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Flexor Digitorum Superficialis to Flexor Digitorum Profundus (STP) Transfer, Adductor Release, and Z-Plasty for a Pediatric, Stroke-Induced Left Hand Spastic Contracture

Sudhir B. Rao, MD1; Mark N. Perlmutter, MS, MD, FICS, FAANOS2; Arya S. Rao3
1Big Rapids Orthopaedics
2Carolina Regional Orthopaedics
3Undergraduate Student, Deparment of Biological Sciences, Columbia University

Transcription

CHAPTER 1

So, this is a 12-year-old little girl who had a stroke. She's 15. 15, okay, roughly at about 12 to 13 years old, she had a stroke. And, she's asleep under anesthesia now, so her hand is rather supple. When she's awake, she has what's called a thumb-in-palm deformity where it's contracted and held in a position like this where she does not have the ability to straighten it- bring her thumb out of her hand. Likewise, the other digits of her hand- the index through the pinky are all contracted. So she has what's called a thumb-in-palm deformity, and her wrist is slightly flexed as well. So this is the posture that she stays in all the time when she's awake. So what we're gonna do today is lengthen the tendons here at the wrist, and there's 2 sets of tendons to every digit. The sublimis, or the superficial tendon, goes towards the proximal interphalangeal joint that I'm pointing to, and the profundus, or deep tendon, goes to the distal joint. So what we're gonna do is transfer these tendons that go to this tendon to this one at the level of the wrist, thereby lengthening them, and that functionally lengthens the deeper tendons, releases these more contracted sublimis tendons, and we'll do the same thing for the thumb, which you can see, even when she's under anesthesia, has a resting contracture at almost 90 degrees. And the thumb normally rests at about 20 degrees- 15 to 20 degrees. So, she is showing some of her contracture, which is much more pronounced when she's awake, and her brain is awake. First thing that we're gonna do is exsanguinate the hand. There's a blood pressure cuff or a tourniquet up on the arm. So, this ace wrap is going to gradually squeeze the blood down towards the elbow. The tourniquet is hiding under our sterile drapes. It's connected to tubing that has a pressure setting to 250 mmHg. Her highest pressure is probably around 100 mm. So, it's substantially higher than her blood pressure, which blocks blood flow from going into the arm.

