32: Crossed Intrinsic Tendon Transfer

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Procedure 32 Crossed Intrinsic Tendon Transfer

Shimpei Ono, Sandeep J. Sebastin, Kevin C. Chung

See Video 24: Crossed Intrinsic Tendon Transfer for Correction of Ulnar Deviation Deformity

Indications

Performed in rheumatoid arthritis patients who have passively correctable ulnar deviation deformity (Fig. 32-1) with associated ulnar subluxation of the extensor tendon at the metacarpophalangeal (MCP) joint (Fig. 32-2) without arthritis or subluxation

Ulnar subluxation of extensor tendon in chronic posttraumatic radial sagittal band injury

FIGURE 32-1

FIGURE 32-2

Examination/Imaging

Clinical Examination

Clinical examination is to determine the condition of the MCP joint and the intrinsic tendons.

A crossed intrinsic tendon transfer cannot be done in a patient who has a subluxed or arthritic MCP joint (Fig. 32-3). These patients need implant arthroplasty because a soft tissue procedure will not be able to hold a subluxed MCP joint in position. In addition, the patient is examined for the presence of MCP joint synovitis that can be addressed at the same operation.

The intrinsic tendons should be examined for the presence of intrinsic muscle contracture (intrinsic tightness). This is done by the Finochietto-Bunnell test, which is performed by passively holding the patient’s MCP joint in full extension and attempting proximal interphalangeal (PIP) joint flexion. PIP joint flexion will be restricted in patients with intrinsic tightness (Fig. 32-4A and B).

FIGURE 32-3

FIGURE 32-4

Imaging

A radiograph of the hand is useful to determine the condition of the MCP joint.

Surgical Anatomy

The common intrinsic tendon is formed by the tendons of the palmar and dorsal interosseous muscles on the ulnar side of the digit and by the interossei (palmar and dorsal) and the lumbrical tendon on the radial side. These tendons pass palmar to the axis of the MCP joint to form the common intrinsic tendon. This tendon then divides into a medial band that inserts along with the central slip into the dorsal base of the middle phalanx and a lateral band that continues to the dorsal base of the distal phalanx (Fig. 32-5A). Contraction of the intrinsic muscles causes MCP joint flexion and interphalangeal (IP) joint extension. The radial and ulnar sagittal bands stabilize the extensor tendon, keeping it over the dorsal midline of the MCP joint (Fig. 32-5B).

FIGURE 32-5

Positioning

The patient is placed in the supine position, and a pneumatic tourniquet is used.

Procedure

Step 1: Examination of the Extensor Apparatus and MCP Joint Synovectomy

The position and condition of the extensor apparatus are noted. Any synovial proliferations are excised.

A longitudinal incision that parallels the extensor tendon is made through the attenuated radial sagittal band.

The MCP joint is opened, and a synovectomy is carried out.

Step 1 Pearls

A 2- to 3-mm wide portion of the radial sagittal band should be left along with the extensor tendon. This will allow a double-breasted repair of the sagittal band and will help reinforce the transferred intrinsic tendon.

Step 2: Elevation of Ulnar Common Intrinsic Tendon

Dissection is carried out on the ulnar aspect of the proximal phalangeal base in a plane superficial to the extensor apparatus. The interosseous tendons are identified at the base of the MCP joint, and they are followed distally until the formation of the common intrinsic tendon (Fig. 32-10).

The common intrinsic tendon is divided transversely at the midproximal phalanx before it divides into medial and lateral bands. It is then divided longitudinally to separate it from the extensor expansion.

The common intrinsic tendon is mobilized proximally to the MCP joint (Fig. 32-11).

FIGURE 32-10

FIGURE 32-11

Step 2 Pearls

Passing a right-angled retractor around the tendon will help isolate the tendon and will protect the neurovascular bundle volar to it.

Step 2 Pitfalls

If the common intrinsic tendon is divided too proximally, it may not reach the extensor tendon.

Step 3: Transfer of the Ulnar Common Intrinsic Tendon

The mobilized ulnar common intrinsic tendon is passed under the soft tissue between adjacent MCP joints (it contains longitudinal veins and dorsal sensory nerves) to reach the extensor tendon of the digit ulnar to it (Fig. 32-12).

The index finger ulnar common intrinsic tendon is used to correct the long finger; the long finger tendon is used for the ring finger; and the ring finger tendon is used for the small finger. Ulnar deviation of the index finger is corrected by double-breasted repair of the radial sagittal band.

