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Summary Tendon transfer is an important technique in the armamentarium of the surgeon attempting to restore function to the hand. A discussion of the principles of this procedure and of the common indications and techniques is presented in this paper.
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INTRODUCTION
Tendon transfer is a surgical procedure that involves moving the insertion of a tendon ^ muscle unit from one location to another. It is usually a salvage procedure and is part of the reconstructive armamentarium of the surgeon, along with nerve repair and nerve grafting, tendon grafts, tenodesis, joint arthrodesis and free muscle transfer. A tendon transfer can be used to restore grasp, improve the position of the hand in space, and to prevent deformity, dislocations and contractures. It is indicated when there is a need to replace the function of a paralysed muscle (often after nerve injury) or damaged tendon, to splint joints or to prevent or treat contractures. Although there was some previous experience, tendon transfers were developed in the second half of the19th century, mainly in the lower limb after poliomyelitis. The principles were consolidated during the rst half of the 20th century.
PRINCIPLES
The principles of tendon transfer are:
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An expendable muscle should be used as a donor. The objective is to cause minimal decit when taking the donor muscle. The donor muscle must be of sucient strength1 (Table 1). The power of a donor muscle is usually somewhat reduced after transfer. It is therefore important to take a strong muscle in anticipation of
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some weakening arising from transfer (usually MRC 5 muscles weaken to MRC 4). If a weak donor is chosen, it will be too weak for useful function after the transfer. The amplitude of a donor muscle is also important (Table 2). Amplitude is the amount a muscle can be stretched from its resting position, plus the amount it contracts. This will be the main determinant of the range of movement. The line of pull should be straight to optimise the working of the transfer. This is not always possible and some transfers need to go through a pulley or through the interosseous membrane in the forearm. Signicant alterations of direction through a pulley weakens the action of a tendon transfer, and therefore a more powerful motor will be required. The correct tension for the transfer should be achieved to provide useful function. This is the critical step of the operation, although the patient can adjust the tension of some transfers to a certain degree by altering the position of the joints that the transfer crosses. For example, if extensor indicis propius (EIP) is transferred after an extensor pollicis rupture, the patient can, to some extent, adjust the tension by exion and extension of the wrist (the tenodesis eect). Transfer must be across supple joints. Any contracture must be released rst and joints should have a good passive range of movement. A tendon transfer by itself will not correct a contracture. The transfer should lie in unscarred tissue, preferably through fatty subcutaneous tissue, to prevent adhesions and to provide smooth gliding.
T able 1 Relative strength of muscles in the hand and forearm, taking FCR = 1 Muscle Strength relative to FCR
Brachioradialis 2.0 Flexor carpi ulnaris 2.0 ECRL,ECRB,ECU,PT,FPL,FDS,FDP1.0 (each tendon) EDC,EIP ,EDQ 0.5 (each tendon) APL,EPB,PL 0.1 (each tendon) Interossei 2.7 (total/combined) Lumbricals 0.5 (total/combined) Reproduced from Gelberman RH. Operative Nerve Repair and Reconstruction. Philadelphia: Lippincott, 1991; 1587, with permission.
The donor muscle must be under voluntary control. This is particularly relevant in certain neurological conditions like cerebral palsy. A motivated and co-operative patient is required to achieve a good result.
PRACTICAL CONSIDERATIONS
A good preoperative assessment of the patient and the involved limb is required, including the compilation of a muscle power chart where indicated. A detailed physiotherapy assessment is extremely helpful. All wounds must be healed and soft tissues should be pliable prior to surgery.This rarely occurs less than 4 ^ 6 months after the original traumatic episode. On occasions, surgery to release contractures and regain passive movement may be required. In general, one awaits reinnervation of muscles after nerve repair before considering tendon transfers. If reinnervation is adequate, no transfers will be required. Some surgeons favour limited early tendon transfer in such cases, for example, in a case of isolated radial palsy a pronator teres transfer to extensor carpi radialis brevis (ECRB) can be done early to overcome the wrist drop. The transfer acts as an internal splint, minimising disability during reinnervation. If the wrist extension forces eventually prove excessive, the transfer can be reversed. To plan the operation, it is helpful to write a balance sheet with three columns. The rst one should indicate what functions need to be replaced. The second should indicate what donor muscles are available. The third should indicate what transfers, and other procedures, are required to achieve the desired goals. A donor Muscle/Tendon that can be spared and has near-equivalent
T able 2 Excursion of musclesinthe adultforearm and hand Muscle Brachioradialis Flexor digitorum profundus (FDP) Flexor digitorum supercialis (FDS) Extensor pollicis longus (EPL) Extensor digitorum communis (EDC) Extensor indicis propius (EIP) Flexor pollicis longus (FPL) Flexor carpi ulnaris (FCU) Flexor carpi radialis (FCR) Extensor carpi radialis longus (ECRL) Extensor carpi radialis brevis (ECRB) Extensor carpi ulnaris (ECU) Extensor pollicis brevis (EPB) Abductor pollicis longus (APL) Lumbrical Thenar muscles Interossei Excursion (cm) 4.0 7.0 6.5 6.0 5.0 5.0 5.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.8 3.8 2.0
Reproduced from Gelberman RH. Operative Nerve Repair and Reconstruction. Philadelphia: Lippincott, 1991; 1587, with permission.
