Extensor Indicis Proprius Tendon Research Articles

Modified Extensor Indicis Proprius Opponensplasty.

Extensor indicis proprius (EIP) opponensplasty is one of the commonly used techniques to restore thumb abduction and opposition in patients with thenar muscle dysfunction from various causes of median nerve palsy. However, its subcutaneous route around the distal ulna may not represent a straight line of pull, and part of the extensor hood sometimes has to be harvested along with the EIP tendon to gain adequate length to reach the insertion. The purpose of the study is to present the alternative method of EIP opponensplasty and report the clinical outcomes. The modified EIP opponensplasty was performed on 16 patients with severe carpal tunnel syndrome. At the final follow-up examination, all patients were able to regain their desired level of activities. The Kapandji score, abduction angle, and the disabilities of the arm, shoulder, and hand score improved in all patients. There were no complications related to harvesting the EIP tendon. Two patients developed finger stiffness, which improved after rehabilitation. This technique is safe and effective for restoring thumb function and can solve the insufficient tendon length problem of the original EIP opponensplasty.

Opposition Transfer Using the Extensor Indicis Muscle and the Extensor Pollicis Brevis Tendon

PurposeThis study aimed to introduce a novel technique utilizing the extensor pollicis brevis and extensor indicis proprius tendons as power sources for thumb opposition reconstruction in cases of severe carpal tunnel syndrome (CTS) associated with thenar muscle atrophy. Further, the efficacy of this novel method and the traditional Camitz technique was compared. MethodsPatients with severe CTS and thumb opposition dysfunction who underwent surgery using the novel technique (n = 7, 9 surgeries) or the Camitz technique (n = 8, 8 surgeries) were included in the analysis. The pre- and postoperative palmar abduction angle, thumb–ring finger opposition (T–R) angle, and Kapandji score were assessed. The repeated measures ANOVA and the Mann–Whitney U test were used for statistical analysis. ResultsThe novel technique was associated with a significant postoperative improvement in palmar abduction angle, T–R angle, and Kapandji score. In particular, the T–R angle of patients who underwent surgery using this technique was superior to that of patients who underwent surgery using the Camitz technique. Therefore, the novel technique was highly effective in improving thumb pronation. ConclusionThe novel technique using the extensor pollicis brevis and extensor indicis proprius tendons is promising for thumb opposition reconstruction in severe CTS cases. Unlike the traditional Camitz technique, this approach promotes stable thumb opposition function without requiring a pulley, thereby yielding satisfactory outcomes. Nevertheless, further studies with a larger sample size should be conducted to validate these findings.

Variations in the extensor indicis proprius muscle in the Burmese population: implications for hand reconstructive surgery

BackgroundThe use of extensor indicis proprius (EIP) muscle tendon for tendon grafting and transplantation in the management of hand injuries is common. Anatomical variations of the EIP tendons have been reported with variable prevalence and presentation in different populations worldwide. Knowledge of possible variation patterns is crucial in reconstructive surgery. The current study aims to describe the prevalence of anatomical variations of the EIP in the Burmese population. MethodsA total of 50 cadavers (39 males, and 11 females) were dissected. Both upper limbs of each cadaver were observed. The presence of the EIP, the number of tendons, the origin and insertion of the muscle and its relation with the extensor digitorum communis (EDC) were recorded and variations reported. ResultsOf the 100 limbs studied in the 50 cadavers, only 1/100 limb was reported to have an absent EIP muscle and tendon. Of the remaining 99/100 limbs examined, one of them consists of a double tendon, that is, EIP and extensor indicis et medii communis (EIMC) were inserted separately onto the index finger and middle finger respectively on the dorsum of the left hand. Further to this, there is one case in which an extra muscle belly was observed in the EIP tendon, this muscle is commonly known as the extensor digitorum brevis manus muscle. All the EIP variations were observed in the male cadavers only. ConclusionOf the 50 cadavers studied, 3/100 limbs exhibited EIP variations in the current studied population. Population-specific studies on these variations may aid in a better understanding of the different anatomical patterns of the muscles in the dorsum of the hand. This may lead to improved diagnosis and surgical management of injuries to the dorsum of the hand and for the use of the EIP tendon in surgical grafts and transplantations.

