C H I R U R G I E R E C O N S T R U C T I V E D E S P A R A L Y S I E S DES MUSCLES INTRINS 2QUES DES DOIGTS Etude de cent cas

SURGICAL RECONSTRUCTION IN INTRINSIC PALSY OF THE FINGERS

A study of hundred cases

E. GAISNE ~, D.D. P A L A N D E ~

G A I S N E E., P A L A N D E D.D. - - Chirurgie reconstructive des paralysies des muscles intr ins~ques des doigts. (En Fran~ais et Anglais). Ann Chir Main, 1986, 5, 1, 13-23,

RIgSUMI2 : Les auteurs analysent les r6sultats obte- nus dans 100 interventions de chirurgie reconstruc- tive des paralysies des muscles intrins~ques des doigts chez des patients 16preux. R6alis6s sous anes- th6sie loco-r6gionale, les proc6d6s op6ratoires sont r6partis en : 41 op6rations de Brand deuxi6me ma- nitre, 14 ~ lasso >> selon Palande, 15 op6rations ins- pir6es de Zancolli, 15 op6rations de Palande, 13 op6rations de Littler et 2 op6rations de Brand pre- miere mani6re. Les r6sultats ont 6t6 satisfaisants dans 74 % des cas, sans changement (20 %), m6dio- cres (6 %). L'analyse statistique de l'6chantillon a mis en 6vidence de fa~on significative de meilleurs r6sultats pour les auriculaires dans les interventions <~ lasso >> et de Palande que dans les Brand deuxi~me mani~re (mains en position lombricale et ouverte). Les auteurs d6gagent des indications en fonction de l 'atteinte nerveuse, du terrain et des conditions envi- ronnantes. La kin6sith6rapie 6tant indispensable a la bonne int6gration du transfert tendineux.

MOTS-CLI~S : Paralysies intrins~ques. - - Maladie de Hansen.

GAISNE E., P A L A N D E D.D. - - Surgical reconstruction in in- trinsic palsy of the fingers. A study of hundred cases. (In French and English). Ann Chir Main, 1986, 5, 1, 13-23.

SUMMARY : The authors analyze the results obtai- ned by surgical treatment in 100 cases of intrinsic palsy of the hand. The distribution of the surgical procedures performed under regional anesthesia was as follows : Brand II : 41, Palande's lasso : 14, Zan- colli : 15, Palande : 13, Littler : 13, Brand I : 2. Re- sults were satisfactory in 74 p. cent, unchanged in 20 p. cent and poor in 6 p. cent of cases. The analysis of this series showed a significant difference in the results obtained in the little finger with better results when Palande's and the lasso procedures were used (for the hand in the lumbrical and open positions). Indications have thus been defined according to the degree of nerve damage and environmental factors. Physical therapy is essential for good integration of tendon transfers.

KEY-WORDS : Intrinsic palsy of the fingers. - - Leprosy.

1.Clinique Chirurgicale B (P' J. Barsotti), CHU Trousseau 37044 TOURS Cedex. 2. Sacred Heart Leprosy Centre, Sakkotai 612401, Kurnbako- ham, Tamil Nadu India.

Tir~s d part : Docteur E. Gaisne, 8, rue de la Californie, 37000 TOURS.

Manuscrlt re~u/i la R~Jclactlon le 2 janvier 1985

14 INTRINSIC P A L S Y OF THE FINGERS

Dans le Sud de l'Inde, la ldproserie du Sacr6 Cceur 5 Kumbakonam, se trouve situ6e dans une zone og la maladie de Hansen pr6sente une forte en- d6micit6 (19 %°).

Le but de ce travail est de rapporter une 6tude moyen terme de 100 interventions de chirurgie re- constructive des paralysies des muscles intrins~ques des doigts chez des patients 16preux.

L'analyse des r6sultats a permis de comparer les diff6rents proc6d6s op6ratoires entre eux, et de pr6- ciser les indications.

A la suite des travaux de Riordan h Carville et de Brand ~ Vellore en 1948, le traitement chirurgical de la maladie de Hansen a fait de rapides progr6s. De nombreuses techniques ont 6t6 propos6es pour la r6animation des muscles intrins~ques des doigts (Brand [7], Bourrel [5], Carayon [9], Languillon [12], Palande [13], Zancolli [18], Tubiana [17]).

CASUISTIQUE La n6vrite 16preuse est une n6vrite hypertrophi-

que. Au membre sup6rieur, les nerfs cubital et m6- dian sont atteints de fagon 61ective. La compression du cubital dans le canal 6pitrochl6o-ol6crhnien, et du neff m6dian dans le canal carpien sont responsa- bles du d6ficit fonctionnel tronculaire partiel ou total.

ANNALES DE CHIRURGIE DE LA MAIN

De janvier 1983 ~ janvier 1984, 100 mains de pa- tients hans6niens non s61ectionn6s ont 6t6 exami- n6es. Seuls les patients op6r6s depuis plus d'un an 6taient inclus dans l'6tude. L'fige moyen des patients est de 33 ans (de 13 a 66 ans). Le sex ratio est de 15 femmes pour 85 hommes. Les types 16preux se r6- partissent en 16promateux (22 %), tuberculoides (8 %) et ind6termin6s (70 %).

La dur6e moyenne pr6-op6ratoire de la paralysie est de 4 ans 5 mois (de 1 ~ 20 ans). Les paralysies sont cubitales (62 %), m6dio-cubitales (37 %), tri- ples (1%) . La main droite 6tant dominante, le c6t6 op6r6 est droit dans 5 1 % des cas, gauche dans 49 %.

La dur6e moyenne du suivi post-op6ratoire est de 4 ans 8 mois (de 1 h 13 ans). Des 100 mains op6r6es, 387 doigts ont 6t6 analys6s du fait de la r6sorption phalangienne distale de certains doigts (92 index, 97 majeurs, 100 annulaires, 98 auriculaires).

Mt~THODES

Les techniques op6ratoires de r6activation des muscles intrins~ques des doigts paralys6s reposent sur plusieurs principes.

