Surgical treatment for the thumb-in-palm deformity in patients with cerebral palsy
Editorial Group: Cochrane Movement Disorders Group
Published Online: 19 OCT 2005
Assessed as up-to-date: 26 JUN 2005
Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Smeulders MJ, Coester A, Kreulen M. Surgical treatment for the thumb-in-palm deformity in patients with cerebral palsy. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD004093. DOI: 10.1002/14651858.CD004093.pub2.
- Publication Status: Edited (no change to conclusions)
- Published Online: 19 OCT 2005
Thumb-in-palm deformity in patients with spastic cerebral palsy is a deformity that impairs the ability to use the thumb and thus severely limits hand function. From the variety of operative procedures that have been described, it may be clear that there is no consensus on the surgical treatment of thumb-in-palm deformity.
To review the efficacy of surgical interventions for the thumb-in-palm deformity in patients with spastic cerebral palsy; to review the selection criteria to surgically treat thumb-in-palm deformity in these patients; and to review the outcome assessment used in these studies.
We identified studies for inclusion from searches of several electronic databases: the Cochrane Central Register of Controlled Trials (Issue 4, 2003), MEDLINE (1966 to December 2004), EMBASE (1980 to December 2004) and CINAHL (1982 to December 2004).
We also cross-checked the reference lists of these studies to identify additional studies.
We considered a trial eligible for inclusion when it met the following criteria. 1) It was described as a randomized clinical trial, clinical controlled trial or prospective study that compared pre-operative- with post-operative outcome assessment. 2) It concerned patients with thumb-in-palm deformity affected by spastic cerebral palsy. There was no restriction in age. 3) It compared or described any surgical intervention to the thumb. 4) It followed subjects for at least six months. 5) Outcomes described included one or more of the following items: rate of success; functional improvement; active and passive range of motion of the thumb; grasp and release; pinch grip; complications and side effects; and quality of life.
Data collection and analysis
Two authors assessed each study using a scoring system. Meta-analysis was not possible because the selected studies were poorly designed, and the results were presented in an incompatible form. Therefore, we compiled a descriptive summary of the results of the individual studies. We did not attempt to acquire the raw data for re-analysis.
We identified 14 prospective studies that compared preoperative and postoperative outcomes as eligible for inclusion in this review. We found no randomized clinical trials or controlled clinical trials. The studies with the best available evidence were prospective studies that compared pre- with post-operative assessment. After assessment, we ultimately included nine studies.
In all the included studies the participants were more or less homogeneous regarding the most important prognostic indications. The nine included studies treated 234 patients. Age at operation ranged from 4-48 years (Median approximately 11 years).
Twenty-four different specific interventions were performed, or combined, aiming to 1) stabilize the first metacarpophalangeal joint, 2) weaken the spastic thumb adductors, and 3) augment thumb abduction and extension.
All of the included studies assessed whether the thumb had stayed out of the palm at follow-up. Additional outcome measures varied among studies.
There was no consensus on the selection criteria for eligibility for surgical treatment. There was also considerable variety in the use of methods of assessment among the studies. There is no standardized method to evaluate the pre- and post-operative data, and most of the assessment methods were not validated. It was impossible to compare the outcomes among studies. Judgement about the effectiveness of one particular surgical intervention was not possible, because different surgical interventions and co-interventions were used within most studies.
Nonetheless, generally, the outcome of surgical treatment of thumb-in-palm deformity was considered satisfactory to both patients and to surgeons in all studies.
Because the methodological quality of the studies is poor, it is impossible to provide a reliable judgement of the role of surgery for thumb-in-palm deformity. This review has demonstrated the need for randomized clinical trials or controlled clinical trials on the surgical treatment of thumb-in-palm deformity. Surgical reconstruction appears to improve hand function, to facilitate hygiene, and to improve the appearance and quality of life. For patient selection, a validated classification system should be developed to determine the type and extent of the cerebral palsied hand. The influence of age, intelligence, and voluntary muscle control still needs to be investigated. Investigators should focus on one particular surgical intervention or a specific group of interventions to find out which procedures produce the best functional improvement.
Plain language summary
Thumb-in-palm surgery appears to lead to modest improvement in hand function and quality of life in people with cerebral palsy.
Cerebral palsy (CP) is a movement disorder caused by damage to the brain around birth. It causes muscle spasms and contractions that can lead to a condition called thumb-in- palm deformity, severely limiting hand function. Thumb-in-palm surgery is sometimes tried to improve ability to use the thumb. This review found no randomized controlled trials of thumb-in-palm surgery, but some other types of studies. Although some people with CP who had thumb-in-palm surgery experienced some improvement in movement, the improvement was generally modest. Trials are needed to show if thumb-in-palm surgery can improve function and quality of life for people with CP.
Thumbinpalm畸形是痙攣性腦性麻痺患者(spastic cerebral palsy)的一種畸形，它會妨礙使用拇指的能力，並且嚴重限制手部功能。從各式各樣已被描述過的手術方式可以知道，目前對此種thumbinpalm畸形的手術治療方式並沒有一良好的共識。
藉由搜尋幾個電子資料庫，我們找到了收錄的研究：Cochrane Central Register of Controlled Trials (Issue 4，2003)，MEDLINE(1966年至2004年12月)，EMBASE(1980年至2004年12月)和CINAHL(1982年至2004年12月)。我們還交叉檢查了這些研究參考文獻的列表，以找出附加的研究結果。
我們認為有資格收錄的試驗符合下列標準: 1)有比較術前與術後成果的隨機臨床試驗、臨床對照試驗或前瞻性研究。2)有關痙攣性腦性麻痺患者的thumbinpalm畸形。沒有年齡限制。3)有比較或描述拇指的手術方式。4)追蹤至少6個月以上。 5)成果的描述包括一個以上的下列項目：成功率、功能改善、拇指主動和被動運動範圍、抓握和放鬆;捏握;併發症及副作用;和生活品質。
我們找了14個比較術前和術後結果的前瞻性研究收錄於本篇回顧分析中。我們沒有找到任何隨機臨床試驗或臨床對照試驗。具有最佳證據的試驗為比較術前與術後評估的前瞻性研究。經審查後，我們最終收錄了9個研究。參與者:所有收錄的研究中參與者的預後指標是近似的。收錄的9個研究包含234例接受治療的病人。接受手術的年齡介於4 – 48歲間(中位數約11歲)。術式:其中包含了24種不同的術式，有些是合併施行，主要目的在於1)穩定第一掌指關節，2)減輕拇指內收肌痙攣，3)增加拇指外展和伸展功能。成效評估: 所有收錄的研究均有評估拇指是否能與手掌分開。其他額外的成效評估則隨各研究而不同。選擇標準:對於合宜的手術治療方式的選擇標準目前仍沒有共識。各研究所使用的評估方式也有相當大的不同。因此也沒有標準的方法來評估術前和術後的資料，大多數評估方法都是不適用的。要比較這些研究的成果是不可能的。要評斷某一特定手術方式的治療效果也是不可能的，因為大多的研究都包含不同的手術方式並且又合併其他的治療。不過一般來說，以手術治療thumbinpalm畸形的成效，對病人和外科醫生來說都是尚稱滿意的。
此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。