Outcome of early postoperative active mobilisation following tendon transfer procedures for claw hand correction: A Prospective study

INTRODUCTION: Post operative immobilization of the hand in a cast is the conventional practice following the tendon transfer for the claw hand deformity correction. The wrist and the Metacarpophalangeal joints (MCP) are immobilized for a period of 4 weeks following the Zancolli's lasso procedure for claw deformity correction. After cast removal, 4 weeks is required for the tendon transfer reeducation before the patient is allowed to use the hand for daily living activities. The period of morbidity with the post-operative immobilization of the hand extends up to 7-8 weeks. Post immobilization stiffness may increase the rehabilitation time and further delay in return to activities. The concept of immediate active mobilization of tendon transfer was reported recently by Rath. His immediate post operative active mobilisation trial shows the benefit of 40% reduction in rehabilitation time . To test this concept on tendon transfer for claw deformity correction , we did a prospective study of an Analysis of results of Early Postoperative Active Mobilization following FDS middle finger 4 tail pulley insertions (4TP) for claw hand correction ( Lasso procedure). The outcomes of this procedure were compared with conventional immobilization in a cast for claw hand deformity correction. AIM OF THE STUDY: To Test the safety, efficacy and reliability of early postoperative active mobilisation after tendon transfer surgery and to compare the outcomes with those after conventional post operative immobilisation in the claw hand deformity correction. MATERIALS AND METHODS: Patients with the mobile claw hand deformities due to the complete ulnar nerve paralysis are taken up for our study. Total no of the patients – 12 cases. Inclusion Criteria - 1. Traumatic ulnar nerve palsy or Tardy ulnar nerve palsy not recovered after surgical treatment, 2. In cases of leprosy , after Completion of the drug therapy , 3. All the MCP and the PIP joints should be supple, 4. Good function of the FDS of the middle finger. Exclusion Criteria - 1. Contracture angle of the fingers more than 300, 2. Extensor expansion damage, 3. Weakness of FDS of middle finger, 4. Ulcer over the finger tips and neuropathic joints. RESULTS: The following are the results of the study: 1.There was no incidence of the transferred tendon rupture during early active Mobilisation. 2. The mean morbidity was 34 days ( range 29 -38 days). 3.The morbidity was reduced by 20 days (37%) with early active mobilisation compared with Rath immobilisation group. 4. The analysis of results of the deformity correction in the open hand position ( MCP joint and PIP joint angles) as per the criteria of Palande shows 82% of the patients had good deformity correction , 10% had fair results and 8% had poor results. 5. The analysis of results of the tendon transfer integration in intrinsic plus position shows good results in 91% of the patients and fair in 6% and poor in 3% of the patients. 6. The analysis of the results of fist closure at the follow up of 6 th month shows 74% of the patients had good results , 20% of the patients had fair results and 6% in poor results. 7. Comparision of the early active mobilisation results with published reports of immobilisation of tendon transfer for claw hand deformity correction shows better outcome and also added benefit of reduced morbidity. CONCLUSION: The early active mobilisation is safe and has the better outcomes of deformity correction compared to immobilisation with a selected donor with a strong insertion. Increased strength of tendon transfer insertion and protection of the insertion during early active mobilisation are the two essential requirements for this new tendon transfer rehabilitation protocol. Wider application of this principle to other tendon transfer can be investigated with incorporating the above two principles. Future randomized controlled trials will provide insight into the differences in post operative behavior of the tendon transfer with early mobilization versus immobilization. The neurophysiologic basis of the isolation of donor, integration of tendon transfer and movement restoration can now be tracked in the immediate postoperative period with functional MRI or PET scans