The Extensor Indicis Proprius Transposition for the Ulnar Collateral Ligament Stabilization in Thumb Hypoplasia Grades II-IIIa.

Congenital upper extremity deformities are rare, the reported incidence is from 0.15% to 0.2%. The thumb is very important for a hand's functionality, as it provides up to 50% of its total performance. Proper pinch grip formation at the age of 12 to 16 months is part of normal development; however, no functional development can affect a child's psychoemotional development. Well-described techniques such as third or fourth superficial flexor transposition can be found in the literature. There is a paucity of studies on using the extensor indicis proprius (EIP) transposition for stabilization of the ulnar collateral ligament for the first metacarpophalangeal joint (MCPJ). Techniques for the usage of EIP tendon for the reconstruction of absent extensor pollicis longus tendon are more commonly practiced as they create abduction and extension for the thumb hypoplasia grade II-IIIa. We performed EIP transposition with subperiosteally fixation for the ulnar collateral ligament stabilization for thumb hypoplasia patients with a mean age of 38 months (11 to 128) and grade II (n=9), grade IIIa (n=4), and grade IIIb (n=1). Long-term follow-up (2 to 10y) for the esthetical and functional study was performed. Patients and parents are satisfied with functional and esthetic outcomes. We believe that the EIP tendon transposition can be an alternative method for thumb hypoplasia patients grade II-IIIa reconstruction.

Bilateral Digital Extensor Hypoplasia Correction: A Case Report and Systematic Review.

Digital extensor hypoplasia (DEH) is a rare malformation that presents with loss of active finger extension at the metacarpophalangeal (MCP) joints. Descriptions of optimal treatment and outcomes in this population are sparse. We describe successful operative treatment of a child with DEH involving the extensor digitorum communis, extensor digiti minimi, and the extensor indicis proprius tendons. The 5-year-old male patient was referred for severe limitation on bilateral finger extension since birth. He had been previously diagnosed with arthrogryposis and managed conservatively. Due to lack of improvement, magnetic resonance imaging was done evidencing hypoplasia/aplasia of the extensor tendons. The patient underwent successful tendon transfers using extensor carpi radialis longus to the common extensor tendons, and one hand required an additional tenolysis procedure. 2 years postoperatively, his MCP position and finger extension are markedly improved, and he is able to grip objects without limitation or difficulty. The patient returned to full activity without restriction.

EARLY ACTIVE MOBILIZATION AFTER RECONSTRUCTION OF RUPTURED FINGER EXTENSOR TENDONS AT THE WRIST JOINT

Background: Subcutaneous spontaneous ruptures of the finger extensor tendons at the wrist frequently occur. This study aims to evaluate the outcomes of patients with extensor tendon ruptures treated by our operative methods and postoperative early active mobilization. Methods: A total of 38 patients with 68 extensor tendon ruptures were included in this study. In the reconstruction of extensor tendon ruptures, tendon transfers (extensor indicis proprius (EIP) tendon transfer and/or interlacing end-to-side suture) and/or free tendon bridge graftings were performed. Immediately after operation in all patients, early active mobilization began by wearing a specially designed bandage or splint. Results: There was no reoccurrence of re-rupture of a tendon post surgery. A patient satisfaction survey revealed that 29 patients rated their results as “excellent” and 9 were “good.” Postoperatively, the active range of motion of the finger metacarpophalangeal (MP) joint averaged +3∘(range:- 14[Formula: see text]+20∘) in extension and 69∘(range: 60–80∘) in flexion. Conclusions: We treated finger extensor tendon ruptures by tendon transfer (EIP tendon transfer to the ruptured extensor tendon and/or interlacing end-to-side suture) and/or bridge tendon grafting. We employed early active mobilization with patients wearing a specially designed bandage or splint immediately after reconstructing surgery. There was no case with re-rupture postoperatively. Our operative techniques and postoperative physiotherapy as early active mobilization in this study led to excellent results after finger extensor tendon ruptures.

Anatomic relationship of extensor indicis propius and extensor digitorum communis: Implications for tendon transfer.

