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Scientific Articles   |    
Flexor Origin Slide for Contracture of Spastic Finger Flexor MusclesA Retrospective Study
Camille Thevenin-Lemoine, MD1; Philippe Denormandie, MD1; Alexis Schnitzler, MD1; Christine Lautridou, MD1; Yves Allieu, MD1; François Genêt, MD, PhD1
1 Departments of Orthopaedic Surgery (C.T.-L., P.D., C.L., and Y.A.) and Physical Medicine and Rehabilitation (A.S. and F.G.), Hôpital Raymond Poincaré, 104 Boulevard Raymond Poincaré, 92380 Garches, France. E-mail address for C. Thevenin-Lemoine: camille.thevenin-lemoine@trs.aphp.fr. E-mail address for P. Denormandie: philippe.denormandie@rpc.aphp.fr. E-mail address for A. Schnitzler: alexis.schnitzler@rpc.aphp.fr. E-mail address for C. Lautridou: christine.lautridou@rpc.aphp.fr. E-mail address for Y. Allieu: yves.allieu2@wanadoo.fr. E-mail address for F. Genêt: francois.genet@rpc.aphp.fr
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Investigation performed at the Departments of Orthopaedic Surgery and Physical Medicine and Rehabilitation, Hôpital Raymond Poincaré, Garches, France



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Mar 06;95(5):446-453. doi: 10.2106/JBJS.K.00190
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Abstract

Background: 

Contracture of the wrist and extrinsic finger flexor and pronator muscles is a common consequence of central nervous system disorders. The proximal release of the extrinsic flexor and pronator muscles was first described by Page and Scaglietti for a Volkmann contracture. The aim of the present study was to assess the amount of increase in extension and the improvements in global hand function that can be expected following this lengthening procedure in patients with central nervous system disorders.

Method: 

A single-center retrospective review of patients with central nervous system lesions and contractures of the wrist and extrinsic finger flexor and forearm pronator muscles, causing aesthetic, hygienic, or functional impairment, was carried out. The Page-Scaglietti technique was used for all interventions. Before the operation, motor nerve blocks were used to distinguish between spasticity and contractures with surgical intervention only for contractures. The Zancolli and House classifications were used to evaluate improvements.

Results: 

Data from fifty-four hands and fifty patients (thirty-five men and fifteen women) were evaluated. The mean duration of follow-up (and standard deviation) was 26 ± 21 months (range, three to 124 months). The mean gain (and standard deviation) in wrist extension with fingers extended was 67° ± 25° (range, −10° to 110°). Preoperatively, no hands were classified as Zancolli Group 1, whereas twenty-five hands were classified as Zancolli Group 1 at the latest follow-up review. Ten nonfunctional hands (rated as House Group 0 or Group 1) became functional as a supporting hand postoperatively. Zancolli and House classifications increased significantly (p < 0.01) postoperatively. In twelve cases, a partial recurrence of the deformity occurred. In seven of these cases, surgery unmasked spasticity or contracture of the intrinsic muscles, which required further intervention.

Conclusion: 

The Page-Scaglietti technique appears to improve range of motion and function in people with wrist and finger contractures due to central nervous system disorders.

Level of Evidence: 

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Douglas Garland, M.D.
    Posted on April 18, 2013
    Indications for forearm flexor slide or other muscle slides
    Long Beach Memorial Medical Center, Long Beach, CA

    By the 1970's Rancho had moved away from the flexor origin slide for many reasons (1).  You mentioned three disadvantages of superficialis-to-profundus tendon transfer described by Braun, one being the  alteration of the muscle length tension ratio on the Blix curve.  It is precisely this alteration that allows success for any spastic extremity surgery. The major tenets of spastic surgery via alteration of length tension (tendon lengthening) are:  decrease spasticity; increase joint range; prevent recurrence of deformity. The flexor slide can only change an arc of motion not increase range since the muscle tendon unit has not been altered.  Since there is no alteration in the muscle tendon unit the degree of spasticity remains unchanged allowing the deformity to recur.  The forearm flexor slide works well as described by Page for ischemic muscle contractures (and perhaps for lower motor neurologic diagnosis such as polio or Guillain Barre, etc).  This group of people have muscles that are weak and/or contracture and lengthening the tendons would further weaken the muscle unit, perhaps causing further loss of function.  Your follow up of 26 months is too short and many deformities will recur with longer follow up because of your failure to change the muscle length/tension ratio.

    Your article compares three populations which is also problematic unless the indication for surgery is a non functional hand and wrist.  Cerebral palsy is congenital perhaps causing some boney deformities while  stroke and brain injury are acquired.  All three populations have their own intricacies.  Stroke patients are dominated by flexor-extensor synergies (cerebral palsy also) and neurologic recovery progresses from the shoulder distally.  Head injury patients often have distal control with less proximal control.  The brain injury population has marked individual variations of UE recovery requiring "tendon specific" surgeries, not "en masse" procedures.

    Finally, spastic muscles cause dynamic deformities and do not necessarily cause contractures although a combination of both may exist - only anesthesia and lengthening of tendons of one muscle group and re-evaluation of the limb permits real time surgical decisions.  This makes surgery principles based on range very arbitrary as you describe even with the aid of blocks.  Decision goals for UE surgery could be:  mild flexor spasticity with some voluntary extensor control - weaken mild spastic muscles by aponeurotomy or fractional lengthening; moderate spastic flexor muscles with decreased joint mobility - "Z" lengthening of individual flexor tendons; non functional UE limbs with significant finger and wrist flexion motor spasticity with joint contractures - sublimis motor to profundus tendon transfer with ulnar motor neurectomy at the wrist  since "Z" lengthening may not allow enough tendon length to achieve a neutral position of the wrist.

    The above discussion may negate some indications for forearm flexor slide or other muscle slides in the spastic motor populations.  Although it may remain a surgical option, it will rarely be used.

    REFERENCE

    1.  Waters R.  Upper Extremity Surgery in Stroke Patients:  Clin Orthop Relat Res. 1978 Mar; (131):20-37

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