Definition, Indications, principles of tendon transfer, Rehabilitation, and Contraindications with diagrams.

1. INDICATIONS AND
PRINCIPLES OF TENDON
TRANSFER

2. INTRODUCTION
 In 19th century, physicians first realized that tendon
transfers could restore function to an extremity.
 Tendon transfer was initially started for poliomyelitis
in 19th century.
 Later on, tendon transfer surgery expanded to
patients with cerebral palsy and also to those who
required reconstructive surgery for traumatic
injuries that were incurred during World war I.

3. DEFINITION
A tendon transfer procedure relocates the
insertion of a functioning muscle-tendon unit
(MTU) in order to restore lost movement and
function.
 The transferred tendon remains attached to its
parent muscle with an intact neurovascular pedicle.
 “Using the power of a functioning muscle unit to activate a
non functioning nerve/muscle/tendon unit”.

4. INDICATIONS OF TENDON TRANSFER
 Most common: Peripheral nerve injury that has no
potential to improve.
 nerve injuries that are physically irreparable
such as root avulsions,
 nerve injuries that do not recover after direct
nerve repair or grafting, or
 failed nerve transfers.
 Late presentation of peripheral nerve injury as muscle re-
innervation is impossible due to motor end-plate fibrosis.

5. INDICATIONS OF TENDON
TRANSFER
Other common indications include:
 loss of muscle or tendon following
trauma,
 central neurologic deficits such as
spinal cord injuries and cerebral
palsy,
 tendon ruptures in patients with
rheumatoid arthritis,
 rarer disorders, including
poliomyelitis and leprosy

6. PRINCIPLES OF TENDON TRANSFER
1. Supple joints prior to transfer
2. Soft tissue equilibrium,
3. Donor of adequate excursion
4. Donor of adequate strength
5. expandability of donor tendon
6. Appropriate alignment: Straight line of pull
7. Synergy
8. Single function per transfer

7. 1. SUPPLE JOINT
• The joint that the tendon transfer will move must have
maximum passive range of motion prior to the procedure.
• A tendon transfer procedure will fail if the joint has become
stiff. Often, aggressive therapy is required to achieve and
maintain a supple joint before performing a tendon transfer
procedure.
• If contracture release is necessary, it should be performed
prior to the tendon transfer procedure, and should be followed
by intensive therapy to maintain range of motion.

9. 2.SOFT TISSUE EQUILIBRIUM
 The principle of soft tissue equilibrium refers
to the idea that a tendon transfer should
pass through a healthy bed of tissue that
is free from inflammation, edema and scar.
 This is necessary to allow the tendon to
glide freely and to minimize adhesions.
 Tendon transfer that passed through
inflamed scar bed will develop adhesion
and reduction of effectiveness of transfer

11. 3. DONOR OF ADEQUATE EXCURSION
 The excursion or maximum linear movement of the
transferred MTU should be adequate to achieve the
desired hand movement.
 This means that the transferred MTU should have
an excursion similar to that of the tendon which it is
replacing.

13. •There is constant relationship between size of the joint and
amount of tendon excursion over joint.
•Each joint as being as a circle having moment arm(MA)
[same as radius]
MA is distance b/w axis of joint and tendon

14. •Moment arm increases when we go proximally.
•MA increases = tendon excursion increases because
size of circle increases proximally.
•Tendon crosses multiple joints so excursion at each
joint added.

15. LOSS OF PULLEY
-BOWSTRING EFFECT
-Increases moment arm
- More tendon excursion
required

16. 3. AMPLITUDE OF EXCURSION
TENDONS AMPLITUDE (mm)
Wrist tendons 33
Flexor profundus 70
Flexor sublimis 64
Extensor digitorum communis 50
Flexor pollicis longus 52
Extensor pollicis longus 58
Extensor pollicis brevis 28
Abductor pollicis longus 28

17. • Excursion of the donor MTU should be =
or > than that of the MTU it is replacing
• always this ideal condition is not possible.
1. tenodesis can be performed to augment
the effectiveness of donor MTU(upto
25mm)
2. Release of surrounding fascia and is
exemplified by transfer of the brachio-
radialis muscle. (additional 2-3cm of
excursion)

18. TENODESIS PHENOMENON/GRASP/EFFECT
Passive insufficiency of finger extensors
occurs when the wrist is flexed

19. Passive insufficiency of finger flexors
occurs when the wrist is extended, causing
fingers to flex

20. EXAMPLE

22. 4. ADEQUATE STRENGTH
The MTU to be transferred must be
strong enough to achieve the desired
movement, but at the same time,
should not be too strong.
Strength of donor MTU should be match
to that of the MTU whose function is
being restored.

