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TENDON TRANSFERS

Tendon Transfers for Thumb

Opposition
Alexander Y. Shin, MD, and Khiem D. Dao, MD

On the length, strength, free lateral motion, and perfect mobility of the
thumb, depends the power of the human hand.
SIR CHARLES BELL

The loss of thumb opposition, especially when associated with median nerve
palsy or traumatic loss of the thenar musculature, results in a severe impairment of
the function of the hand. The numerous publications and types of procedures
describing the restoration of thumb opposition attest to the importance of the opposable thumb.* The earliest surgeries to restore thumb opposition focused on
restoration of the short exors to the completely intrinsic-minus thumb.11,25,31,34 In
1924 Bunnell9 described an opponensplasty in which he passed a tendon through a
constructed pulley at the level of the pisiform, subcutaneously tunneled it across the
palm, and attached it to the dorsal ulnar aspect of the thumb metacarpal, allowing
for mechanically superior opposition. Fourteen years later, Bunnell reported the
results of this technique in 46 cases.8 That report underscored some of the basic
principles of tendon transfers, including the appropriate direction of action, singular
function, and sufcient muscle strength of the donor tendon-muscle unit. Using
these precepts, Bunnell was able to achieve true opposition (thumb brought away
from the ngers and pronated to oppose the ngers pulp to pulp) rather than short
exor action.
Since Bunnells report, a variety of tendon and muscles have been used to
reconstruct opposition of the thumb. These tendon-muscle units include the exor
digitorum supercialis of the long or ring nger,30,31 the extensor indicis proprius
(EIP),10 the extensor pollicis longus,29 the extensor carpi ulnaris,21 the extensor carpi
brevis longus,19 the extensor digitorum quinti,32 the palmaris longus,11 and the

The views expressed in this article are those of the authors and do not reect the ofcial policy of
position of the Department of the Navy, Department of Defense, or the United States Government.
*References 1 3, 5, 6, 9, 10, 13 15, 17 19, 21, 22, 24 29, 31, 32, 34, and 35.
From the Division of Hand and Microvascular Surgery, Department of Orthopaedic Surgery, Naval
Medical Center San Diego, San Diego, California (AYS, KDD); Division of Hand Surgery, Department of Orthopaedics, Mayo Clinic, Rochester, Minnesota

ATLAS OF THE HAND CLINICS Volume 7 Number 1 March 2002

SHIN & DAO

abductor digiti quinti.24 A description of each of these tendon transfers is beyond

the scope of this article. Herein, the technique of two tendon transfers that are
commonly performed for the restoration of thumb opposition, that is, the (EIP), and
the exor digitorum supercialis (FDS) of the ring nger, are described.

PRINCIPLES OF TENDON TRANSFER

Prerequisites
Before any tendon transfer, the surgeon and the patient must understand the
functional and aesthetic goals along with the limitations and expectations of surgery. Once this understanding is established, several fundamental prerequisites are
required when undertaking a tendon transfer.33 First and foremost, tissue equilibrium must be established. Inammation and edema must be subsided, joint contractures must be resolved, and a stable osseous framework must be present. Once
these prerequisites are established, selection of a donor tendon and muscle is made
based on a donor that is functional and expendable. These requirements provide
adequate strength and amplitude without loss of function. The optimal donor tendon travels a straight route and performs a single function.

INDICATIONS FOR OPPONENSPLASTY

The most common indication for opponensplasty is an isolated median nerve
palsy. Median nerve paralysis is most frequently caused by penetrating or perforating injuries to the forearm or wrist, and typically involves damage to the exor
tendon.10 Other indications include traumatic or developmental loss of the thenar
musculature or ruptured or avulsed tendons or muscles.

TENDON TRANSFERS FOR THUMB OPPOSITION

METHODS OF DISTAL TENDON INSERTION

Several options exist for attachment of the tendon transfer, all of which can be
classied as single or dual insertions (Fig. 1).

Figure 1. Four common techniques for distal tendon attachment for opponensplasty. From Curtis RM: Opposition of the thumb. Orthop Clin North Am 5:314,
1974.

