Intrinsic muscles palsies of the hand Management of Thumb Opposition with BURKHALTER s Procedure TRUONG LE DAO, MD, IFAAD 1
Burkhalter W.E, Cristhensen R.C, Brown P.W, Extensor Indicis Proprius opponensplasty J. Bone Joint Surg. 55: 725-732, 1973 This technique has been applied to restore thumb opposition since 1990 in HCMC Hospital of Dermatovenerology. 2
Tendon transfers require a multidisciplinary team particularly physiotherapist for preoperative as well as postoperative assessment and useful exercise. Department of Surgical Reconstruction & Rehabilitation in Leprosy HCMC Hospital of Dermatovenerolory 3
CONTENTS Indications Surgical Principles Technique of Opposition Transfer Surgical Stratery Rehabilitation after Tendon Transfer Outcome 4
INDICATIONS High median-nerve injury, when the FDS are not available. Combined median-ulnar nerve injury, either high or low. 5
SURGICAL PRINCIPLES Which motor muscle? Which route? Which pulley? Which type of insertion? 6
Extensor Indicis Proprius Bunnell called tendon transfers muscle balance operations. The EIP provides thumb mobility and full opposition. 7
Choosing the Route of Transfer The more radial the route, the more thumb abduction it provides to the thumb. The more ulnar the route, the more flexion and pronation it provides to the thumb. The most effective opposition transfer courses to its insertion on the thumb from the directon of the pisiform, paralleling the APB tendon. 8
The best plane for the transfer is superficial to the palmar fascia in the subcutaneous layer. The more direct the route of transfer, the less force is needed to effect thumb movement. The EIP has a more direct route than the FDS. 9
Pulley Ulnar bone is a stiff pully. It doesn t change the tendon direction of more than 45 degrees. 10
Double Insertions (Riordan) The abductor pollicis brevis tendon, the thumb MCP joint capsule. And the extensor pollicis longus over the proximal phalanx, if there is significant direct injury to the ulnar-innervated muscles. 11
Technique of Opposition Transfer A B Abductor Pollicis Brevis Extensor Indicis Proprius 12
First incision An incision is made over the dorsum of the index MCP joint. The EIP is harvested from its insertion. A small portion of the extensor expansion taken with the tendon may ensure that it will reach its new insertion on the thumb. The extensor hood must be meticulously repaired to prevent an extensor lag of the index MCP joint. 13
Second Incision A second incision is made over the distal aspect of the dorsoulnar forearm. The tendon and muscle belly of the EIP must be freed more proximally to provide a more direct line of pull. 14
Third Incision A third incision is made over the pisiform. A wide subcutaneous tunnel is developed between the incisions over the pisiform and the dorsoulnar forearm. The EIP tendon is passed through the tunnel around the ulnar border of the forearm. 15
Fourth Incision A fourth incision is made over the radial aspect of the thumb MCP joint. Another subcutaneous tunnel from the pisiform to the thumb MCP joint provides the pathway for the thumb transfer. The EIP tendon is attached according to Riordan s method. 16
Adjusting the Tension of the Transfer The tension is adjusted with the wrist in 30 degrees of flexion and the thumb in full opposition. The thumb is casted in full opposition and the wrist in flexion with anterior and posterior splints for hand-lower forearm for approximately 4 weeks. 17
Surgical Strategy Preoperative care Thumb Web Release Flexion contracture of the thumb IP 18
Pre Operative Care Scar mobilization by: mechanical massage active motion Maximization of range of motion (ROM): frequent passive ROM dynamic splinting and serial casting aid static splinting Adequate thumb web: A short opponens splint with a C-bar Passive stretching to the thumb metacarpal 19
Flexion contracture of the thumb IP: Serial plaster cast Maximization of muscle strength. Specifically, the proposed donor muscle. Patient education: what the donor does, where it is, and how to initiate its contraction. It is much easier to accomplish this preoperatively. 20
Thumb Web Release If there is still a limited ROM despite good hand therapy and splinting, a thumb webspace release may be necessary at the time or before opposition transfer. Skin coverage for the thumb web is obtained with a Z-plasty, four-flap web-plasty, rotational flap from the dorsum of the index metacarpal and MCP joint, or skin graft. 21
Fixed Flexion Contracture ot the Thumb IP This problem is not always solved by Burkhalter s procedure. If BOUVIER test (+), the radial half of flexor pollicis longus was cut near its insertion and attached to EPL over the middle of the proximal phalanx of thumb. 22
Rehabilitation after Tendon Transfer During in a protective splint or cast After discontinued protective splint 23
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Postoperatively, during the first 3 to 5 weeks : Active and passive ROM exercises are initiated to the joints that do not need protection. Edema is controlled with elevation, and active ROM. By 4 to 5 weeks: Mobilization to all joints. Until 6 weeks: Continuing protective splinting to prevent overstretching. From 6 to 8 weeks: discontinuing protective splint and instituting passive ROM for all joints. Light activities. By 8 weeks: progressive resistance exercises such as putty gripping, weights. By 12 weeks: increasing strength, endurance, and function with a home program if needed. 25
Outcome Advantages Disadvantages 26
Advantage Stabilization of the Thumb MCP joint 27
Advantage Good thumb opposition but no more pronation 28
Disadvantage Lost dorsal flexion of the thumb IP joint 29
Disadvantage There is still Froment s sign 30
Disadvantage Lost dorsal flexion of the Index MCP joint 31
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