FLEXOR
DIGITORUM SUPERFICIALIS TENDON FOR INTRINSIC REPLACEMENT
TRANSFER
Long-term results and the effect on donor fingers J. W. BRANDSMA and M. W. OTTENHOFF-DE JONGE From the All Africa Leprosy and Rehabilitation
Training Centre, Addis Ababa, Ethiopia
This study is a review of 127 hands in 100 patients in whom one or two FDS tendons were used to correct claw-hand deformity and/or loss of opposition of the thumb. In lumbrical replacement the results were graded as excellent in 16 hands (21%) and good in 43 hands (57%). For opponensplasty the results were excellent in 26 hands (32%) and good in 42 hands (51%). Possible defects that can develop in the donor finger are: swan-neck deformity, flexion posture of the DIP joint, not as part of the swan-neck deformity, check-rein deformity or flexion contracture, and insufficient finger flexion. Of the 158 fingers swan-neck deformity was seen in 15%, DIP flexion in 29%, check-rein deformity in 26% and insufficient finger flexion in lS”& The latter occurred with another defect. In 48 fingers (30%) no defects were observed.
Journal of Hand Surgery (British Volume, 1992) 17B: 625-628
MATERIAL
Transfer of a flexor digitorum superficialis (FDS) tendon is one of the operations of choice in the correction of the hand with paralysis of the intrinsic muscles. The FDS muscle is an excellent motor to substitute for the loss of primary MP joint flexors in ulnar palsy to correct claw finger deformity (Brand, 1958; Omer, 1982; Fritschi, 1984; Zancolli, 1979) and loss of opposition in low median palsy (Jacobs and Thompson, 1960; Fritschi, 1984; Ramselaar, 1970; Smith, 1980). Transfer of a FDS tendon has also been advocated for the substitution of loss of adduction/flexion power of the thumb in ulnar and combined ulnar and median palsy (Edgerton, 1965; Goldner, 1967). In radial nerve palsy the tendons of the FDS muscle can be used to substitute for the loss of MP joint extension (Boyes, 1960; Chuinard, 1978; Green, 1982). Smith (1987), in his monograph on tendon transfers of the hand and forearm, describes the use of FDS in other conditions, e.g. brachial plexus injury, rheumatoid arthritis, congenitial deformities of the hand and quadriplegia. The loss of the primary flexor of the PIP joint is bound to leave a functional defect at that joint. Swan-neck and check-rein deformities have been well documented (Boyes, 1965; Brand, 1958; Ranney, 1976; North, 1980; Burkhalter, 1986). The check-rein deformity is defined as a post-operative rigid flexion contracture of the PIP joint. Reddy and Kolumban (1981), have identified two other defects in the donor fingers in a group of leprosy patients who had tendon transfers for paralysis of the intrinsic muscles of thumb and fingers; limited extension of the DIP joint and limitation of PIP joint flexion. In this study we have looked at the long-term results of FDS tendon transfer for intrinsic replacement and the frequency of the various defects following use of this tendon in the treatment of ulnar and/or median nerve paralysis.