One transfer for one function. It is unreasonable to expect a tendon transfer to carry out two dierent functions simultaneously. As far as possible, synergistic muscles should be used. Muscles work in groups and patterns that are controlled at subconscious level. For example, nger exors tend to work at the same time as wrist extensors, while nger extensors tend to work simultaneously with wrist exors. Synergy should be preferred, rather than considered to be essential. The transfer is more readily integrated into normal hand use if a synergistic muscle is used. In the absence of a synergistic muscle others can be used, but the new function will probably be more dicult to incorporate and a longer period of rehabilitation will be required.
Figure 1 The Pulvertaft weave. (Reproduced from Burke FD, McGrouther DA, Smith PJ. Principles of Hand Surgery . New York: Churchill Livingstone,1990, with permission).
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strength and excursion to the tendon function that has been lost should be sought. It is helpful if it is also synergistic with the dysfunctional tendon. In the lower limb, it is common to insert the transferred tendon into bone, while in the upper limb it is usually attached to tendon, usually by a weave as described by Pulvertaft (Fig.1) or by the method described by Andersen.2 If there is any possibility of reinnervation, it is prudent to perform end-to-side attachments. When performing multiple tendon transfers, the donor muscles and recipient tendons are exposed at the onset. The motors are freed from their insertions and transferred via subcutaneous tunnels to the new location.Care needs to be taken to provide a direction of pull that is as straight as possible.Wounds that are no longer needed can be closed at this stage. Transfers are then completed by suturing tendons into new insertions, with the correct tension, using the tenodesis test. The remaining wounds are then closed. Careful haemostasis is required throughout the procedure. After closing all wounds, the hand is splinted in a position that will protect the new transfers. On occasions, one position will not accommodate all transfers in a protected manner. Perhaps one transfer requiring a dierent position to the others may simply be transferred to the new site at the initial operation, but tendon weaving may be delayed for 2 or 3 months until the other transfers have settled in. The nal transfer can then be sutured to the recipient tendon and splinted in a protected manner during healing.
The tenodesis test is used to assess the tension of a transfer prior to skin closure. The normal cascade of the ngers (increasing exion towards the ulnar border digits) moves from a position of exion in maximal wrist extension, to digital extension in maximal wrist exion. A modest overcorrection of the original deformity should be the aim, with the wrist passing through its normal range of movement. If a digital exor tendon reconstruction has been performed to the middle nger, the tension should be adjusted so that the posture during the tenodesis test mimics the ulnar neighbour digit (i.e. the slightly more exed ring nger). If an extensor tendon reconstruction has been performed to the middle nger, the tension should be adjusted to mimic the position of the radial neighbour digit (i.e. the slightly more extended index nger).
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Figure 2 The ring supercialis opposition transfer. (Reproduced from Burke FD, McGrouther DA, Smith PJ. Principles of Hand Surgery . New York: Churchill Livingstone, 1990, with permission).
Figure 4 The Camitz transfer for thumb abduction. (Reproduced from Burke FD, McGrouther DA, Smith PJ. Principles of Hand Surgery . New Y ork: Churchill Livingstone, 1990, with permission).
Figure 3 The extensor indicis propius opposition transfer. (Reproduced from Burke FD,McGrouther DA, Smith PJ. Principles of Hand Surgery . New York: Churchill Livingstone, 1990, with permission).
and wrist extension for about 3 weeks. The thumb may then be mobilised. The Camitz transfer is a useful technique particularly for patients with severe chronic carpal tunnel syndrome with wasting of the abductor pollicis brevis. Palmaris longus is used as the transfer (only present in 70% of patients). After identifying the palmar fascia overlying the transverse carpal ligament, the incision into the distal part of the forearm should be extended and palmaris longus, and its extension into the palmar fascia, mobilised (Fig. 4). The palmar fascia should be divided at the mid-palm and rerouted to the insertion of abductor pollicis brevis as previously described and the carpal
tunnel decompressed. Post-operative management is as for an EIP transfer. In a high-median nerve palsy, as well as opposition, the functions that need replacing are pronation of the forearm, exion of the thumb, and exion of the index nger. Flexion of the middle nger is usually possible because of the crossover bres from the ulnar nerve, but it is weak. A side-to-side attachment of the middle exor digitorum profundus (FDP) to the ring and little FDP in mid-forearm will restore power. Extensor carpi radialis longus (ECRL) and Brachioradialis are available for transfer. ECRL can be transferred to FDP to restore index exion and brachioradialis can be sutured to exor pollicis longus (FPL) to restore thumb exion. The power of brachioradialis is suitable as a replacement of FPL, but the excursion is less than the ideal. This muscle can be extensively mobilised proximally in the forearm to obtain maximal excursion. However, care should also be taken to preserve the neurovascular supply to the muscle.
