TECHNIQUE
The Starfish Procedure for Independent Digital Control
of a Myoelectric Prosthesis
Downloaded from http://journals.lww.com/techhandsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h
Sahitya K. Denduluri, MD, Andrew Rees, MD, Keith M. Nord, MD,
Bryan J. Loeffler, MD, and R. Glenn Gaston, MD
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/09/2023
Abstract: Management of partial hand amputations is a notable
clinical challenge. Historically, myoelectric prostheses have not allowed
for independent digital control, resulting in unsatisfactory function and
high rejection rates among upper extremity amputees. The Starfish
Procedure was developed for patients who sustained loss of multiple
digits through the level of the base of the proximal phalanx or distal
metacarpal. The procedure involves the pedicled transfer of 1 or more
dorsal interosseous muscles to a subcutaneous location. This allows for
a myoelectric sensor to capture the signals generated by these trans-
ferred muscles, thereby enabling intuitive, independent, digital pros-
thetic flexion and extension. In this article, we detail the relevant
anatomy, indications, and technique for performing the Starfish Pro-
cedure. Given our patients’ promising outcomes to date, we hope this
technique paper will encourage upper extremity surgeons of all training
backgrounds to perform this relatively straightforward procedure,
thereby allowing patients with life-altering finger amputations to regain
meaningful function by enhancing control of digital prostheses.
Key Words: Starfish procedure, amputation, digital, myoelectric,
prosthesis
(Tech Hand Surg 2023;27: 61–67)
artial hand amputations are very common,1,2 with amputations
P distal to the wrist accounting for ∼90% of all traumatic
amputations of the upper extremity.3 The traumatic loss of part of
the hand frequently leads to life-altering functional impairment for
patients, limiting completion of activities of daily living and return
to equivalent work.4,5 There are a variety of treatments based on
the unique injury characteristics and patient factors in each case,
including replantation, revision amputation, toe transfer, and a
wide variety of prostheses. Transmetacarpal partial hand amputa-
tions present a particular challenge in management. When the
thumb is involved, replantation leads to improved patient-reported
outcomes, but success is limited when multiple nonthumb digits
are involved.6 Additional salvage techniques, such as toe-to-hand
transfer and heterotopic replantation, are appropriate in some
clinical scenarios. However, in addition to the requirement for
microsurgical equipment and expertise not available at all centers,
functional outcomes have demonstrated limited function in key
hand functions like grip strength and key pincer grasp.7–10
There is a broad array of prosthesis options for partial
hand amputees. Historically, these have included both passive
From the OrthoCarolina Hand Center and Atrium Musculoskeletal Institute,
Charlotte, North Carolina, USA.
Conflicts of Interest and Source of Funding: The authors report no conflicts of
interest and no source of funding.
Address correspondence and reprint requests to R. Glenn Gaston, MD,
OrthoCarolina Hand & Upper Extremity Center, 1915 Randolph Road,
Charlotte, NC 28207. E-mail: glenn.gaston@orthocarolina.com.
Supplemental Digital Content is available for this article. Direct URL cita-
tions appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s website, www.techhandsurg.com.
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
Techniques in Hand & Upper Extremity Surgery  Volume 27, Number 1, March 2023
Copyright r 2022 Wolters Kluwer Health, Inc. All rights reserved.
(primarily cosmetic) and active (powered) devices.11 Tradi-
tionally, these prosthetics have been fraught with low utilization
rates.5 Within the realm of active prosthetics, myoelectric
prostheses have shown promise among amputees by providing
increased recuperation of function and usability.12–14 Specific
barriers to effective myoelectric prosthetic control in partial
hand amputees include a lack of muscle targets superficial
enough for prosthetic sensors, nonintuitive control, and myo-
electric cross-talk between the small muscles in the hand that
generate the discrete signals detected by sensors in the
prosthesis.15–17 The Starfish procedure was developed to
overcome the limitations of previous myoelectric prostheses for
partial hand amputees. The technique described in this article
capitalizes on the natural anatomy of the intrinsic muscles of the
hand to provide unique benefits for partial hand amputees by
allowing for intuitive control of individual digits and thereby
greatly increasing functionality (Supplemental Video 1, Sup-
plemental Digital Content 1, http://links.lww.com/BTH/
A185).17–19 Briefly, this is achieved by transferring 1 or more
of the dorsal interosseous muscles from their native inter-
metacarpal space to a more dorsal and immediately subcuta-
neous position, thereby allowing for reliable myoelectric signal
detection by cutaneous sensors housed within a specialized
prosthesis. This article outlines the anatomy, indications, and
expected outcomes for the Starfish procedure.
ANATOMY
The human hand contains 7 interosseous muscles, 4 dorsal and
3 volar (Fig. 1A). The volar interossei (VI) and dorsal interossei
(DI) lie in close proximity, sometimes even within the same
physiological compartment, deep within the hand between the
metacarpals.20 The DI serves to abduct the fingers whereas
the VI adduct the fingers. Both groups of interossei traverse the
metacarpophalangeal (MP) joints volar to the MP axis of
rotation and therefore act as MP flexors. In addition, their
extensions through the lateral bands pass dorsal to the axis of
proximal interphalangeal (PIP) and distal interphalangeal rota-
tions and thus extend the IP joints. Despite their close prox-
imity, the different interossei that occupy the same interosseous
space act on different digits. For example, the fourth DI muscle
contributes to ring finger (RF) MP flexion, whereas the third VI,
which shares the fourthfourth interosseous space with the fourth
DI, contributes to small finger (SF) MP flexion. The second and
third DI muscles both act to flex the MP joint of the middle
finger. When considering myoelectric control, the first DI
(which controls the index finger) and hypothenar musculature
(specifically the flexor digiti minimi which controls SF flexion)
reside in a subcutaneous location and thus are readily detectable
by surface electrodes. Therefore, typically these muscles do not
require mobilization and transfer to enable surface electrode
detection. The central 2 digits, in contrast, do not naturally have
detectable signals by surface electrodes (Supplemental Video
2A, Supplemental Digital Content 2, http://links.lww.com/
BTH/A186) and thus the second or third DI is considered as a
www.techhandsurg.com | 61
 Denduluri et al Techniques in Hand & Upper Extremity Surgery  Volume 27, Number 1, March 2023

