Volume 51, Number 2Printed in the LS...1

INTERNATIONAL JOURNAL OF LEPROSY

A Comparative Study of EFMT and SublimisTransfer Operations in the Claw Hand'

Gabriel D. Sundararaj, Ambrose J. Selvapandian,and Kandasamy Mani2

Ever since Sir Harold Stiles and Forres-ter-Browne described the sublimis transferoperation for the correction of claw handdeformity in 1922, various surgical proce-dures have been devised to correct the clawhand deformity. Bunnell in 1942 modifiedthis procedure and used both slips of allsublimi for transfer. In 1949 Littler modi-fied this procedure further. Fowler's pro-cedure was described in 1946, and Branddescribed the extensor extensor many tailedtransfer extensor carpi radialis brevis— mo-tor palmaris longus tendon—graft (EEMT)in 1954 and the extensor flexor many tailedtransfer extensor carpi radialis longus— mo-tor palmaris longus tendon—graft (EFMT)in 1956. In the Department of Orthopedicsand Leprosy Reconstructive Surgery, Chris-tian Medical College and Hospital, Vellore,India, these operations have been done rou-tinely since 1951. Looking back over theyears, various operative procedures havebeen popular with operating surgeons dur-ing different periods of time. The earliestfavored operation was the sublimis transferwhich was followed by the EEMT opera-tion. In the middle 1960s and early 1970sthe EFMT operation was commonly per-formed. Of late, we have reverted to thesublimis transfer (Fig. 1).

Operative techniquesStiles used one slip of each sublimis ten-

don to replace the intrinsic of the corre-sponding finger. Bunnell used both slips of

' Received for publication on 13 August 1982; ac-cepted for publication in revised form on 13 December1982.

G. D. Sundararaj, M.S. Orth., D. Orth., Reader inOrthopaedics; A. J. Selvapandian, B.Sc., M.S., F.A.C.S.,F.I.M.S.A., Professor and Head; K. Mani, B.Sc., D.H.S.,Junior Research Assistant, Department of Orthopaedicand Leprosy Reconstructive Surgery, Christian Med-ical College and Hospital, Vellore 632004, Tamil Nadu,South India.

all four sublimi. As a result each finger re-ceived two slips of its own sublimi for in-trinsic replacement. The technique we fol-low is similar to Littler's modification. Weuse both slips of the sublimis to one finger,commonly the long or ring finger. The de-tached slips are pulled out through a mid-palmar incision, and each slip is dividedinto two, giving a total of four slips. Eachslip is rerouted through the lumbrical canalvolar to the deep transverse metacarpal lig-ament and brought to the lateral band. Eachslip is attached to the dorsal surface of thelateral band of the corresponding finger justdistal to the metacarpophalangeal (MP) jointwhich is scraped to receive the tendon. Thisinsertion is placed on the ulnar side for theindex finger and on the radial side for thelong, ring, and little fingers.

In Brand's EFMT operation, the extensorcarpi radialis longus tendon is disinsertedat its insertion and rerouted on the volarside under the flexor retinaculum into thepalm after anastomosing a graft to its end.(The graft is usually the tendon of the pal-maris longus or a strip of the fascia lata.)This graft is split into four, and one slip isused for intrinsic replacement of each finger.The route and site of attachment is the sameas for the sublimis transfer.

In Brand's EEMT the extensor carpi ra-dialis brevis is disinserted and extended us-ing a graft which is subsequently split intofour. The slips for the index and long fingersare rerouted through the second intermeta-carpal space through the lumbrical canal vo-lar to the deep transverse metacarpal liga-ments and inserted in the manner describedearlier into the ulnar and radial aspects ofthe index and long fingers, respectively. Theslips for the ring and little fingers are routedthrough the third and fourth intermetacar-pal spaces, respectively, along a similar routeand inserted onto the corresponding lateralbands on their radial aspects.

197

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— -a E F54.0(.1141i5I.F

- FOWLE0S

00^/011269 74

198^ International Journal qf Leprosy^ 1983

100

A120

jl

■100 I I

I90

0

60

0

40 r7

20 I^11,40

ii150 2^S4^56^SO^60^62

v FAR OF OPF0•710P1

FIG. I. Number of tendon operations on hands from 1951-1981.