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the proximal interphalangeal joint (PIPJ) and distal interphalangeal joint (DIPJ) before exion of the MCP joint. This prevents normal grasp. Weak pinch is particularly disabling, due to the paralysis of adductor pollicis. There is a characteristic claw deformity of the ring and little ngers.This is due to imbalance of the forces at the three joints of each nger.The lumbrical muscles, and the interossei, ex the MCPJ and extend the PIPJ and DIPJ. If they are not working, the action of the unmodied long exors and extensors produces hyperextension of the MPJ and exion of the IP joints. The little nger is often ulnardeviated in extension due to an unbalanced ulnar deviating force of the EDQ.This is called the Watenberg sign. Whenever possible, nerve release or nerve repair is the treatment of choice. Static or dynamic splints can be used as conservative treatment to correct the deformity of intrinsic paralysis. If there is irreversible paralytic loss of intrinsics, two types of surgical procedures are available. One prevents MPJ hyperextension and includes a dorsal bone block, volar capsulorrhaphy (Fig. 5) or capsulodesis.The other augments MPJ exion and interphalangeal extension by sling tenodesis or tendon transfers. Capsulodesis and tenodesis for ulnar claw deformity do not require a tendon transfer, but commonly stretch out with the passage of time. Tendon transfers are preferable for improving the function of the hand, since they oer the best chance of correcting the clawing, thereby improving grip strength and restoring synchronous motion at the MP and IP joints. All ulnar claw deformity tendon transfers must pass volar to the deep transverse metacarpal ligament. In the Stiles^Bunnell tendon transfer, two FDS tendons are used, split and rerouted along the lumbrical canal and sutured to the transverse bres of the radial digital band. For patients with irreparable distal ulnar nerve lesions, this transfer remains an excellent choice. Zancolli described the Lasso procedure where the FDS of each clawed nger is detached distally and passed through a transverse incision made in the A1 pulley, looped and sutured to itself in the distal palm. The FDS then becomes a exor of the MP joint (Fig. 6). If clawing is not severe, surgical reconstruction might best be directed at improving power pinch. Restoration of a powerful pinch is an important aspect of ulnar nerve palsy reconstruction, yet it rarely gets the attention that it merits. ECRB or brachioradialis can be augmented with a tendon graft which is passed through the third intermeta-carpal space and inserted into the radial side of the thumb MCP joint, adducting and pronating the thumb (Fig. 7). An alternative is to transfer the FDS from the middle or ring ngers to the abductor insertion in the thumb, although grip strength is somewhat undermined by this procedure. Index nger abduction can be recreated using a slip of abductor pollicis longus augmented with a tendon graft, inserted into the lateral band of the index nger.
Figure 5 Zancolli volar plate reeng. (Reproduced from Burke FD,McGrouther DA,Smith PJ.Principles of Hand Surgery . NewY ork: Churchill Livingstone,1990, with permission).
Figure 6 Zancolli supercialis lasso. (Reproduced from Burke FD,McGrouther DA,Smith PJ.Principles of Hand Surgery . NewY ork: Churchill Livingstone,1990, with permission).
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Figure 9 Flexor carpi ulnaris to EDC to regain digital extension. (Reproduced from Burke FD, McGrouther DA, Smith PJ. Principles of Hand Surgery . New Y ork: Churchill Livingstone, 1990, with permission).
Figure 7 Brachioradialis (or ECRB) and graft to recreate thumb adduction. (Reproduced from Burke FD, McGrouther DA, Smith PJ. Principles of Hand Surgery . New Y ork: Churchill Livingstone,1990, with permission).
Figure 10 Palmarislongus to extensor pollicislongus to regain thumb extension. (Reproduced from Burke FD, McGrouther DA, Smith PJ. Principles of Hand Surgery . New Y ork: Churchill Livingstone,1990, with permission).
Figure 8 Pronator teres to ECRB to regain wrist extension. (Reproduced from Burke FD,McGrouther DA, Smith PJ. Principles of Hand Surgery . New York: Churchill Livingstone, 1990, with permission).
