith MW, Mendelson LS. The brachioradialis: anatomy, properties, and value for tendon transfer in tetraplegics. J Hand Surg 1988;13A: ) House m. Reconstruction of the thumb in tetraplegia following spinal cord injury. Orthop Clin North Am 1985;195: ) House m, Comadoll J, Dahl AL. One-stage key pinch and release with thumb c3ipal- metac3ipal fusion in tetraplegia. J Hand Surg 1992; 17A:53D-8. 6) House JH, Shannon MA. Restoration of strong grasp and lateral pinch in tetraplegia: a comparaison of two methods of thumb control in each patient. J Hand Surg 1985;IOA: ) Johnson DL, Gellman H, Waters RL, Tognella M. Brachioradialis transfert for wrist extension in tetraplegic patients who have fifth-cervical level neurological function. J Bane Joint Surg 1996;78A: ) Moberg E. Surgicaltreatrnent for absent single-hand grip and elbow extension in quadraplegia. J Bane Joint Surg 1975;57A: ) Mohammed KD, Rothwell AG, Sinclair SW, Willems SM, Bean AR. Upper-limb surgery for tetraplegia. J Bane Joint Surg 1992;74B: ) Smith AG. Early complications of key grip hand surgery for tetraplegia. Paraplegia 1981;19: Il) Zancolli EA. Surgery for the tetraplegic hand with active strong wrist extension preserved. A study of 97 cases. Clin Orthop 1975;11: Techniques in Harul and Upper EXlremily Surgery

3 STUL Part Il wrist extension. This is the key grip as described by identification of the EPL after opening the extensor Moberg. retinaculum facing Lister's tubercle. The two tendons are In the active pinch, the BR is transferred to the FPL. dissected at the musculotendinous junction to preserve maximum length. The ends are prepared and tenodesed Passive Key Grip by Tenodesis ofthe FPL and Extensor to the radius through a bone tunnel whose direction will Pollicis Longus (EPL) to the Radius (According to Al determine the success of the tenodesis. The goal is to lieu) (Gl-2) increase the opposing action of the FPL and reduce the Operative Technique. The operation is perfonned retropulsion effect of the EPL. with a pneumatie tourniquet. A laterallongitudinal access The distal radius is approached anteriorly. A bone allows palmar identification of the FPL and dorsal tunnel is bored through from the radial styloid to the an- Abductor Pollicis Longus Extensor Pollicis Longus - ---". 1j4-->i"-<- --'Flexor Pollicis Longus A Extensor Pollicis Longus FI.,o, Polliels Longus \ Extensor Pollicis Brevis FIG. 1. Key grip and extensor pollicis brevis (EPB) tenodesis. This technique was developed by Allieu et al. to contruct the key grip by flexor pollicis longus (FPL) tenodesis through a transosseous tunnel in the radial epiphysis. In addition, associated procedures for thumb positioning are performed. A: An FPL opening plasty to the dorsal annular ligament of the carpal. B: An opponons piasty du ring pinch closing with the EPB around the flexor carpi radialis. B Volume 4, Issue 1 65

4 y Allieu et al. FIG. 2. Passive extensor pollicis brevis (EPS) opponens plasty. The EPS is taken fram its insertion point to the musculotendinous junction. The tendon is dissected proximally and passed around the flexor carpi radialis tendon and then sutured to itself or to the brachioradialis if it was used to activate the flexor pollicis longus. terior medial side of the radius. Its diameter is gradually increased to 4.5 mm. The two tendons are inserted into the tunnel in the opposite direction, thus setting their tension simultaneously (Fig. 1). The tension of the transfers is applied step by step by modifying wrist flexion and extension. The FPL is stretched first so that, when the wrist is at 20 flexion, the pulp of the thumb touches the index; the EPL is fixed in tension in this position. When the final adjustments have been made, the two tendons are fixed to each other. Postoperative Management. The patient is immobilized in a very mild wrist flexion; the first web is open. Reeducation is begun at week 4, and intensive exercises are begun at week 6. BR-to-FPL Trans/er (Level G2). For these patients, who have a strong and resistant ECR longus, to activate