CHAPTER 2

There's a Tri-County Hospital in my town that has tons of these. I do 2 of these a month. She's moving, my friend. Interesting, we gave her a healthy block as well. Let me just wait a second. I'm surprised she bled at all 250. I'll take it up a little bit too. 30, maybe. 30. She had really an excellent block. I'm surprised. Could we have- we can't give Lidocaine, but we can perhaps give more bupivacaine. If you don't mind. So what we're doing now is using a small electrical device- the company that manufactures it calls it a Bovie, and it cauterizes small little skin blood vessels. So we're injecting a little bit more numbing medicine now. Although we injected her before we even began the surgery, as soon as she was asleep. For some reason, she's responding with a little withdrawal reaction, so she's having some discomfort. You can see the injection spots where we gave her similar injections. This numbing medicine is bupivacaine. It takes a while to start working, which is why we injected it before the surgery. So, it takes about 10 to 15 minutes to kick in, and it's- we injected her approximately 20 minutes ago expecting it to work by now. This is the fascia. This is the most superficial fascia. In this region where the fat is, we'll find a median nerve that gives sensation to the thumb, index finger, long finger, and the thumb side of the ring finger. Seemingly some pressure in that wrist. This white tissue is fat that surrounds the nerve. The nerve is likely to be this structure right here. This is one of our superficial flexor tendons. Slide this down. Hook that right there. This retractor has dull points on them, so he can safely retract this nerve that's right under the retractor. I think that's the nerve. It may just be fat. Our goal first is to identify the nerve. The nerve is probably. Right over here. Right there. That's the nerve. Right there. Oh, is it? Oh, I see it now. You see it, right? Yeah. Underneath it is palmaris longus- just fat. So, I'm retracting all the superficial tendons here- underneath- this retractor. He's excising some of the fat. These are our deep flexor tendons that are visible now. This is the coating of the tendon. It's called a teno-, which is Latin for tendon, -synovium, which is a medical term describing the coating of a tendon that makes the lubricating fluid and protects the tendon. We're going to take more of that off to isolate the tendons. Again, I have the superficial, or sublimis tendons under my retractor. These are some of the deep tendons. If I wiggle the thumb, you can see the- tendon closer to Dr. Rao move. The nerves should be under… Okay, put your hand on that thumb, please. Let's take a look at that nerve one more time. So, what he was isolating was the profundus tendon, or the deep tendon, to the index, which should move the index fingertip joint, and if you could see it move there. Do you want to tag them for suturing as we go along? Yeah. So, with a marking pen, he's indicating the- a deep tendon. Hold that finger straight. You got it. He's going to put a tag suture in it, which we will then put a hemostat on and keep labeled. See if she has another hemostat, please, this one is terrible. Leave it long. Clamp a little short. I will, I just want get it some wrap around, so I can… So we tagged the profundus tendon to the index finger, now we're going to go through and try to find the one to the long finger. And I'm moving the long finger. We can see the tendons move. We're going to take out more synovium now to isolate it. I'm going to stretch it out as much as I can, so he can see the tendon as long as it possibly is. We'll continue this process of isolating the deep tendons, and we're gonna transect those as close towards her elbow- as we can. You can see it moving underneath of this hemostat. They're all joined here. Maybe we can keep them joined together. Yeah, I just want to make sure, we have the pinky one… I think it's joined to the… So, in this case, all of her tendons are… See what that is. That's probably her pinky. That's a lumbrical, no- It's her pinky. Okay. So that's her pinky digit. That's the sublimis. To the pinky. You want to hook that out of your way. It's just the sublimis. Mm hmm. So it looks like all of her deep tendons are essentially fibrosed together. And so, we're going to keep them together. We can probably hemostat all of them in one. Yeah, hemostat, please? Yeah, we can put all the sutures in 1 hemostat, perhaps. Yeah. I'll come obliquely to grab it better. So all the deep tendons are tagged together now. Again, unfortunately, because of her lack of independent finger motion over the last several years since her stroke, she has not- they have essentially glued themselves together. Now Dr. Rao's cleaning up the synovium off of the superficial tendons. This is the median nerve right here. Do you see the blood vessels in it? You want to click this retractor up, and we'll re-isolate it. I don't know if that's the median nerve, I'll check. I bet it is. I've never seen a tendon have that vascularity. I just want to make sure that's what it is. Yeah. So our nerve is protected under the retractor now. Everything else we'll see are superficial tendons. We'll clean off the synovium as our next step, and you can see this is part of the superficial muscle that's attaching and blending into the tendon. We'll isolate the tendons proximally. Hemostat? I'm sorry, distally, and so we cut the deep tendons here, we'll cut the superficial tendons here, and sew them together, and the additional length allows us… That's the middle- now, he's going to isolate out the index finger superficial tendon. That's the index finger right there, you can see it move. This is the- you have the long finger in your pickup. The ring and the pinky are together. No, the pinky is- no, no, the pinky is… Ring. And then, I'm not sure what that is. Probably an accessory to the pinky- or the pinky. Well the pinky we found right here, remember? That was the- well… I'm moving the pinky only right now. So, it looks like there's more than one. Where's your profun- superfil… I'm going to move the profundus to the pinky only. One of these is the FPL. Right there. That's the FPL. That's the flexor tendon to the thumb. Let me do a Z on that right now, so I can get that out of the way. Okay, get it done.

CHAPTER 3

So, there's only one- so what he's going to do is cut a Z lengthening in this, so he's gonna cut down the length and cut out the 2 separate ends, and then put end-to-end to make that tendon longer. He's going right down the middle of the- the flexor pollicis longis, which is the long flexor to the thumb. Pollicis being Latin for thumb. He'll angle 90 degrees at the end of there. Is it flexed or extended? It is- the thumb- hold on one second, let me get to the thumb. It is flexed now. Extend it. You can give it more length, maybe. So that's- I'm hyperextending the thumb as much as possible, which brings the tendon into his sight. Flex it. Okay, so that's the cut end of it. Now, I'm going to flex the thumb as much as possible, which delivers the tendon that used to be hidden up in his hand. A little more. And so now there's 2 halves, so if I straighten out the thumb, maximally, and bring the wrist back, there's sufficient overlap in those 2 segments to sew those together and functionally lengthen the thumb. The FiberWire is made out of a polyethylene-type material. It's made of the same Kevlar type material that they make bullet-proof vests out of. So it's very, very strong.