After radial nerve palsy three functions are lost: extension of the wrist, the ngers and the thumb. The classic combination of transfers is PT to ECRB to restore
wrist extension (Fig. 8), FCU (or FCR) to extensor digitorum longus to restore nger extension (Fig. 9) and palmaris longus to extensor pollicis longus (EPL) to restore thumb extension (Fig. 10). The amplitude of a wrist exor is 30 mm, which is insucient to fully replace digital extensors with an amplitude of 50 mm. The patient will use the tenodesis eect, exing the wrist to achieve full digital extension. Pronator teres has insucient length to reach ECRB and needs to be mobilised with a 2^3 cm strip of periosteum at its insertion to bridge the gap.
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CURRENT ORTHOPAEDICS
Transferring exor carpi radialis (FCR) may cause a radial deviation of the wrist, particularly with a posterior interosseous nerve palsy, where the innervation to ECRL is preserved. Flexor carpi ulnaris (FCU) seems to oer an advantage in this situation, allowing the wrist to move into a more suitable position of ulnar deviation. If PL is absent, the option is to use FDS of middle and ring ngers through the interosseous membrane to motor extensor digitorum and EPL and, as before, PT to ECRB. This is known as Boyes transfer. A patient with a radial nerve palsy may develop an adaptive functional pattern consisting of wrist exion to achieve nger extension. There are several types of splints that can be used, but all of them are cumbersome and, at times, they need to be worn for a very long time. An option is to use theinternal splintprocedure where a PT to ECRB transfer is carried out at the time of nerve repair in an end-to-side fashion, eliminating the need to wear a splint during nerve regeneration. If wrist reinnervation subsequently produces overactive wrist extension, the transfer can be taken down.
In this case, it is preferable to err on the side of tightness rather than leaving the transfer too loose.
Figure 11 Extensor indicis propius transfer to EPL to regain thumb extension, (a) incisions; (b) technique.
Figure 12 Extensor indicis propius rerouted for passively correctable camptodactyly (also for ulnar clawing).The transferred tendon will ex the metacarpo-phalangeal joint and extend the interphalangeal joints.
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OTHER INDICATIONS
Tendon transfers can also be applied to a variety of other situations, including combined nerve injuries, brachial plexus palsy involving the shoulder and elbow or the hand and forearm, or after polio and leprosy. Each patient will have his or her own unique motor decit which must be assessed and treated following the principles described at the beginning of this paper. Patients with muscular dystrophy and other progressive neuromuscular diseases are only considered for tendon transfer if the rate of progression is suciently slow, so that the transfer is likely to be of benet for more than 2 or 3 years.
POST-OPERATIVE CARE
Post-operative care is crucial to the outcome of tendon transfers and close co-operation with the hand therapist is essential. Immobilisation is usually indicated for a minimum of 3 weeks after tendon transfers and tenodesis. Oedema will translate into stiness. Oedema can be minimised by careful surgical technique, meticulous haemostasis, appropriate dressings and splinting, and elevation of the limb, particularly during the rst 48 h after surgery. If oedema develops, it can be treated with elevation, exercises (if appropriate), coban bandages or an air-pressure glove. If the joints are sti postoperatively, they must be mobilised but joint manipulation must be avoided. The period of immobilisation will depend, to an extent, on the robustness of repair. A stout Pulvertaft weave permits early mobilisation with less risk of adhesions. The patient will need to train the tendon transfer to work in the new position. If the objective is to return the limb to functional activities, the best therapy is to practise those tasks, or very similar ones. The patient needs to be encouraged to use the hand. Occasionally electrical stimulation can be of help, since simultaneous muscle contraction and joint motion can provide the feedback necessary to induce the transferred muscle to contract at the appropriate time. The best therapy is to use the hand for normal and useful activities as soon as possible after the wounds are healed and the tendon junctures are secure.
REFERENCES
1. 2. 3. 4. 5. Gelberman R H. Operative Nerve Repair and Reconstruction. Philadelphia: Lippincott, 1991; 1587. Brand P W, Hollister A. Clinical Mechanics of the Hand. St Louis: Mosby, 1993; 386. McFarlane RM, Curry GI, Evans H B. Anomalies of the intrinsic muscles in camptodactyly. J Hand Surg 1983; 8: 531544. Gupta A, Burke F D. Correction of camptodactyly. J Hand Surg 1980; 15B: 168170. Tonkin M A. The upper limb in cerebral palsy. Curr Orthop 1995; 9: 149155.
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6. 7.
Hamlin C. Upper extremity reconstruction in the tetraplegic patient. Techn Hand Upper Extrem Surg 2001; 5: 91104. Gschwind C R Surgical management of the upper limb in tetraplegia. Curr Orthop 1999; 13: 18
FURTHER READING
Smith RJ. Tendon Transfers of the Hand and Forearm. Boston: Little, Brown&Co.,1987; 337 .