SHIN & DAO

Dual insertion techniques are designed to rotate (pronate) the thumb and either
passively stabilize the metacarpophalangeal joint (MPJ) or minimize interphalangeal
joint (IPJ) exion. This movement is theoretically benecial in patients with combined median and ulnar nerve decits who lack all thumb intrinsic function16;
however, some surgeons question the utility of dual insertion techniques because
the transfer will function predominantly on the tighter of the two insertions.16
Brands technique of distal tendon insertion involves splitting the tendon end
into two slips. One slip is woven through the abductor pollicis brevis tendon and
then passed distal to the MPJ and attached to the extensor pollicis longus tendon.7
The second slip is passed subcutaneously across the extensor mechanism dorsally
and attached to the adductor pollicis on the ulnar side of the MPJ.15 This maneuver
provides rotation of the thumb and stabilizes the MPJ, which is recommended in
patients with complete loss of thenar musculature function and an unstable MPJ.15
Other options for distal attachment include the Royle-Thompson method, which
also involves splitting the tendon into two slips.37 One slip is passed through a drill
hole made in the metacarpal neck from radial to ulnar, with the metacarpal pulled
into as much opposition as possible. This slip is tied to the other half that is initially
passed dorsally over the extensor hood at the MPJ and through a small tunnel in
the fascia and periosteum at the base of the proximal phalanx. The proximal insertion onto the metacarpal head assists in rotation of the thumb, and the distal
insertion achieves slight rotation of the MPJ without causing its exion, an
undesired effect.37
Riordans technique of attachment involves interweaving the transferred tendon
into the abductor pollicis brevis tendon, with continuation onto the extensor pollicis
longus tendon distal to the MPJ.30 This maneuver aids in extension of the terminal
phalanx of the thumb in patients with exed posturing of the IPJ, as seen in
combined median and ulnar nerve decits.15
In Littlers technique, the transferred tendon is attached into the abductor pollicis brevis tendon radially because Littler believes that the abductor pollicis brevis is
the most important thenar musculature in normal opposition.23 Bunnells method
involves passing the tendon through a small drill hole made at the proximal phalanx base from the dorsoulnar to palmar-radial direction to provide pronation of the
thumb.8 The tendon may be secured by anchoring it to the periosteum on the radial
side of the phalanx, sutured onto itself or secured with a pull-out suture.

TRANSFER TENSIONING
Regardless of the attachment method selected, correct tensioning is imperative
to achieve optimal results. Tensioning is achieved when the thumb is in maximal
opposition with passive wrist extension and in maximal extension with passive
wrist exion. The corollary dictates that the tension requires tightening if full thumb
opposition is not obtained with maximal wrist extension, and loosening if full
thumb extension is not obtained with maximal wrist exion. Provisional sutures are
placed at the selected attachment sites, and the wrist is placed through a range of
motion. Final sutures are placed to secure the transfer after the desired tension is
achieved.

TENDON TRANSFERS FOR THUMB OPPOSITION

PULLEY PLACEMENT
To determine the optimal direction of action or pulley location, Cooney and
associates14 performed a cadaveric study that simulated tendon transfer to restore
thumb opposition. The results indicated that any tendon transfer for thumb opposition required an adequate moment arm for the thumb trapeziometacarpal joint and
the thumb MPJ. Furthermore, a pulley in the area of the pisiform restored the
necessary direction of action of the thenar muscles and provided motion in the
planes of abduction, exion, or combined abduction-exion (Fig. 2).

Figure 2. Pulley placement for thumb opposition tendon transfers includes pulleys
proximal to the pisiform (extensor carpi
ulnaris, extensor carpi radialis longus),
rotated on the pisiform (abductor digiti
quinti [muscle]), distal to the pisiform extensor indicis proprius (EIP), tendon
loops of the exor carpi ulnaris (FCU)
and the carpal tunnel (Camittransfer).
(From Cooney WP, Linscheid RL, An KN:
Opposition of the thumb: An anatomic
and biomechanical study of tendon transfers. J Hand Surg 9A:3, 1984.)

SHIN & DAO

EXTENSOR INDICIS PROPRIUS TENDON TRANSFER

The EIP opponensplasty was described in 1956 by Chouhy-Aguirre of Buenos
Aires12 and was subsequently popularized by Burkhalter,10 who reported on a large
series in 1973. This transfer is easy to perform, and the results of treatment have
been uniformly good. The EIP opponensplasty has little, if any, donor-site morbidity
and adequate strength to position the thumb.
With the patient under regional or general anesthesia, the operative extremity is
exsanguinated and an arm pneumatic tourniquet used. The incisions are outlined
(Fig. 3A and B), and a longitudinal incision is made over the index MPJ.