AND
METHODS
In 1987 and 1988 the authors assessed 127 hands in 100 patients who voluntarily reported back to the hospital. All these patients had undergone surgery for ulnar and/ or median nerve paralysis in which a FDS tendon had been transferred 158 times to either initiate MP flexion of the fingers or to substitute for the loss of thumb opposition. There were 37 women and 63 men. All but three of the 100 patients that were reviewed had leprosy. The period of post-operative follow-up varied from five months to 22 years (average 6.5 years). Several surgeons performed the operations, using different surgical techniques. Of the total of 158 superficialis tendons that were used for transfer, the removal had most often been near its insertion on the middle phalanx and through a mid-lateral incision. Occasionally it had been harvested through an oblique incision over the volar aspect of the proximal phalanx, and in the last two years the most common method was removal through a transverse incision near the distal palmar crease, leaving a 1 to 2 cm stump of tendon. Each of the surgeons used the technique he was most comfortable with. Also the method of insertion of the tendon slip varied with the surgeon, as both Stiles-Bunnell FDS transfer (Brand, 1958) and the Zancolli lasso technique had been used (Zancolli, 1979) for lumbrical replacement. The most frequently used method of insertion for opponensplasty (>95%) had been the so-called Y insertion according to Brand (1966). In the lumbrical replacement as well as the opponensplasty both the middle and the ring finger served as donor fingers. In addition the index finger FDS was used eight times for opponensplasty because the FDS of neither the ring nor the middle finger was available (Table 1). Post-operative loss of PIP joint extension with the MP joints held in flexion by the patient was compared with 625
626
THE
Table l-Fingers
Lumbrical
Donorfinger
replacement
Ring Middle
12 64 16
Ring Middle Index
70 4 8 82
Total Opponensplasty
Table 2-Result
of lumbrical replacement with FDS
n=76
n
%
Excellent : clawing fully corrected Good : improvement of angles Fair: pre- and post-operative angles equal Poor: deterioration of angles Unknown
16 43 4 9 4
21 57 5 12 5
16
100
n=82
n
%
Excellent: strong opposition, maximum range of motion (r.0.m.) no IP flexion Good : good use of transfer, limited strength as observed by therapist Fair: weak opposition, limited strength and/or range of motion Poor: transfer does not pull Unknown: median nerve recovered
26
32
42
51
8
10
4 2
5 2
82
100
Total
Table 3-Result
of opponensplasty
with FDS
Total
Table 4-Post-operative Effect
n
%
Swan-neck DIP flexion (isolated) Check-rein No defects
23 46 41 48
15 29 26 30
158
100
28
18
Insufficient Insufficient
flexion
finger flexion always occurred together with another defect.
Table 5-Removal
VOL.
17B No. 6 DECEMBER
Four grades have been used to record the results of lumbrical replacement and opponensplasty. The grades are defined in Tables 2 and 3. Good or excellent results were found in 78% and 83% respectively. Table 4 shows the effect of removal of FDS on the DIP and PIP joints of the donor fingers. Of the 158 donor fingers that were assessed, 48 (30%) showed no defects. Swan-neck deformity occurred in 23 fingers (15%). Isolated DIP flexion occurred in 46 fingers (29%) and was thus the most frequent defect. The angles of DIP flexion posture (extensor lag) varied between 10” and 80”. Mild flexion (< 20”) of the DIP joint was usually seen when it was not part of the swan-neck deformity. Thus in 59% of the fingers there were either no defects or a very mild flexion deformity of the DIP joint. PIP flexion in the 41 cases of check-rein deformity varied from 15” to 70”. The maximum PIP flexion in 28 donor fingers with insufficient flexion varied from 35” to 85”. Of the 127 operated hands, 26 hands had two FDS tendons removed at the same time for combined lumbrical replacement and opponensplasty. Of these, seven showed the same defect in both donor fingers, 12 showed one or more different defects and seven had no defects (Table 5).
FDS is by no means the only muscle used to substitute for loss of primary MP flexors in ulnar palsy. In the period 1979 to 1988, extensor carpi radialis longus was used 223 times, extensor carpi radialis brevis 32 times and palmaris longus 23 times. FDS was used 275 times for this purpose in the same period. Its use avoids the need for a free tendon graft which is required when a primary wrist motor is to be used. The relatively high proportion of FDS tendons taken from the middle finger for lumbrical replacement and the
of two FDS tendons from one hand n = 52jingers
Check-rein
Swan-neck
(26 hands) Same effect in both fingers Different
effects
1992
DISCUSSION
effects on donor fingers
Total
SURGERY
RESULTS
158
Total
OF HAND
the same angles taken pre-operatively in order to grade the post-operative result of the tendon transfer used for lumbrical replacement. PIP and DIP joint angles were also measured post-operatively to record the degree of secondary defects following FDS removal. Ranges of thumb opposition and flexion at the IP joint of the thumb were measured to grade the result of opponensplasty.