In the Fowler's transfer two motor ten-dons are used—the extensor indicis pro-prius and the extensor digiti minimi quinti.Each of these, following its disinsertion atthe MP joint level, is split into two. Theextensor indicis proprius slips are used forthe index and long fingers, and the extensordigiti minimi quinti slips are used for thering and little fingers. Their routes and sitesof insertion are identical to that of Brand'sEEMT.

MATERIALS AND METHODSThe aim of this study was to assess the

results of 200 cases each of EFMT and sub-limis transfer operations performed on lep-rosy hands for claw hand correction. Thesecases have been selected by systematic sam-pling from the operative index cards whichwere available with all up-to-date data. Asa routine, the first, second, and third followups were made six months, one year andtwo years postoperatively. Every sixth op-erated hand was selected from a total of1237 EFMT operations, and every fourthcase was selected from a total of 829 sub-limis transfer operations performed in theyears 1951 to 1980. Since these operationshad been performed over a period of three

decades, surgeons of varying experience hadbeen involved. The criteria used by differentsurgeons for their choices of operative pro-cedures used have sometimes been unclear.A finger with very obviously hypermobilejoints is generally not selected for a sublimistransfer. Although a high proportion of pa-tients with fingers that were still in the clawedposition were selected for sublimis transfer,all hands selected for sublimis transfer havenot been stiff hands with proximal inter-phalangeal joint (PIP) contracture. Slightlyover 50% of the cases selected for sublimistransfer have been in supple hands with noPIP contracture.

The incidences of preoperative and post-operative contractures of the PIP joints,reclawing of the fingers, postoperative in-trinsic plus deformity and functional im-provement of the hands have been studiedand compared. The occurrence of sublimisminus deformity in fingers following re-moval of the sublimis tendon for transferhas been noted in postoperative cases.

RESULTS AND DISCUSSIONContractures

As a routine, three angles are measuredat the PIP joint:

51, 2^Sundararaj, et al.: EFMT and Sublimis Transfer Operations^199

TABLE 1. Number of hands showing contracture of fingers, preoperative and postoper-ative. N = 200 in each group.

Preoperative^ PostoperativeProcedure

Index^Long^Ring^Little^Index^Long^Ring^Little

EFMT^

18^15^14^

29^8^8^10^17Sublimis^41^38^54

^63^26^21^33^38

1. Unassisted angle — the angle at thePIP joint when the patient with a clawhand attempts to straighten the fin-gers. Normally, in this position the MPand the PIP joints go into hyperexten-sion and flexion deformities, respec-tively.Assisted angle — the angle measuredat the PIP joint as the patient attemptsto straighten the lingers of the clawhand, MP hyperextension being pas-sively limited by the examiner's finger.

3. Contracture angle — this denotes thecontracture at the PIP joint. Contrac-ture of the PIP joint is caused by con-tracture of various structures such asthe capsule, sublimis tendon, subcu-taneous tissue, and skin. Such con-tractures are seen in cases of long-standing deformity.

This contracture angle must be dif-ferentiated from adaptive shorteningof the sublimis tendons which resultsin a flexion deformity at the PIP joint.This occurs following constant use ofthe hands with the wrist in flexion ashappens in a claw hand deformity.Flexion of the wrist produces a teno-desis effect on the finger extensors,thereby opening the fingers by exten-sion at the interphalangeal joints. Insuch a case, there exists no contractureat the joint and the deformity is pro-duced by the shortened sublimis ten-dons.

Contractures at the PIP joint are gradedin the following manner:

0-9° = minimal10-20° = mild21-40° = moderate

Over 40° = severe

Only moderate and severe degrees of con-tracture are of functional significance andonly these are accounted for as contractures.

Few hands selected for EFMT operationshad residual preoperative contracture. Sub-limis transfer, however, is the operation ofchoice for stiff hands with contracture; hencethe incidence of preoperative contracture ofthe PIP joint in the sublimis series was high.The incidence of postoperative contracturewas significantly less in both series (Table1). An interesting observation in the sub-limis series is that the incidence and degreeof PIP contracture decreased with everysubsequent follow up. It is suggested thatthe transferred tendon acts as a dynamiccorrective force which continues to act fa-vorably over a prolonged period of time tocorrect the PIP contracture.

