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Tendon Transfer for Triple Nerve Paralysis of the Hand in Leprosy

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Tendon Transfer for Triple Nerve Paralysis of the Hand in Leprosy Lepr Rev (2002) 73, 319±325 Tendon transfer for triple nerve paralysis of the hand in leprosy ELAINE MCEVITT & RICHARD SCHWARZ Green Pastures Hospital, Box 5, Pokhara, Nepal Accepted for publication 27June 2002 Summary Paralysis of ulnar, median and radial nerves is seen in less than 1% of those affected with leprosy. This condition is a particular challenge for the surgeon, physiotherapist, and patient. A retrospective chart review was conducted at the Green Pastures Hospital and Rehabilitation Centre (GPHRC) and Anandaban Leprosy Hospital (ALH) in Nepal, and results were graded by the system outlined by Sundararaj in 1984. Thirty-one patients were identi®ed, and 21 charts were available for review. Excellent or good results were obtained in 93% of patients for wrist extension, 85% of patients for ®nger extension, 90% of patients for thumb extension, 71% of patients for intrinsic reconstruction, and 63% of patients for thumb opposition reconstruction. These results are reasonable but inferior to those obtained by Sundararaj in his study. Surgical intervention offers a very signi®cant improvement in function in these very dif®cult hands. Intensive physiotherapy is required both pre- and postoperatively. Introduction Hansen's disease results from infection with Mycobacterium leprae with subsequent involvement of skin, nerve, and mucosal tissue. Nerve damage occurs in 20±25% of patients.1 In the upper limb the nerve paralysis most frequently affects the ulnar nerve. Median nerve dysfunction may occur later or develop simultaneously, most frequently affecting the distal innervation (simian hand).2 High radial nerve involvement is least common (wrist drop), with 1% of patients having combined ulnar, median, and radial paralysis (triple nerve palsy).1,2 The typical pattern is that of high radial nerve palsy combined with high ulnar nerve and low median nerve loss. The aim of reconstructive hand surgery in leprosy is to correct deformity and restore the primary functions of grasp and pinch. In patients with triple nerve paralysis, functioning muscles available for transfer are limited. Especially in those with high median nerve involvement, wrist fusion is occasionally indicated to stabilize the wrist joint in slight extension to allow ef®cient ¯exion of the digits. This may free wrist ¯exor tendons for Correspondence to: R. Schwarz (e-mail: [email protected]) 0305-7518/02/064053+00 $1.00 q Lepra 319 320 E. McEvitt & R. Schwarz Table 1. Grading of reconstruction of wrist, ®nger, and thumb Grade Description Excellent Power >3 Good Power 3 Fair Power 2 Poor Power < 2 Wrist fusion Good if hold position of 08 extension transfer for other motor functions. The typical pattern of nerve involvement allows potential tendon transfer of the pronator teres (PT), ¯exor digitorum super®cialis (FDS), ¯exor carpi radialis (FCR), palmaris longus (PL) muscles and possibly ¯exor carpi ulnaris (FCU). The most common pattern of reconstruction is a two-stage procedure with the reconstruction of extension of the wrist, ®ngers, and thumb in the ®rst stage, and the reconstruction of opposition and intrinsic function (MCP ¯exion with simultaneous IP extension) in the second stage. In his series of patients, Sundararaj demonstrated that greater than 89% of patients had good or excellent results from each of the ®ve tendon transfer operations. Materials and methods A retrospective chart review was performed to evaluate the results of surgical reconstruction for triple nerve paralysis in leprosy patients in Nepal. Charts were reviewed at GPHRC (Green Pastures Hospital and Rehabilitation Centre) and ALH (Anandaban Leprosy Hospi- tal). Patients were identi®ed by reviewing the Operating Theatre logbooks from 1977 to 1999 to identify patients who had underwent surgery for wrist drop. Charts were reviewed for demographics, duration of deformity, pattern of nerve involvement, operations performed, and results. Table 2. Grading system for intrinsic function and thumb opposition; recon- struction results Grade Intrinsic function Opposition Excellent MP joint ¯ex to 908 Pulp thumb to pulp of little IP joint extend fully or ring ®nger No claw Good MP ¯exion to 708 Pulp of thumb to pulp of Less than 108 claw middle or index ®nger with IP extended Fair MP ¯exion 50±708 or Thumb opposition only if moderate claw (10±408) IP ¯exed Poor MP ¯exion < 508 or severe No opposition claw > 408 Tendon transfer for triple nerve paralysis 321 Table 3. Results of wrist extension reconstruction Result PT-ECRB Fusion Other Excellent 5 1* Good 7 3 ± Poor 1 ± 1** No record 2 1 ± Total 15 4 2 * PL to ECRB. ** PT to ERCL. Results were classi®ed as described by Sundararaj.1 For wrist, ®nger and thumb extension the grading system is shown in Table 1. Table 2 outlines the grading system