from which FDS was taken Operation
JOURNAL
DIP flexion
10
2
2
4
4
9
NO
defect 14 (hands n = 14) 7 (hands n = 12)
FDS
TENDON
621
TRANSFER
large number removed from the ring finger for opponensplasty can be explained by the fact that many patients had a combined ulnar and median nerve palsy. In these cases we prefer this combination of donor tendons. At least three factors may contribute to the development of swan-neck deformity when FDS is used : removal of the primary flexor from the PIP joint, attachment of the tendon slip into the extensor mechanism in the case of ulnar claw correction and laxity of the volar plate of the PIP joint. Flexion torque is decreased when FDS is removed from a finger, whereas the extension torque is increased by virtue of the attachment of the tendon slip to the extensor mechanism in claw finger correction when the Stiles-Bunnell technique is used. Extension torque is not increased with the Zancolli lasso operation. It would therefore be interesting to see if, and to what extent, swan-neck deformity does develop following this operation as compared to the classical Stiles-Bunnell tendon transfer. We have seen swan-neck deformities in fingers other than the donor fingers when the fingers were fully mobile before surgery. This indicates that adding extension torque alone can be sufficient to cause the deformity. Tightness of the volar plate and residual preoperative contractures can prevent the development of a swan-neck deformity. This may explain the development of isolated DIP flexion in addition to the fact that FDP has a smaller moment arm for the DIP joint as compared to the PIP joint. The mechanism leading to check-rein deformity is not clearly understood. The most common view is that scarring occurs after removal of the FDS tendon, gradually causing a progressive flexion contracture. The check-rein deformity usually develops after the rehabilitation period which usually lasts for between seven and nine weeks after surgery. It is therefore important to continue supervision in order to be able to detect the early development of a flexion contracture and prevent it from becoming progressive and permanent. Loss of flexion becomes apparent immediately after cast removal, three to four weeks post-operatively. This could be caused by adhesions between FDP and adjacent structures restricting proximal excursion of the tendon. North and Little (1980) felt that the consequences of loss of FDS are related to the method used to remove it. They have described a surgical technique that should minimise the chances of producing check-rein and swanneck deformities. In this technique the tendon is divided through an incision between the Al and A2 pulleys. The fact that different defects developed in 12 hands in which two FDS tendons were removed may be an indication that the surgical technique alone does not determine if and what defects develop, assuming that the technique of harvesting the tendons has been the same. The pre-operative condition of the fingers was comparable in these fingers (Table 5). Reddy and Kolumban (198 1) described two beneficial effects on donor fingers from which the FDS was
harvested. They noticed that in many patients extension of the PIP joint improved post-operatively when contractures of the PIP joint had been present pre-operatively. They also noticed that in cases of attenuation of the extensor mechanism, insertion of the graft in the lateral band often corrected the lag in active-assisted extension. We have also observed these beneficial effects. We have not been able to show any relationship between the surgeon’s experience and/or the method of removing of the tendon, the pre-operative condition of the finger and the occurrence of secondary defects in this study. In summary, we believe that the cause of secondary defects on the donor finger following removal of FDS is multifactorial. The pre-operative condition of the PIP joint, the method of harvesting the tendon, surgical skill, the possible addition of extension torque at the PIP joint in a lumbrical replacement, post-operative immobilization and rehabilitation, the motivation of the patient and the expertise of the therapist all determine if and to what extent secondary defects develop. A prospective study with adequate documentation regarding the pre-operative condition of the hand, the surgical technique and post-operative immobilization, and detailed information about post-operative care and re-education should shed further light on the occurrence of secondary defects, as well as the conditions which favour the development of these defects so that appropriate measures can be taken to avoid them.
