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A Single-stage Operation for Reconstruction of Hand Flexion, Extension, and Intrinsic Function in Tetraplegia: The Alphabet Procedure

Fridén, Jan MD, PhD; Reinholdt, Carina MD; Turcsányii, István MD; Gohritz, Andreas MD

Techniques in Hand & Upper Extremity Surgery: December 2011 - Volume 15 - Issue 4 - p 230–235
doi: 10.1097/BTH.0b013e31821b5896

Surgical reconstruction is an established method to restore grip and grasp function after traumatic cervical spinal cord injury and tetraplegia. It can offer the patient improved ability to perform activities of daily living. Traditionally, surgical reconstruction of hand function has required separate operations for flexors and extensors. Here, we present a combination of procedures that provides key pinch and finger flexion together with opening of hand as a 1-stage operation. This reconstruction includes 7 individual operations that are performed in the following order: (1) split flexor pollicis longus-extensor pollicis longus distal thumb tenodesis, (2) reconstruction of passive interossei, (3) thumb CMC arthrodesis (4) brachioradialis-flexor pollicis longus tendon transfer, (5) extensor carpi radialis longus-flexor digitorum profundus tendon transfer, (6) EPL tenodesis, and (7) extensor carpi ulnaris tenodesis. We have chosen to entitle this reconstruction the alphabet or ABCDEFG procedure, an abbreviation for Advanced Balanced Combined Digital Extensor Flexor Grip reconstruction. To reduce the risk of adhesions after this extensive surgery and to facilitate relearning the activation of transferred muscles with new functions, early active training is performed. It is concluded that this 1-stage combination of operations can reliably provide grip, grasp, and release function in persons with C6 tetraplegia, patient satisfaction is high, time and effort for patient and caregivers are less, and incidence of complications is comparable with other published treatment modalities.

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National Center of Reconstructive Hand Surgery in Tetraplegia, Department of Hand Surgery, Sahlgrenska University Hospital, Göteborg, Sweden

Source of Funding: Funding for this project was provided from the Swedish Research Council Grant 11200, Norrbacka-Eugenia and Promobilia Foundations and University of Gothenburg.

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Conflicts of Interest: The authors report no conflicts of interest.

Address correspondence and reprint requests to Jan Fridén, MD, PhD, Department of Hand Surgery, Sahlgrenska University Hospital, Göteborg S-413 45, Sweden. e-mail:

© 2011 Lippincott Williams & Wilkins, Inc.