Updated: 6/24/2021

Tendon Transfer Principles

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  • Principles
    • Principles of tendon transfers 
      • match muscle strength
        • force proportional to cross-sectional area
          • greatest force of contraction exerted when muscle is at resting length
        • amplitude proportional to length of muscle
        • work capacity = (force) x (amplitude)
        • motor strength will decrease one grade after transfer
          • should transfer motor grade 5
      • appropriate tensioning
      • appropriate excursion
        • can adjust with pulley or tenodesis effect
        • Smith 3-5-7 rule
          • 3 cm excursion - wrist flexors, wrist extensors
          • 5 cm excursion - EDC, FPL, EPL
          • 7 cm excursion - FDS, FDP
      • surgical priorities
        1. elbow flexion (musculocutaneous n.)
        2. shoulder stabilization (suprascapular n.)
        3. brachiothoracic pinch (pectoral n.)
        4. sensation C6-7 (lateral cord)
        5. wrist extension and finger flexion (lateral and posterior cords)
      • selection
        • determine what function is missing
        • determine what muscle-tendon units are available
        • evaluate the options for transfer
      • basic principles
        • donor must be expendable and of similar excursion and power
        • one tendon transfer performs one function
        • synergistic transfers rehabilitate more easily
        • it is optimal to have a straight line of pull
        • one grade of motor strength is lost following transfer
  • Presentation
    • Physical exam
      • brachial plexus injury
        • Horner's sign
          • correlates with C8-T1 avulsion
          • often appears 2-3 days following injury
        • severe pain in anesthetic limb
          • indication of root avulsion
        • loss of rhomboid function
          • indication of root avulsion
      • radial nerve palsy
        • classified according to location of lesion proximal or distal to the origin of PIN
          • low radial nerve palsy
            • PIN syndrome
          • high radial nerve palsy
            • loss of radial nerve proper function (triceps, brachioradialis, ECRL plus muscles innervated by PIN)
      • median nerve palsy
        • classified according to location of lesion proximal or distal to the origin of AIN
          • low median nerve palsy
            • loss of thumb opposition (APB function)
          • high median nerve palsy
            • loss of thumb opposition
            • loss of thumb, index finger, and middle finger flexion
      • ulnar nerve palsy
        • low ulnar nerve palsy
          • loss of power pinch
          • abduction of the small finger (Wartenberg sign)
          • clawing
            • results from imbalance between intrinsic and extrinsic muscles
        • high ulnar nerve palsy
          • loss of ring and small finger FDP function
            • primary distinguishing deficit
          • clawing less pronounced because extrinsic flexors are not functioning
  • Studies
    • Sensory and motor evoked potentials
      • better than standard EMG/NCS
  • Treatment
    • Nonoperative
      • physical therapy, splinting, and antispasticity medications
        • indications
          • decreased passive range of motion
          • spasticity
    • Operative
      • early surgical intervention (3 weeks to 3 months)
        • indications
          • total or near-total brachial plexus injury
          • high energy injury
      • late surgical intervention (3 to 6 months)
        • indications
          • partial upper-level brachial plexus palsy
          • low energy injury
        • postoperative care
          • protect for 3-4 weeks then begin ROM
          • continue with protective splint for 3-6 weeks
          • synergistic transfers are easier to rehabilitate (synergistic actions occur together in normal function, e.g., finger flexion and wrist extension)
    • Specific Transfers & Indications
      Goal to regain
      FROM: Donor tendon (working)
      TO: Recipient Tendon (deficient)
      Musculocutaneous nerve palsy
      Elbow flexion
      Pectoralis major, latissimus dorsi
      Biceps
      Elbow flexion
      Common flexor mass
      Point more proximal on humerus (Steindler flexorplasty)  
      Radial nerve & PIN palsy
      Elbow extension
      Deltoid, latissimus dorsi, or biceps
      Triceps
      Wrist extension
      Pronator teres
      ECRB
      Finger extension
      FDS, FCR, or FCU
      Thumb extension
      Palmaris longus or FDS
      EPL
      Low median nerve palsy
      Thumb opposition and abduction
      FDS (ring)
      Base proximal phalanx or APB tendon (use FCU as pulley - classic Bunnell opponensplasty)

      EIP
      APB (pulley around ulnar side of wrist)
      High median nerve palsy
      Thumb IP flexion
      BR
      FPL
      Index and long finger flexion
      FDP of ring and small finger (ulnar nerve)
      FDP of index and middle (side-to-side transfer)
      Ulnar nerve palsy
      Thumb adduction
      FDS or ECRB
      Adductor pollicis
      Finger abduction (index most important)
      APL, ECRL, or EIP
      1st dorsal interosseous
      Reverse clawing effect
      FDS, ECRL (must pass volar to transverse metacarpal ligament to flex proximal phalanx)
      Lateral bands of ulnar digits
  • Complications
    • Adhesions
      • necessitate aggressive therapy and possible secondary tenolysis
  • Prognosis
    • Age
      • leading prognostic factor
      • worse after age 30
    • Anatomic location
      • distal is better than proximal
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(OBQ13.103) A 26-year-old man presents with chronic hand weakness. The clinical appearance of his hand, and radiographs are shown in Figures A through C. Surgical exploration and decompression is performed. Besides addressing thumb interphalangeal and index distal interphalangeal joint flexion, which is the most appropriate treatment to restore thumb opposition?

QID: 4738
FIGURES:
1

Ring flexor digitorum superficialis transfer to the abductor pollicis brevis

22%

(975/4339)

2

Extensor indicis proprius transfer to the abductor pollicis brevis

53%

(2294/4339)

3

Neurotization of thenar muscles

5%

(210/4339)

4

Camitz palmaris longus transfer to the abductor pollicis brevis

16%

(688/4339)

5

Thumb carpometacarpal joint arthrodesis

2%

(103/4339)

L 4 B

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(OBQ10.14) A 50-year-old woman sustains an open both bone forearm fracture seen in Figure A and undergoes the treatment seen in Figure B. During surgery the posterior interosseous nerve was transected and primary repair was attempted. One year following surgery the patient continues to have no posterior interosseous nerve function. Which of the following treatments will best restore function?

QID: 3102
FIGURES:
1

Sural nerve grafting to the posterior interosseus nerve

5%

(147/2838)

2

Wrist fusion with transfer of the flexor carpi ulnaris to the finger extensors

1%

(42/2838)

3

Transfer of the flexor carpi radialis to extensor digitorum and the palmaris longus to the extensor pollicis longus

65%

(1848/2838)

4

Transfer of the pronator teres to the wrist extensors and the palmaris longus to the finger extensors

9%

(246/2838)

5

Transfer of the flexor carpi ulnaris to the wrist extensors and the palmaris longus to the extensor pollicis longus

19%

(532/2838)

L 3 B

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