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Tendon transfer for dropped fingers

It is quite common in rheumatoid arthritis and also osteoarthritis of the wrist for the tendons that straighten the little and ring fingers to rupture. This rupture is called an atrition rupture which means that the tendon rubs over a bony surface (or swollen joints in rheumatoid patients) and essentially wears out. Because of the nature of the rupture it means that there is an area of tendon that has been damaged and that tendon cannot be repaired. As the tendon cannot be repaired a tendon is taken from somewhere else and attached to the tendon in order to straighten fingers. The tendon that is normally used is the tendon that allows you to point your index finger. The index finger has two tendons attached to it, one that independently extends the finger to allow it to point and the other tendon is a common tendon attached to all the fingers and all of them to straighten. So if you take one of the tendons from the index finger and use it to power another movement is still maintained from the other tendon that is left, and this still allows the index finger to extend.

ANAESTHETIC

General or regional anaesthetic.

OPERATIVE PROCEDURE

There are three incisions, one over the index finger knuckle one longitudinal 4cm incision over the back of the hand in between the little and ring fingers and a 4cm incision over the back wrist. The tendon that we use for the tendon transfer is always the tendon over the knuckle which is on the middle finger side. Through the cut over the knuckle the tendon is cut. By pulling that cut tendon you can identify where that tendon is at the back of the wrist and through the cut on the back of the wrist that tendon is pulled through the wound at the back of the wrist. Through the incision on the back of the hand between the little and ring fingers the remnant of the tendons to these fingers is identified. These two tendons are then sutured together so that there is a 2cm long segment where the two tendons are sewn together. A tunnel is then made subcutaneously (under the skin) from the wound on the back of the hand to the one on the back of the wrist. The tendon is then pulled through from the wound on the back of the wrist through into the wound on the back of the hand. The index finger tendon is then passed through the common joined tendon of the little and ring fingers three times as 90° to each other (which is called a "three pass weave") and each weave is sewn together to enable the index finger tendon to attach to the little and ring finger tendon. The wounds are then closed.

POST OPERATIVELY

The hand is placed in a splint with the little and ring fingers straight. The splint is maintained for 3 weeks and at this stage the splint is removed and the sutures removed. A further splint is then made by the occupational Therapy staff which should be maintained at night for a further three weeks. Physiotherapy should commence at three weeks to encourage movement of the fingers.

COMPLICATIONS

  1. Infection - occurs in approximately 1% of cases and is rare in a hand that has a good blood supply.
  2. Tendon rupture - unfortunately the repair of the tendon that has been performed can rupture and if it ruptures the procedure may need to be repeated (1-5%).
  3. Complex regional pain syndrome