Nous pouvons distinguer les transferts tendineux dynamiques, et les proc6d6s dits de stabilisation pas- sive.

Located in the southern part of India, Sacred Heart Le- prosy Centre at Kumbakonam is situated in zone in which Hansen's disease is endemic (19 %0).

The goal of this work is to report on middle-term results of 100 cases of surgical reconstruction in intrinsic palsy of the fingers involved with Hansen's disease.

Analysis of results allowed comparison of the different operative procedures and to define their indications.

Surgical management of Hansen's disease has made rapid progress following the work in 1948 by Riordan in Carville and Brand in Vellore, india. The techniques that have been proposed to reconstruct intrinsic power of the fingers are many: Brand [7], Bourrel [5], Carayon [9], Languillon [12], Palande [13], Zancolli [18] and Tubiana [17].

CASES STUDY

Neuritis in leprosy is a hypertrophic form of neuritis. In the upper limb, the ulnar and median nerves are involved in elective fashion. Partial or total functional disorders are due to compression of the ulnar and/or median nerves as they run behind the epicondyle or course through the car- pal tunnel respectively.

Between January 1983 and January 1984, one hun- dred hands of unselected patients with Hansen's disease were examined. Only those patients with more than one year of follow-up were included in this study. The mean age of the patients was 33 years (range 13 to 66 years). Fifteen patients were female and 85 male. These lesions were classified as lepromatous (22 %), tuberculoid (8 %) or undetermined (70 %).

The mean duration of symptoms before operation was 4 years and 5 months (range 1 to 20 years). Paralysis in- volved the ulnar nerve in 62 p. cent of cases, the median and ulnar nerves in 37 p. cent and all three major nerves of the upper limb in one case. The disorder was located in the right hand in 51 p. cent and in the left hand in 49 p. cent.

The mean follow-up after operation was 4 years and 8 months (range 1 to 13 years). Because of the distal absorption of one or more fingers, 387 out of 400 digits were analyzed (92 index, 97 long, 100 ring and 98 little fingers).

METHODS The basic principles of the operative techniques for re-

construction of the intrinsic muscles of the paralyzed fin- gers were variable: either dynamic tendon transfers or procedures based on passive stabilization were perfor- med.

Of the former, the techniques used were as follows : - - 41 cases of Brand's type II reconstruction [5], i.e., tranfer of the tendon of the extensor carpi radialis Iongus prolonged by a fascia lata graft divided into several slips which course through the carpal tunnel and are attached to the dorsal aponeurosis of the interosseous muscles via the volar route (mean follow-up period: 5 years and 5 months).

2 cases of Brand's type I reconstruction [5], i.e., trans- fer of the tendon of the extensor carpi radialis Iongus pro- longed by a fascia lata graft divided into several slips which run through the intermetacarpal spaces to the dor- sal apparatus via the dorsal route (mean follow-up 4 years and 3 months).

V O L U M E 5

N ° 1 - - 1 9 8 6 PARALYS1ES DES MUSCLES 1NTRINSEQUES DES DOIGTS 15

Parmi les transferts tendineux dynamiques, nous avons revu :

- - 41 op&ations de Brand deuxidme mani~re [5] ou transpositions du tendon du muscle premier ra- dial prolong6 d 'une greffe apon6vrotique (fascia lata) h plusieurs languettes, /~ travers le canal car- pien, par voie palmaire, sur l'expansion dorsale des interosseux (recul moyen 5 ans 5 mois).

- - 2 op&ations de Brand premi&e mani~re [5] .ou transpositions du tendon du muscle premier radial prolong6 d'une greffe apon6vrotique ~ plusieurs lan- guettes, entre les m6tacarpiens, par vole dorsale, sur l'expansion dorsale des interosseux (recul moyen 4 ans 3 mois).

- - 15 opdrations de Palande [15] (fig. 1). Le but de cette intervention est la double correction de la paralysie des muscles intrins6ques des doigts et de l 'inversion de l 'arche palmaire. Les muscles trans- pos6s peuvent 6tre le premier radial ou le petit pal- maire. Le muscle est prolong6 d 'une greffe apon6- vrotique, qui apr6s avoir chemin6 dans le canal carpien est divis6 en cinq languettes. Chacune des languettes passe en avant du ligament transverse interm6tacarpien profond, le long des lombricaux pour les II °, i II °, IV ° doigts, La languette externe est sutur6e ~ la terminaison tendineuse du premier interosseux dorsal. Les trois languettes m6dianes apr~s avoir contourn6 les terminaisons tendineuses des muscles interosseux palmaire et dorsal sont suturdes/~ elles-m6mes. La languette interne passe autour des tendons des muscles hypoth6nariens, au bord interne de la t~te du V e m6tacarpien avant d 'y ~tre sutur6e.

Ces sutures sont faites, poignet neutre, flexion des m6tacarpo-phalangiennes (MP) 55 °, interphalan- gienne (IP) 6tendues. recul moyen 2 ans.

- - 13 op&ations de Littler [6] ou transpositions du tendon fl6chisseur commun superficiel sur l'expan- sion dorsale des interosseux. Recul moyen 6 ans 11 mois.

Parmi les proc6d6s dits de ~ stabilisation pas- sive ~, nous avons distingu6 les proc6d6s stabilisant la MP par limitation de l'extension avec avancement r6g16 des poulies des fl6chisseurs [14, 18]. Ces inter- ventions inspir6es de Zancolli sont au nombre de 15 dans notre s6rie (recul moyen 5 ans 3 mois).

Enfin, les proc6d6s qui restaurent la flexion active MP laissant ~ l 'extenseur son action sur les IP lors- que la MP est emp~ch6e de se mettre en hyperex- tension. Cette intervention ~ lasso ~ [10, 11] modifi6e selon Palande est r6alis6e par la transposition du tendon des muscles premier radial ou petit palmaire, prolong6 d'une greffe apon6vrotique ~ plusieurs lan- guettes, h travers le canal carpien sur la poulie proximale. Nous avons revu ici 14 cas avec un recul moyen de 3 arts (fig. 2).