muscle transfer for control of the long finger and fourth DI
preferred as a muscle transfer for RF control (Supplemental
Video 2B, Supplemental Digital Content 3, http://links.lww.
com/BTH/A187).
The motor entry points (MEPs) for the different interossei
are discrete and can be accessed and protected through a dorsal
Downloaded from http://journals.lww.com/techhandsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h
Those with amputations distal to the level of the PIP joint
usually maintain adequate overall hand function and grip
strength, but may benefit from a digital prosthesis. Digital
amputations proximal to the PIP joint, but with a preserved MP
joint, often result in significant limitations with regard to
grasping. If there is sufficient stump length to accommodate a

or volar approach.21 The interossei typically have a singular standard ring, then the patient may be fitted for a finger pros-
MEP that arises from the deep motor branch of the ulnar nerve. thesis; otherwise, we favor shortening the ray to the level of the
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/09/2023

The DI- MEPs enter from the ulnar side, whereas the VI-MEPs
enter from the radial side (with the exception of the first palmar
interosseus).21 Their discrete MEPs and associated vascular
pedicle can be raised as a unit.17,22 Given this anatomy, in the
Starfish procedure, most commonly 2 DI are carefully mobi-
lized along with their respective neurovascular pedicles and
transferred to the dorsum of adjacent metacarpals (Fig. 1B).
The nonmuscular tissue of the hand is also of relevance to
the Starfish procedure as a potential autograft for interposed
tissue between transferred muscles to prevent myoelectric
cross-talk. The volar plate and associated flexor tendon sheaths
both lie volar to the metacarpal and constitute stout and rela-
tively bulky connective tissue that can be mobilized to serve as
inert interposing tissue (Fig. 1C, D). Similarly, the extrinsic
extensor tendons lie dorsal to the metacarpals and, when pre-
served, can be readily mobilized and anchored between the
transferred interosseous muscle bellies.
INDICATIONS/CONTRAINDICATIONS
Patients with partial hand amputations distal to the level of the
mid-metacarpal, with adequate preservation of intrinsic mus-
culature, are generally considered suitable candidates for the
Starfish procedure. Thus far, we have performed the operation
for patients who sustained amputations secondary to trauma,
infection, and ischemic conditions.
mid-metacarpal at the time of the Starfish procedure. We give
special consideration to the preservation of the index finger,
however, particularly when it is sensate and of adequate native
length that the thumb is able to pinch against it. This can be
extremely useful to patients, particularly when they are not
wearing their prostheses. Myoelectric digits on the adjacent
metacarpals can allow for improved dexterity and strength,
whereas sensate pinch is achieved with the thumb and native
residual index digit.
With regard to intrinsic muscles, the following viable
muscles are most commonly selected to control the corre-
sponding digital prostheses: first DI for the index finger, the
second or third DI for the long finger, the fourth DI for the RF,
and hypothenar muscles for SF. Though the first DI and
hypothenar function can be reliably palpated, we will often
perform electromyography if there is any concern about the
myoelectric signal adequacy of the second, third, or fourth DI
muscles. These can also be stimulated intraoperatively with a
nerve/muscle stimulator. In unique cases, the VI or even the
lumbricals can be considered when appropriate DI is not
available. Specifically, the first VI or index lumbrical is an
alternative muscle for index finger control. The long finger
lumbrical can control long finger flexion, the second VI or ring
lumbrical can control the RF, whereas the third VI or SF
lumbrical can be utilized for SF control.
Contraindications generally include partial digital ampu-
tations with preservation of the PIP joint, insufficient intrinsic

FIGURE 1. Axial cross-sectional schematic of the hand at the level of the mid-metacarpal demonstrating normal anatomy and the Starfish
procedure. A, Normal cross-sectional anatomy showing the usual locations of the intrinsic muscles and flexor tendon sheaths relative to the
index, long, ring, and small metacarpals. B, Starfish procedure with third and fourth DI muscles transferred to the dorsum of the ring and small
metacarpals, respectively. Alternatively, the second DI can be transferred to the dorsum of the long metacarpal in lieu of the third DI for control
of a long finger prosthesis (not shown in the schematic). C, An example of myoelectric signal separation by transferring the flexor tendon
sheaths and extensor tendons between the transferred third and fourth DI muscles. D, Location of sensors within the prosthesis (represented in
blue) to capture signals from the transferred interossei and native hypothenar muscles. Not pictured is a sensor overlying the first DI, which is
also maintained in its native position, for control of an index finger prosthesis.

62 | www.techhandsurg.com Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

Copyright r 2022 Wolters Kluwer Health, Inc. All rights reserved.

 Techniques in Hand & Upper Extremity Surgery  Volume 27, Number 1, March 2023 The Starfish Procedure for Myoelectric Prosthesis

musculature, active local infection, ipsilateral brachial plexus or

nerve palsy affecting intrinsic function, cognitive impairment
such that prosthesis control cannot be learned or reliably
performed, or patient preference to decline the operation and/or
not wear a prosthesis. Notably, as the Starfish procedure can be,
and often is, performed in a delayed manner, there are very few
Downloaded from http://journals.lww.com/techhandsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h

absolute, long-term contraindications. Lastly, if the patient does

not have insurance coverage or funding for a myoelectric
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/09/2023

prosthetic hand, then the procedure should be delayed until

such means are available as the surgery does not confer any
immediate functional gain for patients (unless other needs such
as neuroma treatment or soft tissue management are needed and
the Starfish Procedure can be done simultaneously).
Though all technical details are not included below, we
have also devised a variation of the Starfish procedure,
the “pedicled Starfish,” for patients who necessitate a complete
hand amputation, but in whom the appropriate interossei can be
preserved and transferred into the forearm. That is, at the time
of hand amputation, the respective intrinsics can be isolated and
moved to a subcutaneous location in the distal forearm either in
a pedicled manner or using free tissue transfer. Subsequently,
the signals generated by these transferred muscles can be har-
nessed to intuitively control independent myoelectric digits.