References BOYES, J. H. (1960). Tendon transfers for radial palsy. Bulletin of the Hospital for Joint Diseases, 21: 2: 97-105. BOYES, J. H. (1965). Panel discussion. American Journal of Surgery, 109: 381395. BRAND, P. W. (1958). Paralytic clawhand: with special reference to paralysis in leprosy and treatment by the sublimis transfer of Stiles and Bunnell. Journal of Bone and Joint Surgery, 40B: 4: 618-632. BRAND, P. W. The hand in leprosy. In: Pulvertaft R. G. (Ed.): ClinicalSurgery: The Hand. London, Butterworth, 1966: 279-295. BURKHALTER, W. E. Median nerve palsy. In Green D. P. (Ed.): Operative Hand Surgery, New York, Churchill Livingstone, 1982: 1032-1035. CHUINARD, R. G., BOYES, J. H., STARK, H. H. and ASHWORTH C. R. (1978). Tendon transfers for radial nerve palsy: use of superficialis tendons for digital extension. Journal of Hand Surgery, 3: 6: 560-570. EDGERTON M. T and BRAND, P. W. (1965) Restoration of abduction and adduction to the unstable thumb in median and ulnar oaralvsis. Plastic and 1 Reconstructive Surzerv. 36: 150-164. FRITSCHI, E. P. Surgical Reconstruction and Rehabilitation in Leprosy, 2nd Edn. New Delhi, The Leprosy Mission, 1984,66-71. FRITSCHI, E. P. Surgical Reconstruction and Rehabilitation in Leprosy, 2nd Edn. New Delhi, The Leprosy Mission, 1984, 102-108. GOLDNER, J. L. (1967). Replacement of the function of the paralysed adductor pollicis with the flexor digitorum sublimus: a ten year review. Journal of Bone and Joint Surgery, 49A: 3: 583-584. GREEN, D. P. Radial nerve palsy. In Green D. P. (Ed.): Ommtioe Suraerv - _ ofthe ” Hand. New York, Churchill iivingstone. 1982: 1023. . JACOBS, B. and THOMPSON, T. C-(196$. Opposition of the thumb and its restoration. Journal of Bone and Joint Surgery, 42A: 6: 1015-1026. NORTH, E. R. and LITTLE, R. J. W. (1980). Transferring theflexorsuperficialis tendon: technical considerations in the prevention of proximal interphalangeal joint disability. Journal of Hand Surgery, 5 : 5: 498-501, OMER, G. Ulnar nerve palsy. In: Green, D. P. (Ed.): Operative Surgery ofthe Hand. New York, Churchill Livinestone. 1982: 1063-1065. RAMSELAAR, J. M. Tendon Tmr.&s to’Restore Opposition of the Thumb. Leiden, Stenfert Kroese, 1970.
628 RANNEY, D. A. (1976). The superficialis minus deformity and its operative treatment. Hand, 8: 3: 209-214. REDDY, N. R. and KOLUMBAN, S. L. (1981). Effects on fingers of leprosy patients having surgical removal of sublimus tendons. Leprosy in India, 53: 4: 594-599. SMITH, R. J. and HASTINGS, H. Principles ofTendon Transfers to the Hand. American Academy of Orthopedic Surgeons Instructional Course Lectures, 1980: 29: 129-152. SMITH, R. J. Tendon Transfers of the Hand and Forearm. Boston, Little Brown and Company, 1987: 7&73.
THE
JOURNAL
OF HAND
SURGERY
VOL.
ZANCOLLI, E. Structural and Dynamic Philadelphia, Lippincott, 1979: 310.
Accepted: 19 March 1992 J. W. Brandsma, Nationallnstitutefor Postbus 1161,380O BD Amersfomt,
17B No. 6 DECEMBER
Bases of Hand Surgery,
Researchand PostgraduateEducationin the Netherlands.
