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• W2109504516 abstract "We believe that the article by Ratner et al1Ratner J.A. Peljovich A. Kozin S.H. Update on tendon transfers for peripheral nerve injuries.J Hand Surg. 2010; 35A: 1371-1381Google Scholar does not fully reflect current biomechanical understanding of ulnar palsy and how the functional defects of an ulnar palsy should and could be addressed surgically. The primary joint stabilizers/flexors of the metacarpophalangeal joints are the interossei, of which there are 2 for each finger as opposed to only 1 lumbrical. The strength of the lumbricals is only a fraction of that of the interossei.2Brand P.W. Hollister A.M. Clinical mechanics of the hand. 3rd ed. Mosby, St. Louis1999Google Scholar There may be initial clawing of only the ring and little fingers in a recent palsy, but latent clawing will usually already be present in the index and middle fingers.3Brandsma J.W. Schwarz R. Giurintano D.J. A review of the biomechanics of intrinsic replacement in ulnar palsy.J Hand Surg. 2010; 35B: 94-102Google Scholar Only with the presence of a Martin Gruber anastomosis, with radially innervated interossei, could there be sufficient flexion moment in these 2 fingers. In such a rare case, the index or middle finger, or both, could be excluded in a tendon transfer. In our experience of a few thousand patients with ulnar palsy, the index or middle fingers, or both, have only been excluded 2 to 3 times (W.B., 30 years' physical therapy in leprosy experience and D.S., 12 years' leprosy surgery experience). The interossei are the anticlawing muscles and the function of these muscles needs to be replaced. The fact that insertion of tendon slips either in the pulley (Zancolli Lasso) or directly into interosseus tendons or bone restores normal sequence of closing of the fingers, and that clawing disappears, makes the point. Schreuders and Stam4Schreuders T.A.R. Stam H.J. Strength measurements of the lumbrical muscles.J Hand Ther. 1996; 9: 303-305Abstract Full Text PDF PubMed Scopus (22) Google Scholar showed in an innovative way that there is a considerable mismatch in strength of the interossei and lumbricals, and that the index and middle fingers in an ulnar palsy retain only about 12% of the original flexion moment. These figures were based on patients with an early ulnar palsy. Given time, most patients will develop overt 4-finger clawing. Both authors hope that on the basis of this review article, it will not become accepted common practice (again) to do a 2-tail tendon transfer only. Figures 20 and 21 in the article are misleading in this regard. Strength of the thumb can be greatly affected in an ulnar palsy. Thumb adduction and index abduction are powered by the ulnar nerve. Whether thumb strength needs to be addressed surgically should be determined by the owner. Does the patient experience loss? This will most likely depend on such factors as age, hand dominance, and functional demands. In our experience, thumb/index finger adduction loss rarely needs to be addressed. More research is needed to determine which component in experienced loss of thumb strength would then need to be addressed: abduction of the index, adduction of the thumb, or both. We are pleased to note that the authors make reference to a recent article by Rath et al,5Rath S. Selles R.W. Schreuders T.A. Stam H.J. Hovius S.E. Randomized clinical trial comparing immediate active motion with immobilization following tendon transfer for claw deformity.J Hand Surg. 2009; 34A: 488-494Google Scholar advocating early active motion after tendon transfers. I have always wondered why early active motion is practiced with delicate end-to-end sutures in tendon repairs and not with secure interwoven tendons in tendon transfers, which I have been advocating for the past 10 years. Update on Tendon Transfers for Peripheral Nerve InjuriesJournal of Hand SurgeryVol. 35Issue 8PreviewTendon transfer surgery to restore fundamental wrist and hand function is made possible by the redundancy that exists among the actions of our upper-extremity musculature. Potential donors for transfer are those muscles with adequate power to motor the recipient tendon, similar tendon excursion to the recipient, and function in phase with the recipient. Resolution of wound healing, union of fractures, and mobilization of stiff joints are prerequisites for a functioning tendon transfer. Injuries to the radial, median, and ulnar nerves occur above (high nerve injury) and below the elbow (low nerve injury). Full-Text PDF In ReplyJournal of Hand SurgeryVol. 36Issue 4PreviewWe thank Dr. Brandsma not only for his comments with regard to our recent publication, but also for his contributions to our understanding of the biomechanics of the hand. We agree that the primary metacarpophalangeal joint flexors are the ulnar innervated interossei and that the lumbricales provide a more modest contribution. As was asserted in his letter, the surgical plan of care must be tailored to meet the patients' needs. Certainly those patients presenting with clawing in all 4 digits will require an anticlawing procedure to be performed that addresses each digit. Full-Text PDF" @default.
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• W2109504516 title "Update on Tendon Transfers for Peripheral Nerve Injuries" @default.
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