The extensor indicis proprius (EIP) tendon is a frequently used donor for a variety of tendon transfers, most commonly for reconstruction of the extensor pollicis longus (EPL). EIP is known to have frequent anatomic variants including split tendons and variations in tendon arrangement. To characterize the anatomy of the EIP at the level of the extensor retinaculum, where tendon harvest is often performed, and share our preferred technique for EIP to EPL transfer. Twenty-nine fresh-frozen cadaveric forearms without history of forearm or hand injury or surgery were dissected. Tendon circumference and relationship of the EIP and extensor digitorum communis to the index (EDCI) at the metacarpophalangeal (MCP) joint and the distal extensor retinaculum were recorded. Distance from the distal extensor retinaculum to the EIP myotendinous junction was measured. EIP was ulnar to the EDCI in 96.5% of specimens (28/29) at the distal edge of the extensor retinaculum. In the remaining specimen, EIP was volar to EDCI. Tendon circumference at the distal extensor retinaculum averaged (9.3 mm ± 1.7 mm) for EDCI and 11.1 mm (± 2.7 mm) for EIP (P = 0.0010). The tendon circumference at the index MCP joint averaged 11.0 mm (± 1.7 mm) for EDCI and 10.6 mm (± 2.1 mm) for EIP (P = 0.33). EIP had a greater circumference in 76% (22/29) of specimens at the distal extensor retinaculum whereas EIP had a greater circumference in only 31% (9/29) of specimens at the MCP joint. The EIP tendon is frequently ulnar to and greater in circumference than the EDCI at the distal extensor retinaculum, which can be taken into consideration for tendon transfers involving EIP.

Extensor Pollicis Brevis Transfer to Extensor Pollicis Longus for Delay Spontaneous Ruptures: A Case Series and Functional Outcomes at One Year Follow Up

Introduction: When Extensor Pollicis Longus (EPL) spontaneously ruptures, two major risk factors are present: rheumatoid arthritis and distal radius fracture. The gold standard treatment is the transfer of Extensor Indicis Proprius (EIP) to restore the functionality of the thumb. Utilization of Extensor Pollicis Brevis (EPB) was used initially, in patients with rheumatoid arthritis. The aim of this study is to ascertain if the EPB transfer technique is the most competent and efficient surgical method for rupture of EPL, analyzing functional outcomes, complications and final patient`s satisfaction. Material & Methods: Eighteen patients (14 female and 4 men) with an average age of 43 years old were introduced in this study. All cases reported no history of trauma. From the derived clinical history, 8 cases suffered from rheumatoid arthritis, 4 patients reported initial corticosteroid injection in radial side of wrist, one case was revised surgery and in rest cases the etiology was unknown. Radiographic investigation was normal in all cases, while magnetic resonance studies detect EPL ruptures. All patients were operated in a mean time of 3, 4 weeks (ranging from 2 to 6 weeks) after the diagnosis and in all cases the tendon applied was the EPB. After surgery all patients followed the same rehabilitation program. Results: The mean follow-up was 20,5 months (range from 15 months to 36 months). None of patients missed the last re-examination. Results were evaluated according to complications, range of motion of the thumb (elevation deficit, opposition distance, difference flexion-extension deficit), Quick Dash Score, EQ-5D-5L, and satisfaction of the patients. No intra-or extra-operative complications or re-ruptures were noted. At the final follow up the mean range of elevation deficit was0,7(from 0,5 to 1,5), opposition distance was 0,8(range from 0,5 to 1,8) and difference flexion-extension deficit was 1,6˚ (from 0˚ to 5˚). The Quick Dash score was 1.38 (varied from 0.0- 6.8) and the EQ-5D-5L was 92. Finally, the majority of patients appeared to be very satisfied (66,7%) or satisfied (27,8%). Conclusion: Extensor Pollicis Longus tendon spontaneously ruptures due to specific factors. Restore of thumb functionality is achieved only with tendon transfer technique and the use of Extensor Indicis Proprius tendon has been described as the gold standard. Extensor Pollicis Brevis tendon transfer is an alternative technique with significant advantages which preserves good functionality of the thumb and excellent patient satisfaction.

Opponensplasty using the extensor indicis proprius tendon for severe carpal tunnel syndrome in 40 patients.

The aim of this study was to assess the clinical results after extensor indicis proprius opponensplasty in patients with carpal tunnel syndrome and severe thenar muscle atrophy. Forty patients who underwent this procedure during open carpal tunnel releases. The mean follow-up period was 17 months (range 10 to 36). Kapandji scores significantly improved from 5.5 before surgery to 9.6 at final follow-up. Thumb pronation angle also significantly improved from 111° before surgery to 149°. Side and pulp pinch strength significantly improved postoperatively, as well as DASH scores at final follow-up. In conclusion, the extensor indicis proprius tendon transfer technique represents a reliable opponensplasty procedure to achieve consistent results in patients with severe carpal tunnel syndrome.Level of evidence: IV.

