PMC5620405_01
(Case presentation, initial and intraoperative findings according to the first procedure): (A) Clinical photograph of both forearms showing left (arrow) complete loss of wrist and thumb's extension and incomplete loss of extension in MCP joints II-V; (B) MRI demonstrating the monstrous GL (arrows) which surrounds the proximal radius shaft approximately a half part of its total circumference; (C) Clinical photograph showing the radial nerve (white arrow) which was fixed to the capsule of the GL (blue arrows); (D) Clinical photograph after monobloc removal of the entire GL and careful dissection of the radial nerve showing the overstretching-related partial disruption of the nerve with a gap of 1 cm involving a half part of its overall circumference (arrow).
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F1
The strength of extension of the wrist and thumb's extension and abduction was completely lost according to grade 0 in Medical Research Council (MRC) scale (0-5), and the extension in the metacarpophalangeal (MP) joints II-V showed palsy grade 3 in MRC scale (Fig. 1A). MRI revealed a submuscular, clearly demarcated and encapsulated tumor with a homogeneous and high-intensity signal similar to subcutaneous fat which surrounds the proximal radius shaft approximately a half part of its total circumference, and without visible septae inside the tumor after gadolinium injection (Fig. 1B). The radial nerve was carefully dissected, it was fixed to the capsule of the GL (Fig. 1C). After that, an overstretching-related partial disruption of the nerve with a gap of 1 cm involving a half part of its overall circumference was visible (Fig. 1D).
(Case presentation, intraoperative situs according to the Merle d'Aubigne and Lance procedure): (A) Clinical photograph showing dissection and distal detachment of the PT (green arrow), dissection and distal detachment of the FCU (white arrow), and dissection of the PL before its distal detachment (blue arrow), a large surgical incision was required for sufficient release of the longstanding intermuscular adhesions that is an essential prerequisite for its rerouting and well functioning gliding; (B) Clinical photograph showing the rerouted PL (green arrow) and FCU (white arrow).
TOORTHJ-11-794_F2.jpg
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F2
Six weeks after removal of the GL, a triple tendon transfer procedure that included the transfer of the pronator teres (PT) to the extensor carpi radialis longus/brevis (ECRL/B), the transfer of the flexor carpi ulnaris (FCU) to the extensor digitorum communis (EDC), and the transfer of the rerouted extensor pollicis longus (EPL) to the palmaris longus (PL) was performed (Figs. 2A, B).
(Case presentation, 10-months follow-up): (A) Clinical photographs of both forearms showing left (arrow) good restoration of wrist and long fingers II-V extension; (B) Clinical photograph showing powerful object grasp; (C) Clinical photographs of both forearms showing left (arrows) complete restoration of thumb's extension and abduction, and sufficient thumb's circumduction with a powerful tip-to-tip pinch to the fifth finger.
TOORTHJ-11-794_F3.jpg
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F3
At the 10-months follow-up, strength of wrist extension, thumb's extension and abduction, and long fingers II-V extension had all improved to grade 4 in MRC scale that was accompanied with a sufficient circumduction of the thumb (Figs. 3A-C).