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WORKSHOP REPORT
Re-enablement of the neurologically impaired
hand – 2: surgical correction. Report of a Surgical
Workshop held at Green Pastures Hospital and
Rehabilitation Centre, November 2004,
Pokhara, Nepal
R. J. SCHWARZ** & J. W. BRANDSMA*, ON BEHALF OF
THE WORKSHOP PARTICIPANTS AND REVIEWERS
*Formerly Consultant Rehabilitation, **formerly Surgeon and
Medical Superintendent, Green Pastures Hospital and Rehabilitation
Centre (GPH&RC)
*International Nepal Fellowship (INF), PO Box 28, Pokhara, Nepal
Accepted for publication 25 September 2006
Introduction
In a separate paper (see this issue) the authors discussed non-surgical aspects of the
neurologically impaired hand as frequently seen in people affected by leprosy neuropathy.
These aspects included applied anatomy, terminology and assessment. An adequate
understanding of the neurologically impaired hand, and its primary and secondary
impairments, is necessary to be able to judge how specific surgical interventions may affect
the functioning of the hand. It was also concluded that to be able to fully ’value’ the effects of
reconstructive procedures, the assessment and evaluation of interventions should be at the
three levels of human functioning: impairment, activity and participation.
1
It is recommended that the reader is familiar with the material discussed in the companion
article to this paper.
2
In this paper, the common surgical procedures are discussed. The procedures for
uncomplicated neurologically impaired hand with paralysis of ulnar, median or radial nerve
paralysis will be discussed first, followed by surgical interventions for the impairments that
may have developed secondary to the paralysis or the surgery. Recommendations for best
practice and further research will be given.
Workshop participants/reviewers: P Das, F Duerksen, J Joshua, MRC Macdonald, GN Malaviya, S Murray,
JF Negrini, A Salafia, TAR Schreuders
Correspondence to: J. W. Brandsma (e-mail: wim@alert.et)
Lepr Rev (2006) 77, 326–342
0305-7518//064053+17 $1.00 qLepra 326
Primary impairments
The most commonly affected nerve in the upper extremity is the ulnar nerve, followed
by the median nerve. Median nerve palsy usually presents with associated ulnar nerve
palsy, but can occur in isolation. Radial nerve palsy is relatively rare. When present, it is
usually part of a ‘triple palsy’, impairment of ulnar, median, and radial nerves. High
median nerve impairment and the occurrence of the so-called flail hand, that is, the hand
without any intrinsic or extrinsic muscle function, is extremely rare and will not be
discussed.
Ulnar nerve palsy
In leprosy affected nerve-impaired hands, dynamic correction (tendon transfer) procedures
are the operations of choice to correct the claw deformity.
3–7
Static corrections should only
be considered when there are no active muscles available, e.g. in triple/high median nerve
palsies. A pulley advancement or Srinavasan’s extensor diversion would be preferred static
techniques, as they have less likelihood of recurrence of deformity than a metacarpopha-
langeal (MCP) joint capsulodesis.
8–12
When performing tendon transfers, the surgeon should
consider the type of hand and the severity of impairments and choose the most appropriate
procedure, rather than performing the same procedure for all patients.
13
All secondary
impairments should preferably be corrected prior to the procedure, although not always
will all secondary impairments be correctable. The exception is ’hooding’, which can be
corrected at the same time as the intrinsic replacement procedure.
14,15
Mild hooding, less than
20–30 degrees short of active-assisted extension, can often be overcome by prolonged
serial casting.
RECOMMENDED PROCEDURES
For the hypermobile hand, we recommend a palmaris longus to pulley or lateral band
insertion or a transfer of the extensor carpi radialis longus (ECRL) to the A1-2 pulley
insertion.
16 – 19
We refer to the study by Lee and Rodrigues for a discussion about the relative
advantage of various insertion sites of a transfer.
20
For the mobile hand that does not extend beyond neutral in active assisted-extension, we
prefer a lateral band insertion or a flexor digitorum superficialis (FDS) insertion to the
pulley.
21– 27
The technique of harvesting the FDS tendon may influence the risk of post-operative
complications in the donor finger, such as swan-neck and check-rein deformities.
28,29
Existing
evidence would suggest that a palmar approach is associated with a lower rate of donor finger
complications than a lateral approach.