Figure 3. An 18 year old mechanic whose hand was caught in the intake of a jet,
with resultant traumatic loss of the thenar muscles and the motor recurrent branch
of the median nerve. The patient underwent several debridements and wound
coverage procedures, that left him with a sensate hand without thumb opposition.
The preoperative incisions are drawn on the dorsal (A) and volar (B) aspects of the
hand in preparation for an EIP opponensplasty. The dotted line represents the path
of the tendon transfer.

TENDON TRANSFERS FOR THUMB OPPOSITION

The EIP tendon is identied ulnar to the extensor communis tendon (Fig. 4A, B,
and C).

Figure 4. The EIP tendon at the metacarpophalangeal joint is the ulnarmost structure prior to the sagittal band (A). The EIP is isolated by dividing the sagittal band
attachment and its attachment to the extensor digitorum communis (EDC) of the
index nger (B). The harvested tendon is then tapered distally (C), and the sagittal
band is reconstructed to the EDC tendon, closing the gap of the harvested tendon.

SHIN & DAO

An incision is made on the ulnar side of the EIP through the sagittal band, and
extended distally. Similarly, an incision is made on the radial side of the EIP,
separating it from the extensor digitorum communis and tapering to the distal
incision on the ulnar side. The sagittal band is then reconstructed using nonabsorbable 4-0 sutures. Once the distal attachment of the EIP is released, a linear incision
is made over the dorsal ulnar aspect of the distal forearm. The deep fascia is
divided longitudinally, and the EIP tendon and muscle belly are identied and
delivered into the proximal wound (Fig. 5).

Figure 5. A longitudinal incision is made along the dorso-ulnar aspect of the forearm, and
the deep fascia divided longitudinally. The EIP muscle belly and tendon are identied and
delivered from the wound.

TENDON TRANSFERS FOR THUMB OPPOSITION

Frequently, it is necessary to make a small transverse incision over the EIP tendon
in the dorsum of the hand to free it from the extensor digitorum communis of the
index nger (Fig. 6A and B).

Figure 6. A and B, Often, the EIP muscle belly and tendon cannot be delivered
secondary to adhesions or connection of the EIP tendon in the dorsum of the hand.
As such, an incision in the dorsum of the hand is often required to free the EIP
tendon.

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SHIN & DAO

A small longitudinal incision is made just distal to the pisiform, and a subcutaneous
tunnel is created across the ulnar border of the forearm from the dorso-ulnar distal
forearm incision to the incision distal to the pisiform (Fig. 7A, B, and C).

Figure 7. A small longitudinal incision is made just distal to the pisiform, and a subcutaneous tunnel across the ulnar border of the forearm is created from the dorso-ulnar distal
forearm incision to the incision distal to the pisiform (A). The subcutaneous tunnel needs
to be large enough to accept the muscle belly of the EIP, otherwise it may prevent full
excursion of the donor tendon. The tendon is passed using a tendon passer or a hemostat (B and C).

TENDON TRANSFERS FOR THUMB OPPOSITION

A large enough subcutaneous tunnel must be created to allow the entire EIP muscle
belly to lie against the subcutaneous border of the ulna. The EIP tendon is passed
through the tunnel and out the pisiform incision. A second subcutaneous tunnel is
made across the palm to the thumb MPJ (Fig. 8A and B).

Figure 8. The line of pull of the donor tendon is estimated by placing the donor
tendon to the proposed insertion site on the distal portion of the thumb metacarpal
(A). A subcutaneous tunnel is then fashioned between the incision at the pisiform
and the thumb MPJ (B), and the EIP tendon is passed through the tunnel.

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SHIN & DAO

The method of attachment of the distal tendon transfer is controversial and has
been discussed previously. Regardless of the method of distal attachment, the transferred EIP needs to be securely xed, either through bone tunnels or by weaving
through the abductor pollicis brevis, EIP, or exor pollicis brevis (Fig. 9A and B).
The thumb is placed into full opposition with the small nger, and the EIP transfer
is tensioned and secured.