TECHNIQUE
Setup
At the surgeon’s discretion, after discussion with the anesthesi-
ologist, the Starfish procedure can be performed under general
anesthesia or regional nerve block with monitored anesthesia
care. The patient was positioned supine on a standard operating
table with the operative extremity placed on a radiolucent hand
table extension. A nonsterile tourniquet was applied to the
upper arm, and the forearm and hand are prepped and draped in
the usual sterile manner. After Esmarch exsanguination, the FIGURE 2. Preoperative photographs of a 45-year-old man
tourniquet was typically inflated to 250mm Hg (Fig. 2). who underwent the Starfish procedure after sustaining traumatic
amputations of the index, long, ring, and small fingers (SF) from
Exposure a machine press. Subsequent figures will be intraoperative pho-
tographs of the same patient. A, Dorsal view. B, Palmar view.
The first portion of the procedure usually involves disartic-
ulation at the MP joints of any digits, in which the digital stump
long finger whereas the adjacent second VI adducts and flexes
cannot accommodate a digital prosthesis. A thick dorsal flap of
the RF. If the second VI is mistakenly transferred dorsally along
skin and subcutaneous tissues, including the extensor mecha-
with the third DI, then the myoelectric sensor placed over these
nism, was elevated from distal to proximal (Figs. 3–5). The DI
muscles, which would be responsible for moving the long
and metacarpals were exposed to the level of the metacarpal
finger myoelectric digit, may be erroneously activated when the
bases. If still present, the proximal phalangeal remnants were
patient attempts to flex the RF.
then excised by circumferentially releasing the soft tissues of
Next, the metacarpals were shortened to accommodate the
the MP joints of the involved rays (Fig. 6). Care was taken to
fit of the future prosthesis (Fig. 8). On the basis of prior
identify the common digital nerves volarly, which can later be
research and clinical work performed at our institution, we
addressed with either traction neurectomy or by coaptation with
recommend resecting 3 cm of the metacarpal distally, which
an adjacent common digital nerve to prevent/treat neuroma
typically results in an osteotomy through the diaphysis. This
formation.
allows for a symmetric size match of the myoelectric digits
Deep Exposure and provides adequate residual metacarpal for fitting. After
carefully protecting the surrounding soft tissues using baby
The appropriate DI was then extraperiosteally elevated using a
Hohmann retractors, a micro-sagittal saw was used to make the
scalpel from their metacarpal attachments, mobilizing each
bony cuts while gently irrigating the field to prevent thermal
from distal to proximal although remaining cognizant of the
injury (Fig. 8). The dorsal cortex of each cut metacarpal, which
neurovascular pedicle, which typically enters the muscle at
often tends to be prominent distally, was then beveled with the
the level of the proximal meta-diaphyseal junction of the
saw to prevent postoperative irritation.
metacarpal (Fig. 7). Care must also be taken to identify the
correct plane between the dorsal and VI muscles, which is most
easily accomplished distally by looking at the metacarpal heads Reconstruction
end-on. Inadvertently transferring some or all of the corre- The previously-mobilized DI muscles were now transferred to
sponding volar interosseus will result in conflicting myoelectric the dorsal surfaces of the metacarpals. This is accomplished by
signals for prosthesis control. For example, within the third flipping over each DI such that the volar surface of the muscle
webspace, the third DI ulnarly deviates (abducts) and flexes the in its native position was now facing dorsally, thereby bringing