Okay, so he's holding the thumb in a functional position now. Not at full extension and not at full flexion. And he's doing a side-to-side repair of the lengthened flexor pollicis longus tendon. Do you want to wet that, please? This suture's so strong that often scissors won't cut it, and we use scalpels. Go ahead and flex the thumb now. Thank you. And he'll make this secure repair at multiple sites along the length of the split tendon. Let's stretch it a little bit. So that's our thumb flexor tendon that's now lengthened.

CHAPTER 4

Now we're going to isolate the superficialis tendons distally. Hemostat. I'm going to move that there, I'm going to move you, proximally. So you have the media nerve in your grip, so do not pull excessively. That should be the middle. Middle. Okay, what I'm going to do is start cutting them right now, so that way we don't have to worry about it. Right. So that's the superficial tendon to the middle. I'm going to flex that finger, so more of it's delivered into the wound. That's the middle. The ring is right next to it, there. We might be able to Pulvertaft this. I think so. Okay, so 2 down, let's do the pinky next. Let's do the pinky. That looks like the pinky. I think that's our superficial to the pinky. Yeah. Although we had something deeper earlier. Yeah, but sometimes there are accessories to it, but if this is… This is clearly the sublimous. That's the- definitively, yeah. He's going to take of the muscle that comes from the forearm off of the tendon, so we can have more length of tendon. And that's the superficial tendon to the pinky. This may be an acc- Yeah. It should be deep and in the middle. There it is right there. That's one. Let me just flex it, and see… It doesn't… If you pull on that, what happens, see, so if he pulls on this tendon here, you see how it's only bending at this joint. That's confirming it's not the profundus to that. So he's going to, again, take off sublimis muscle that's been attached to it. Remove some extra muscle. Confirming again that's the tendon. So we've got 4 tendons that we've cut. There should be a pinky one. everything else should be… Profundus. Hemostat.

CHAPTER 5

So, everything else I'm moving now… That's the index. Profundus. And this is everything else. Right, see how they all flex? So this is the- long finger through pinky finger are all glued together. Only the index finger is separate. So we cut this dital, and let's do a Pulvertaft on this. Mm hmm. I'm sure we can. So, ask her for a small hemostat. Mosquito. I'm going to bend these in for him. So if I flex all the fingers- the fingertips in particular… He's cutting through the index finger deep tendon. We'll set that off to the side. This might be index. No, the index is not that one, I don't think. Is it? Pull on it? Yeah, it is, you're right. So that's the superficial to the index and the deep to the index, and we're going to sew those together, which, since they were overlapping significantly, we're going to do this. It significantly increases the length of the tendon that will bend the end of her finger, which will pull her whole hand in. He put in a slit in there. I'm going to hold this Mark, go ahead and do the suture- she has. Suture, please? Adsons? I have… No, no- other. So, this is called a Pulvertaft repair, a classic repair. Hold the finger right there. You'll probably get a better grip with the Browns. So, you use the Browns. The Brown osteotome has small teeth and it will get a better grip. So he's going to pull those together. One is going through the other, and I'm going to put a suture through the split, through the tendon, and then back through the split again. And Dr. Rao's adjusting the tension that he wants. Which end do you want, this one? Yeah, you can switch it back. Bend the finger in more for me. I think we have to open up one more of this A-0 FiberWire. It's in the cabinet out there. That's the remaining… So this is the collection of all the profundus tendons, which are glued together. And these are the superficial tendons that we separated, and we will attach them together to this mass. So she won't be able to move them independently, but she couldn't do so beforehand. She will have her hand open to a functional position for hygiene. Flex those fingers, please. So by me bending the wrist, and the fingers will- well the fingers, I certainly am putting the tendons- at laxity, which let's him divide them en mass, collectively. And now, this is the collective mass of deep tendons. These are the collective mass- or individual superficial tendons, and we'll sew them in. If you separate them, you could do a Pulvertaft. We should be able to pass all of them together. Yeah. Hemostat? Hemostat? I've got one. Oh, you have one, okay. 3-0. Is that what you like? We can go a bit more distal, perhaps. Do what now? Let me- relax the tension a little bit more. Okay. The redo that you just saw was the- relax the tension more, so that we had less tension on the repair. I'm going to pass all the tendons through, that way- we have it as one mass. I like that idea. We should have one more tendon, where's the pinky? That was the pinky. We need a ring finger. Ring finger- that's the one. There it is, right there. I'm going to tag that- right about there, right there. Around the ring finger one. That's the middle finger. I'm going to mattress this. Yeah. The weave that we just did, called the Pulvertaft is infinitely stronger than an end-to-end repair. Much more durable. I got it. Suture. Want to finish that up? Yeah, I want to put more in. So we're gonna support those repairs with through and throughs- stitches through all of them, as much as we can. John, I'll have my chair back, please. Thank you. If you could flex all the fingers. Yeah. Since all the profundus tendons are kind of joined together in the distal forearm, we don't have to individually repair them together. If she in fact had dexterity in her motion between her fingers individually, we would repair them individually, but she lacks all hand function, and this is largely for personal hygiene, to clean her hand, so she doesn't have pain in her hand by maintaining it flexed. And she's at an age where image is important. And these will all, again, heal as one. See how now all her fingers are relaxed.

