Immediate Thumb Extension following Extensor Indicis Proprius–to–Extensor Pollicis Longus Tendon Transfer Using the Wide-Awake Approach

Author(s): Michael B, Sparkes GL, Higgins A, Neumeister MW, Lalonde DH

Source: Plast Reconstr Surg 119: 1507, 2007.


The authors examined their experience with simple tendon transfers performed under the wide-awake approach.  Wide-awake surgery is performed by injecting lidocaine with epinephrine in the operative field without the use of tourniquet, sedation, or general anesthetic.  Seven patients underwent transfer of the extensor indicis proprius to the extensor pollicis longus between 2002 and 2005 for restoration of thumb extension using local lidocaine with epinephrine alone. One of the seven patients experienced rupture of the initial transfer, necessitating transfer of the extensor carpi radialis longus to the extensor pollicis longus using the wide-awake approach.

All seven patients were able to extend their thumbs fully by means of the extensor indicis proprius intraoperatively immediately following transfer suture placement.  Restoration of function was not ablated by loss of proprioception or visual feedback. At a mean follow-up of 15 months, thumb extension was restored to within normal limits in the affected thumb, with a slight decrease in grip and tripod pinch strength.  Additionally, all patients were able to easily extend their thumb using the extensor indicis proprius on the first attempt without appearing to have the brain learn this new function.

The authors conclude that this technique permits the surgeon to observe the patient perform a full comfortable active range of motion of the digit and make necessary adjustments before the skin is closed. The movement of the affected thumb can be compared with the normal thumb while a temporary suture is still in place, thereby allowing for a more accurate adjustment of tendon transfer tension with active movement prior to skin closure without the risks associated with regional or general anesthesia.  Furthermore, the patient’s ability to extend their thumb using the extensor indicis proprius on the first attempt suggests that the brain is able to learn this new function instantly rather than after months of intensive hand therapy, as is commonly thought for tendon transfers.

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