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved. www.techhandsurg.com | 63
Copyright r 2022 Wolters Kluwer Health, Inc. All rights reserved.
 Denduluri et al Techniques in Hand & Upper Extremity Surgery
Downloaded from http://journals.lww.com/techhandsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/09/2023
FIGURE 3. A broad, U-shaped incision is marked and carried out
to expose the metacarpals. A, Dorsal view. B, End-on view.
the muscle fibers as close to the skin as possible. The fascia of
the DI was secured to the dorsal periosteum of the metacarpal
using a 3-0 braided, absorbable suture in a figure-of-eight
manner. Typically, we transferred the second DI to the dorsal
aspect of the long finger metacarpal, which subsequently serves
as the myoelectric signal for controlling the long finger
prosthesis. Alternatively, the third DI can be transferred for
control of the long finger prosthesis (Fig. 9). The fourth DI was
FIGURE 4. Skin and subcutaneous tissues are elevated from the
extensor mechanism.
64 | www.techhandsurg.com Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2022 Wolters Kluwer Health, Inc. All rights reserved.
 Volume 27, Number 1, March 2023
FIGURE 5. Fifth extrinsic extensor tendons are elevated from the
periosteum of the underlying metacarpals, and retracted with the
overlying skin flap.
moved to the dorsum of the fifth metacarpal and provides the
signal for the RF prosthesis (Fig. 10). In general, we attempted
to maximize the distance between the transferred DI muscles
(second or third DI on the third metacarpal and fourth DI on the
fifth metacarpal) so as to best separate the myoelectric signals
driving the long and RF prostheses.
To further separate the myoelectric signals from the
transferred DI, extensor tendons were mobilized from the dorsal
skin flap and laid into the space between the metacarpals
(Fig. 11). These extensor tendons were secured distally to the
volar soft tissues using a 3-0 braided, absorbable suture in a
figure-of-eight manner. Alternatively, the flexor tendon sheaths
can be mobilized dorsally and secured between the transferred
metacarpals in a similar manner.
Closure
The wound was irrigated with normal saline and the skin was
reapproximated in a tension-free manner using a 4-0 monofila-
ment, nonabsorbable suture. Placement of a drain is usually not
necessary after achieving hemostasis after tourniquet deflation.
A bulky soft compressive dressing was applied at the
completion of the procedure, and the extremity was placed
into an elevation foam pillow.
FIGURE 6. Sharp excision of a remnant long finger proximal
phalanx.
 Techniques in Hand & Upper Extremity Surgery  Volume 27, Number 1, March 2023
Downloaded from http://journals.lww.com/techhandsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/09/2023
FIGURE 7. Elevating the third dorsal interosseous (DI) muscle in
an extraperiosteal manner from the long and ring metacarpals.
Rehabilitation
The first postoperative visit is usually around 2 weeks, at which
point sutures are removed. Contraction of the transferred
intrinsics can usually be palpated by the examiner at this early
time point, and surface EMG testing may be used to confirm the
function of transferred muscles. The patient may begin intrinsic
muscle strengthening and edema control modalities, though
formal occupational hand therapy is not always necessary. Once
FIGURE 8. Measuring (Panel A) and resecting (Panel B) the distal
3 cm of the long, ring, and SF metacarpals.
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2022 Wolters Kluwer Health, Inc. All rights reserved.
The Starfish Procedure for Myoelectric Prosthesis
FIGURE 9. Securing the third DI muscle to the dorsal periosteum
of the third metacarpal using a 3-0 braided, absorbable suture in
a figure-of-eight manner.
the soft tissue envelope has matured, the initial prosthesis mold