the pinch, it is possible to strengthen the tenodesis effect of the wrist by transferring the BR to the FPL. The EPL tenodesis is performed in a way similar to that for the pinch opening. Technique. Under the same conditions, we use a longitudinal lateral approach that is prolonged FIG. 3. Transfer of the brachioradialis to the flexor pollicis longus. Illustration by T. G. Huff Associates. proximally. The BR is freed from the radial styloid and widely released, as described previously. The BR is sutured to the EPL by a transtendinous type of stitch (Fig. 2). The tension is set in such a way so that, when the elbow is flexed, the wrist is at 10 extension and the thumb is in contact with the index finger. The EPL is lifted from the osteofibrous groove and fixed on the extensor retinaculum on the lateral side of the radius. Postoperative Management. The patient is immobilized by an orthesis, with the elbow at 90 flexion, the wrist at 20 flexion, and the thumb in opposition at contact with the index finger. The reeducation program is the same as that described for the key grip. PositioIÙng and Stabilization of the Thumb and Index Finger Passive FPL activation by tenodesis or by tendon transfer is not sufficient to ensure a good quality grip. Two other conditions are also necessary. Thumb positioning: These procedures are always necessary when the intrinsic muscles of the tbumb are included in the lesion segment. This situation is usual in middle- and low-level tetraplegia but is not systematic in high-ievel tetraplegia. 66 Techniques in Rand and Upper Extremity Surgery

5 STUL Part II Extensor Pollicis Longus FIG.4. New Zealand procedure. The flexor pollicis longus (FPL) and extensor pollicis longus (EPL) are dissected from a laierai approach in the thumb. The radial half of the FPL is released laterally and freed proximally up to the annular pulley. The radial half is fixed in a transtendinous way on the EPL. An axial pin maintains the interphalangeai joint at 20 flexion. Illustration by T. G. Huff Associates. Simplification of the first-column polyarticular chain. Thumb-Positioning Procedures. For thumb positioning, two techniques are possible: a procedure on the soft parts or an arthrodesis of the thumb carpometacarpal (CM) joint (4,6). Soft-Parts Procedures. Whenever the CM joint is preserved, the thumb must be positioned not only during closing but also during opening of the pineh. Thumb Positioning at Pinch Closing. For EPL passive opponens piasty, the surgical approach is the same as that used to activate the FPL. The extensor pollicis brevis (EPB) is taken from ils insertion point to the musculotendinous junction. The tendon is dissected proximally and passed around the flexor carpi radialis tendon and then sutured to itself or to the BR if the BR was used to activate the FPL (Figs. lb, 2, 3). The tenodesis tension is such that, when the wrist is at 20 flexion, the thumb is in opposition. Thumb Positioning at Pinch Opening. This procedure is very important because it resists the EPL retropulsion effect that leads to the ciosing of the frrst web. For this reason, we use abductor pollicis longus (APL) tenodesis on the dorsal side of the wrist (Fig. la). With the same lateral surgical approach as that used for the passive key grip, the APL is identified at the base of the thumb and disseeted to its musculotendinous junction. The tendon from the first osteofibrous groove is freed and then fixed on the dorsal annular ligament facing Lister's tubercie. Arthrodesis of the Thumb CM Joint (5). The CMjoint surgical approach is anterior. The articulation is dissected, and, once the ideal positioning of the joint is obtained (40 abduction, 40 antepulsion), the antepulsion is fixed with an axial pin. We place two parallel pins between the first and second metacarpals, and then the axial pin is removed ta perforrn two parallel articular resections from the trapeze and the first metacarpal. Once this is done, the interrnetacarpal pins are removed to fix the arthrodesis in compression by divergent pins. Stabilization of the Articular Column of the Thumb. Preservation of the CM joint ensures that most of the FIG. 5 FIG. 6 FIGS Results of constructing a passive key grip. Volume 4, Issue 1 67