La restauration de l'arche transverse interm6ta- carpienne distale a 6t6 r6alis6e soit par un :

proc~d~ statique : ~ l'aide d'une bandelette de fascia lata sutur6e entre l'insertion distale du petit palmaire et le bord ant6ro-interne de la capsule MP du V (10 cas dans le Brand II, 3 cas dans ie ~ lasso ~) ; - - p r o c ~ d ~ dynamique: selon la technique de Pa- lande (14 cas).

- - 15 cases of Palande's operation [15]. The aim of this operation is double : correction of intrinsic palsy and in- version of the palmar arch. The extensor carpi radialis Iongus or the palmaris IonguS may be used for the trans- fer. The muscle is prolonged by a fascia lata graft which is divided into 5 slips after passing through the carpal tun- nel. Each slip passes volar to the deep transverse inter- metacarpal ligament and runs along the lumbricals of the lind, Iilrd and IVth fingers. The most lateral slip is Sutured to the tendon of the first dorsal interosseous muscle. The three medial slips are sutured to themselves after being routed around the tendons of the dorsal and volar interosseous muscles. The medial slip passes around the tendons of the hypothenar muscles at the level of the me- dial border of the head of the Vth metacarpal and then is sutured to itself.

The tendons are sutured with the wrist in neutral posi- tion, the metacarpophalangeal joint at 55 ° of flexion and the interphalangeal joints in extension. The follow-up pe- riod was two years.

13 Littler operations [6] in which the flexor digitorum sublimis is transferred to the dorsal aponeurosis of the in- terossei. The mean follow-up period was 6 years and ele- ven months.

Of the , passive stabilization, procedures, we prefer operations which stabilize the metacarpophalangeal joint

by limitation of extension with advancement of the pulleys of the flexors [14, 18]. This type of operation, which is de- rived fron Zancolli's procedure, was performed 15 times in our series (mean follow-up per iod: 5 years and 3 months).

Lastly there are procedures which restore active flexion of the metacarpophalangeal joint in which the action of the extensors on the interphalangeal articulations is pre- served when the metacarpophalangeal can no longer be overextended. T h i s , lasso ,, type of procedure [10, 11], modified by Palande, consists of transposition of the tendon of the extensor carpi radialis Iongus, prolonged by an aponeurotic graft divided into several slips, running through the carpal tunnel and the proximal pulley. Four- teen cases treated in this manner with an average follow- up of 3 years were reviewed (fig. 2).

Restoration of the distal transverse intermetacarpal arch was accomplished either by :

a static procedure : a band of fascia lata was sutured between the distal insertion of the palmaris Iongus and the anteromedial edge of the capsule of the metacarpo- phalangeal joint of the little finger (10 cases in Brand's II procedure, 3 cases in the , lasso ,, procedure) ;

a dynamic procedure : according to Palande's techni- que (14 cases).

ANNALES DE CHIRURGIE 16 INTRINSIC P A L S Y OF THE F I N G E R S DE LA M A I N

Languettes aponevrotiques

Nerf et vaisseau digitaux

| ~ ~ I Gaine du tendon / J : \. / _l fl6chisseur \ ~ / - - . / /

Dire ' oes ,anguettes ~alLOire \ ~ d o r s a i

Ligament transverse inter-metacarpien.'~ ~ T . e . n d , on Iombrlcal profond ] i ~ o u HI

• , ,~.~ ~

~ ~ ~ '~chisseurs

Tendons interosseux palmaire et dorsal

~\Tendon du Iombrical

--Fixation de la languette

. 50 °

-~ -'a0= .E x ~ . ]O =

= - 200

- I0 = ,

.~ + 10 a

÷ 20 = t < -PO °

(flexion "valeur negative", + hyper-extension "valeur positive")

Languette aPonevrotique O;Sur s

HEDIOCRE

I MOYEN

80N

-40 ° - ]0 = -2g ° -10 ° 0 +lO = -20 ° +}0 = *40 • +Y0 °

A~iculation metacarpo-phalangienne

Fig. 1. - - Opdrat ion de Palande (d 'apres D.D. Palande).

Fig. 2. - - Operat ion ,, Lasso ,,.

Fig. 3. - - Criteres d 'apparence. Main ouverte.

Fig. 1. - - Palande's operation (described by D.D. Palande). Fig. 2. - - ,, Lasso ,, operation. Fig. 3. - - Criteria of appearance. Open hand.

C R I T E R I A OF RESULTS

Results were appreciated according to functional gain and appearance [14].

Functional criteria

Hand in ,, lumbrical position ,, or , wing (four finger) flexion of the f ingers,

Goniometr ic measurement of the proximal interphalan- geal joint =

Results : good : a ~< 300 fair : 30 ° < ~ < 60 ° poor : ~ > /60 °

Closed hand Results : good : tips of f ingers able to touch the distal palmar

crease

fair : f ingert ips able to touch the palm less than one centi- meter from the distal palmar crease

poor : f ingertips unable to touch the palm.

Criteria of appearance

Open hand (fig. 3) The angle of one of the palmar arches was studied Distal transverse intermetacarpal arch

• Open hand • Fingers in extension

• The hinge of the goniometer is placed perpendicular to the axis of the hand at the level of the distal neck of the middle (111) metacarpal (angle 6).

Results : good :13 I>15 ° fair : 10 ° ~< 13 ~< 14 ° poor : l~ < 10 °

V O L U M E 5 Y o 1 - - 1 9 8 6 PARALYSIES DES MUSCLES INTRINSt~QUES DES DOIGTS

C R I T I ~ R E S D E R I ~ S U L T A T S

Nous avons dis t ingu6 les cr i t6res de fonc t ion et d ' a p p a r e n c e [14].

Criteres de fonction

Main en ~ pos i t ion lombricale ~ ou <~ f l ex ion en volet des doigts ~

M e s u r e g o n i o m d t r i q u e de l ' ang le IPP " a

R~sultat B o n • (~< 30 ° M o y e n ' 30 ° < a < 50 ° M 6 d i o c r e " a~> 60 °

Main ferrn#e

R#sultat B o n • ext r6mit6s d i s ta les des doig ts tou- chan t le pl i p a l m a i r e distal .