30
The FDS can be easily and safely harvested through the
palmar incision during a FDS to pulleyinsertion procedure.Duerksen recommends a tenodesis of
the FDS stump to the A2 pulley to prevent swan-neck. He also stresses the need for good
haemostasis when the vinculae are transsected. (Duerksen, personal communication).
For the stiff hand, with mild contractures present, we recommend an ECRL or FDS to
lateral band insertion.
31,32
Technically, the ECRL transfer requires more skill but the FDS
may leave a defect in the donor finger. The FDS, however, is the stronger muscle. Both are
easy to re-educate.
Re-enablement of the neurologically impaired hand – 2 327
For fear of compromising the median nerve in the carpal tunnel, some surgeons
prefer to stay on the extensor side of the wrist when tunnelling an extrinsic tendon to the
fingers in an isolated ulnar palsy. Brand has shown that there is ample space in the
carpal tunnel to accommodate an extra tendon. When the tunnelling is done in a correct
manner this fear seems to be unjustified.
33,34
Some surgeons add a fifth slip to the
thumb for correction of thumb interphalangeal joint hyperflexion, or into the metacarpal
head of the little finger to correct the loss of the metacarpal arch.
35 – 37
In each case, the
additional slip acts on a joint with different moment arm and different excursion, and in
the case of the extra slip to the thumb, a very different direction of pull.
Biomechanically, the value of these additional transfers is questionable and they may
compromise the function of the intrinsic replacement.
38
No research has been done to
assess the effectiveness of either addition. An additional slip to the thumb is not
recommended, and the effect of adding a slip to the fifth metacarpal needs to be properly
assessed.
RESEARCH
More studies are needed comparing the different procedures to correct claw finger deformity
to find out the relative (dis) advantages given the pre-operative condition of the hand.
6,39,40
The FDS of ring and middle fingers are important potential donor muscles in ulnar and
median nerve palsy. In a large number of patients, removal of the FDS results in a defect on
the donor finger. When should the FDS not be removed? What can be done to prevent or
correct a defect? Does the incision and method of harvesting the tendon have a bearing on the
incidence of a secondary defect?
Little is known regarding how intrinsic paralysis effects grip/pinch strength and to what
extent the strength of the hand is affected by the various tendon transfer procedures. Often a
better grip/pinch function is expressed by the patient as better/improved strength because the
grip is more secure and pinch activities are restored. Is grip strength related to the muscle
used, its relationship to the wrist axis and insertion?
Early mobilization of flexor tendon repairs following traumatic lacerations is common
practice. Following tendon transfers the hand/fingers are commonly immobilized for 3 weeks
in a cast. Some centres, however, now open the plaster cast after a few days, leaving a slab,
and begin mobilization. The effect of early mobilization on time to discharge and end result
needs to be assessed.
How does the dorsal versus volar approach of wrist extensor to fingers effect the
metacarpal arch and grip strength? Some research has been done in this area.
41
The effect of tendon transfers in ulnar palsy on the ability to perform activities of daily
living needs to be researched.
The thumb in ulnar palsy
Ulnar nerve palsy causes paralysis of the first dorsal interosseus, the adductor pollicis
and often the flexor pollicis brevis. The two basic impairments seen in the thumb in
ulnar nerve palsy are a marked decrease in strength of the key pinch and in the pulp-to-
pulp pinch (due to paralysis of adductor pollicis, first dorsal interosseus and flexor
pollicis brevis).
R. J. Schwarz & J. W. Brandsma328
RESTORATION OF KEY PINCH (ADDUCTION)
Little is known about the effects of restoration of adduction loss in ulnar nerve palsy. What is
known is that restoration is not commonly practised! Two studies have reported an increase in
key pinch strength, but no functional outcomes have been measured.
42,43
Many surgeons
support the use of a FDS to adductor pollicis transfer in ulnar palsy.
42 – 45
The ECRB transfer
described by Smith has the real disadvantage of sacrificing the principle extensor of the
wrist.
42
Smith stopped using this transfer after he had described it (personal communication).
Both the ECRB and FDS transfers for restoration of adduction have the disadvantage of a
near 90-degree turn in the transferred tendon, putting it at a mechanical disadvantage. Fisher
et al. reported the use of ECRL for adductor replacement. They used the APL to substitute for
the loss of the first dorsal interosseus.
