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Updated: Jun 24 2021

Tendon Transfer Principles

Images transfers.jpg opponensplasty illustration.jpg
  • 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)
      • 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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