Functional outcome of extensor carpi radialis longus transfer for finger flexion in posttraumatic flexor muscle loss

doi:10.1016/j.jhsa.2004.11.017

The Journal of Hand Surgery

Volume 30, Issue 2, March 2005, Pages 267-272

https://doi.org/10.1016/j.jhsa.2004.11.017 Get rights and content

Purpose

The purpose of this study was to assess the functional outcome after extensor carpi radialis longus (ECRL) transfer for restoration of finger flexion in patients with flexor muscle loss after direct trauma.

Methods

We evaluated 8 patients who had ECRL transfer between 1995 and 2003. Flexion gained was assessed by measuring the digit-to-palm distance (DPD). The grip strength was compared with that of the opposite normal limb. The average follow-up period was 41 months. We compared the results obtained with other modalities of restoration of finger flexion, namely a pedicled latissimus dorsi muscle transfer or a free functioning muscle transfer (FFMT) using the series available in the literature.

Results

Four patients had a good result with a DPD of 0 cm in all fingers and an average grip strength of 65% of the opposite hand. Two patients had an average result with a DPD of 1.5, 2, 1.7, and 1.5 cm for the index, middle, ring, and small fingers, respectively, and an average grip strength of 58%; 2 patients had a poor result with a DPD of 5.0, 5.5, 5.0, and 3.0 cm for the index, middle, ring, and small fingers, respectively, and with an average grip strength of 21% of the opposite hand.

Conclusions

The ECRL transfer yields good results if the intrinsic muscles of the hand are functioning, the extensor compartment is uninjured, and the lower third of the forearm where the tendon junction is performed is relatively unscarred. In such instances the range of movement and grip strength achieved are better than a latissimus dorsi muscle pedicle graft and are comparable with a FFMT. This is achieved earlier than the time taken for reinnervation of FFMT and without the attendant risks for flap failure. The ECRL transfer for finger flexor restoration is a more simple alternative that should be considered when possible.

Section snippets

Patients and methods

Eight male patients between the ages of 14 and 51 years (average age, 28 y) had ECRL transfer for the reconstruction of finger flexors in the period between 1995 and 2003. All 8 patients had loss of the flexor compartment muscles secondary to direct trauma. The injury involved the dominant upper limb in 6 of 8 patients. Two patients had associated injury to the median nerve and 1 had injury to the ulnar nerve. One patient had a critical vascular injury that necessitated brachial artery repair

Results

Patients were followed up for an average period of 41 months (range, 12–96 months). Four patients (patients 1–3, 7) had a good result with a DPD of 0 cm in all fingers and an average grip strength of 65% of the opposite hand (Figs. 2A–2F). Two patients (patients 4, 5) had an average result with a DPD of 1.5, 2.0, 1.7, and 1.5 cm for the index, middle, ring, and small fingers, respectively, and an average grip strength of 58%, whereas 2 patients (cases 6, 8) had a poor result with a DPD of 5.0,

Discussion

Three options are available for replacement of loss of flexor muscles in the forearm. The first is a transfer of the ECRL tendon to FDP, 1, 2, 3, 4 the second is an extended pedicle latissimus muscle flap, 5, 6, 7 and the third is a free muscle transfer. 8, 9, 10, 11, 12

If the extensor musculature of the forearm is intact then transfer of the ECRL may be the preferred procedure because it is quicker and simpler and provides good functional recovery in a shorter time. ¹¹ Wrist extensors are

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Cited by (15)