6 y. Allieu et al. range of motion in the thumb is preserved. The interphalangeai (IF) and metacarpophalangeal (MP) joints must be stabilized. At the IF level, we perform the crossed tenodesis technique by transferring part of the FPL to the EPL, as described by Mohammed et al. (9) (Fig. 4). The MP joint is stabilized by a dorsal capsulodesis of the EPL and EPB at the back of the articulation. IP Stabilization: The New Zealand Procedure (Fig. 4). The procedure is protected postoperatively for 4 weeks with a l2/l0-mm pin that maintains the IP joint at 20 0 flexion. MP Stability. To avoid hyperflexion of the MP, we perform a dorsal capsulodesis of the EPB and EPL or as soon as the MP flexion exceeds 30 0 Morever, by shifting and fixing these tendons to the MP radial side of the thumb, a pronation effect of the first column is obtained, which stabilizes the pinch. When MP flexion is very important, we can perform an arthrodesis directly, which will result in a more active pinch. Index-Finger-Positioning Procedure. When the lesion segment is long, the flexors are hypotonie and the MP index is not stabilized in flexion. Wrist extension induees a limited flexion of the index finger. It will be possible to position the index finger correctly by performing the lasso surgical procedure of Zancolli (li) on the finger by using the flexor digitorum superficialis. Sorne patients prefer to preserve the flexibility of the hand, and they may passively position the MP index finger rather than use the key grip by using the rolling technique described by Môberg (8). The aim of this procedure is to obtain a strong and stable key grip, with a good opening (Figs. 5, 6). Complications After Key-Grip Construction (10) Surgery causes pain by irritating the sensitive branch of the radial nerve, as does arthrodesis of the CM. In both cases, the pain very often regresses after a few weeks. Weakening due to stretching of the FPL tenodesis, which necessitates a surgical tightening. Gpening defect due to stretching of the EPL tenodesis and flexion contracture of the MP joint of the thumb. This complication is particularly frequent after pinch activation by the transfer of the BR to the FPL. in this case, an arthrodesis of the MP joint has to be associated to a secondary tenodesis. REFERENCES 1) Brys D, Waters RL. Effect of triceps function on the brachioradialis transfer in quadraplegia. J Hand Surg 1987; 12A: ) Freehafer AA, Mast WA. Transfer of brachioradialis to improve wrist extension in high spinal-cord injury. J Bone Joint Surg 1967;49A: ) Freehafer AA, Peckham PH, Keith MW, Mendelson LS. The brachioradialis: anatomy, properties, and value for tendon transfer in tetraplegics. J Hand Surg 1988; 13A: ) House JH. Reconstruction of the thumb in tetraplegia following spinal cord injury. Orthop Clin North Am 1985;195: ) House JH, Comadoll J, Dahl AL. One-stage key pinch and release with thumb carpal- metacarpal fusion in tetraplegia. J Hand Surg 1992; 17A:53O-8. 6) House JH, Shannon MA. Restoration of strong grasp and lateral pinch in tetraplegia: a comparaison of two methods of thumb control in each patient. J Hand Surg 1985;IOA: ) Johnson DL, Gellman H, Waters RL, Togne1la M. Brachioradialis transfert for wrist extension in tetraplegic patients who have fifth-cervicallevel neurological function. J Bone Joint Surg 1996;78A: ) Moberg E. Surgical. treatment for absent single-hand grip and elbow extension in quadraplegia. J Bone Joint Surg 1975;57A: ) Mohammed KD, Rothwell AG, Sinclair SW, Willems SM, Bean AR. Upper-limb surgery for tetraplegia. J Bone Joint Surg 1992;74B: ) Smith AG. Early complications of key grip hand surgery for tetraplegia. Paraplegia 1981;19: II) Zancolli EA. Surgery for the tetraplegic hand with active strong wrist extension preserved. A study of 97 cases. Clin Orthop 1975;11: Techniques in Rand and Upper Extremity Surgery