CHAPTER 6

So, remember, before the surgery, she had a 90 degree bend here while she was still anesthetized. Prior to her going to sleep, her thumb was tucked into this position. It will rest in this position now, outside of her hand. He hand is much more relaxed now. Before the surgery, she was in a bent position like this, and so when she's awake, now, she should have a posture with her hand like this, when she's oriented, and her brain is awake. So we have accomplished what our needs of the surgery were. If she had a wrist contracture at the same time, we would go over here and release or lengthen wrist contractures. Perhaps even take that tendon and transfer it to the back of the hand, which would make it a wrist extensor. But for this case, we're finished. We're going to close the skin in layers. The median nerve is right here. It's been protected the whole time. You can see the small blood vessels in it, and our surgery's done for the day. We're going to close the skin. And that was the easiest part of the surgery we're going to do today. The next part that we're going to do is release a contracture, an adduction contracture. So, do you have the suture?

CHAPTER 7

Let me give- surrender instruments back, and then I'll continue explaining. Thank you. She has an adduction contracture to her hand, so we're going to release the adductor muscle, perhaps- perhaps the first dorsal interosseous muscle to allow her- to prevent the part of her deformity, which brought her thumb in like this. We relieved the flexion, but now we're going to relieve the adduction. So we're going to open up this web space. That may require us taking a skin flap from the back here and moving it down. That's not determined yet, but we'll see. Is that a 3-0? Do you have enough to finish it? It's a 4-0. Yeah. So he's closing the subcutaneous layer now. In a moment, he'll start at the end and run a continuous subcutaneous suture, and make it as cosmetic as possible. Steri-Strips? So one this to mention probably to everybody is that although the hospital we work at serves- is a resource poor community and a resource-compromised hospital, the talent here and the educational level is not poor. The techs are wonderful, the nurses are wonderful. the doctors, outstanding. The medical student helping us in this case sewed for the first time last night and did his- way better than I did my first hundred times sewing, so- the skill level's high, which is why we're here, so we can both learn from each other. Cut it long right now, we can cut that short later.

CHAPTER 8

So, do you want to scrub in? No. Okay, so… So, we're doing an adductor release now. We did a sublimis to profundus lengthening, simple.

CHAPTER 9

We can go up a little on the Bovie. Thank you. So, as you can see, I've taken an incision that looks like a Z, and the reason for that is… Retract this, please. When this is all done, the skin flaps will be transposed, and that will lead to a deepening of the web space, which is what we want. So, it's a simple rearrangement of the skin. So, it's a Z-cut into the tendon, and we will trade places with the skin, functionally lengthening the direction of the contracture. So, change it from a contracture between the thumb and index finger to a contracture- to a non-contracture with the tension lines now going this way instead of longitudinally, which will allow her to open up her thumb more. He's looking carefully for the neurvovascular bundles. Sometimes there are superficial veins that we encounter. Do we have a deeper retractor? I can use the other end whenever you want me to. And so there's a muscle that lives between- the metacarpal bones in the hand, here, and the first metacarpal. And he's going to take the attachment of that adductor muscle, which adducts the thumb inwards and take it off of the side of the first metacarpal.