Technical considerations and outcome of free functioning gracilis muscle transfer for finger flexion in patients with Volkmann's Ischemic Contracture
2021, Injury
Citation Excerpt :
Proximally, the gracilis was attached to the medial epicondyle and intermuscular septum in the lower third of the arm with strong 1-0 PDS sutures. Distally the FDP tendons were plicated together under appropriate tension to reproduce the cadence of the fingers on passive traction.11, The tendon of the gracilis was then attached to the FDPs of all the fingers with a Pulvertaft weave and sutured with 3-0 Prolene sutures.
Severe Volkmann's Ischemic Contracture (VIC) is a reconstructive challenge for the surgeon because of the loss of entire flexor muscle mass and lack of powerful wrist extensors for restoration of finger flexion. In such cases, free functioning muscle transfer (FFMT) using gracilis is our choice. We herein summarize the technical considerations to achieve a successful outcome and report functional outcome achieved in our series.
Between 2007-2018, 22 patients of VIC underwent gracilis FFMT for restoration of finger flexion. FFMT was done as a second stage following an initial stage of neurolysis/excision of fibrotic flexor muscles/contracture release/flap cover in these patients. Cases were retrospectively reviewed and their functional outcome at a minimum of one-year follow up was analyzed. Follow-up duration ranged from 2-13 years (average-4 years). At the final follow up, the motor and sensory recovery was evaluated using the Medical Research Council Grading and their function using Disabilities of the Arm, Shoulder, and Hand (DASH) score.
The average age at surgery ranged from 3-45 years (average-18.4 years). All the transferred muscles survived. Secondary procedures to further improve the hand function were done in nine patients. The motor recovery for finger flexion was graded as M2 in two, M3 in nine and M4 in 11 cases. These 20/22 patients who recovered M3/M4 finger flexion expressed high satisfaction with the operation while other two also felt that they were better after the surgery. DASH score was available for 13 patients and it averaged 13.21 (Range-1.8-34.5). Grip strength was available for 10/22 patients and it averaged 10.5 kg (range-0-21kg) amounting to 24% of the normal side. The sensory recovery was graded as S4 in two, S3 in 17 and S2 in three cases.
Gracilis FFMT is a reliable option for restoration of finger flexion in patients with severe VIC. Outcome is better when done after an early preliminary stage of excision of fibrosed muscles and neurolysis which allows recovery of intrinsic function and sensation. FFMT is best carried out 3-6 months after the first stage with supple skin and good passive range of movement in the fingers.
Role of free functioning muscle transfer in improving the functional outcomes following replantation of crush avulsion amputations of the forearm
2019, Injury
Citation Excerpt :
Chuang et al. also highlighted the challenge of reconstruction of these injuries [2]. They classified traction avulsion amputation into four types- Type I- Avulsion at or close to the musculotendinous aponeurosis with the muscle remaining intact and functional; Type II- Avulsion within muscle bellies but distal to the neuromuscular junction with the proximal muscle still being innervated; Type III- Avulsion within the muscles but at or proximal to the neuromuscular junction, with the entire muscles being denervated and/or destroyed; Type IV- Avulsion through the joint (elbow disarticulation) [3]. They found that the FFMT was required to reconstruct the long flexor function in 16% of Type I; 43% of Type II; 100% of Type 3 and 70% of Type IV avulsion amputations [2].
Replantation still remains the best form of reconstruction following major upper limb amputations. Regaining a functional limb is a challenge in avulsion amputations when there is entire loss of a compartment as it happens in proximal third of forearm amputations or when the avulsion occurs through the musculotendinous junction. In these circumstances, primary repair of the long flexors or extensors is not possible and options of secondary tendon transfers do not exist due to lack of donor tendons. These factors could weigh in negatively in making the decision for replantation at the time of presentation. We are presenting a series of 5 cases of avulsion amputation of the forearm wherein the functional outcome was enhanced by secondary Free Functional Muscle transfers (FFMT) using gracilis for finger flexion. Outcome scores improved from Chen IV to II in three patients and to III in two patients. The feasibility of gaining useful outcome through secondary procedures like FFMT should serve as an encouragement to extend the indications for replantation in avulsion amputations of the forearm.
Using the strengthening the reporting of observational studies in epidemiology (STROBE) statement to assess reporting of observational trials in hand surgery
2013, Journal of Hand Surgery
To use the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement checklist to critically evaluate the change in quality of observational trial reporting in the Journal of Hand Surgery American between 2005 and 2011.
A cross-sectional analysis of observational studies published in the Journal of Hand Surgery American was designed to sample 2 6-month periods of publication (March 2005 to August 2005 and June 2011 to November 2011). Fifty-one items were extracted from the STROBE statement for evaluation. Overall STROBE compliance rates for articles and specific checklist items were determined. Final compliance percentages from each period were compared by Student t-testing. Changes in item compliance over time were quantified.
Overall compliance with the STROBE statement was 38% (range, 10%–54%) in 2005 and 58% (range, 39%–85%) for 2011 manuscripts representing a significant improvement. Seventy-five percent or greater of articles (2005/2011) provided the explicit reporting of background (100%/97%), follow-up time (85%/94%), overall interpretation of data (100%/94%), and results of similar studies (95%/89%). Twenty-five percent or less of articles provided the study design in the abstract (10%/20%), a clear description of the study's setting (10%/23%), the handling of missing data (0%/6%), the potential directions of bias (5%/11%), and the use of a power analysis (0%/17%). Eighty-six percent (44/51) of items were more frequently satisfied in 2011 articles than in 2005 publications. Absolute increases in compliance rates of 40% or greater were noted in 10 items (20%) with no worsening in compliance for an individual item over 6%.
