Opponensplasty in intrinsic-muscle paralysis of the thumb in leprosy.

1. 1
Management of Thumb Opposition
with BURKHALTER’s Procedure
TRUONG LE DAO, M.D.
Intrinsic muscles palsies of the hand

2. 2
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.

3. 3
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

4. 4
CONTENTS
• Indications
• Surgical Principles
• Technique of Opposition Transfer
• Surgical Stratery
• Rehabilitation after Tendon Transfer
• Outcome

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INDICATIONS
• High median-nerve injury,
when the FDS are not available.
• Combined median-ulnar nerve injury,
either high or low .

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SURGICAL PRINCIPLES
• Which motor muscle?
• Which route?
• Which pulley?
• Which type of insertion ?

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• Bunnell called tendon transfers muscle
balance operations.
• The EIP provides thumb mobility and full
opposition.
Extensor Indicis Proprius

8. 8
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.

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• 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.

10. 10
Pulley
• Ulnar bone is a stiff
pully. It doesn’t change
the tendon direction of
more than 45 degrees.

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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.

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Abductor
Pollicis
Brevis
B
Extensor
Indicis
Proprius
A
Technique of Opposition Transfer

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• 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.
First incision

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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.

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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.

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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.

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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.

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Surgical Stratery
• Preoperative care
• Thumb Web Release
• Flexion contracture of the thumb IP

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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

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• 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.

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Thumb Web Release
• If there is still a limited ROM
despite good hand therapy and
splinting, a thumb web-space
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.

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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.

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Rehabilitation after Tendon Transfer
• During in a protective splint or cast
• After discontinued protective splint

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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.

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Outcome
• Advantages
• Disadvantages

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Advantage
Stabilization of the Thumb MCP joint

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Advantage
Good thumb opposition but no more pronation

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Disadvantage
Lost dorsal flexion of the thumb IP joint

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Disadvantage
There is still Froment’s sign

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Disadvantage
Lost dorsal flexion of the Index MCP joint

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The End
Thank you for your attention!