46
RESTORATION OF PRIMARY THUMB MCP FLEXION
In many cases of ulnar nerve palsies, the loss of primary thumb MCP flexion will lead to
interphalangeal (IP) joint hyperflexion (Froment’s sign), sometimes combined with MCP
hyperextension (Z-thumb). This is a significant deformity, as the contact surface of the thumb
becomes the nail rather than the pulp, leading to an unstable grip and the risk of self-injury.
RECOMMENDED PROCEDURES
Often in combined ulnar/median nerve palsy, the two-tailed opponensplasty will correct the
deformity. If surgical intervention is indicated, four options are available.
MCP arthrodesis. This is recommended for a stiff or severely hyperextended Z-thumb
(Figure 1).
15
Figure 1. Severe Z-deformity of thumb.
Re-enablement of the neurologically impaired hand – 2 329
Half of flexor pollicis longus to extensor pollicis longus transfer. This is recommended for
a mobile Z-thumb.
12,47
IP arthrodesis. This procedure is recommended when there is a fixed flexion contracture
of the IP joint.
Adductor replacement as described above. This could be considered in the mobile
thumb.
48,49
RESEARCH
The possible benefits of adductor replacement for the thumb in ulnar nerve palsy need to be
researched with special regard to the functional outcomes. When should an adductor
replacement be used?
Which surgical techniques should be employed to give the best outcome given the
primary and secondary impairments?
Median nerve palsy
Loss of opposition is a very significant functional impairment, although in pure median nerve
palsy opposition is often adequately preserved, especially when the flexor pollicis brevis is
entirely innervated by the ulnar nerve. In cases of isolated median palsy without adequate
functional opposition, palmaris longus transfer should be considered.
50
In combined ulnar/
median nerve palsies reconstructive surgery is always indicated. Secondary defects, such as
web space and joint contractures, need to be dealt with prior to or at the time of surgery.
RECOMMENDED PROCEDURES
Extensor indicis proprius (EIP) and FDS transfers are both considered good options in pure
median nerve palsies.
4,51 – 55
In combined ulnar and median palsy, the Brand two-tailed FDS
transfer is recommended to assist in interphalangeal extension.
38,56,57
An EIP or extensor
pollicis longus (EPL) transfer, often in combination with a half flexor pollicis longus to EPL
transfer, is also an option (Figure 2).
58,59
Attachment of the transfer to the radial side of the
joint capsule produces good abduction but insufficient rotation for pulp-to-pulp pinch
activities.
Figure 2. Extensor pollicis longus transfer (From: Schwarz and Brandsma, Surgical rehabilitation in leprosy and
other neuropathies. EKTA, Kathmandu, 2004).
R. J. Schwarz & J. W. Brandsma330
RESEARCH
Guidelines for indications for opponensplasty in isolated median palsy need to be developed.
A study, comparing the commonly available techniques for opponensplasty in isolated
median nerve palsy is needed.
Guidelines are needed for indications for tendon transfers in combined ulnar and median
palsy given the presence of possible underlying secondary impairments.
Triple palsy
This is an uncommon but serious impairment. The typical pattern is a high ulnar/high radial
and low median nerve palsy. Sometimes there will be high median nerve impairment in which
case there will not be any muscles available for transfer. Some patients may not be candidates
for surgery due to a lack of motivation or a severe deficit with associated secondary
deformities. This condition can be managed surgically in two sessions as follows.
60 – 69
RECOMMENDED PROCEDURES
In the first stage, the PT is transferred to ECRB and yoked to the ECRL, and re-routed to the
base of the ring metacarpal. The FCR is transferred to the EDC, possibly also the EPL.
Alternatively, the PL could be transferred to dissected and re-routed EPL.
In the second session, the FDS of the long finger is transferred to the lateral bands of the
fingers and the FDS of the ring finger is used for opponensplasty.
Yoking of the re-routed ECRL to ECRB for the pronator teres transfer is strongly
recommended, as there is a significant risk of radial deviation if the pronator teres is attached
to the ECRB alone.
38,70,71
The FCR transfer also has a tendency to cause radial deviation. A
wrist arthrodesis is almost never indicated. This may reduce the function of the hand but
rarely the power, as the wrist is now stable in a functional position. If available, primary writs
moving muscles could be used to further enhance the function of the hand.
68,72,73
In a
severely paralysed hand, a hinge-hand procedure may often give a better result than an
arthrodesis as it allows the tenodesis effect of wrist flexion on finger extension and vice
versa.