1992
2nd Edn.,
Physiotherapy,
At the time of the study both authors were employed in the Department of Surgery and Rehabilitation of the All Africa Leprosy and Rehabilitation Training Centre, PO Box 165, Addis Ababa, Ethiopia. 0 1992 The British Society for Surgery of the Hand
DIGITORUM SUPERFICIALIS TENDON FOR INTRINSIC REPLACEMENT
TRANSFER
Long-term results and the effect on donor fingers J. W. BRANDSMA and M. W. OTTENHOFF-DE JONGE From the All Africa Leprosy and Rehabilitation
Training Centre, Addis Ababa, Ethiopia
This study is a review of 127 hands in 100 patients in whom one or two FDS tendons were used to correct claw-hand deformity and/or loss of opposition of the thumb. In lumbrical replacement the results were graded as excellent in 16 hands (21%) and good in 43 hands (57%). For opponensplasty the results were excellent in 26 hands (32%) and good in 42 hands (51%). Possible defects that can develop in the donor finger are: swan-neck deformity, flexion posture of the DIP joint, not as part of the swan-neck deformity, check-rein deformity or flexion contracture, and insufficient finger flexion. Of the 158 fingers swan-neck deformity was seen in 15%, DIP flexion in 29%, check-rein deformity in 26% and insufficient finger flexion in lS”& The latter occurred with another defect. In 48 fingers (30%) no defects were observed.
Journal of Hand Surgery (British Volume, 1992) 17B: 625-628
MATERIAL
Transfer of a flexor digitorum superficialis (FDS) tendon is one of the operations of choice in the correction of the hand with paralysis of the intrinsic muscles. The FDS muscle is an excellent motor to substitute for the loss of primary MP joint flexors in ulnar palsy to correct claw finger deformity (Brand, 1958; Omer, 1982; Fritschi, 1984; Zancolli, 1979) and loss of opposition in low median palsy (Jacobs and Thompson, 1960; Fritschi, 1984; Ramselaar, 1970; Smith, 1980). Transfer of a FDS tendon has also been advocated for the substitution of loss of adduction/flexion power of the thumb in ulnar and combined ulnar and median palsy (Edgerton, 1965; Goldner, 1967). In radial nerve palsy the tendons of the FDS muscle can be used to substitute for the loss of MP joint extension (Boyes, 1960; Chuinard, 1978; Green, 1982). Smith (1987), in his monograph on tendon transfers of the hand and forearm, describes the use of FDS in other conditions, e.g. brachial plexus injury, rheumatoid arthritis, congenitial deformities of the hand and quadriplegia. The loss of the primary flexor of the PIP joint is bound to leave a functional defect at that joint. Swan-neck and check-rein deformities have been well documented (Boyes, 1965; Brand, 1958; Ranney, 1976; North, 1980; Burkhalter, 1986). The check-rein deformity is defined as a post-operative rigid flexion contracture of the PIP joint. Reddy and Kolumban (1981), have identified two other defects in the donor fingers in a group of leprosy patients who had tendon transfers for paralysis of the intrinsic muscles of thumb and fingers; limited extension of the DIP joint and limitation of PIP joint flexion. In this study we have looked at the long-term results of FDS tendon transfer for intrinsic replacement and the frequency of the various defects following use of this tendon in the treatment of ulnar and/or median nerve paralysis.