M o y e n ' e x t r 6 m i t 6 s d i s t a l e s des doig ts t o u c h a n t la p a u m e ~ moins d ' u n cen t im6t re du pl i p a l m a i r e distal .

M d d i o c r e " ex t r6mi t6s d is ta les des d o i g t s ne p o u v a n t t o u c h e r l a p a u m e .

Crit~re fl'apparence Main ouver te (fig. 3) 1. Main en position

Iombricale Nous avons 6tudi6 l ' a n g u l a t i o n d ' u n e des a rches 2. aainfermee

p a l m a i r e s • 3, Main ouverte

A r c h e transverse in term#tacarpienne distale

• Ma in ouve r t e , • Doig t s en ex tens ion , • P ivot du gon iom6 t r e plac6 p e r d e n d i c u l a i r e m e n t

/t l ' axe de la ma in , au n iveau du col d is ta l du t ro i - s i6me m 6 t a c a r p i e n (angle [3).

17

R~sultat Bon : [3 I> 15 ° M o y e n : 10 ° ~<~<~ 14 ° M 6 d i o c r e : [3< 10

In f l ex ion latdrale des doigts :

• ma in o u v e r t e , • doigts e n ex tens ion , • le gon iom6t re m e s u r e la ddv ia t ion (y) r ad i a l e

ou cubi ta le du do ig t au n iveau de l ' a r t i cu l a t i on m6- t a c a r p o p h a l a n g i e n n e .

Rdsultat bon y ~ 5 ° m o y e n 6 ° ~<y~< 15 ° m6d ioc re 7 > 15 °

R t ~ S U L T A T S

R6sultats globaux objectifs

Amelio- Sans ration changement

283 (73 %) 84 (22 %)

2 6 ( 8 % ) 295 (85 %) 291 (75 %) 91 (24 %)

Det6rio- ration

2o (5 %)

25 (7 %) 5 (1%)

Resultats globaux subjectifs

- - P a t i e n t s sa t is fa i ts ou p l e i n e m e n t sa t is fa i ts • 38 - - P a t i e n t s p r d s e n t a n t une am61iora t ion n e t t e " 45 - - P a t i e n t s n o n amdl io r6s " 17

Lateral deviation of the fingers • Open hand

• Fingers in extension

• The gon iomete r measures the radial or ulnar deviat ion (y) of the f inger at the level of the metacarpopha langea l art iculation.

Results : good : y ~< 5 ° fair : 6 o ~< y ~< 15 ° poor : y > 15 °

R E S U L T S

Objective overall results

Impro- No change Deterio- vernent ration

1, Hand in the lumbrical position 283 (73 %) 84 (22 %) 20 (5 %)

2. Closed hand 2 6 ( 8 % ) 295 (85 %) 25 (7 %) 3. Open hand 291 (75 %) 91 (24 %) 5 (1%)

Subjective overall results

- - Statisf ied or comple te ly satisf ied pat ients : 38 (good) - - Patients who present c lear improvement : 45 (fair)

- - Patients wi thout improvement : 17 (poor)

R e s u l t s a c c o r d i n g s to t h e o p e r a t i v e p r o c e d u r e (fig. 4 a & 7b)

Hand in lumbrical position

Impro- No change vement

Brand II 105 45 Lasso 41 14 Zancolli I 35 15 Palande 51 5 Littler and Brand I 51 5

Total 283 (73 %) 84 (22 %)

Open hand

Brand II 110 45 Lasso 44 12 Zancolli I 39 16 Palande 55 5 Littler and Brand I 43 13

Total 291 (75 %) 91 (24 %)

Closed hand

Deterio- ration

20 (5 %)

5 (1%)

Brand II Lasso Zancolli I Palande Littler and Brand I

6 3 4 3

10

121 49 44 50 31

Total 26 (8 %) 295 (85 %)

lO

3 7 5

25 (7o %)

18 INTRINSIC P A L S Y OF T H E F I N G E R S

TABLEAU I. - - Resultats fonctionnels.

TABLE I. - - Functional results.

ANNALES DE CHIRURGIE DE LA MAIN

PRE- OPERATOIRE

BaN

~"" "-:" ':"' : : ~,'- ; ,'"-'-" : ;4 ~ I MOY,

MED.

BaN

I:::;.',::~.',::::"::,:-:':,:::'451 MOY,

[ za I MED

IE i DON

I::-;:~:.v--!',:;"5.:'~':384 MOY.

ll4 I MED,

l~ DON

MaY.

,s? [ MED.

T O T A L 3 8 7 do ig f s :

PRE- OPERATOi R E

BON

MOY.

TSI MED.

[ ] BaN

MOY

s21 MED.

1| DON

MOY

99( MED.

I I DON

MO¥

97J MED.

TOTAL 3 8 7 do ig l s :

I . FONCTlON(Posi t ion Iombricole}

POST- OPERATOIRE

16~ AMELIORATION [="

117-'.-'-'!:;I SANS CHANGEMENT 130:': '-::.~:. '- ' , [

I N D E X DETERIORATION [ ~

]7E AMELIORATION I ¢~

SANS CRANGEMENT

MAJEUR DETRIORATION [ ]

172 AMELIORATION Ie~ SANS CHANGEMENT

[ ] ANNULAIRE DETERIORATION F6"l

I¢ 'I AMELIORATION LB

SANS CHANGEMENT

AURICULAIRE DETERIORATION ~]"

am~lior~s: 2 8 3 ( 7 5 % 1 ; inchang~s: 8 4 ( 2 2 % ) ; de te r i o r6s :20 (5%)

2. A P P A R E N C E ( M a i n ouverte) POS T-OPERATOIRE

15 AMELIORATION [ 6°

SANS CHANGEMENT

I N D E X DETERIORATION

I 6c AMELIORATION I 7e

SANS CHANGEMENT

MAJEUR DETERIORATION {]'I

I 5 AMELIORATION 174 SANS CHANGEMENT

r25 I ANNULAIRE

AMELIORATION I 7°

1:1~3":~::::,:~:,':~ SANS CHANGEMENT

Iz8 I A U R I C U L A I R E DETERIORATION ]]t

PRE- OPERATOIRE

r3 I DON

[ ] MOY.