74 – 76
SECONDARY IMPAIRMENTS
Secondary impairments can develop as a result of primary impairments, primarily muscle
imbalance and loss of protective sensation. Basic exercises and life style changes can too a
great extent prevent these from happening. Secondary impairments may also follow certain
reconstructive procedures.
The hand without secondary impairments is potentially the best hand for a successful
outcome of tendon transfer surgery. The general principle with these impairments is to Avoid,
Recognize and Treat.
The secondary impairments can in almost all instances be avoided by early diagnosis of
leprosy, appropriate health education, therapy and timely surgery for primary impairments if
indicated.
77
Secondary impairments must be recognized quickly before they progress to a point
Re-enablement of the neurologically impaired hand – 2 331
of irreversibility or serious functional loss. Finally, they should be treated appropriately as
outlined below.
Joint contractures
Longstanding ulnar nerve palsy with clawing can lead to contractures of collateral ligaments,
volar plate and joint capsule of the PIP and, less often, the DIP joints (Figure 3). Prevention of
contractures, involving ‘passive’ and active-assisted exercises after the diagnosis of ulnar
palsy, obviously gives superior results to treatment after they are established. For the ‘mobile’
hand, that is the hand with full assisted extension, active-assisted extension exercises will
suffice to prevent contractures.
78,79
When contractures are present, ‘passive’ extension
exercises are needed to overcome the contractures. Depending on the severity of the
contractures this may be supplemented with serial casting or other splints.
80,81
The splinting
can be carried out with either serial plasters, a thermoplastic splint, or the JESS (Joshi
External Stabilising System).
82,83
Once splinting shows no progress over a period of 2 weeks,
it is unlikely that any additional benefit will be seen. At this point surgical options should be
considered. Severe contractures will not infrequently be seen in patients with poor
motivation, and so an evaluation of the patient’s motivation for surgery must be made before
embarking on any of these procedures.
PIP joint contracture
The PIP joint contracture is the most common contracture associated with clawing. If therapy
fails to fully extend the joint, and the joint can still fully flex, attempts should be made to carry
out a soft tissue release rather than an arthrodesis. A mobile moderately contracted PIP joint
Figure 3. Moderate contractures of ring finger and severe contracture of little finger.
R. J. Schwarz & J. W. Brandsma332
is more functional than a fixed one.
14,15,84
A ‘mobile’ contracted joint refers to a joint which
has an extension loss on passive extension but still has a reasonable range of motion into
flexion.
RECOMMENDED PROCEDURES
A skin and lateral ligament release as described by Fritschi can be very effective, or a local
flap can be used to cover the skin defect.
14,85
Gradual distraction with the JESS system has
reported good results (Figure 4).
83,86
The JESS system when taking special precautions can
be used safely on the neuropathic hand. Once the contracture has been maximally released,
the intrinsic replacement should be done using the FDS from the contracted finger, if still
contracted, and transferred to the lateral bands to maximize PIP extension. Dorsal fixation of
the lateral bands may have to be carried out as well.
PIP joint arthrodesis in a functional position should be considered in severe fixed joint
contractures that fail all attempts at release.
15,87,88
The angle of fixation needs to be discussed
with the patient and depends on hand usage. Occasionally amputation at the PIP joint will
give equivalent results to arthrodesis.
12
RESEARCH
A comparison between the JESS system and present conventional techniques such as serial
casting and exercises needs to be done. Outcome measures should specify complications,
cost, patient acceptance and time to correction of deformity.
Figure 4. Bilateral single JESS (From: Schwarz and Brandsma, Surgical rehabilitation in leprosy and other
neuropathies. EKYA, Kathmandu, 2004).
Re-enablement of the neurologically impaired hand – 2 333
DIP joint contracture
A severe DIP contracture may cause functional problems with grasp and pinch and is, in an
insensate hand, a risk factor for ulceration. Soft tissue releases are generally inadequate, and
arthrodesis is recommended.
Thumbweb contracture
Thumb web contractures should be prevented by simple exercises. When present and mild,
the contracture can be overcome with simple exercises and splinting.
Severe contractures will require surgical intervention, with either a Z-plasty and/or a
dorsal release and skin graft..
14,89
The most severe types may require a dorsal flap
webplasty.