Tendon repair with intercalated partial extensor carpi radialis longus tendon graft for chronic extensor pollicis longus tendon rupture.

The main treatment choices for chronic extensor pollicis longus (EPL) tendon rupture consists of tendon transfer and tendon repair with tendon graft. Tendon transfer with extensor indicis proprius (EIP) is currently considered the gold standard treatment which yields predictable and satisfactory results, but potentially compromises the strength of independent extension of the index finger. We propose our method of using a partial extensor carpi radialis longus (ECRL) tendon graft to repair chronic EPL tendon tears. The distal stump of the EPL was located through an incision at the basal joint level. The proximal stump was located through a curved incision at the dorsoradial wrist where the partial ECRL tendon graft was harvested. The tendon graft was subcutaneously transposed, sutured at both ends, and tensioned at full thumb extension with a neutral wrist position. From March 2016 to June 2019, 23 patients (mean age: 59.7 years; mean follow-up: 29.6 months) were retrospectively reviewed. All the patients were followed for a minimum of 12 months. The final total active motion was 93.2% of the contralateral thumb. The mean Quick Disabilities of the Arm, Shoulder and Hand score was 6.0. There was one complication possibly due to poor EPL muscle quality, and the patient was subsequently treated with EIP tendon transfer. Our study showed that using a partial ECRL tendon graft to repair chronic EPL tendon rupture results in satisfactory functional outcomes. The advantages of this method include preservation of EIP function and using the same incision for graft harvesting and tendon repair. This method can be considered an alternative to EIP tendon transfer in patients with high demand for their index finger function.

Secondary reconstruction in zones V-VII in extensor tendon injuries

Due to various functional impairments after primary extensor tendon repair or lack of treatment, secondary tendon reconstruction is often required. Anatomical considerations, the outcome of the injury and its treatment and the patients' individual demands on the function of the hand affect the choice of the procedure. Description of techniques for secondary reconstruction after extensor tendon injury in zonesV-VII. Overview of surgical treatment concepts for secondary extensor tendon repair in zonesV-VII of the extensor tendons of the fingers and thumb. Discussion of alternative surgical techniques for secondary extensor tendon repair. While techniques for reconstruction of sagittal band injuries are predominant in zoneV, side-to-side tendon transfers, the use of tendon grafts and end-to-end tendon transfers prevail in zonesVI-VII. The reconstruction of the extensor pollicis longus tendon function using transfer of the extensor indicis proprius tendon is the standard procedure. For secondary repair of an extensor tendon function, anatomical features and functional interaction of the extrinsic and intrinsic hand musculature need to be considered depending on the zone affected.

Traumatic index extensor tendon attenuation mimicking closed tendon rupture: two case reports

BackgroundWhile some traumatic closed index extensor tendon ruptures at the musclotendinous junction have been previously reported, closed index extensor tendon pseudorupture due to intertendinous attenuation is exceedingly rare with only one case report of a gymnastics-related sports injury in the English literature. Herein, we report two non-sports injury related cases of traumatic index extensor tendon attenuation mimicking closed tendon rupture, including the pathological findings and intraoperative video of the attenuated extensor indicis proprius tendon.Case presentationA 28-year-old man and a 30-year-old man caught their hands in a high-speed drill and lathe, respectively, which caused a sudden forced flexion of their wrists. They could not actively extend the metacarpophalangeal joints of their index fingers. Intraoperatively, although the extensor indicis proprius and index extensor digitorum communes tendons were in continuity without ruptures, both tendons were attenuated and stretched. The attenuated index extensor tendons were reconstructed either with shortening by plication or step-cut when the tendon damage was less severe or, in severely attenuated tendons, with tendon grafting (ipsilateral palmaris longus) or tendon transfer. Six months after the operation, the active extension of the index metacarpophalangeal joints had recovered well.ConclusionsTwo cases of traumatic index extensor tendon attenuation were treated successfully by shortening the attenuated tendon in combination with tendon graft or transfer. We recommend WALANT (wide-awake local anesthesia and no tourniquet) in the reconstruction surgery of index extensor tendon attenuation to determine the appropriate amount of tendon shortening or optimal tension for tendon grafting or transfer. Intraoperative voluntary finger movement is essential, as it is otherwise difficult to judge the stretch length of intratendinous elongation and extent of traumatic intramuscular damage affecting tendon excursion.