[ ] MED.

"rsl BaN

lr~ Moz Oz MED. I-f-i

~6[ DON I~ MOY. MED.

T41 DON IS~ I

[ ] MOY MED,

TOTAL 3 4 6 doigts: o m ~ l i o r ~ s : 2 6 ( 8 % ) ;

om61ior6s: 2 9 1 ( 7 5 % ) ; inchong~s: 9 [ ( 2 4 % ) i d ~ t ~ r i o r ~ s : 5 ( ] % )

3. F L E X I O N ( M a i n ferm(~e )

POST- OPERATOIRE

] a AMELIORATION

[ ] SANS CHANGEMENT

INDEX DETERIORATION

I st AMELIORATION SANS CHANGEMENT

MAJEUR DETERIORATION

ANNULAIRE

AURICULAIRE inchonges: 295(85%) ;

[ ]

[ 70: : - . - : . :.'...'..: :,.:::.;'.-..':-.-.::.'.-:- I

r-~

[]

[ ]

A MELIORATIOIq

SANS GHANGEMENT [ 7 4 : : : : : . , ' . . . ' . . = ' , : : : ' . , : . ; : : : : : : : : : , . ]

DETERIORATION

AME LIORATION SANS CHANGEMENT I 7Z:. ' : , . ; : : : . : ' . : . . . ' , . : . : : . . . ' : : : . . : : ,,'.:1

DETERIORATION T'~

d~f~r io r~ : 25 ( 7 % )

MOY.= Moyen MED.= Mediocre

VOLUME 5 N ° 1 -- 1986 PARALYS1ES DES MUSCLES INTRINSEQUES DES DOIGTS ]9

Resultats selon les procedes operatoires (fig. 4a & 7b)

Flexion en volet des doigts

Brand II Lasso Zancolli I Palande Littler et Brand I

Total

Am@liB- ration

105 41 35 51 51

283 (73 %)

Sans D@t@rio- changement ration

45 9 14 1 15 5

5 4 5 1

84 (22 %) 20 (5 %)

R(~sultats sur I ' inflexion laterale des doigts (tableau II)

Activit6 professionnelle des patients op6r6s sur 82 dossiers exploitables (tableau III).

Avant intervention

Apr@s intervention

Travail dur

24

21

Travail non Travail I~gel ,Sans activit~ en force

37 21 2

39 17 5

Main ouverte

Brand II 110 Lasso 44 Zancolli I 39 Palande 55 Littler et Brand I 43

Total 291 (75 %)

45 12 1 6

5 13

91 (24 %) 5 (1%)

Main fermde

Brand II 6 121 Lasso 3 49 Zancolli 4 44 Palande 3 50 Littler et Brand I 10 31

Total 26 (8 %) 295 (85 %)

10

3 7 5

25 (7 %)

R(~sultats fonct ionnels

Pour chacun des doigts, selon les tests de fonc- tions et d'apparence (tableau I).

DISCUSSION

Dans la s6rie que nous pr6sentons, plus de 74 % des patients ont 6t6 am61ior6s que leurs mains soient en position intrins6que (flexion en volet des doigts) ou ouverte.

Seulement, un peu plus de 3 % des patients ont pour ces m6mes crit6res, pr6sent6 en post-op6ra- toire une d6t6rioration, alors qu'en pr6-op6ratoire, 45 % en position intrins6que et 9 1 % en position ouverte 6taient d'un grade m6diocre.

Pour la main en position ferm6e, nous notons 8 % d'am61ioration et 85 % d'absence de changement. Ceci s'explique par le fait que les conditions pr6- op6ratoires 6taient bonnes dans plus de 82 % des cas. En effet, malgr6 la griffe, et la perte du m6ca- nisme normal de flexion des doigts, nous constatons que le patient, par flexion du poignet, peut amener ses pulpes distales dans le pli palmaire distal.

T A B L E A U II. - - Inflexion laterale des doigts. T A B L E II. -- Late ra l i n f l ex ion on the f i ngers .

LASSO

LITTLER £T BRAND I

901:__~ . ' ' . I ~oN I" . . " ' I n~

35 #IIIIIIA MOY ~ 311

3B I I MED O ]O

15 [ ] Ben I ' I T 9

32 ~ MOY [] 14

S [] MeD 0 3

371. .1 BDN I ' . ' ' . ' - I 39

n [ ] MoY [ ] ~R

2 Q MCO O J

z4EC] BON ~ 37

25 FJ777~ MOY [] ii

J D BED 0 A

3 ~ ear I' . t Ja

1 3 0 HED 8 Zl

TOTAL

z o a . . . . . - . . . . I BON I . - - . . • . . . - ' - 1 2 ~

115 V//llll/I///I/I/llllJ MOY ~\\\\\\\\\\\\\\\] 87

65 l _ _ J MED ~ $3

BRAND I I

LASS0

Amdlioration

Sans chanoemenL

D@t~riaraLion

t I I I I . I ~z

k\\\\\\\\\\\\\\\\\\\\\~ B2

[ ~ ] z0

Amdlioration ~ 3 1

Sans changemenk ~-2

D6tdriorotion 0 3

AmdlioraL~on O13

Sans chanoement k\\\\\\\~ 33

D@t~rioration O l 0

Amdlioration ~ 16

SODS chanoemen[ ~\\ \ \ \ \~ 27

D@tdrioration [] 9

LITTLER £T BRAND I

AmdlloratJon

Sons changemen[

Ddkdrioration

tOtA~

Am@Izorakion

Sans changement

D@~@rioration

k\\\\\\\~l 26

[ ] ]e

[ " - " . " . • " . . " . " ' . ' I li~O (37 !;)

~ \ \ \ \ \ \ \< \ \ \ \ \ \ \ \ \ \1 \ \ \ \ \ \ \ \1 \ \ \ \ \ \1 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ I lRO (50 ~)

I ~ 52 (a3 ~)

20 INTRINSIC P A L S Y OF THE FINGERS ANNALES DE CHIRURGIE

DE LA MAIN

Bourrel [4] sur une sErie de 12 operations de Brand (I et II) a pour la position main ouverte : 5 rEsultats excellents, 5 bons, 1 passable et 1 mauvais ; pour la position intrins~que : 7 excellents, 4 bons, 1 mauvais et pour la position main ferm~e : 6 excel- lents, 6 bons (recul de 18 mois f~ 7 ans).