FIGURE 32-12

Step 3 Pearls

The transfer of the intrinsic tendon has two benefits. It reduces the ulnar deviation force acting on the finger and increases the radial deviation force on the adjacent ulnar digit.

Step 4: Centralization of Extensor Tendon

A 3- to 4-mm longitudinal slit is made in the midportion of the extensor tendon overlying the MCP joint. The ulnar common intrinsic tendon is passed through this slit and sutured to itself using one or two horizontal mattress 3-0 Ethibond sutures. Tension is adjusted by keeping the MCP joint in extension and correcting the ulnar deviation deformity. This centralizes the extensor tendon (Figs. 32-13 and 32-14).

A double-breasted repair of the radial sagittal band is done using one or two 3-0 Ethibond mattress sutures (Fig. 32-15).

FIGURE 32-13

FIGURE 32-14

FIGURE 32-15

Step 4 Pearls

A division of the abductor digiti minimi may be required for the small finger. This is a strong ulnar deforming muscle and is approached from the dorsum around the ulnar side of the MCP joint. One must take care not to divide the ulnar neurovascular bundle or the tendon of the flexor digiti minimi.

Step 5: Skin Closure

The tourniquet is released, and hemostasis is obtained.

The skin is closed using 4-0 nylon (Fig. 32-16).

FIGURE 32-16

Postoperative Care and Expected Outcomes

The hand is immobilized with a volar hand splint that keeps the MCP joint extended and corrects the ulnar deviation deformity. The wound is inspected 10 days later, and the sutures are removed. The patient is then given a thermoplastic splint to maintain the MCP joint in extension for another 4 weeks. This is followed by a gradual mobilization protocol and protective splinting for another 4 weeks.

A crossed intrinsic transfer provides reliable long-term correction of the ulnar drift deformity in patients without MCP joint subluxation. However, it may be associated with a decrease in active range of motion at the MCP joint.

Clark DI, Delaney R, Stilwell JH, et al. The value of crossed intrinsic transfer after metacarpophalangeal silastic arthroplasty: a comparative study. J Hand Surg [Br]. 2001;26:565-567.

The authors retrospectively studied 73 rheumatoid hands undergoing primary MCP joint replacement. In 28 hands, a crossed intrinsic transfer was performed, and in 45 hands, it was not. A similar splintage and rehabilitation program was followed in each group. The two treatment groups had similar preoperative ulnar drift (crossed intrinsic transfer group mean, 27 degrees; comparative group mean, 29 degrees). After a follow-up of 50 months, the crossed intrinsic transfer group had statistically less ulnar drift (crossed intrinsic transfer group mean, 6 degrees; comparative group mean, 14 degrees; P = .01). There were no other significant differences at follow-up. (Level IV evidence)

Oster LH, Blair WF, Steyers CM, Flatt AE. Crossed intrinsic transfer. J Hand Surg [Am]. 1989;14:963-971.

The authors presented a retrospective analysis of the long-term results of the crossed intrinsic transfer. Thirty rheumatoid hands and one hand with systemic lupus erythematosus were examined. The average follow-up was 12.7 years. The average postoperative ulnar drift for all fingers was 5 degrees, and the magnitude of it did not increase over time. The average active range of motion for the MCP joint was 47 degrees, and for the PIP joints, 58 degrees. The outcomes for crossed intrinsic transfer attached to the lateral band were similar to outcomes for transfers attached to the collateral ligament of the MCP joint. The crossed intrinsic transfer procedure effectively provides long-term correction of ulnar drift in the rheumatoid hand. (Level V evidence)

Pereira JA, Belcher HJ. A comparison of metacarpophalangeal joint Silastic arthroplasty with or without crossed intrinsic transfer. J Hand Surg [Br]. 2001;26:229-234.

The authors presented 43 hands undergoing Silastic interposition arthroplasty of the index, middle, ring, and little finger MCP joint for rheumatoid arthritis that were randomly allocated to undergo replacement with or without crossed intrinsic transfer. The patients were reviewed at a median of 17 months after surgery. The demographic characteristics and preoperative clinical measurements of the two groups were indistinguishable. Both groups showed improvement in ulnar drift and an altered arc but no change in total range of motion at the MCP joint. Grip strength and pulp-to-pulp pinch were significantly and comparably improved in both groups. There was no difference in pain scores or perceived function between the treatment groups. The authors concluded by saying that crossed intrinsic transfer does not significantly affect the outcome of silicone interposition arthroplasty of the MCP joint in rheumatoid patients. (Level IV evidence)

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