SURGICAL TECHNIQUES

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Allieu's EPL-FPL tenodesis

Marc Revol, MD, Jean-Marie Servant, MD

(Service de Chirurgie Plastique. Hopital Saint-Louis. 75475 Paris Cedex 10. France)

 

     
Allieu Y., Coulet B., Chammas M. Functional surgery of the upper limb in high level tetraplegia.
     
     
In this clinical case, EPL tendon was missing at the level of the wrist and forearm, but not at the level of the thumb. EPL function of retropulsion was obviously replaced with EPB tendon. Therefore, the following atypical tenodesis was performed with EPB and FPL.

 

     

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Incision is gently curved at the radial side of the wrist.
 
It begins in the snuffbox, at the proximal end of the first web, and is extended for approximately 10 to 12 cm in a line convex to the radial side of the wrist.
 
     
 
The branches of the radial nerve must be protected.
 
The skin flap is raised under the superficial veins, and it should be dissected up to the ulnar head.
 
     
 
The distal edge of the extensor retinaculum is rather easy to find.
 
Distally from this edge, the loose dorsal fascia over the metacarpal region of the hand is removed on 3 to 5 cm, in order to see ECRL, ECRB and EPL tendons. In this case, EPL tendon is missing.
 
     
   
     
  Because EPL tendon is missing, EPB tendon is dissected, and its function is tested by a gentle proximal traction, which fortunately produces a retropulsion of the thumb in this case.
     
   
     
   
     
  Superficial fascia is incised between radial vessels and FCR tendon. Then deep fascia is incised and FPL tendon is then easily recognised and dissected.
     
   
     
  Periosteum of the distal radius is incised  at each part of the BR tendon, under APL tendons.
     
  A dorsal periosteum flap is raised under ECRL and ECRB tendons, which are left undisturbed.
     
  In the same way, a palmar periosteum flap is raised under the PQ muscle.
     
  A transversal tunnel is drilled into the distal radius, from palmar to dorsal side. The size of this tunnel must fit the size of EPB and FPL tendons.
     
  The palmar hole is shown here.
     
  The dorsal hole is shown here, between ECR and APL tendons.
     
  EPB tendon is passed through the tunnel, from dorsal to palmar side.

FPL tendon is passed in the same way, from palmar to dorsal side.

     
   
     
   
     
  EPB and FPL tendons are sutured to each other, either at the palmar and at the dosal aspect of the wrist. It is of paramount importance to check the proper tension of this suture. Pinch must be opened in retropulsion when the wrist is passively flexed, and the key-grip is activated when the wrist is passively extended (see further).
     
   
     
   
     
   
     
  Palmar and dorsal periosteum flaps are sutured to each other and/or to the BR tendon. It covers the tenodesis and increases its adhesions. Furthermore, it restores the pathway of ECR tendons, which must be left undisturbed.
     
   
     
  Opening of the pinch when wrist is passively flexed, with retropulsion of the thumb.
     
  Closure of the pinch when wrist is passively extended.
     
   
     
   
     
     
     
   

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