Bourre l ne note pas de deformations en col-de- cygne ; il souligne le bon rEtablissement de la ferme- ture physiologique des doigts, que le procEd6 de Zancolli ne permet pas complEtement. Nous n'avons pas note de difference significative entre les rEsultats de ces deux procEdEs. Cependant, nous notons qu'il y avait plus de grades bons ou moyens prE-opEratoi- res dans les Zancolli que dans les Brand II, position intrins~que.

Sundaraj et coll [16] ont prEsent6 une sErie de 200 cas de Brand II et 200 operations de Littler (Echan- tillonnage systdmatique parmi les opErEs de 1951 1980). Leur taux de rEsultats satisfaisants (bon ou moyen) est pour l 'ensemble des tests fonctionnels de 95 %. Si nous reprenons nos rEsultats pour les rEsul- tats finaux, nous avons un taux moyen (3 tests) de 88 %.

Dans notre sErie, le procdd6 de << lasso >> a donne de meilleurs rdsultats, de fa~on significative, que le procEdE de Brand II en position intrins~que. Dans la sErie de 22 mains de Boucher [1], nous notons, que pour le test de flexion en volet des doigts, les rEsul- tats sont tous bons ou moyens pour 36 doigts souples et nuls pour 4 des 32 doigts enraidis. De m~me, dans notre sErie, pour 30 grades bons ou moyens prE-opd- ratoires et 26 grades mEdiocres, nous n'avons plus

en post-opEratoire qu'un seul grade mediocre (taux d'amElioration de 73,2 %).

Pour le test d 'apparence (ou correction de la dE- formation) Boucher pour l 'ensemble des 68 doigts a 9 rEsultats nuls. Pour 56 doigts que nous avons revus (54 grades mddiocres prd-opEratoires) nous avons 8 grades mEdiocres en post-opEratoire (ce qui corres- pond ~ un taux d'amElioration de 79 %). Ces rEsul- tats rejoignent ceux de Boucher et coll [2] qui sur 48 cas ont 80 % de rdsultats bons ou tr~s bons. Ces au- teurs soulignent l'intEr~t de cette technique, simple, n 'ayant pas nEcessit6 de rEEducation.

Brown [8] rapporte 44 griffes cubitales corrigdes par capsulorraphie type Zancolli avec quelques mo- difications techniques. Le taux d'amdlioration est de 46 %, d'aggravation de 12 %. Dans les 15 cas que nous avons revus, main en position intrins~que, l 'amdlioration est de 64 %, la dEtErioration de 9 %.

Bourrel et coll. [3] ont rapport6 74 transplanta- tions des flEchisseurs superficiels selon la technique de Sterling-Bunnel modifiEe. Pour l'ex~ension des doigts, les rdsultats ont 6t6 trEs bons et bons dans 71,6 %, mauvais dans 2,6 %. Pour nous les taux sont respectivement : 78,6 % d'amEliorations et 0 % de degradation. Pour la fonction intrinsEque, les au- teurs rapportent 89 % de tr~s bons et bons, et 4 % de mauvais . Nous avons r e spec t ivemen t 9 1 % d'amdlioration et 1,7 % d'aggravation. Enfin, pour la flexion des doigts, ces mEmes auteurs ont respec- tivement : 73,3 % de tr~s bons et bons et 2,6 % de mauvais rEsultats. Pour nous, le taux d'am61ioration est de 18,20 %, d 'aggravation 9 %.

Functional results

For each finger according to the functional tests and their cosmetic appearance (table I).

Results concerning the lateral deviation of the fingers (table il)

Professional activity of 82 patients whose records were available (table III).

TABLE III

Before operation

After operation

Hard labor Ordinary Light work Without work activity

24 37 21 2

21 39 17 5

DISCUSSION

In our series, more than 74 p. cent of the hands of pa- tients were improved in the intrinsic (four finger flexion) or open positions.

However, according to these same criteria, a little more than 3 p. cent cent of patients were worse postoperatively while preoperatively, 45 p. cent and 91 p. cent of patients had poor results in intrinsic function or hand opening res- pectively.

Concerning the possibility of closing the hand, 8 p. cent of patients were improved and 85 p. cent unchanged in our series. This may be explained by the fact that preope- rative conditions were good in more than 82 p. cent of cases, i.e. the patient was able to bring his finger tips into contact with the distal palmar crease by flexing his wrist in spite of his claw hand and the loss of the normal mecha- nism of flexion.

Bourrel [4], who performed a series of 12 Brand opera- tions (I and II) reported 5 excellent, 5 good, one fair, and one poor result with regard to extension ; 7 excellent, 4 good and one poor result for the intrinsic position ; and 6 excellent and 6 good results for the closed hand test (fol- low-up ranging from 18 months to seven years).

There were no swan-neck deformities in Bourrel's series. He underscored the good physiological closing of fingers resulting from this technique which is not always completely possible with Zancolli's procedure. We did not notice any significant difference between these two proce- dures. However, there were more good or fair results with Zancollrs procedure than with Brand's type II operation with regard to the intrinsic position.

Sundaraj and co-authors [16] presented a series of 200 cases of Brand's type II and 200 cases of Littler's proce- dures (selected randomy) operated between 1951 and 1980. For these authors, 95 p. cent satisfactory (good or fair) results were found for the three criteria. For these same three tests, our study showed an average of 88 p. cent satisfactory results.