The overall quality of the reporting of observational trials in the Journal of Hand Surgery American improved from 2005 to 2011. Current observational trials in hand surgery could still benefit from increased reporting of methodological details including the use of power analyses, the handling of missing data, and consideration of potential bias.
Diagnostic III.
The effectiveness of early mobilization after tendon transfers in the hand: A systematic review
2013, Journal of Hand Therapy
Systematic review.
Over the past decade, early mobilization (initiated within a week) has become an increasing trend in postoperative rehabilitation after tendon transfer surgery in the hand. However, there are no published reviews summarizing the effectiveness of early mobilization protocols in comparison with conventional immobilization in tendon transfer rehabilitation.
To systematically review available evidence on the effectiveness of early mobilization protocols to conventional immobilization protocol after tendon transfers in the hand.
A literature search of the Cochrane Library, PubMed, PEDro, EMBASE, and CINAHL databases was conducted (1980 to date). Randomized controlled trials (RCTs), case–control, and other study designs were included. Six articles were eligible for inclusion in the analysis (five RCTs and one retrospective study) and 260 articles that did not meet inclusion criteria were excluded. Level of evidence (Center for Evidence-based Medicine) and methodological quality (Structured Effectiveness Quality Evaluation Scale [SEQES] score) of each study were assessed by two independent reviewers.
This review found three high quality trials (SEQES score: 35–43 of 48), with level 1b and 2b evidence, supporting early mobilization of tendon transfers. The literature reports reduced total cost, total rehabilitation time, and demonstrates that early mobilization is a safe approach with no incidence of tendon ruptures or insertion pull out. In the initial phase of rehabilitation, outcomes like range of motion, grip strength, pinch strength, total active motion of digits, deformity correction, and tendon transfer integration were significantly superior with early mobilization compared with immobilization. However, in the long term, these outcomes were similar in both the groups, suggesting that early mobilization protocol improves hand function in the initial phase of rehabilitation (four weeks) and the long-term results (two months to one year) are equivalent to immobilization.
Based on a limited number of small studies, there is evidence of short-term benefit for early mobilization, but inconclusive findings for longer-term outcomes. Until the body of evidence increases, clinicians should consider the clinical context, their experience in optimizing patient outcomes after surgery, and the patient's preferences when selecting between early and late mobilization after tendon transfer.
2a.
Determining physiological cross-sectional area of extensor carpi radialis longus and brevis as a whole and by regions using 3D computer muscle models created from digitized fiber bundle data
2009, Computer Methods and Programs in Biomedicine
Architectural parameters and physiological cross-sectional area (PCSA) are important determinants of muscle function. Extensor carpi radialis longus (ECRL) and brevis (ECRB) are used in muscle transfers; however, their regional architectural differences have not been investigated. The aim of this study is to develop computational algorithms to quantify and compare architectural parameters (fiber bundle length, pennation angle, and volume) and PCSA of ECRL and ECRB. Fiber bundles distributed throughout the volume of ECRL (75 ± 20) and ECRB (110 ± 30) were digitized in eight formalin embalmed cadaveric specimens. The digitized data was reconstructed in Autodesk^® Maya^® with computational algorithms implemented in Python. The mean PCSA and fiber bundle length were significantly different between ECRL and ECRB (p ≤ 0.05). Superficial ECRL had significantly longer fiber bundle length than the deep region, whereas the PCSA of superficial ECRB was significantly larger than the deep region. The regional quantification of architectural parameters and PCSA provides a framework for the exploration of partial tendon transfers of ECRL and ECRB.
An additional radial wrist extensor and its clinical significance
2007, Annals of Anatomy
The knowledge of anatomical variations in the antebrachial and dorsal regions of the arm and hand are useful in hand surgery. The extensor carpi radialis intermedius and extensor carpi radialis accessorius are two classic variants described for the radial wrist extensors, in the antebrachial region. We report an additional extensor carpi radialis muscle taking origin from the common extensor origin, between the extensor carpi radialis longus and extensor digitorum communis. The tendon of the variant muscle divides below the abductor pollicis longus and becomes attached to the base of the second and third metacarpal bone. Due to its considerable size and independent origin from the lateral epicondyle, we suggest the present variation should be named extensor carpi radialis tertius. The clinical significance of the present variation is discussed.

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Original articlesTendon transferFunctional outcome of extensor carpi radialis longus transfer for finger flexion in posttraumatic flexor muscle loss

Purpose

Methods

Results

Conclusions

Section snippets

Patients and methods

Results

Discussion

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

Hand Clin

J Hand Surg

Treatment of established Volkmann’s contracture

J Bone Joint Surg

Original articles
Tendon transfer
Functional outcome of extensor carpi radialis longus transfer for finger flexion in posttraumatic flexor muscle loss