CHAPTER 10

I might just use a Bovie and divide it. So he's going to use the electric knife to divide the muscle. At the same time, it coagulates any bleeders- you're touching the metal a little bit over here. And once that adductor- A-D-D-U-C-T-O-R muscle is released, there will be less pull when she's awake to pull the thumb in. Will she need a night splint? She will need a splint. Every one of these… For all the fingers, or just for the thumb? For the thumb- to bring the thumb out and to hold the fingers in extension. I'm going to release the first dorsal interosseous. Okay. And, we should be…

CHAPTER 11

So now he's making a dissection down further into the top of the- index finger. He's going to identify what's called the first dorsal interosseous muscle. It is a muscle that takes the index finger and moves it in this direction. My first dorsal interosseous is working right now. By releasing that, there's less pull into that first web space. I think we'll go back to the old retractor. Okay. It's not that tight, we may not need to release that. So he's palpating the muscles in the thumb right now to make sure that they're loose enough to not require release or require further release of that first dorsal interosseous. The adductor muscle's already released. The adductor has a dual origin from the first and second metatarsal heads, and I'm just trying to free up the- attachment to the first metatarsal. Way down there. So that's the release down there. Let's have that big retractor. There's a little vein that's bleeding, and we're just gonna find that and stop its bleeding. All right, let's close- with some 3-0 3-0 Monocryl. A lot looser. Yeah, she's a lot looser.

CHAPTER 12

So, let's show the skin where it was originally. This is how it was. And you can see how contracted she is there. Now we're going flip the graft- the 2 corners over, and see how much wider I can open up the digits. From- it's doubled its ability. Let's do it again. So there's- and this is a simple Z-plasty. You can, this is a 2-tailed Z-plasty. We could do a 4-tailed, which would give us even more motion, but this is satisfactory, particularly if it's a non-functional hand. So, again, that's how she came to us, and that's how much we're going to give her. A tremendous increase. So, she has a full, you know, 60-70 degrees, and we want to just not- she hyperextends here, so we want to splint her not into hyperextension, but neutral in that position. Yeah. And I'm just going to take a standard suture. Can I have a soaking sponge, please? These 3-0's take a month to dissolve. You can cut them out in 2 or 3 weeks. Can we ask like 10 minutes, please? You can start opening dressings. Some splints too, plaster splints. These are dissolvable sutures that we're using. Dr. Rao doesn't have a microphone on, so I'll repeat what he had sharply pointed out. This child is growing, and so, we did our best guess in over-lengthening her now, compensating for that. But she can have a certain degree, if not a complete recurrence to where she was before, and this surgery may have to be redone once she reaches skeletal maturity. Hopefully, we lengthened her enough where that won't be necessary. We're using a running mattress suture now. The mattress suture itself, the formal name of it, will grab more tissue. It is stronger than just a regular non-over and over and over suture. Everts the edges better, better healing, nicer looking scar. I think she'll be happy with this. I think she'll be very happy with this. Have they opened our dressings? Yeah. I wish we had these Steri-Strips. They're much better. The woven pattern just makes them stronger. There you go.

CHAPTER 13

What you just witnessed was a completion of a case of a spastic contracture of a hand in a child who several years ago had a stroke and resulted in left plasticity, where the thumb was, before the surgery, contracted in the center of her hand, and her lesser digits, the index through the pinky, were contracted down like this, and this was her resting posture all the time while she was awake. She also had a bit of a wrist contracture because of that. So the goal today was to open up the fingers, and open up the thumb, so that while she's at rest, she can get hygiene in her hand and less pain from just maintaining the thumb. Because she had a stroke, doesn't mean she doesn't feel pain, and if you just hold your thumbs tight like this, you'll have significant pain over time. Potentially even some numbness in your hand from holding it bent. So, to eliminate that, we took the tendons in her forearm, which go to these fingers and to her thumb, and we lengthened them. Basically, there's 2 sets of tendons, deeper ones and superficial ones. We cut the superficial ones proximally at my fingertips, and the distal ones- the deeper ones distal where my fingertips are, and we lengthened them by bringing them end-to-end, and that made these fingers functionally loner, and now, she has pretty similar to a resting hand posture. Then, we deepened the web space with a Z-contracture, and you'll see the incision makes the letter Z, just like what we did here, and then, we rearranged the skin so that the tension lines go between- that were between here, and not letting her open up her first metacarpal to second, they weren't able to open up, so we took the tension lines that were shaped like this and then moved them like this. So now it opens up like an accordion would open up. And so now her thumb opens up as much as mine does, and there's no contracture here. You'll see in the video that even when she was asleep, she had a 90 degree bend to this joint, and these were bent in like this. Now, she has a very normal looking hand, and hopefully, she'll maintain that through development as she continues to grow.