The dissertation is devoted to the development of a differentiated approach to the
thumb opposition surgical restoration based on the clinical and biomechanical criteria
and analysis of the structural and functional state of the hand and forearm.
In the thesis analytically revised historic evolution of approaches and the current
state of problem of the optimal method of thumb opposition surgical restoration
selecting.
Physiological characteristics of the target muscle-motors (forces, amplitudes and
work parameters) enough for Steindler, Thompson, and Bunnell techniques
effectiveness in all insertion variants. However, do not effective enough by to the
parameters of insufficient physiological excursion for Guber methods, and by
insufficient by force and work parameters for Edgerton-Brand, Burkhalter and Taylor
methods. When the strength of the target muscle-engine decreases to the M4 level, the
effectiveness of the tested techniques significantly decreases: Thompson - up to 2
points by Kapandji, Steindler and Bunnell - up to 1-2, for others - tends to zero.
In an experiment with physiological parameters and a functional state of the
muscle-motor up to M5 - most of the opponenoplasty are effective, with a decrease in
its strength to M4 - are ineffective. The obtained data allow us to select the method of
opponenoplasty according to the resources and functional state of the muscle-motor
and to predict the treatment effectiveness.
To evaluate the clinical efficacy of various surgical techniques, surgical treatment
of 80 patients has monitored.
It was found that a differential approach to the choice of the method of surgical
restoration of the first-hand opposition, based on the compliance with the structuralfunctional
variant of its violation, allows to restore the opposition within the limits of
2,4 + 0,7 points for Kapandji, and 1,6+ 0.6 cm, according to the AAOS-Kurinny test
with opponenoplasty. Moreover, 2.9 + 0.6 points and 3.5 + 0.5 cm, respectively, after
opponenodesis.
It has been observed that for patients with moderate and significant variants of the
opposition loss (1st and 2nd type), the best results are given by methods of using
fingers and hand flexors (Thompson, Bunnell methods), which allow get the
restoration of the opposition to the level of 3-6 points for Kapandji. The effectiveness
of this approach has ensured by the fact that the insertion of the transposed tendon and
its vector with moderate opposition violation (1 group) provides for the correction of
the most affected component of the opposition. With a significant opposition loss (2-
group) - the best results - are double insertion of the transposed tendon (to the base
phalanx and the first metacarpal) with the direction of the vector to pisiform bone.
It was found that in the case of a combination of opposition loss with the thumb
contracture (3A variant of the injury), it is expedient to perform simultaneous
mobilization and opponenoplasty, and in case of stable contracture and impairment of
the thumb structures, especially the destruction to the saddle joint, is indicated by an
opponenodesis.
In patients with loss of the long fingers flexion must first restore their function
and then carry out the opponenoplasty. Last one should be performed with taking into
account restored active flexion of long fingers, or (in the case of gross deficiency of
muscle engines (3C group) - an opponenodesis should be performed;
In the treatment of multi-structural hand injuries , the surgical restoration of the
thumb opposition must be preceded after a complex of structure-forming and functionforming
operations. After the restoration of the opposition - helpful small corrective
interventions (arthrodesis of the interphalangeal joint of the first finger or corrective
osteotomy of the heel bone) that improve the restoration can be performed.
The current version of local anesthesia (WALANT - anesthesia), which causes an
active intraoperative interaction with the patient, provides an obvious improvement in
the results of the opponenoplasty.