can be taken by 6 weeks after surgery. In our experience, the
final prosthesis is completed and ready to be worn around 3 to
5 months after surgery.
EXPECTED OUTCOMES
To date, we have performed over 20 Starfish procedures and all
of our patients have been able to generate detectable myo-
electric signals for every transferred muscle. The vast majority
of these patients use a myoelectric prosthesis daily. As
prosthesis control is intuitive, most patients can rapidly control
their myoelectric prosthesis with little instruction. Occupational
therapy is helpful for strengthening, conditioning, and opti-
mization of prosthesis utilization. Because native digital flexion
and grasp are initiated with MP flexion, the transferred
intrinsics naturally contract when patients think to close their
digit or hand. Although we have found that most patients
accurately control their prosthetics immediately, there are some
who can improve their control by being taught to specifically
think about performing MP flexion with IP extension to close
their prosthesis. Specifically, thinking about typing or playing
piano seems to help as those actions rely more on MP flexion
FIGURE 10. Securing the fourth DI muscle to the dorsal periosteum
of the fifth metacarpal using a 3-0 braided, absorbable suture in a
figure-of-eight manner.
www.techhandsurg.com | 65
 Denduluri et al Techniques in Hand & Upper Extremity Surgery
Downloaded from http://journals.lww.com/techhandsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/09/2023
FIGURE 11. Showing the extrinsic extensor tendons interposed
between the transferred third and fourth DI muscles for signal
separation.
than IP flexion. Patients who have undergone the Starfish
procedure at our center have, on average, used a myoelectric
prosthesis for 5.5 hours per day and for 5 to 6 days per week,
both for household activities and while at work.
Through observation and interviewing our patients, we
have identified some improvements to the myoelectric pros-
thesis to optimize long-term use. First, compared with a native
hand, the interossei require more sustained and forceful con-
tractions to maintain myoelectric digits in a flexed position.
Muscle fatigue and gradual signal reduction can result in the
unintended release of prosthetic digit flexion. We address this
muscle fatigability issue by having patients work with a certi-
fied hand therapist on an intrinsic conditioning and endurance
program. In addition, we have worked with our prosthetists to
develop a locked grasping function, activated and deactivated
by a volitional double contraction of the respective intrinsic
muscles. This has allowed our patients to maintain a sustained
grip for more high-demand activities without requiring a sus-
tained muscle contraction and constant myoelectric signal.
Secondly, it is important to set an appropriate threshold and
gain for digital control so that the digit is not hyperexcitable,
but also does not require a powerful contraction to initiate
flexion. Finally, some patients describe certain settings where
they would prefer for all digits to simultaneously open or close
as opposed to controlling each individually. By working with
our prosthetists, a setting can be established to enable the
prosthesis for a more simplified “all open” or “all close” con-
trol, which some patients enjoy at times.
Overall, the majority of our patients report being either
extremely satisfied or very satisfied with their prostheses.
Average Disabilities of Arm, Shoulder and Hand Questionnaire
scores improved from 59.2 (11.7 to 93.3) preoperatively to 39.2
(0.8 to 70.8) after the Starfish procedure. Postoperatively,
Visual Analog Scale pain scores averaged 3.5 (0 to 8.8) for
residual limb pain and 3.4 (0 to 9.1) for phantom pain. Nine
patients (60%) reported phantom sensation and 8 patients