AND
METHODS
In 1987 and 1988 the authors assessed 127 hands in 100 patients who voluntarily reported back to the hospital. All these patients had undergone surgery for ulnar and/ or median nerve paralysis in which a FDS tendon had been transferred 158 times to either initiate MP flexion of the fingers or to substitute for the loss of thumb opposition. There were 37 women and 63 men. All but three of the 100 patients that were reviewed had leprosy. The period of post-operative follow-up varied from five months to 22 years (average 6.5 years). Several surgeons performed the operations, using different surgical techniques. Of the total of 158 superficialis tendons that were used for transfer, the removal had most often been near its insertion on the middle phalanx and through a mid-lateral incision. Occasionally it had been harvested through an oblique incision over the volar aspect of the proximal phalanx, and in the last two years the most common method was removal through a transverse incision near the distal palmar crease, leaving a 1 to 2 cm stump of tendon. Each of the surgeons used the technique he was most comfortable with. Also the method of insertion of the tendon slip varied with the surgeon, as both Stiles-Bunnell FDS transfer (Brand, 1958) and the Zancolli lasso technique had been used (Zancolli, 1979) for lumbrical replacement. The most frequently used method of insertion for opponensplasty (>95%) had been the so-called Y insertion according to Brand (1966). In the lumbrical replacement as well as the opponensplasty both the middle and the ring finger served as donor fingers. In addition the index finger FDS was used eight times for opponensplasty because the FDS of neither the ring nor the middle finger was available (Table 1). Post-operative loss of PIP joint extension with the MP joints held in flexion by the patient was compared with 625
626
THE
Table l-Fingers
Lumbrical
Donorfinger
replacement
Ring Middle
12 64 16
Ring Middle Index
70 4 8 82
Total Opponensplasty
Table 2-Result
of lumbrical replacement with FDS
n=76
n
%
Excellent : clawing fully corrected Good : improvement of angles Fair: pre- and post-operative angles equal Poor: deterioration of angles Unknown
16 43 4 9 4
21 57 5 12 5
16
100
n=82
n
%
Excellent: strong opposition, maximum range of motion (r.0.m.) no IP flexion Good : good use of transfer, limited strength as observed by therapist Fair: weak opposition, limited strength and/or range of motion Poor: transfer does not pull Unknown: median nerve recovered
26
32
42
51
8
10
4 2
5 2
82
100
Total
Table 3-Result
of opponensplasty
with FDS
Total
Table 4-Post-operative Effect
n
%
Swan-neck DIP flexion (isolated) Check-rein No defects
23 46 41 48
15 29 26 30
158
100
28
18
Insufficient Insufficient
flexion
finger flexion always occurred together with another defect.
Table 5-Removal
VOL.
17B No. 6 DECEMBER
Four grades have been used to record the results of lumbrical replacement and opponensplasty. The grades are defined in Tables 2 and 3. Good or excellent results were found in 78% and 83% respectively. Table 4 shows the effect of removal of FDS on the DIP and PIP joints of the donor fingers. Of the 158 donor fingers that were assessed, 48 (30%) showed no defects. Swan-neck deformity occurred in 23 fingers (15%). Isolated DIP flexion occurred in 46 fingers (29%) and was thus the most frequent defect. The angles of DIP flexion posture (extensor lag) varied between 10” and 80”. Mild flexion (< 20”) of the DIP joint was usually seen when it was not part of the swan-neck deformity. Thus in 59% of the fingers there were either no defects or a very mild flexion deformity of the DIP joint. PIP flexion in the 41 cases of check-rein deformity varied from 15” to 70”. The maximum PIP flexion in 28 donor fingers with insufficient flexion varied from 35” to 85”. Of the 127 operated hands, 26 hands had two FDS tendons removed at the same time for combined lumbrical replacement and opponensplasty. Of these, seven showed the same defect in both donor fingers, 12 showed one or more different defects and seven had no defects (Table 5).
FDS is by no means the only muscle used to substitute for loss of primary MP flexors in ulnar palsy. In the period 1979 to 1988, extensor carpi radialis longus was used 223 times, extensor carpi radialis brevis 32 times and palmaris longus 23 times. FDS was used 275 times for this purpose in the same period. Its use avoids the need for a free tendon graft which is required when a primary wrist motor is to be used. The relatively high proportion of FDS tendons taken from the middle finger for lumbrical replacement and the
of two FDS tendons from one hand n = 52jingers
Check-rein
Swan-neck
(26 hands) Same effect in both fingers Different
effects
1992
DISCUSSION
effects on donor fingers
Total
SURGERY
RESULTS
158
Total
OF HAND
the same angles taken pre-operatively in order to grade the post-operative result of the tendon transfer used for lumbrical replacement. PIP and DIP joint angles were also measured post-operatively to record the degree of secondary defects following FDS removal. Ranges of thumb opposition and flexion at the IP joint of the thumb were measured to grade the result of opponensplasty.