25. • MTU should not be weaken by injury or
de- nervations.
• In general a donor MTU will loose up-to one
grade of motor strength simply by being
transfer.

26. 5. EXPANDABLE DONOR
•The principle of using an expendable MTU as a donor
means that there must be another remaining muscle that can
continue to adequately perform the transferred MTU’s
original function.
• There is ample redundancy built in hand and forearm
• For example- there are 2 wrist flexor and 3 wrist
extensor.
• FCR orFCU can be transfer without loosing wrist
flexion.
• ECRL or ECRB or ECU can be transfer without loosing
wrist extension ,so 2out of 3 wrist extensor can be
transferred.

27. • PL is completely redundant.
• EIP & EDM excellent donor whose
harvest results in minimal donor
deficit.
• In addition – each finger has two flexors
(FDS & FDP) which can be used as donor
MTU.

28. 6. APPROPRIATE ALIGNMENT
: STRAIGHT LINE OF PULL
Tendon transfer procedures are most
effective if there is a straight line of pull. This
is because direction changes diminish the
force that the transferred MTU is able to
exert on its insertion.
A change in direction of just 40 degrees will
result in a clinically significant loss of force.

29. • For example, a PT to ECRB transfer is commonly used to
restore wrist extension in patients with radial nerve palsy.
•This transfer can be performed in an end-to-side or end-to-end
fashion
• END – TO- END is better than END – TO – SIDE transfer.
•IF THERE IS CHANCE OF RADIAL NERVE RECOVERY
than end- to- side transfer is done.

30. • However if a direction change is unavoidable or
even necessary. In these cases, the tendon should
be passed around a fixed, smooth structure that
can act as a pulley.
• Example- opponenplasties are routed from
the level of pisiform toward the abductor
pollicis brevis insertion , a line of pull that
produces thumb opposition.
• Although this direction change weakens the
transfer, it is necessary to achieve opposition

32. 7. SYNERGY
The principle of synergy refers to the
fact that certain muscle groups
usually work together to perform a
function or movement.

33. • Example-
• Wrist extension and finger flexion are
synergistic for grasping.
• Wrist flexion and finger extension are
synergistic.
• So when wrist flexors are transfer to restore
finger extension then patient learn to use the
transfer without much difficulty.
• Certain MTU such as FDS are able to adapt to new
function readily whether that muscle is synergistic or not.

34. 8. Single function per transfer
• The final principle is that a single tendon should be used to
restore a single function.
• Transfer of one MTU to restore multiple functions will
result in compromised strength and movement.
•The exception to this rule is that a single MTU can be used
to restore the same movement in more than one digit.

35. For example, the FCU cannot be used to power
wrist and finger extension, or to power finger
extension and thumb abduction. However, it can be
used to power the extension of all four fingers.

36. REHABILITATION
• In general tendon transfer are immobilize for
4weeks post operatively.
• During this 4 weeks , it is critical to maintain
motion in the uninvolved joint in order to
prevent stiffness.
• Splint applied for 2weeks post operatively.
Suture removal is done at the time of splint
removal.
• Followed by cast is applied for next 2weeks.

37. • Rehabilitation is initiated after 4weeks.
• Thermoplast splint is made and it is worn when patient
is not performing prescribed exercise.

38. • After 4weeks gentle active and assisted active
exercise is initiated and also synergistic
movements are taught.
• Electrical stimulation and biofeedback can be
useful.
• At 6weeks passive stretching of the transfer is
gradually introduce.
• At 8th weeks strenghtning is begun and splint is
gradually weaned off for light hand use.
• Full unrestricted activity is allowed at 3months
post operatively.

39. CONTRAINDICATIONS
to tendon The only absolute contraindication
transfer is a lack of appropriate donors.
 The availability of muscle-tendon units with less
than grade 5 strength is a relative contraindication.
 Similarly, if only muscles that have been
denervated and then re-innervated are available,
this is also a relative contraindication.

40. CONTRAINDICATIONS
 Transfers planned in individuals with progressive
neuromuscular diseases should be carefully
considered
underlying
before proceeding
disease process may affect
because the
the
transferred unit.

41. THANK YOU