title: Releasing the A3 pulley and leaving flexor superficialis intact increases pinch force following the Zancolli lasso procedures to prevent claw deformity in the intrinsic palsied finger.
abstract: Objective estimates of fingertip force magnitude following surgery to prevent digital metacarpophalangeal (MCP) hyperextension (clawing) in cases of paralysis of the hand's intrinsic muscles will assist clinicians in setting realistic expectations for post-operative pinch strength. We used a cadaveric/optimization approach to predict and confirm the maximal biomechanically possible fingertip force in the intrinsic palsied hand before and after two popular tendon transfer methods to the volar plate of the MCP joint. Both surgeries were also evaluated after release of the A3 pulley-a modification predicted by our published computer model of the forefinger to increase fingertip force magnitude. We predicted maximal static fingertip force by mounting eight fresh cadaveric hands on a frame, placing their forefinger in a functional posture (neutral abduction, 45 degrees of flexion at the MCP and proximal interphalangeal joints, and 10 degrees at the distal interphalangeal joint) and pinning the distal phalanx to a 3D dynamometer. We pulled on individual tendons with tensions up to 25% of maximal isometric force of their associated muscle and measured fingertip force and torque output. Using these measurements, we predicted the optimal combination of tendon tensions that maximized palmar force (analogous to pinch force, directed perpendicularly from the midpoint of the distal phalanx, and in the plane of finger flexion-extension) for four cases: (i) the non-paretic case (all muscles available), (ii) intrinsic palsied hand (no intrinsic muscles functioning), (iii) transfer of flexor superficialis tendon to the volar plate of the MCP (Zancolli lasso) in the intrinsic palsied hand, and (iv) leaving flexor superficialis intact and transferring a tendon of comparable strength to the volar plate of the MCP in the intrinsic palsied hand. Lastly, we applied these optimal combinations of tension to the cadaveric tendons and measured fingertip output. With the A3 pulley intact, the maximal palmar force in cases (ii)-(iv) averaged 48 +/- 23% SD (non-paretic = 100%; case (iv) (61 +/- 25%) > cases (ii) and (iii) (43 +/- 23% and 39 +/- 19%, respectively), p < 0.05). Releasing the A3 pulley significantly increased the average palmar force in cases (ii)-(iv) (73 +/- 42%, p < 0.05), with no significant differences among them. Thus, releasing the A3 pulley may improve palmar force magnitude when it is necessary to transfer the digit's own flexor superficialis tendon to the volar plate of the MCP to prevent clawing in the intrinsic palsied hand.
authors.affiliation: Neuromuscular Biomechanics Laboratory, Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, NY 14853-7501, USA. fv24@cornell.edu
authors.forename: Francisco J
authors.initials: FJ
authors.lastname: Valero-Cuevas
authors.forename: Vincent R
authors.initials: VR
authors.lastname: Hentz
mesh_terms: D001696:Biomechanical Phenomena; D002102:Cadaver; D005384:Finger Joint / Q000502:physiology / Q000601:surgery; D005385:Fingers / Q000502:physiology / Q000601:surgery*; D006801:Humans; D018482:Muscle, Skeletal / Q000502:physiology / Q000601:surgery*; D010243:Paralysis / Q000503:physiopathology / Q000517:prevention & control*; D013514:Surgical Procedures, Operative; D013710:Tendons / Q000502:physiology / Q000601:surgery