from which FDS was taken Operation
JOURNAL
DIP flexion
10
2
2
4
4
9
NO
defect 14 (hands n = 14) 7 (hands n = 12)
FDS
TENDON
621
TRANSFER
large number removed from the ring finger for opponensplasty can be explained by the fact that many patients had a combined ulnar and median nerve palsy. In these cases we prefer this combination of donor tendons. At least three factors may contribute to the development of swan-neck deformity when FDS is used : removal of the primary flexor from the PIP joint, attachment of the tendon slip into the extensor mechanism in the case of ulnar claw correction and laxity of the volar plate of the PIP joint. Flexion torque is decreased when FDS is removed from a finger, whereas the extension torque is increased by virtue of the attachment of the tendon slip to the extensor mechanism in claw finger correction when the Stiles-Bunnell technique is used. Extension torque is not increased with the Zancolli lasso operation. It would therefore be interesting to see if, and to what extent, swan-neck deformity does develop following this operation as compared to the classical Stiles-Bunnell tendon transfer. We have seen swan-neck deformities in fingers other than the donor fingers when the fingers were fully mobile before surgery. This indicates that adding extension torque alone can be sufficient to cause the deformity. Tightness of the volar plate and residual preoperative contractures can prevent the development of a swan-neck deformity. This may explain the development of isolated DIP flexion in addition to the fact that FDP has a smaller moment arm for the DIP joint as compared to the PIP joint. The mechanism leading to check-rein deformity is not clearly understood. The most common view is that scarring occurs after removal of the FDS tendon, gradually causing a progressive flexion contracture. The check-rein deformity usually develops after the rehabilitation period which usually lasts for between seven and nine weeks after surgery. It is therefore important to continue supervision in order to be able to detect the early development of a flexion contracture and prevent it from becoming progressive and permanent. Loss of flexion becomes apparent immediately after cast removal, three to four weeks post-operatively. This could be caused by adhesions between FDP and adjacent structures restricting proximal excursion of the tendon. North and Little (1980) felt that the consequences of loss of FDS are related to the method used to remove it. They have described a surgical technique that should minimise the chances of producing check-rein and swanneck deformities. In this technique the tendon is divided through an incision between the Al and A2 pulleys. The fact that different defects developed in 12 hands in which two FDS tendons were removed may be an indication that the surgical technique alone does not determine if and what defects develop, assuming that the technique of harvesting the tendons has been the same. The pre-operative condition of the fingers was comparable in these fingers (Table 5). Reddy and Kolumban (198 1) described two beneficial effects on donor fingers from which the FDS was
harvested. They noticed that in many patients extension of the PIP joint improved post-operatively when contractures of the PIP joint had been present pre-operatively. They also noticed that in cases of attenuation of the extensor mechanism, insertion of the graft in the lateral band often corrected the lag in active-assisted extension. We have also observed these beneficial effects. We have not been able to show any relationship between the surgeon’s experience and/or the method of removing of the tendon, the pre-operative condition of the finger and the occurrence of secondary defects in this study. In summary, we believe that the cause of secondary defects on the donor finger following removal of FDS is multifactorial. The pre-operative condition of the PIP joint, the method of harvesting the tendon, surgical skill, the possible addition of extension torque at the PIP joint in a lumbrical replacement, post-operative immobilization and rehabilitation, the motivation of the patient and the expertise of the therapist all determine if and to what extent secondary defects develop. A prospective study with adequate documentation regarding the pre-operative condition of the hand, the surgical technique and post-operative immobilization, and detailed information about post-operative care and re-education should shed further light on the occurrence of secondary defects, as well as the conditions which favour the development of these defects so that appropriate measures can be taken to avoid them.
