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Transfer of the Abductor Pollicis Brevis Tendon to Flexor Carpi Radialis for the Restoration of Tip-Pinch in Severe Carpal Tunnel Syndrome
Michael V. Birman, MD; Jonathan R. Danoff, MD; Melvin P. Rosenwasser, MD
Trauma Training Center, Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY

Hypothesis: In patients with severe thenar paralysis secondary to carpal tunnel syndrome, we hypothesize that following open carpal tunnel release, concomitant transfer of the abductor pollicis brevis (APB) origin to the flexor carpi radialis (FCR) tendon will lead to improved patient function and satisfaction, by restoration of thumb opposition and palmar abduction.  This novel tendon transfer and clinical results will be discussed.

Methods: Between November 2004 and November 2010, the senior author performed 17 FCR to APB opponensplasties at the time of open carpal tunnel release.  The procedure mobilizes the capsulo-ligamentous origin of the abductor pollicis brevis over the trapezium and advances it into the FCR tendon proximal to the FCR tunnel.  The FCR is advanced one revolution around an Allis clamp, approximately 1 cm, prior to APB tendon insertion, thereby abducting the thumb out of the palm and promoting tip pinch. Patients were evaluated through outcome scores (DASH, SF-36, and visual analog pain scale), physical examination, and a questionnaire of patient function and satisfaction. 

Results: Fourteen patients were available for questionnaires; eight were also available for physical examination.  The mean patient age at surgery was 77 years (range 63-87 years) and mean follow-up was 2.7 years (range 4-75 months).  The mean DASH score was 19.8 (SD 15.6) and the mean VAS pain score was 0.8 (SD 2.1).  In comparison to the contralateral side, the radial abduction distance ranged from 56-114%, palmar abduction distance ranged 63-100%, and key pinch strength ranged 91-125%.  Seventy-five percent of the examined patients were able to move their thumbs across the palm to the tip and base of the small finger.

Summary Points:

  • Transfer of the APB origin to the FCR tendon can restore thumb opposition for thenar paralysis secondary to severe carpal tunnel syndrome. 
  • Good functional outcomes, most notably the ability to bring the thumb across the palm to the base of the fifth digit, patient satisfaction, and no complications lead us to conclude that this is both an effective and safe procedure. 
  • Compared to other described opponensplasty techniques, this procedure has no donor site morbidity, as the FCR is neither detached from its insertion, nor removed from its retinacular tunnel, and it requires minimal dissection and no subcutaneous rerouting, thereby minimizing the potential for scarring and tendon adhesions. Also the straight-line vector of pull obviates the need for a pulley.  The transfer is synergistic and in our experience requires little specific transfer training to use.

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