90 – 92
Carpometacarpal joint disorders
The thumb carpometacarpal (CMC) joint (trapezio-metacarpal joint) is the key joint for
thumb function. This is the joint where opposition occurs. Encountering any pathology in this
joint with pure median palsy is unlikely. It may happen in ulnar palsy and is often seen in
long-standing, combined, ulnar and median palsy. Two pathologies can be seen.
CONTRACTURE OF THE CARPOMETACARPAL JOINT
This is common, and associated with longstanding ulnar-median palsy leading to retro-
positioning of the thumb and shortening of the carpometacarpal ligaments. This can cause
restriction in opposition and may be associated with first web space contracture and dorsal
skin deficiency. If this fails to respond to therapy, surgical release is indicated prior to
opponensplasty.
CARPOMETACARPAL DISLOCATION
This condition is often unrecognized but is reported in 20% of ulnar/ median nerve palsy
hands.
93
It is possible that under-recognition is a cause of some failed opponensplasties.
Various techniques have been described.
14,93 – 95
CMC joint arthrodesis is not recommended,
as it is likely to cause an even greater impairment.
Capsular reconstruction as described by Eaton is highly successful and causes no joint
limitation problems (Figure 5). A good repair will put the thumb in a more abducted position.
RESEARCH
Guidelines are needed for better assessment and understanding of thumb carpometacarpal
disorders. These are needed to able to better evaluate and compare the outcome of various
surgical procedures to correct thumb CMC disorders.
R. J. Schwarz & J. W. Brandsma334
PIP extension deficit (hooding deformity)
The cause for ‘hooding’ is attenuation of the central extensor tendon, either from
longstanding clawing or from trauma on the dorsal PIP joint and exposure/ necrosis of the
central tendon. In longstanding cases a PIP joint contracture may develop. A Boutonniere
deformity is a more severe presentation of this condition, and is essentially a hooding
deformity with a fixed distal inter-phalangeal joint extension contracture.
RECOMMENDED PROCEDURES
The hooding deformity is well treated by the dorsal fixation of the lateral band procedure,
which can be carried out at the same time as the intrinsic reconstruction.
14
Other options
would be reconstruction of the central tendon (more likely to fail) or a lateral band crossover.
In a Boutonniere deformity it is important to first correct the joint contractures with therapy.
When correcting the clawing deformity, if a Boutonniere deformity is present in the ring or
Figure 5. Reconstruction of thumb carpometacarpal joint (From: Schwarz and Brandsma, Surgical rehabilitation in
leprosy and other neuropathies. EKTA, Kathmandu, 2004).
Re-enablement of the neurologically impaired hand – 2 335
middle finger, it is recommended to use the FDS from that finger as the donor tendon.
Surgical release of the contracted DIP joint may also be indicated.
RESEARCH
The incidence of hooding/boutonniere deformity in intrinsic paralysis and its independent
functional effects are unknown and the long-term effects following correction need to be
further researched.
Finger flexor tightness
In longstanding clawing, the chronic flexed position of the fingers can lead to shortening of
the long flexors of the fingers. Usually this responds well to splinting (preferred) and
exercises. Some hands will require many months of therapy to attain full muscle length.
These patients may be best served with fascia and aponeurosis release.
96,97
RESEARCH
.A method of quantifying the degree of extrinsic finger flexor tightness needs to be
developed.
.When are exercises/splinting indicated or is surgery needed to overcome severe flexor
tightness and to what extent does flexor tightness interfere with the outcome of intrinsic
replacement?
.Can the intrinsic replacement procedure be carried out concomitant to the aponeurosis
release? If not, what time gap is required?
Minus or mitten hand
This condition is defined as a hand with severely shortened digits, especially the thumb
(Figure 6). Malaviya has graded this condition according to severity and degree of thumb
involvement.
98
This serious deformity comes from many years of neglect and fortunately is
seen much less commonly now. This is the most obvious example of the adage ‘prevention is
better than cure’, as truly there is no cure for this condition. Certain interventions however
can ameliorate the functional deficits these patients have.
A thorough assessment is required of both hands and feet, the patient’s motivation and
what their required functional limitations are. Patients with this severe a deformity tend to
have low motivation so interventions should be kept simple. In most cases various hand
orthoses can be made to enable the patient to carry out the needed activities of daily living
(ADL).
99
These are custom-made from self-hardening putty such as Modulan (Ciba-Geigy).
