The Extensor Pollicis Longus-Loop-Knot (ELK) Procedure for Dynamic Balance of the Paralyzed Thumb Interphalangeal Joint

Abstract

Hyperflexion of the thumb interphalangeal (IP) joint interferes significantly with pinching between the thumb and the index finger in a paralyzed hand. The extensor pollicis longus-loop-knot (ELK) procedure was used successfully in 7 tetraplegic patients to balance the IP joint between strong restored flexor function and lacking or weak antagonism of the thumb extensors. A V-shaped incision was made over the extensor hood at the level of the IP joint, the extensor pollicis longus (EPL) tendon was elevated, a loop was formed, secured by sutures, and then turned proximally onto the EPL tendon itself and fixed on both sides. The operation reliably limited the maximum range of IP flexion at 20 to 30 degrees from neutral. Postoperative problems did not occur. The ELK procedure is easy and quick and secures the optimal setting of IP flexion with limited flexibility, which is advantageous compared with rigid bony arthrodesis. It also avoids certain disadvantages of the commonly used flexor pollicis longus split tenodesis and is therefore a valuable alternative for the correction of Froment's sign due to intrinsic or extrinsic paralysis of the thumb.

Reach out and grasp the opportunity: reconstructive hand surgery in tetraplegia

“…Multiple incisions are necessary for the single-stage grip reconstruction (Alphabet) operation; therefore, thorough planning is necessary for the different approaches and the sequence of actions. We prefer making the seven individual operations in the following order: (1) distal EPL tendon duplication (loop knot) (Fridén et al., 2013); (2) carpometacarpal (CMC)1 arthrodesis; (3) reconstruction of passive (or active when feasible) intrinsics; (4) BR-FPL tendon transfer; (5) extensor carpi radialis longus (ECRL)-FDP tendon transfer; (6) EPL-dorsal forearm fascia tenodesis; and (7) extensor carpi ulnaris (ECU) tenorrhaphy (Reinholdt and Fridén, 2013a). This order optimizes tensioning, balancing, accessibility and protection of the completed transfers and arthrodesis.…”

Improving hand function after spinal cord injury

“…The loss of adduction and opposition create an imbalance at the MCP joint, resulting in hyperflexion of the interphalangeal (IP) joint (Froment's sign) after tendon transfer or tenodesis of the FPL for thumb flexion. Flexion balance can be improved by the split FPL tendon transfer to the EPL (Mohammed et al; or the EPL loop anchor procedure (Fride ´n et al, 2013). Introduced by Zancolli, arthrodesis of the carpometacarpal joint in a position for effective key grip will stabilize the thumb for strong pinch and improve thumb control for reconstruction of key grip, particularly for patients in International Groups 1-4 with limited retained active muscles.…”

Outcomes and Complications of Tendon Transfers to Address Pinch and Grasp Weakness: A Systematic Review of the Operative Management of Ulnar Nerve Paralysis

“…6,10,11 The described use of static tenodesis procedures (e.g., Riordan static tenodesis, Smith sling tenodesis, Srinivasan tenodesis) in the literature is largely limited to tetraplegic patients and therefore were not captured in the literature review. [25][26][27][28][29][30]…”