Figure 9. A and B, The EIP tendon is then weaved into the abductor pollicis brevis
tendon and secured with nonabsorbable 3-0 suture with the thumb in maximal
opposition to the small nger. Once this is completed, a bulky hand dressing
maintains the position of maximal thumb opposition for 2 weeks, at which time the
sutures are removed and a custom orthoplast splint is fabricated to hold the
position of maximal opposition until 4 weeks after surgery.

TENDON TRANSFERS FOR THUMB OPPOSITION

The tourniquet is released, hemostasis is obtained, and the wounds are meticulously closed. A bulky hand dressing with plaster splints is placed with the wrist in
exion and the thumb in full opposition for 10 to 14 days, at which time the skin
sutures are removed. Hand therapy is initiated to maintain motion in the ngers,
and an orthoplast splint is fabricated to maintain wrist exion and full thumb
opposition for a total of 4 weeks. At this time, range of motion exercises, tendon
gliding exercises, and retraining of the transferred tendon and muscle begin (Fig.
10A, B, and C).

Figure 10. A C, At approximately 3 months after surgery, the patient demonstrated well healed wounds and excellent thumb opposition and strength.

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SHIN & DAO

FLEXOR DIGITORUM SUPERFICIALIS TENDON TRANSFER

Another common tendon transfer to restore thumb opposition is the exor
digitorum supercialis tendon from the ring nger (FDS IV). This technique begins
with a palmar transverse skin incision made over the MPJ of the ring nger (Fig.
11).

Figure 11. Skin incision markings

for ring nger FDS tendon transfer.
A The incision to harvest the FDS.
B The incision to create the FCU pulley. C The incision to expose the new
insertion of the transfered FDS. (From
Jablon M: Oppensplasty with ring nger
exor digitorum supercialis tendon. In
Blair WF, Steyers CM (eds): Techniques
in Hand Surgery. Baltimore, Williams
and Wilkins, 1996, pp 675 681.)

The A1 pulley is identied and incised longitudinally, and the FDS tendon is
identied. Passive pull on the tendon will ascertain whether the FDS IV tendon has
been isolated. With the nger passively exed, the FDS tendon is divided transversely just proximal to its bifurcation.

TENDON TRANSFERS FOR THUMB OPPOSITION

At this point, a pulley for the FDS IV tendon is constructed. A second curvilinear or zig-zag incision is made at the volar ulnar distal forearm in the region of the
FCU tendon insertion (see Figure 11). The FCU and the FDS IV tendons are exposed
while the ulnar nerve and artery are protected. The radial half of the FCU tendon is
divided transversely approximately 4 cm proximal to its insertion onto the pisiform.
The radial half of the tendon is separated longitudinally from the ulnar half, creating a distally based strip of tendon graft. The tendon graft is looped distally and
passed through the distal portion of the FCU near the pisiform insertion and
secured with nonabsorbable sutures (Fig. 12).

Figure 12. Pulley construction using the distally based radial half of
the distal FCU tendon,
with attachment onto the
pisiform. Arrow indicates
path of tendon through
the FCU pulley. (From
Jablon M: Oppensplasty
with ring nger exor digitorum supercialis tendon. In Blair WF, Steyers
CM (eds): Techniques in
Hand Surgery. Baltimore,
Williams and Wilkins,
1996, pp 675 681.)

The FDS IV tendon is isolated from the surrounding tendons at the wrist and
delivered through the volar ulnar forearm incision. The FDS IV tendon is passed
through the constructed pulley and wrapped in saline-soaked gauze to prevent
desiccation.
A third incision is made on the dorsum of the thumb MPJ, with care to prevent

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SHIN & DAO

injury to branches of the supercial radial nerve (see Fig. 11). A subcutaneous
tunnel is created between this incision and the wrist incision that is wide enough to
accept the FDS IV tendon. The FDS IV tendon is passed through this tunnel to exit
at the thumb incision. The thumb is placed into full opposition with the small
nger, and the FDS IV tendon is secured with the surgeons preference for distal
attachment of the tendon to the thumb.
The postoperative course is similar to that described for the EIP opponensplasty.