Surgical interventions should generally focus on the thumb, as the majority of hand
functions involve the thumb.
100
If the entire proximal phalanx is present, usually no
lengthening procedure is indicated.
RECOMMENDED PROCEDURE
Phalangization of the thumb metacarpal is indicated if less than half of the proximal phalanx
is present.
101,102
This is best done by a deep Z-webplasty, or better by a dorsal flap webplasty.
Following phalangization, a tendon transfer may be indicated to enhance pinching.
R. J. Schwarz & J. W. Brandsma336
For more proximal degrees of loss, a finger transfer may be indicated.
98,103
Gillie’s
procedure, while recommended in the past, has a high complication rate.
98,104,105
If no
phalanxes are present a second metacarpal transfer may be indicated.
106
Osteocutaneous
flaps based on the radial or the posterior interosseus arteries may be suitable in some
centres.
98,107,108
For hand loss up to the wrist level, a Krukenberg operation may provide
functional benefit.
109,110
First webspace wasting
This is almost universal in ulnar nerve palsy. In many societies it does not appear to be a
problem, but in some societies cosmetic concerns lead to many patients requesting
correction.
Dermal grafts, although tedious due to the large amount of dermis required, have a good
success rate whereas fat grafts have a strong tendency to resorb.
15
Silicone implants,
especially of the gel capsule type, have a good cosmetic appearance, are technically easy to
carry out, and have a low complication rate.
111,112
Secondary impairments related to surgery
DEFECTS ON DONOR FINGER WHEN FDS IS USED
Check-rein
This presents as a fixed PIP joint flexion contracture and is caused by adhesions from the
FDS stumps to the flexor tendon sheath with subsequent scar contracture. Anderson reported
an 8% incidence using a lateral FDS removal incision vs 0% when a palmar approach
Figure 6. Severe mitten hands.
Re-enablement of the neurologically impaired hand – 2 337
was used.
54,113
Brandsma reported 26% in his series.
28
Prevention is again the best policy,
with early post-operative exercises, gentle PIP joint extension, and immediate night splinting
once the complication is detected. Once established, surgical release is indicated, but this has
a high incidence of recurrence.
Research A better understanding of check-rein deformity is needed. When is it likely to
develop and how can it best be prevented or corrected if established?
Swan-neck
Also known as FDS-minus or intrinsic plus finger, it presents as PIP extension with DIP
flexion. It can be a very disabling deformity. It was seen in 44% of cases using a lateral FDS
harvesting incision vs 8% using a palmar incision in Anderson’s series.
113
The deformity will
be very common in hypermobile hands if the FDS is used as a donor tendon, and as such an
FDS transfer in a hypermobile hand is contraindicated. Implantation of the FDS stump into
FDP or the flexor tendon sheath at the time of transfer has been proposed to prevent this
complication but a comparative trial has not been done. In mild cases only passive flexion
exercises are indicated.
Recommended procedures If fixed deformities have developed, Littler’s procedure
(excision of a triangle of oblique fibres at the mid proximal phalangeal level) may be
indicated.
114
Other procedures, such as lateral band re-routing or lateral band distal slide
may give better results.
15,29,115 – 119
Research Existing approaches for the prevention of swan-neck deformity need to be more
widely implemented. Better techniques for treatment of established swan-neck deformities
may need to be developed.
DIP joint hyperflexion
Hyperflexion of the DIP joint is commonly seen after FDS removal and is essentially a mild
form of the swan-neck deformity.
28
Sometimes this deformity is referred to as a profundus
plus deformity. It is generally not a significant functional problem. Methods of prevention
and treatment are similar to those described under swan-neck deformity.
Summary
The last half-century has seen tremendous advances in the surgical treatment of neuropathic
conditions of the hand. Many of these procedures give clear benefit to patients and have been
established by clinical practice and well-formulated assessment. However, much remains to
be discovered, especially with respect to which procedures should be used on which hands,
and the impact of various procedures on the ability to carry out activities of daily living.
Increased communication between the ‘West’, where funding is available for well designed
trials and where reference textbooks are usually published, and the ‘East’, where the surgery
is most commonly performed, will undoubtedly lead to an even better understanding of the
treatment of the neuropathic hand.
R. J. Schwarz & J. W. Brandsma338
Acknowledgements
We wish to thank American Leprosy Missions for sponsoring the hand workshop and an
anonymous reviewer for useful comments.
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