ReclawingReclawing is manifested by reappearance

of MP joint hyperextension postoperative-ly. Reclawing is graded as follows:

0-10° = minimal11-40° = mild41-90° = moderate

Over 90° = severe

All degrees of reclawing have been consid-ered and accounted for.

The incidence of reclawing was highest inthe little and ring fingers. On comparing theincidence of reclawing in the individual fin-gers, the incidence in the EFMT series wasappreciably more than in the sublimis se-ries. The differences in the incidences of re-clawing in these two series in the index, long,and ring fingers were found to be statisticallysignificant (Table 2, Fig. 2).

Intrinsic plus deformityThe intrinsic plus deformity presents with

hyperextension at the PIP joint and flexionat the DIP joint. This is seen following theuse of high tension to suture the graft (ortransferred tendon) onto the dorsal expan-

PINGLONGINDEX LITTLELITTLE

E F M.T.

SUBL IMIS EFMT

SUBLIMIS

1 0 %

200^ International Journal of Leprosy^ 1983

FR:. 2. Percentage of reclawing of lingers after op-^Fie. 3. Percentage of intrinsic plus deformity oferation.^ fingers.

sion. It is also seen following fibrosis andsubsequent shortening of the graft.

In the intrinsic plus deformity, the MPjoint cannot be fully extended while the PIPjoint is flexed or vice versa. This is the Bun-nell test which should be performed withthe proximal phalanx in line with the meta-carpal without permitting any radial or ul-nar deviation.

The incidence of intrinsic plus deformitywas low in both series (less than 5% for anyindividual finger). However, its incidence inthe EFMT series was higher than in the sub-limis series. The differences in the inci-dences of intrinsic plus deformity in the ringand little fingers were found to be statisti-cally significant (Table 3, Fig. 3). This iscontrary to expectation, since the trans-ferred sublimis tendon is believed tooveract after transfer to produce a high in-cidence of intrinsic plus deformity.

Sublimis minus deformityThe sublimis minus deformity also re-

sults in hyperextension of the PIP and flex-ion of the DIP joints and hence could bemistaken for the intrinsic plus deformity if

the Bunnell test is not performed. Here theBunnell test is negative and the finger jointshave no restriction of movement. The sub-limis minus deformity, being a mobile de-formity, is of little functional disability andthe power of the finger does not apparentlydiffer from that of another finger without itssublimis tendon. It is, however, a cosmeticdisability. Occasionally intrinsic plus de-formity might occur in a finger whose sub-limis tendon has been removed, in whichcase it ceases to be a sublimis minus de-formity. Since the Bunnell test would thenbe positive in this finger, it would be purelyan intrinsic plus deformity.

This deformity was seen more often inthe sublimis series, more so in the long fin-ger since the long finger sublimis tendon wascommonly used for intrinsic replacement.Its occurrence in the EFMT series is follow-ing the removal of the sublimis tendon foropponens replacement (Table 4).

RESULTSThe functional results have been graded

as good, fair, and poor. This is based on thesurgeon's, occupational therapist's, and

TABLE 2. Number of hands showing re-clawing ()flingers. N = 200 in each group.

Procedure Index Long Ring Little

EFMT 21 20 49 70Sublimis 7' 8b 32' 60

Significantly less than EFMT, p < 0.01, chi square.b Significantly less than EFMT, p < 0.02, chi square.

Significantly less than EFMT, p < 0.05. chi square.

TABLE 3. Number of hands showing post-operative intrinsic plus deformity ()flingers.N = 200 in each group.

Procedure^Index^Long^Ring^Little

EFMT^

9^10^9Sublimis^3^3'^lb

Significantly less than EFMT, p < 0.05, chi square.b Significantly less than EFMT, p < 0.02, chi square.

51, 2^Sundararaj, et al.: EFAIT and Sublimis Transfer Operations^201

TABLE 4. Nundier of hands showing post-operative sublimis minus defOrmity . fin-gers. N = 200 in each group.

Procedure^Long^Ring

EFMT^ 14^16Sublimis^29^17

physiotherapist's assessment of the post-operative hand. The surgeon assesses theappearance of the hand and complicationssuch as contracture, reclawing, and intrinsicplus deformity, and the tension and func-tion of the transferred tendon or graft. Theoccupational therapist's assessment con-sists of various tests for precision, pinch,grip, and general performance.

