Burkhalter's Procedure

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Management of Thumb Opposition

with BURKHALTER’s Procedure

TRUONG LE DAO, M.D.

Intrinsic muscles palsies of the hand

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Burkhalter W.E, Cristhensen R.C, Brown P.W,

Extensor Indicis Proprius opponensplasty

J. Bone Joint Surg. 55: 725-732, 1973

This technique has been applied to restore

thumb opposition since 1990 in HCMC

Hospital of Dermatovenerology.

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Tendon transfers require a multidisciplinary

team particularly physiotherapist for

preoperative as well as postoperative

assessment and useful exercise. Department of Surgical Reconstruction

& Rehabilitation in Leprosy

HCMC Hospital of Dermatovenerolory

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CONTENTS

• Indications

• Surgical Principles

• Technique of Opposition Transfer

• Surgical Stratery

• Rehabilitation after Tendon Transfer

• Outcome

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INDICATIONS

• High median-nerve injury,

when the FDS are not available.

• Combined median-ulnar nerve injury,

either high or low .

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SURGICAL PRINCIPLES

• Which motor muscle?

• Which route?

• Which pulley?

• Which type of insertion ?

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• Bunnell called tendon transfers muscle balance operations.

• The EIP provides thumb mobility and full opposition.

Extensor Indicis Proprius

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Choosing the Route of Transfer

• The more radial the route, the more thumb

abduction it provides to the thumb.

• The more ulnar the route, the more flexion

and pronation it provides to the thumb.

• The most effective opposition transfer

courses to its insertion on the thumb from

the directon of the pisiform, paralleling the

APB tendon.

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• The best plane for the transfer is superficial to

the palmar fascia in the subcutaneous layer.

• The more direct the route of transfer, the less

force is needed to effect thumb movement.

The EIP has a more direct route than the FDS.

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Pulley

• Ulnar bone is a stiff

pully. It doesn’t change

the tendon direction of

more than 45 degrees.

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Double Insertions (Riordan) • The abductor pollicis brevis tendon, the thumb

MCP joint capsule.

• And the extensor pollicis longus over the proximal phalanx, if there is significant direct injury to the ulnar-innervated muscles.

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Abductor

Pollicis

Brevis

B

Extensor

Indicis

Proprius

A

Technique of Opposition Transfer

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• An incision is made over the

dorsum of the index MCP joint.

The EIP is harvested from its

insertion. A small portion of the

extensor expansion taken with

the tendon may ensure that it will

reach its new insertion on the

thumb.

• The extensor hood must be

meticulously repaired to prevent

an extensor lag of the index MCP

joint.

First incision

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Second Incision

• A second incision is made over the distal

aspect of the dorsoulnar forearm.

• The tendon and muscle belly of the EIP must

be freed more proximally to provide a more

direct line of pull.

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Third Incision • A third incision is made over the pisiform.

• A wide subcutaneous tunnel is developed

between the incisions over the pisiform and

the dorsoulnar forearm.

• The EIP tendon is passed through the tunnel

around the ulnar border of the forearm.

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Fourth Incision

• A fourth incision is made over the radial aspect of the thumb MCP joint.

• Another subcutaneous tunnel from the pisiform to the thumb MCP joint provides the pathway for the thumb transfer.

• The EIP tendon is attached according to Riordan’s method.

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Adjusting the Tension of the Transfer

• The tension is adjusted with the wrist in 30

degrees of flexion and the thumb in full

opposition.

• The thumb is casted in full opposition and

the wrist in flexion with anterior and posterior

splints for hand-lower forearm for

approximately 4 weeks.

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Surgical Stratery

• Preoperative care

• Thumb Web Release

• Flexion contracture of the thumb IP

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Pre Operative Care

• Scar mobilization by:

– mechanical massage

– active motion

• Maximization of range of motion (ROM):

– frequent passive ROM

– dynamic splinting and serial casting aid

– static splinting

• Adequate thumb web:

– A short opponens splint with a C-bar

– Passive stretching to the thumb

metacarpal

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• Flexion contracture of the

thumb IP:

– Serial plaster cast

• Maximization of muscle

strength. Specifically, the

proposed donor muscle.

• Patient education:

– what the donor does,

where it is, and how to

initiate its contraction. It is

much easier to accomplish

this preoperatively.

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Thumb Web Release

• If there is still a limited ROM

despite good hand therapy and

splinting, a thumb web-space

release may be necessary at

the time or before opposition

transfer.

• Skin coverage for the thumb

web is obtained with a Z-plasty,

four-flap web-plasty, rotational

flap from the dorsum of the

index metacarpal and MCP

joint, or skin graft.

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Fixed Flexion Contracture ot the Thumb IP

• This problem is not always solved by Burkhalter’s

procedure.

• If BOUVIER test (+), the radial half of flexor pollicis

longus was cut near its insertion and attached to EPL

over the middle of the proximal phalanx of thumb.

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Rehabilitation after Tendon Transfer

• During in a protective splint or cast

• After discontinued protective splint

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• Postoperatively, during the first 3 to 5 weeks :

– Active and passive ROM exercises are initiated to

the joints that do not need protection. Edema is

controlled with elevation, and active ROM.

• By 4 to 5 weeks: Mobilization to all joints.

• Until 6 weeks: Continuing protective splinting to

prevent overstretching.

• From 6 to 8 weeks: discontinuing protective splint and

instituting passive ROM for all joints. Light activities.

• By 8 weeks: progressive resistance exercises such as

putty gripping, weights.

• By 12 weeks: increasing strength, endurance, and

function with a home program if needed.

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Outcome

• Advantages

• Disadvantages

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Advantage

Stabilization of the Thumb MCP joint

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Advantage

Good thumb opposition but no more pronation

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Disadvantage

Lost dorsal flexion of the thumb IP joint

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Disadvantage

There is still Froment’s sign

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Disadvantage

Lost dorsal flexion of the Index MCP joint

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The End

Thank you for your attention!