Tendon transfer- principles and techniques

1. TENDON TRANSFER

2. • Definition
• Indications
• Principles
• Radial nerve palsy (goals & tendon transfers)
• Median nerve palsy (goals & tendon transfers)
• Ulnar nerve palsy (goals & tendon transfers)
• Rehabilitation

3. Definition
• Re-routing of a functioning muscle tendon
unit (MTU) to a new insertion, in order to
restore a function that has been lost

4. Indication
• Nerve root avulsions (irreparable),
• Failed nerve repairs or reconstructions,
• Nerve injuries that present too late for recovery
due to motor end-plate fibrosis.
• Loss of tendon or muscle substance from trauma.
• Tendon rupture (such as in rheumatoid arthritis)
• Central neurologic deficits (e.g., spinal cord
injuries, stroke, and cerebral palsy).
• Leprosy

5. PRINCIPLES OF TENDON
TRANSFER

6. • Supple Joints
• Soft Tissue Equilibrium
• Adequate Excursion
• Appropriate Strength of Donor
• Expendable Donor
• Straight Line of Pull
• Synergy
• Single Transfer, Single Function

7. Supple Joints
• Hand therapy or surgical release
• Joint or contracture release should never be
performed at the same time as the tendon
transfer.

8. Soft Tissue Equilibrium
• Free of edema, inflammation, or scar, so that
the tendon transfer can glide freely

9. Adequate Excursion
• Donor MTU should have enough excursion, or
linear movement, to achieve the desired
motion at the target joint.
• Equal to or greater than that of the MTU it is
replacing
• Extrinsic finger flexors 70 mm of excursion
• Extrinsic finger extensors 50 mm of excursion
• Extrinsic wrist motors 30 mm of excursion

11. Appropriate Strength of Donor
• Strongest donor (BR and FCU)- relative
strength of 2 units.
• FCR, the wrist extensors, the finger flexors,
and PT- 1 unit.
• Finger extensors- 0.5 units each.
• Weakest donor (PL) and thumb extensors and
abductors- 0.1 units.

12. • Donor MTU will lose up to one grade of motor
strength simply by being transferred

14. Expendable Donor

15. Straight Line of Pull
• Any direction change or pulley decreases the
force of the transfer
• Exceptions:
– PT to ECRB
– Opponensplasties

16. Synergy
• Wrist extension and finger flexion are
synergistic for grasping
• Wrist flexion and finger extension are
synergistic (FCR to EDC transfer)

17. Single Transfer, Single Function
• FDS or FCR would be inadequate to restore
both wrist and finger extensions

18. RADIAL NERVE PALSY

19. Restoration of
• Finger MCP extension
• Thumb extension and radial abduction
• Wrist extension (in cases of high radial nerve
palsy)

20. PT to ECRB

21. • End-to-end fashion.
• If there is potential for recovery of radial nerve
function, then end-to-side fashion
• Transferred PT continues to act as a forearm
pronator
• Insertion on ECRB as opposed to the ECRL- to
minimize radial deviation of the wrist

22. FCU to EDC

23. • Transfer of FCU
– Loss of dart-throwing motion
– Radial deviation (without a functioning ECU)

27. • Limitation of FCR is that its excursion
(approximately 33 mm) is inadequate to
provide full MCP extension.
• Tenodesis effect used to bring the MCP joints
into full extension

29. • FDS is also a good donor
– Excellent excursion (approximately 70 mm)
– Flexion of donor finger is preserved by the
remaining intact FDP.
• Disadvantage
– some grip strength is lost.
• In the patient with a fused wrist who cannot
employ the tenodesis effect, the FDS is the
preferred donor MTU

30. PL to EPL transfer
•Restoration of radial
abduction as well as
extension

33. • Tension on PL to EPL transfer is set with the
wrist in neutral position and with maximum
tension on both the PL and EPL
• Tension is set with the wrist in neutral and the
MCP joints in full extension for FCR to EDC
• PT to ECRB transfer is tensioned with wrist in
full extension.

34. • The PT to ECRB transfer should be tensioned
last so that the surgeon can passively flex and
extend the wrist, using the tenodesis effect to
evaluate the tension of the FCR to EDC
transfer

36. MEDIAN NERVE PALSY

37. Goal
• In low median nerve palsy- to restore thumb
opposition.
• In high median nerve palsy- also restoration of
FPL and index FDP function.