V O L U M E 5 N o ] - - 1 9 8 6 PARALYSIES DES MUSCLES 1NTRINSEQUES DES DO1GTS 2 1

Fig. 4. - - M.G. Operation de Pa- lande. Main ouverte. J + 1 an. a) Preoperatoire. b) Post-opera- toire,

Fig. 4. - - Palande's operation. Open hand. After one year. a) Preoperative. b) Post-operative. 4a 4b

Fig. 5. - - M.G. Op(~ration de Pa- lande. J + 1 an. Main en position o u v e r t e , a) P r ( ~ o p d r a t o i r e . b) Post-opdratoire.

Fig. 5. - - Palande's operation. After one year. Hand in the open position, a) Preoperative. b) Post- operative. 5a 5b

When the results of reestablishment of the intrinsic po- sition are considered, the <, lasso ,, procedure provides si- gnificantly better results than the Brand II technique. In a series of 22 patients, Boucher [1] tested four finger (intrin- sic position) flexion and found that results were better when the fingers were supple (good or fair results in 36 cases) compared to when the finger joints were stiff (4 of 32 cases in which results were nil). Likewise, in our series of 30 - good - or - fair ,, and 26 ,, poor ,, preoperative ra- tings, only one case was rated ,, fair,, postoperatively (improvement rate : 73.2 %).

The cosmetic result (or correction of the deformity) was judged nil for 9 of 68 digits in Boucher's series. Of 56 fin- gers (54 with , poor ,, preoperative ratings) reviewed by our team, only 8 were considered to be poor postoperati- vely (i.e. 79 % improvement rate). These results are comparable to those of Boucher et al. [2] who had 80 p.

cent good or very good results in 48 cases. These au- thors underline the value of this technique which is simple and does not require rehabilitation.

Brown [8] reported on 44 claw hands corrected by a modified Zancolli type capsulorrhaphy. The improvement rate was 46 p. cent while in 12 p. cent of patients, results were worse. In our 15 cases, the lumbrical position was improved in 64 p. cent and aggravated in 9 p. cent of cases.

Bourrel and co-workers [3] reported 74 sublimis trans- fers according to a modified Sterling-Bunnell technique. Results concerning extension were very good or good in 71.6 p. cent of cases and poor in only 2.6 p. cent. In our cases, results were improved in 78.6 p. cent of cases and worsened in 0 p. cent respectively. These same authors reported 89 p. cent good or very good results and 4 % poor results concerning the intrinsic position. In our

ANNALES DE CHIRURGIE 22 INTRINSIC P A L S Y OF THE FINGERS DE LA MAIN

6a

Dans notre s6rie, il n'a pas 6t6 mis en 6vidence de diff6rence significative quant aux r6sultats quel que soit le proc6d6 r6alis6 pour corriger l'arche trans- verse interm6tacarpienne distale.

Concernant l'inflexion lat6rale des doigts, nous constatons que pour un patient sur deux, il n 'y a pas eu de modification apr6s l 'intervention et que 37 % des sujets ont 6t6 am6lior6s. Parmi les diverses tech- niques, il appara~t que l'op6ration Lasso a donn6 le plus d'am61ioration.

La d6formation en col-de-cygne des doigts n 'a pas 6t6 analys6e particuli~rement.

Au total, ces r6sultats rejoignent ceux rapport6s dans la litt6rature [11].

La place de la kin6sith6rapie doit 6tre particuli~- rement soulign6e. Dans la 16proserie du Sacr6- Coeur, il existe un d6partement de r66ducation fonc- tionnelle employant cinq personnes. Ainsi, en pr6- op6ratoire des exercices de contraction 6lective du muscle ~ transposer sont r6alis6s. Des attelles tem-

series, 91 p. cent of patients showed improvement while 1.7 p. cent were worse. Concerning the flexion of fingers, these same workers reported 73.3 p. cent good and very good results and 2.6 % poor results. In our hands, 18 to 20 p. cent of patients are improved, 9 % are worse.

There were no significant differences among the tech- niques concerning the correction of the distal transverse metacarpal arch in our series.

When we considered the results relative to lateral mo- vements of fingers, it was found that half of the patients were unchanged, while only 37 p. cent were improved. The ,, lasso, procedure appeared to provide the best re- sults.

The swan-neck deformity was not analyzed. Overall, our results are comparable to those found in

the literature [11].

6b

Fig. 6 . - M,G. Op(~ration de Pa- lande. J + 1 an. Flexion en volet des doigts, a) Pr(~operatoi re. b) Post-operatoire.

Fig. 6 . - Palande's operation. Open hand. After one year. Hinge flexion of the finger, a) Preopera- tive. b) Post-operative.

Fig. 7. - - M.G. Op(~ration de Palande. J + 1 an. Arche trans- verse interm(~tacarpienne distale, a) Preop6ratoire (90°). b) Post-operatoire (20°).

Fig. 7. - - Palande's operation. Open hand. After one year. Dis- tal transverse intermetacarpal fixation, a) Preoperative (10°). b) Postoperative (20°).

7a

7b

VOLUME 5 N ° 1 - - 1986 P A R A L Y S I E S DES MUSCLES

poraires plfitr6es sont utilis6es pour faire prendre conscience du mouvement perdu : l 'hyperextension m6tacarpophalangienne est pr6venue passivement, permettant au patient de retrouver une extension in- terphalangienne active. De m6me, les articulations interphalangiennes proximales ct distales 6rant im- mobilis6es par des attelles pl~tr6es cylindriques, le patient retrouve une flexion m6tacarpophalangienne tout en gardant ses doigts 6tendus. Ces attelles pl& tr6es digitales permet tent aussi de lutter contre les contractures.

En post-opdratoire, la r66ducation a pour but de permettre au nouveau sch6ma moteur d'6tre semi- automatique : isolement du transfert yeux ferm6s, puis ouverts, avant la composition d 'un mouvement complexe.

