PMC9870800_01
Preoperative images of a patient C. A Complete claw in open hand position. B Intrinsic minus hand, lumbrical position. C Thumb to index finger opposition.
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fig2
There was a complete claw hand (Fig. 2), with a flexion contracture at the proximal interphalangeal (PIP) joint of 30  in the ring finger and 20  in the little finger.
FDS 4-tail transfer surgery. A Marking of the longitudinal incision over the proximal phalanx. B Donor FDS tendon through a transverse incision just proximal to the distal palmar crease. C FDS tendon split into 4 tails. D Exploration of the extensor expansion. E FDS tendon slips in extensor expansion. F Tension adjustment. G Sutured FDS slip to lateral band. H Plaster of Paris cast, with wrist at 10 -20  flexion, MCP joint at 90  flexion, and IP joint extension.
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fig3
Longitudinal incisions were marked on the radial side of the little, ring, and middle fingers and on the ulnar side of the index finger just dorsal to the midlateral line and over the middle 2 quarters of the proximal phalanx to access the extensor expansion (Fig. 3A). Two slips of FDS tendons were withdrawn through these incisions (Fig. 3B). This tendon was split longitudinally into 4 equal tails (Fig. 3C). Extensor expansion was identified at the proximal phalanx through the longitudinal incision (Fig. 3D). The FDS tendon slip was grasped and withdrawn through the lumbrical canal (Fig. 3E). The graft was then sutured to the lateral band of the extensor expansion of each finger with appropriate tension (Fig. 3F). Tension was adjusted the wrist in 10 -15  and metacarpophalangeal (MCP) joint in 90  of flexion by giving maximum tension to the little finger slip while suturing it to the lateral band (Fig. 3G). The hand was splinted in a plaster cast, with the wrist in 10 -20  of flexion, MCP joint in 90  of flexion, and interphalangeal (IP) extension (Fig. 3H).
PMC9870800_02
The Zancolli lasso procedure. A FDS of the ring finger split into 4 slips. Arrow 1 shows an oblique incision on the proximal phalanx of the ring finger to remove FDS insertion. Arrow 2 shows a transverse incision on the distal palmar crease. Arrow 3 shows a longitudinal incision on the palm, distal to the carpal tunnel. B FDS slips taken out from the incision at the distal palmar crease. C FDS slips after manipulation over the A1 pulley.
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fig4
The FDS was split into 4 slips, 1 for each finger (Fig. 4A). The 4 tendon slips were passed through the subcutaneous tunnel from the proximal and the distal incisions on the palm (Fig. 4B). Once the tendon slips were brought out through the distal palmar crease incision, they were manipulated into passing through the A1 pulley of each finger and sutured back onto themselves forming a lasso (Fig. 4C), keeping the hand in the proper cascade.
PMC9870800_03
Orthoses used after the surgery. A Dorsal blocking orthosis wrist is neutral, MCP joints are 90  flexed, and IP joints are extended. B Dorsal blocking orthosis wrist is neutral and MCP and IP joints are free (day orthosis). C Plaster of Paris finger cylinder.
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fig5
Dorsal blocking orthosis with the wrist in neutral, MCP joint 90  flexed, and IP joint extended was used as night orthosis (Fig. 5A). Dorsal wrist neutral orthosis with free MCP joints (Fig. 5B) was used during the day to protect the coaptation of the transferred tendon. The IP joints were maintained in neutral using a finger cylinder cast (Fig. 5C) to prevent clawing (as mentioned above).
Exercises. A Activation of the EDC by blocking the MCP joint at 90  flexion. B Lumbrical position to train the MCP joint flexion and extension as IP joints are extended with the help of a finger cylinder cast. C Open hand and intrinsic plus position without assistance. D Isolated strengthening of the EDC at the PIP joint by blocking (blue arrow) the finger at the proximal phalanx (similarly, isolated strengthening of the EDC at the DIP joint is performed by the extension of the DIP joint while blocking the middle phalanx). E Active ROM exercise with a cloth. F Newspaper crumpling; a piece of newspaper is held with both hands, affected hand is placed at one end of the paper and the other hand holds the diagonally opposite end. Both upper limbs are supported. The patient is asked to crumple the paper with the affected hand without losing contact as per the directions shown by the arrow. This mass action is to be continued till the paper softens. G Strengthening of the EDC with a resistance loop; avoid hyperextension at the MCP joint. H Exercises with theraputty; holding the putty with the IP joints extended. The same action is performed with a book or cardboard.
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fig6
The IP joint extension was trained by inhibiting the force of the EDC at the MCP joint (blocking the MCP joint in flexion) and transferring the force to the IP joint for extension (Fig. 6A). Patients were asked to flex and extend the MCP joints as the finger cast maintained the IP joint extension, simulating intrinsic plus hand position (Fig. 6B). Patients were taught to actively maintain an open hand (wrist neutral, MCP joint neutral, and IP joint extended) and lumbrical position (MCP joint 90  flexed, IP joint extended) (Fig. 6C). Extension of PIP and distal interphalangeal (DIP) joints (tendon blocking) was also performed with the hand placed on the table and by blocking the segment proximal to the joint (Fig. 6D). The strengthening protocol was progressed using a resistance loop, theraputty with variation in the MCP joint flexion angle (Fig. 6G, H). Active range of motion (ROM) exercises and gentle activities, such as paper crumpling and rolling a cloth, were performed to improve ROM (Fig. 6E, F).
PMC9870800_04