Reconstruction strategies after rupture of the extensor pollicis longus tendon: A systematic review

Ruptures of the extensor pollicis longus (EPL) tendon result in a major loss of function. The most practiced reconstruction surgery appears to be extensor indicis proprius (EIP) transfer, which is contraindicated in certain cases. The objective of this review was to present the various reconstruction methods for the EPL tendon. A systematic review was conducted of the literature from 2010 to 2020 on strategies for reconstructing the EPL tendon. A search of the PubMed database was done using the following keywords: ‘extensor’, ‘pollicis’, ‘longus’, and ‘thumb’. Data analyzed were the type of study, the number of patients, surgery, follow-up, and results. Of the 142 articles selected from PubMed, only 18 (12.7%) were included in the analysis. Follow-up ranged from 6 months to 6 years, with an average of 28 months, and the total number of patients was 515. Numerous strategies exist for reconstruction following rupture of the EPL tendon. The preferred modality seems to be a transfer of the EIP tendon with intraoperative testing of applied tension with the interphalangeal joint in extension, hand flat, forearm in pronation, and neutral wrist position. When the EIP is not available, other transfers should be considered if the patient has significant tendon attrition, or a graft should be considered if an isolated defect is present.

A Simple and Quick Tendon Transfer Technique to Restore Thumb Extension.

Abstract Extensor pollicis longus (EPL), the long extensor tendon for the thumb, is one of the commonest tendon to rupture and require treatment. In case of closed rupture of EPL, direct repair is usually not possible, requiring tendon reconstruction to restore function. Traditionally, extensor indicis proprius (EIP) tendon is transferred under general or regional anaesthesia through two (or more) incisions. The author proposes and demonstrates that it is possible to carry out this transfer through one short incision under local anaesthesia with good outcome and minimal complications.

Functional evaluation of early tendon transfer for thumb opposition in median nerve palsy

BackgroundThere is paucity of literature on early tendon transfer in surgical rehabilitation of hands with median nerve injuries. Since the single most important functional deficit in median nerve palsy is the loss of thumb opposition, we evaluated the results of early tendon transfer in restoration of thumb opposition. MethodsThis prospective study involved 10 cases of isolated median nerve paralysis (axonotmesis or neurotmesis) that underwent early tendon transfer for restoration of thumb opposition. A pre- and post-operative evaluation in terms of power and precision grip strength and range of opposition of thumb was done. Median nerve exploration was performed in 4 cases and was supplemented by a tendon transfer for thumb opposition. The extensor indicis proprius (EIP) opponensplasty was performed in nine out of ten cases. In one case where the patient had scarring over the EIP tendon, palmaris longus (PL) opponensplasty was performed. ResultsThe median age at injury was 29 years (range; 8 years–57 years). Minimum period of follow-up was 6 months. Six patients who underwent EIP transfer had excellent opposition while 3 had good opposition. The patient, in whom PL opponensplasty was done, had an excellent opposition. The median time for return to work was 2.75 months.There was significant improvement in the power grip and all three types of precision grip at 6 months follow-up. The percentage deficit in the affected hand compared to the normal hand was significantly reduced. There was no case of tendon pull out in our study, nor did any of our patients have an extensor lag following EIP transfer. ConclusionEarly tendon transfer has a unique role in the management of median nerve palsy hand and we suggest this procedure should be considered in both high and low lesions.