38. • Thumb opposition comprise
components of palmar
abduction, pronation, and
flexion
• Opponensplasty
– Superficialis opponensplasty
(FDS)
– Huber opponensplasty (ADM)
– Camitz opponensplasty (PL)
– EIP opponensplasty

39. Superficialis opponensplasty
(FDS)
(Typical Bunnell
opponensplasty)
•Cannot be used in cases of high
median nerve Palsy
•In laceration at the wrist FDS
tendons are often injured along
with the median nerve

41. • Multiple pulleys
– A distally based strip of FCU that is sutured to
itself to form a loop at the level of the pisiform
– FCU tendon itself
– Flexor retinaculum
– Guyon‘s canal

43. ElP opponensplasty

44. • Advantages:
– Always an option in cases of isolated median
nerve palsy
– No pulley is required
– Donor deficit is minimal
• Transfer is tensioned with the thumb in
maximum palmar abduction and mild flexion.

46. Camitz
opponensplasty
• originally
described by
Bunnell
• in patients with
severe long-
standing carpal
tunnel syndrome

48. Huber transfer
• Reserved for patients with congenital
hypoplasia of the thumb, because it recreates
some of the bulk of the thenar eminence
• Patients in whom the FDS or EIP is not
available for transfer (such as combined high
median and radial nerve palsy

50. BR to FPL transfer

52. side-to-side suture
of the index (and
sometimes long
finger) FDP
tendon to the
adjacent FDP
tendons at the
level of the distal
forearm.

53. ECRL to index FDP
transfer

54. • With the wrist flexed, the surgeon should be
able to passively extend the index finger and
radially abduct and extend the thumb
• Splint: Wrist is flexed to 20°, and the thumb is
positioned in palmar abduction and flexion

55. ULNAR NERVE PALSY

56. Goals for restoration:
• Loss of key pinch
• Development of clawing
• Loss of integration of finger flexion (cupping
motion)
• Finger abduction and adduction are lost
• Loss of the critical dart-throwing motion.

59. Bouvier test for clawing
Passively correcting MCP hyperextension and
checking for extension at the IP joints. .
If the IP joints can
extend, Bouvier test
is positive, and the
clawing is defined as
simple
If the IP joints remain
flexed, Bouvier test is
negative, and the
clawing is complex.

61. • Simple:
• A procedure to passively maintains MCP
flexion (static procedures)
– Volar plate advancement
– MCP joint fusion
– FDS tenodesis using half of the slip of the FDS
• Complex:
• Dynamic transfer (by using the FDS to restore
the intrinsic tendon function)

62. Static procedures
Volar plate capsulodesis

63. Zancolli capsulodesis

64. Zancolli procedure(omer modification)

65. Dynamic tendon transfers
Fowler wrist tenodesis

66. FDS transfer
•The ring or long
finger FDS
•It is split into two
slips, one for the ring
finger and one for the
small finger.
•If clawing is present
in all four fingers, it is
possible to divide the
FDS into four slips

67. Burkhalter Lasso
Brooks-jones
Anderson

68. • Tensioned: MCP - 60 deg flexion
Wrist- neutral
• Immobilised:
MCP- 90 deg flexion
Wrist- 10 deg flexion

69. • Wrist level motors used to correct clawing, but
all require elongation with a tendon graft.
BR FCR
ECRL ECRB
• FCR should only be used in cases of low ulnar
nerve palsy, in which the FCU is intact.
• Advantage: augment rather than diminish grip
strength

70. ECRL transfer

71. BRAND EF4T
W—F-30
MCP-F-70
WI-N
MCPI-90
IP-STRAIGHT
ECRL

72. Brand EE4T
W-E-40
MCP-F-70
ECRB

73. Side-to-side suturing of
FDP tendons of the ring and
small finger to the adjacent
functioning long finger FDP
tendon
The index FDP not included to
maintain independent index
FDP function

74. • Multiple transfers for restoration of key pinch
ECRB EIP
FDS BR
• Many function well because of
– compensation by the FPL
– adductor pollicis receives aberrant innervation
from the median nerve

75. Free palmaris longus
tendon graft
Extensor carpi radialis
brevis
Transfer of
elongated ECRB to
adductor pollicis
(Smith transfer)

76. FDS to adductor pollicis (Littlers transfer)

77. • In all cases, the surgeon should confirm
normal FDP function prior to using the FDS
• Thumb immobilization: in a position of pinch
• Wrist position: Flexion if FDS is used, but
extension in other cases

78. Tip pinch
• APL is
elongated with
a free tendon
graft from the
PL or plantaris
and inserted
into the tendon
of the first
dorsal
interosseous

79. EDM tendon transfer for little-finger
abduction

80. REHABILITATION

81. • At 2 weeks:
– Suture removal
– Splint worn in OT changed
– Strict immobilisation
• At 4 weeks:
– Rehabilitation initiated
– Thermoplast splint worn when not exercising

82. – Gentle active and assisted active range of motion
– Synergistic movements
– Electrical stimulation and biofeedback
• At 6 weeks:
– Passive stretching of the transfer

83. • At 8 weeks:
– Strengthening is begun
– Splint is gradually weaned off for light hand use
• At 3 months:
– Full unrestricted activity is allowed