Une fois le malade rentr6 chez lui, il sera revu par l 'op6rateur r6guli6rement mais aussi mensuellement par une 6quipe soignante ambulante comprenant un kin6sith6rapeute. Ce dernier a re~u une formation qui lui permet d 'a jouter ~ son r61e de physioth6ra-

INTRINSI~QUES DES DO1GTS 23

peute un r61e d'dducateur de sant6 : pr6vention et d6pistage pr6coce des d6formations, encouragement au traitement r6gulier...

En conclusion, nous d6gageons les indications sui- vantes [111. Main en griffe

Doigts souples Deux derniers doigts : patients peu coop6rants,

pas de physioth&apie possible : capsulorraphie et avancement des poulies.

Trois ou quatre doigts : patients coop6rants, pos- sibiliMs de physioth~rapie.

* sans collapsus de l 'arche palmaire - - op6ration de Brand I ou II

* avec inversion de l 'arche palmaire - - op6ration lasso - - op6ration de Palande.

Doigts raides : op6ration de Littler.

R E M E R C I E M E N T S a M.S . Ra j a g o p a l a n p o u r l ' 6 t u d e statist i- que.

Physical therapy is of paramount importance. In Sacred Heart Leprosy Centre five people are employed in the re- habilitation department. Preoperatively, elective contrac- tion exercises of the muscle to be transferred are taught. Temporary plaster of Paris casts are fashioned in order to make the patient understand which movement has been lost. Metacarpophalangeal hyperextension is prevented passively, allowing the patient actively to extend his inter- phalangeal joints. Likewise, when the proximal and distal interphalangeal articulations are immobilized by cylindri- cal plaster splints, the patient is capable of metacarpo- phalangeal flexion while the distal joints remain extended. These plaster splints help prevent contractures as well.

Postoperatively the goal of rehabilitation is to provide a - semi automatic, new motor unit : isolated movement of the transfer, first eyes closed, then open, before trying more complex movements.

Once the patient is discharged from the Centre, he is seen regularly by the surgeon and monthly by an ambula- tory therapeutic team including a physical therapist, whose role is not limited to physical therapy. He must also

be a health educator: prevention and early detection of deformities, promotion of well established therapy pro- grams, regular treatment, etc.

In conclusion, we suggest the following indications [11]. Claw hand

Supple fingers The two ulnar fingers are involved : uncooperative p a -

t i e n t s , physica/ therapy impossible : capsulorrhaphy and pulley advancement.

Three or four fingers are involved: cooperative pa- tients, possibility of physica/ therapy • uncollapsed palmar arch

- - Brand's operation, version I or II • inversed palmar arch

- - Lasso operation - - Palande's operation

Stiff fingers Littlers'operation.

W e would like to t h an k M.S. R a j a g o p a l a n for his help with sta- tistics.

REFERENCES

1. BOUCHER P. - - Correction de la griffe cubitale Mpreuse par le pro- c6d6 du ~< lasso ~, de Zancolli. Chirurgie, 1982, 108, 753-757.

2. BOUCHER P., OBERLIN C. - - Evaluation of the ~< lasso , of Zan- colli in the Leprous Claw and about 48 cases. X l l lnternattonal Le- prosy Congress New Delhi, 1984, february 20-25. Abstracts : V 254 A.

3. BOURREL P., CARAYON A., L A N G U I L L O N J. - - La transplan- tation des fl6chisseurs superficiels dans 74 cas de paralysie 16preuse des muscles intrins~ques de la main. Rev Chir Orthop, 1961, 47, 4, 484- 503.

4. BOURREL P. - - L'op6ration de Brand h propos de douze observa- tions personnelles. Ann Chir Plast Esther, 1968, 23, 4, 297-304.

5. BOURREL P. - - Place de la chirurgie dans le traitement et la r6habi- litation des 16preux. Chtrurgie (Paris), 1982, 108, 744-752.

6. BOURREL P. - - Interventions palliatives pour paralysies des nerfs de la main, p. 69. Colloque H6pital Inter-Arm6e Laveran, Marseille, 1978.

7. BRAND P.W. - - Paralytic claw hand. J Bone Joint Surg, 1958, 40 B, 618-632.

8. BROWNE P.W. - - ZancoUi capsulorrhaphy for ulnar claw. J Bone Joint Surg, 1970, 52 A, 868-877.

9. CARAYON A., BOURREL P., L A N G U I L L O N J. - - Surgery in Le- prosy, 1 vol. 186 p. Paris, Masson, 1964.

10. CARAYON A., T U B I A N A R. - - L'influence de ZancoUi sur la r6ha- bilitation de la main ldpreuse. M~d Trop (mars), 1977, 37, 4, 481-495.

11. GAISNE E. - - Place de la chirurgie dans le traitement de la maladie de Hansen en Inde du Sud, chirurgie de la main en particulier, p. 250, Th&e de M~decine (Tours), 1984.

12. L A N G U I L L O N J. - - La 16pre. Acta leprol (Gen6ve), 1978, 71-72, 1- 168.

13. PALANDE D.D. - - A review of twenty-three operations of the ulnar nerve in leprous neuritis. J Bone Joint Surg, 1973, 55 A. 7, 1457-1464.

14. PALANDE D.D. - - Correction of paralytic claw finger in leprosy by capsulorrhaphy and pulley advancement. J Bone Joint Surg, 1976, 58A, 1, 59-66.

15. PALANDE D.D. - - Correction of intrinsic. Minus hands associated with reversal of the transverse metacarpal arch. J Bone Joint Surg, 1983, 65 A, 4, 514-521.

16. SUNDARAJ G.D., SELVAPANDIAN A.J. , MANI K. - - A compa- rative study of E.F.M.T. and sublimis transfer operations in the claw hand. lnt J Lepr, 1983, 51, 2, 197-202.

17. TUBIANA R. - - Le traitement de la griffe cubitale. Ann Chir Main, 1984, 3, 2, 173-187.

18. ZANCOLLI E.A. - - Functional and Surgical Anatomy of the Hand. 2dEd. Philadelphia. J.B. Lippincott Co, 1968. '