STRATEGY and INDICATIONS

Principles

Marc Revol, MD, Jean-Marie Servant, MD

(Service de Chirurgie Plastique. Hopital Saint-Louis. 75475 Paris Cedex 10. France)

 

   

 

  

 

 

We have codified surgical indications into a 10-point strategy, mainly inspired by Zancolli.
 
        Area of application (International classification groups)  
        0 1 2 3 4 5 6 7 8 9 10  
  Strategic principle #                        
  GENERAL 1 Delay between accident and upper limb surgery must be longer than one year (365 days) + + + + + + + + + + +  
  ELBOW 2 Elbow before hand : Active elbow extension should be restored before surgery on hand (specially BR or ECRL tendon transfers)

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 + + + + +  

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  3  Choice for elbow extension exists between two muscles : deltoid and biceps. Today, the biceps-to-triceps transfer is our first choice. + + + + + +  

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  HAND 4 One single operative stage is needed for group 1 hand   +    
  5 Two operative stages are necessary in groups 2 to 6 : the first for opening, the second for closure.   + + + + +    
  6 Except for groups 0 and 1, finger intrinsic palliative surgery must be systematicaly performed during the first stage on hand. Zancolli's lassos are the best.   + + + + + + + + +  
  7 Thumb stabilization is needed in groups 1 to 6.   + + + + + +    
  8 EDC and EPL are restored by tenodesis in groups 1 and 2, and by BR transfer in groups 3, 4 and 5.   + + + + +    
  9 Except for groups 0 and 1, grasp (fingers) and pinch (thumb) should be simultaneously restored   + + + + + + + + +  
  10 Up to group 6 included, the goal for the thumb is lateral pinch ("key grip").   + + + + + +    
  + NO new operation before obtaining full functionnal results from the former one  
                               
                               
 
Controversies.
None of the points in our strategy reflects a consensus.
 
Principle 1 : some authors recommend upper limb surgery as early as possible, from 6 or 7 months after the injury. However, we think that this period is too short, primarily due to patients’ psychological state. Stabilisation of spasticity and/or neurogenic bladder disturbances requires often one year. Moreover, it's only after returning at home that the patient can precisely appreciate the remaining function of his/her upper limbs, and strongly motivate himself/herself for surgery. Obviously, other factors, such as a strongly motivated patient or the presence of pressure sores, need to be considered.
 
Principle 2 : Bottero et al.  found that elbow extension is responsible for important tenodesis effects on BR and ECRL. When these muscles are transferred they should be postoperatively in 90° of elbow flexion to optimally decrease their tension during the healing period. However, this position conflicts with simultaneous reanimation of elbow extension, which is recommended by Allieu . We strongly disagree with association of restoration of elbow extension with a BR or ECRL transfer. As stressed by Brys and Waters, active elbow extension should be restored before BR or ECRL tendon transfers to actively control their tension; in fact, all of the authors seem to agree with this last point
 
Principle 3 : When there is a choice between using the deltoid or the biceps, almost all authors choose the deltoid to reactivate the triceps. We take the opposite position, as we have practically abandoned the deltoid transfer since 2002. In our opinion rehabilitation is not technically more difficult after biceps transfer than after deltoid transfer, and none of our patients never complained about the constant decrease in elbow-flexion power after biceps transfer. Moreover, in contrast to the deltoid transfer, the biceps-to-triceps transfer does not require a tendon graft nor a synthetic material. This technique is therefore much more simple and has less risks of complications.
 
Principle 5 : A small number of authors (Allieu), recommend a one-stage procedure on the hand, or even a one-stage procedure on the hand and the elbow, despite obtaining inferior functional results. Moreover, when they do a two-stage procedure on the hand, they begin with the flexor phase. However, our first clinical case led us to choose the opposite order, which is recommended by Zancolli.

A related controversy is the extensor phase procedure. In some cases, the spontaneous tenodesis effects of the wrist on EDC is sufficient enough to avoid a surgical reinforcement of MCP joints extension, either by EDC tenodesis, or by BR to EDC transfer. But in the great majority of cases, this spontaneous tenodesis effect is unsufficient to extend MCP joints, and we believe that a surgical procedure must be performed to improve opening of the hand.
 
Principle 6 : A routine indication for doing intrinsic palliative procedures on the fingers is not given by all authors. It is obvious that the results of the lasso operation may be sometimes disappointing. We agree with Coulet et al. that the main prognosis factor is the length of the injured spinal cord metamere. When the injured metamere is long, doing an intrinsic palliative procedure on the fingers is theoretically more important than when it is short, because the hand is totally denervated and deformed. Unfortunately in these cases, denervation of the forearm muscles leads them to lose their tone and visco-elasticity, and the lasso myo-tenodesis is therefore inefficient. Many other palliative procedures than the lasso exist, such as MCP capsuloplasty, or the House procedure. We do not use them routinely in tetraplegia, as we do not think they are more efficient than the lasso operation. However, principle 6 will probably need to be revisited in the future with respect to the concept of the length of the injured metamere. When injured metamere is long (FDS without any contraction or elasticity), it is unuseful to perform a lasso procedure. Consequently, there will be a claw deformity.
 
Principle 8 : Restoration of finger extension is still a controversial issue in groups 3, 4, and 5. Some authors advocate active extension using the BR transfer, whereas others prefer to achieve finger extension through an EDC tenodesis . According to Hentz and Leclercq , poor results with BR to EDC transfers seem to be related to paralysis of the flexor carpi radialis. Therefore, they do not recommend BR to EDC transfer in groups 3 or 4.

So, BR to EDC transfer seems to be indicated only in groups 5. Consequently, EDC tenodesis is indicated in groups 3 and 4. In these cases, it seems wise to restore active flexion of the wrist by BR to FCR transfer, thus improving the tenodesis effect.
 
Principle 9 : While almost all authors restore both pinch and grasp in group 3 and beyond hands, in group 2 hands, the fingers are most often abandoned to acquire their spontaneous tenodesis effects, while surgery deals only with the key-grip. This attitude was first enunciated by Möberg, who stated that the hand should be extended as completely as possible to permit human contact and caresses. Before planning surgery, all of our group 2 patients were clearly informed that they would definitely not be able to extend their fingers completely after surgery. Our series shows that patients chose between surgery following our point 9 (28 cases) and no surgery on the hand (19 cases). None of our patients chose only restoration of pinch.