Over 95% of the hands had good or fairresults with significant improvement in thefunction of the hand and an effective motortransfer (Table 5). The good results in thisstudy must be attributed to the operativetechnique using a standard frame for posi-tioning and proper tension adjustment andgood physiotherapy.

CONCLUSION

1. The incidence of reclawing and intrinsicplus deformity, although low, was higherin the EFMT series. This is probably dueto the slightly complicated operativetechnique of the EFMT operation.

2. The overall percentage of satisfactory re-sults (good and fair) was about the samein both series-95%.

3. There seems to be a place for performingeither of these two common operativeprocedures in selected cases provided thepreoperative and postoperative manage-ments are carefully supervised. Techni-cal errors and postoperative complica-tions were seen more often in the EFMToperation than in the sublimis proce-dure.

TABLE 5.^Results.

Procedure Good Fair Poor Total

EFMTSublimis

129126

6567

67

200200

SUMMARY'Two hundred cases each of EFMT and

sublimis transfer operations performed forcorrection of claw hand deformity followingHansen's disease were studied and the re-sults compared. The cases were selected bysystematic sampling. The incidences of re-clawing in the index, long, and ring lingerswere found to be more in the EFMT series.Also the postoperative intrinsic plus de-formity was seen more often in the ring andlittle fingers in the EFMT series. The oc-currence of a sublimis minus deformity fol-lowing removal of the sublimis tendon isrecognized and described. Both operativeprocedures produced 95% satisfactory re-sults.

RESUMENSe compararon los resultados de 200 operaciones

EFMT y 200 'elevaciones' efectuadas para corregir lamano en garra resultante de Ia enfermedad de Hansen.Los casos se seleccionaron por muestreo sistematico.La incidencia de re-engarramiento en los dedos indice,medio y anular fue mayor en las operaciones EFMTque en las 'elevaciones'. La deformidad intrinsica "plus"en los dedos anular y menique tambien fue mas fre-cuente en las operaciones EFMT. Se observO y se des-cribe Ia apariciOn de una deformidad "minus" subsi-guiente a Ia remosiOn del tendon elevador. Ambosprocedimientos operativos produjeron un 95% de re-sultados satisfactorios.

RESUME

On a etudie deux cents cas d'intervention chirurgi-cale EFMT et transfert du sublimis, pratiques pourcorriger Ia main en grille causee par Ia maladie deHansen. Les resultats ont ete compares. Les cas ont etechoisis par echantillonnage systematique. L'incidencede la correction de Ia grille dans l'index, dans Ic medianet dans l'annulaire, etait plus prononcee que dans Iaserie EFMT. On a egalement constate les difformitesintrinseques postoperatoires plus frequemment dansl'annulaire et dans l'auriculaire dans la serie EFMT.L'apparition d'une difformité du sublimis minus a Iasuite de la resection du tendon du sublimis est decrite.Dans les deux cas, les interventions chirurgicales ontentraine 95% de resultats satisfaisants.

Acknovrledgments. The authors wish to thank Mr.Sam Henry, Chief Assessor, and Mr. V. N. Radha-krishnan for his secretarial help.

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reference to paralysis in leprosy and treatment by

202^ International Journal of Leprosy^ 1983

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2. BRAND, P. W. Tendon grafting. Illustrated by a newoperation or intrinsic paralysis of the lingers. J.Bone it. Surg. (Edinburgh) Ser. 13 43 (1961) 444-453.

3. Riük DAN, a C. "tendon transplantations in me-dian nerve and ulnar nerve paralysis. .1. Bone Jt.Surg. (Boston) Ser. A 35 (1932) 312-320.

4. RiolmAN, D. C. The hand in leprosy. A seven-yearclinical study. Part I. General aspects of leprosy. J.Bone Jt. Surg. (Boston) Ser. A 42 (1960) 661-682.

5. RioRDAN, D. C. The hand in leprosy. A seven-yearclinical study. Part II. Orthopaedic aspects of lep-rosy. J. Bone It. Surg. (Boston) Ser. A 42 (1960)683-690.

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7. Sil.vie.ANDiAN, A. J. Final Report—Leprosy Re-search and Rehabilitation Project, 1976, pp. 27-31.