References BOYES, J. H. (1960). Tendon transfers for radial palsy. Bulletin of the Hospital for Joint Diseases, 21: 2: 97-105. BOYES, J. H. (1965). Panel discussion. American Journal of Surgery, 109: 381395. BRAND, P. W. (1958). Paralytic clawhand: with special reference to paralysis in leprosy and treatment by the sublimis transfer of Stiles and Bunnell. Journal of Bone and Joint Surgery, 40B: 4: 618-632. BRAND, P. W. The hand in leprosy. In: Pulvertaft R. G. (Ed.): ClinicalSurgery: The Hand. London, Butterworth, 1966: 279-295. BURKHALTER, W. E. Median nerve palsy. In Green D. P. (Ed.): Operative Hand Surgery, New York, Churchill Livingstone, 1982: 1032-1035. CHUINARD, R. G., BOYES, J. H., STARK, H. H. and ASHWORTH C. R. (1978). Tendon transfers for radial nerve palsy: use of superficialis tendons for digital extension. Journal of Hand Surgery, 3: 6: 560-570. EDGERTON M. T and BRAND, P. W. (1965) Restoration of abduction and adduction to the unstable thumb in median and ulnar oaralvsis. Plastic and 1 Reconstructive Surzerv. 36: 150-164. FRITSCHI, E. P. Surgical Reconstruction and Rehabilitation in Leprosy, 2nd Edn. New Delhi, The Leprosy Mission, 1984,66-71. FRITSCHI, E. P. Surgical Reconstruction and Rehabilitation in Leprosy, 2nd Edn. New Delhi, The Leprosy Mission, 1984, 102-108. GOLDNER, J. L. (1967). Replacement of the function of the paralysed adductor pollicis with the flexor digitorum sublimus: a ten year review. Journal of Bone and Joint Surgery, 49A: 3: 583-584. GREEN, D. P. Radial nerve palsy. In Green D. P. (Ed.): Ommtioe Suraerv - _ ofthe ” Hand. New York, Churchill iivingstone. 1982: 1023. . JACOBS, B. and THOMPSON, T. C-(196$. Opposition of the thumb and its restoration. Journal of Bone and Joint Surgery, 42A: 6: 1015-1026. NORTH, E. R. and LITTLE, R. J. W. (1980). Transferring theflexorsuperficialis tendon: technical considerations in the prevention of proximal interphalangeal joint disability. Journal of Hand Surgery, 5 : 5: 498-501, OMER, G. Ulnar nerve palsy. In: Green, D. P. (Ed.): Operative Surgery ofthe Hand. New York, Churchill Livinestone. 1982: 1063-1065. RAMSELAAR, J. M. Tendon Tmr.&s to’Restore Opposition of the Thumb. Leiden, Stenfert Kroese, 1970.
628 RANNEY, D. A. (1976). The superficialis minus deformity and its operative treatment. Hand, 8: 3: 209-214. REDDY, N. R. and KOLUMBAN, S. L. (1981). Effects on fingers of leprosy patients having surgical removal of sublimus tendons. Leprosy in India, 53: 4: 594-599. SMITH, R. J. and HASTINGS, H. Principles ofTendon Transfers to the Hand. American Academy of Orthopedic Surgeons Instructional Course Lectures, 1980: 29: 129-152. SMITH, R. J. Tendon Transfers of the Hand and Forearm. Boston, Little Brown and Company, 1987: 7&73.
THE
JOURNAL
OF HAND
SURGERY
VOL.
ZANCOLLI, E. Structural and Dynamic Philadelphia, Lippincott, 1979: 310.
Accepted: 19 March 1992 J. W. Brandsma, Nationallnstitutefor Postbus 1161,380O BD Amersfomt,
17B No. 6 DECEMBER
Bases of Hand Surgery,
Researchand PostgraduateEducationin the Netherlands.
1992
2nd Edn.,
Physiotherapy,
At the time of the study both authors were employed in the Department of Surgery and Rehabilitation of the All Africa Leprosy and Rehabilitation Training Centre, PO Box 165, Addis Ababa, Ethiopia. 0 1992 The British Society for Surgery of the Hand