(53%) reported phantom pain. There were no patients with
clinical evidence of neuroma at the final follow-up.
COMPLICATIONS
Fortunately, in our experience, complications are rare with the
Starfish procedure. The most commonly observed issue among
our patients was wound dehiscence, usually secondary to
66 | www.techhandsurg.com Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2022 Wolters Kluwer Health, Inc. All rights reserved.
 Volume 27, Number 1, March 2023
inadequate soft tissues needed to appropriately close the distal
edge. We have addressed this by preserving excess skin and
subcutaneous tissues, when possible, and even using “spare
parts” such as fillet flaps. Next, there is a theoretical risk of
damage to the neurovascular pedicle of each transferred
interosseous muscle, though we have not encountered this
complication to date. For surgeons wishing to perform the
Starfish procedure, it is critical to identify and maintain the
integrity of the neurovascular bundles when dissecting and
separating the interossei proximally. Finally, when soft tissue
coverage is needed, we have found it to be very important to
create a thin envelope to not only allow for optimal prosthetic
fitting but also to ensure that the distance between the
transferred muscles and myoelectric sensors is not so great as
to prevent signal detection.
CONCLUSION
In summary, the Starfish procedure allows patients with life-
altering partial hand amputations to regain meaningful use of
the affected upper extremity by allowing for independent digital
control of a myoelectric prosthesis. We have performed this
technically straightforward operation on a number of amputees
who now use a prosthesis daily and report improved outcomes
with high satisfaction. We hope this technique paper will equip
upper extremity surgeons of all training backgrounds to
perform this relatively simple procedure and significantly
improve the quality of life for patients who have sustained
devastating hand injuries.
REFERENCES
1. Atroshi I, Rosberg HE. Epidemiology of amputations and severe
injuries of the hand. Hand Clin. 2001;17:343–350.
2. Spires MC, Do BK, Davis A. Prosthetic Restoration and Rehabilitation
of the Upper and Lower Extremity. Demos Medical Publishing; 2013.
3. Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb
deficiency: epidemiology and recent trends in the United States. South
Med J. 2002;95:875–883.
4. Gaine WJ, Smart C, Bransby-Zachary M. Upper limb traumatic
amputees: review of prosthetic use. J Hand Surg. 1997;22:73–76.
5. Burger H, Maver T, Marinček Č. Partial hand amputation and work.
Disabil Rehabil. 2007;29:1317–1321.
6. Chung KC, Yoon AP, Malay S, et al. Patient-reported and functional
outcomes after revision amputation and replantation of digit
amputations: the FRANCHISE multicenter international retrospective
cohort study. JAMA Surg. 2019;154:637–646.
7. Williamson JS, Manktelow RT, Kelly L, et al. Toe-to-finger transfer for
post-traumatic reconstruction of the fingerless hand. Can J Surg.
2001;44:275–283.
8. Kotkansalo T, Vilkki SK, Elo P. The functional results of post-traumatic
metacarpal hand reconstruction with microvascular toe transfers.
J Hand Surg Eur Vol. 2009;34:730–742.
9. Venkatramani H, Bhardwaj P, Sierakowski A, et al. Functional
outcomes of post-traumatic metacarpal hand reconstruction with free
toe-to-hand transfer. Indian J Plast Surg. 2016;49:16–25.
10. Kvernmo HD, Tsai TM. Posttraumatic reconstruction of the hand—a
retrospective review of 87 toe-to-hand transfers compared with an
earlier report. J Hand Surg. 2011;36:1176–1181.
11. Imbinto I, Peccia C, Controzzi M, et al. Treatment of the partial hand
amputation: an engineering perspective. IEEE Rev Biomed Eng.
2016;9:32–48.
 Techniques in Hand & Upper Extremity Surgery  Volume 27, Number 1, March 2023 The Starfish Procedure for Myoelectric Prosthesis