for intrinsic function and for thumb opposition. Results Thirty-one patients were identi®ed who had had wrist drop surgery (15 GP, 16 AN). Twenty-one charts were available for review (10 GP, 11 AN). There were 17 males and four females, and mean age was 34.6 years. The non-operated hand was normal in 35%, had ulnar/median palsy in 59% and had wrist drop in 6%. The mean years of wrist drop prior to surgery were 6. Complete involvement of the ulnar nerve occurred in 19 patients (90%), and of the median nerve (distal innervation) occurred in 18 (86%). Complete radial involvement occurred in 16 patients (76%). In the remaining patients there was incomplete paralysis of these nerves. The results of procedures for wrist extension reconstruction are shown in Table 3. Transfer of PT to ECRB was most common, and overall there were good or excellent results in 93% initially, although two of these weakened after a 4-year period. The results of ®nger extension are shown in Table 4. The most common transfer was FCR to EDC, which gave good or excellent results in 85%. The results for thumb extension reconstruction are shown in Table 5. Most commonly, FCR was transferred to EPL (FCR tendon split) with good or excellent results in 90%. Results for intrinsic reconstruction are outlined in Table 6. The most common operations were the FDS `lasso' procedure or transfer of FDS to the lateral bands (sublimus procedure), with good or excellent results in 71%. Table 7 presents the results for Table 4. Results of ®nger extension reconstruction Result FCR-EDC FDS-EDC Other Excellent (power > 3) 4 1 ± Good (power 3) 3 1 2 Fair (power 2) ± ± ± Poor (power < 2) 1 ± 1 No record 3 ± ± Total 11 2 3 322 E. McEvitt & R. Schwarz Table 5. Results of thumb extension reconstruction Result FCR-EDC FDS-EDC Other Excellent (power > 3) 3 ± ± Good (power 3) 3 1 2 Fair (power 2) ± ± 1 Poor (power < 2) ± ± ± No record 1 2 1 Total 7 3 4 Table 6. Results of intrinsic function reconstruction Result FDS-A2 FDS-LB Other Excellent (908 ¯exion) 2 ± ± Good (708 ¯exion) 1 2 ± Fair (508 ¯exion) ± 1 ± Poor (< 508 ¯exion) ± 1 ± No record ± ± 1 Total 3 4 1 Table 7. Results of opposition reconstruction Result FDS-OPP FPL-OPP Excellent (opposition to 4/5 digit) 1 1 Good (opposition to 2/3 digit) 3 ± Fair (opposition with IP ¯exed) ± ± Poor (no opposition) 3 ± No record 1 1 Total 8 2 Table 8. Results of tendon transfer in patients who had all ®ve functions reconstructed Result Patients All ®ve functions working 3 Wrist, ®nger and thumb extension only working 1 Limited intrinsic function and wrist extension only 1 patients undergoing reconstruction of thumb opposition. The most common procedure was the FDS opponensplasty with good or excellent results in 63%. In our series, ®ve patients underwent reconstructive surgery of all ®ve functions. The results for this group are shown in Table 8. Tendon transfer for triple nerve paralysis 323 Nine complications were identi®ed in our patient population. These were radial wrist deviation (three), tendon adhesions requiring tenolysis (three), wound infection (one), deep infection requiring removal of bone (one) and median nerve neuritis (one). Discussion Patients undergoing reconstructive surgery for triple nerve paralysis in this study presented late, with a mean duration of wrist drop of 6 years. Some of these patients had developed severe joint contractures or had resorbed digits and therefore were not considered appropriate for tendon transfers for all functions. Only eight of the 21 patients had intrinsic reconstruction and 10 patients had opposition reconstruction. Reasons for this were partial nerve involve- ment as noted above, refusal of further surgery, and unsuitability for further reconstruction. One option that should be kept in mind when dealing with these severely paralysed hands is that of carrying out a tenodesis of the ®nger extensors in combination with a pronator teres to ERCB transfer.6 The EDC tendons are tenodesed to the ulna with the ®ngers straight and the wrist in 10±158 of extension. In this way the ®ngers extend when the wrist ¯exes, but can ¯ex when the wrist is extended. This allows at least functional extension of the digits when the wrist is ¯exed. It needs to be stressed that the key to obtaining a good functional hand is good active wrist extension and that wrist arthrodesis should be considered only when other dynamic options are not available. Ninety-three percent of patients having wrist drop surgery had good or excellent results compared with 90% of patients in Sundararaj's series. Wrist arthrodesis was graded as good if the desired degree of extension was maintained postoperatively. Patients with PT to ECRB tendon transfers for wrist extension overall had better results as compared to wrist arthrodesis, both for functional wrist extension and other hand functions. As such in patients without high median nerve paralysis PT to ERCB transfer should be considered the standard procedure.
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