Prevalence of the extensor digitorum, extensor digiti minimi and extensor indicis tendons and their variations

We aimed to investigate tendon variations of the extensor digitorum (ED), extensor digiti minimi (EDM), and extensor indicis proprius (EIP) muscles. Our study was performed on 43 fetal cadavers (86 extremities), aged between 17 and 40 weeks of gestation. The number of ED tendons varied from three to six, proximal to the extensor retinaculum (ER), and from three to eight, distal to the ER. The ED most often had four tendons, both proximally and distally from the ER. The ED tendons of the fourth finger were observed to be most frequently duplicated. The most common juncturae tendinum (JT) was type 1 in the second intermetacarpal space (IMCS), type 2 in the third IMCS, and type 3r in the fourth IMCS according to von Schroeder classification. The number of EIP and EDM tendons varied from one to two and from one to five, respectively. The EIP double tendons inserted both into the ulnar and palmar sides of the extensor digitorum of the second finger, which had not been reported in the literature. In our study, 7% of hands had variant muscles. In 4.7% of hands, the extensor indicis et medii communis was observed, while the extensor medii proprius and the extensor digitorum brevis manus were observed in 1.2% and 1.2% of hands, respectively. Knowing the prevalence of the ED, EDM and EIP tendons and their variations in the fetal period should help to treat partial loss of hand function or injury after birth and to correct congenital hand deformities.

Reconstruction de la pince latérale dans la paralysie isolée du 1er interosseux dorsal – une nouvelle technique chirurgicale

Lack of function of the first interosseous muscle (FDI) might be responsible for insufficient stabilization of the index finger during lateral pinch, and may induce disability in hand function. The first cause of FDI palsy is ulnar nerve palsy. We describe a new tendon transfer to reanimate the FDI muscle, using the extensor indicis proprius tendon. The tendon is sectioned at its distal insertion and rerouted in the first extensor tendon compartment. We report one case of isolated first interosseous muscle palsy secondary to direct trauma. Preoperatively, the patient complained of a severe lack of strength during key pinch with an ulnarly deviated index finger. Thirty months postoperatively, the patient recovered active abduction of the index finger and lateral pinch was measured at 5.5kg (54 N). Compared to the original Bunnell transfer our technique restores the native moment arm of the FDI muscle and does not require a tendon graft.

Reconstruction of lateral pinch in an isolated paralysis of the first dorsal interosseous muscle – A new surgical technique

Lack of function of the first interosseous muscle (FDI) might be responsible for insufficient stabilisation of the index finger during lateral pinch, and may induce disability in hand function. The first cause of FDI palsy is ulnar nerve palsy. We describe a new tendon transfer to reanimate the FDI muscle, using the extensor indicis proprius tendon. The tendon is sectioned at its distal insertion and rerouted in the first extensor tendon compartment. We report one case of isolated first interosseous muscle palsy secondary to direct trauma. Preoperatively, the patient complained of a severe lack of strength during key pinch with an ulnarly deviated index finger. Thirty months postoperatively, the patient recovered active abduction of the index finger and lateral pinch was measured at 5.5kg (54N). Compared to the original Bunnell transfer our technique restores the native moment arm of the FDI muscle and does not require a tendon graft.

Extensor Pollicis Longus Tendon Rupture after Non-Displaced Extra-Articular Distal Radius Fracture: A Case Report

Background: Spontaneous tendon rupture of hand is not frequent. These ruptures can occur after a fracture. Aim: We report a case of spontaneous rupture of extensor pollicis longus tendon, and describe the treatment. Case presentation: We report the case of a 63-year-old woman who had extensor pollicis longus tendon rupture after non-displaced extra-articular distal radius fracture, treated by wrist circular cast immobilization. Extensor indicis proprius tendon transfer was performed, with an excellent functional result. Conclusion: Extensor pollicis longus tendon rupture can occur after non-displaced extra-articular distal radius fracture. Its treatment by tendon transfer helps to restore function of hand.

Giant cell tumor of tendon sheath in the wrist that damaged the extensor indicis proprius tendon: a case report and literature review

BackgroundGiant cell tumor of the tendon sheath (GCTTS) is a benign soft tissue (synovial membrane) tumor that rarely involves the hands or wrists. And Tendon impairment caused by GCTTS is extremely rare.Case presentationHere, we reported a case of a 60-year-old female with a 10-year history of gradually increasing mass in her left dorsal wrist. The EIP tendon was partially impaired by the mass.The patient was treated with surgical excision of the mass and reconstruction of the EIP tendon. The histopathological examination suggested the presence of GCTTS. After surgery, the patient had adequate functional recovery and no tumor recurrence after 2 years’ follow-up.ConclusionGCTTS in hands and wrists rarely damages the tendon. Early diagnosis and proactive interventions may likely contribute to good prognostic outcomes.