RESULTS OF TREATMENT
Burkhalter and associates10 reported excellent results in 57 of 65 patients undergoing EIP opponensplasty, dened as 75% function compared with the opposite/
normal thumb or less than 20 degrees difference between the plane of the opposite
thumbnail and the plane of the palm with good power. Fair results were seen in
four patients, and four others had complete failure (i.e., no rotation or opposition of
the thumb). Extensor lag of the index nger was seen in one patient in this series.
The preliminary results of FDS opponensplasty using the Royle-Thompson technique in nine patients (10 hands) were reported by Thompson.37 There were ve
excellent, three good, one fair, and one poor result. Although an objective grading
scheme was not provided, the good and excellent results exceeded expectations.
Jacobs and Thompson20 reported their results for 96 patients (103 transfers)
based on a grading scheme.36 A good or excellent result had at least 75% of the
function of the opposite thumb or less than 20 degrees difference between the plane
of the opposed thumbnail and the palm, with good power. A fair result had good
rotation of thumb and poor power or less rotation and good power. Patients with a
poor result had no thumb rotation or slight thumb rotation and poor power from
the opponensplasty. All but three of the patients had opposition transfers for poliomyelitis. Using a variety of donor tendons (mainly, FDS IV and FDS III tendons),
pulley designs, and insertion techniques (mainly, the Royle-Thompson attachment),
77 good/excellent, 9 fair, and 17 poor results were reported. Similar results were
obtained with the FDS IV and FDS III tendons.
Sundararaj and Mani36 reported their results in 20 patients using FDS IV (17)
and FDS II (3) transfers for triple nerve palsies (radial, ulnar, and median) secondary to Hansens disease. Unfortunately, they did not elaborate on the methods of
distal tendon insertion. Their results were classied as excellent if the pulp of the
thumb could oppose to the pulp of the small or ring nger with the thumb IPJ
extended, good if the pulp of the thumb could only touch the middle or index
nger, fair if opposition was possible only with the thumb IPJ exed, and poor if no
opposition was possible. Excellent or good results were obtained in 85% of cases.
Anderson and associates2 compared 50 extensor indicis proprius with 116 FDS
ring nger opponensplasties. Their analysis demonstrated that the EIP opponensplasty was best in supple hands, whereas the FDS opponensplasty was more suitable in less pliable hands. Complications were more frequent in the FDS group and
included limitation of extension of the donor ring nger, exion contractures of the
proximal interphalangeal joint, and radial migration of the transferred tendon in the
wrist.

SUMMARY
The choice of opponensplasty of the thumb should be based on the available
donor muscle-tendon units, the overall condition of the hand, and a thorough
discussion with the patient. Regardless of the muscle-tendon unit chosen, the principles of tendon transfer must be strictly adhered to to obtain optimal results.

TENDON TRANSFERS FOR THUMB OPPOSITION

References
1. Anderson GA, Lee V, Sundararaj GD: Extensor
indicis proprius opponensplasty. J Hand Surg
16B:334 338, 1991
2. Anderson GA, Lee V, Sundararaj GD: Opponensplasty by extensor indicis and exor digitorum supercialis tendon transfer. J Hand
Surg 17B:611 614, 1992
3. Baek GH, Jung JM, Yoo WJ, et al: Transfer
of extensor carpi radialis longus or brevis
for opponensplasty. J Hand Surg 24B:50 53,
1999
4. Bell C: The Hand Its Mechanism and Vital
Endowments as Evincing Design. The Bridgewater Treatises, vol. 4. London, William Pickering, 1833
5. Bindra RR, Bhandarkar DS, Taraporvala JC:
Opponensplasty an experience of twentythree cases using three techniques. J Postgrad
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6. Bourrel P, Courbil JL, Giraudeau P: Transplantation of the extensor indicis proprius for restoration of opposition of the thumb: Apropos
of 15 cases. Ann Chir 32:597 600, 1978
7. Brand PW: Tendon transfers for median and
ulnar nerve paralysis. Orthop Clin North Am
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8. Bunnell S: Opposition of the thumb. J Bone
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Address reprint requests to
Alexander Y. Shin, MD
Department of Orthopaedic Surgery
Division of Hand Surgery
Mayo Clinic E14A
200 First Street SW
Rochester, MN55905
shin.alexander@mayo.edu

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