12. Kuiken TA, Guanglin L, Lock BA, et al. Targeted muscle
reinnervation for real-time myoelectric control of multifunction
artificial arms. JAMA. 2009;301:619–628.
13. Ma J, Thakor NV, Matsuno F. Hand and wrist movement control of
myoelectric prosthesis based on synergy. IEEE Trans Hum-Mach Syst.
Downloaded from http://journals.lww.com/techhandsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0h
17. Gaston RG, Bracey JW, Tait MA, et al. A novel muscle transfer for
independent digital control of a myoelectric prosthesis: the Starfish
procedure. J Hand Surg. 2019;44:163.e1–163.e5.
18. Niedermeier S, Gaston RG, Loeffler BJ. The Starfish procedure. Tech
Orthop. 2021;36:345–348.

2015;45:74–83. 19. Grier AJ, Loeffler BJ, Gaston RG. Starfish procedure. Hand Clin.
14. Bouwsema H, van der Sluis CK, Bongers RM. Changes in performance over 2021;37:447–455.
time while learning to use a myoelectric prosthesis. J NeuroEngineering 20. DiFelice A, Seiler JG, Whitesides TE. The compartments of the hand:
CywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 06/09/2023

Rehabil. 2014;11:16. an anatomic study. J Hand Surg. 1998;23:682–686.

15. Biddiss EA, Chau TT. Upper limb prosthesis use and abandon-
ment: a survey of the last 25 years. Prosthet Orthot Int. 2007;31:
236–257.
16. De Luca CJ, Merletti R. Surface myoelectric signal cross-talk among muscles
of the leg. Electroencephalogr Clin Neurophysiol. 1988;69:568–575.
21. Daugherty THF, Mailey BA, Bueno RA, et al. Targeted muscle reinnervation
in the hand: an anatomical feasibility study for neuroma treatment and
prevention. J Hand Surg. 2020;45:802–812.
22. Zancolli E. Structural and dynamic bases of hand surgery. Am J Phys
Med Rehabil. 1970;49:321.

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved. www.techhandsurg.com | 67
Copyright r 2022 Wolters Kluwer Health, Inc. All rights reserved.