different surgeries and the use of it, rehabilitation process and its use in physiotherapy

1. Tendon Transfers
By Dr Krishna Bhatt

2. Tendon Transfers
• Definition
– The Detachment Of A Functioning Muscle-
Tendon Unit From Its Insertion And
Reattachment To Another Tendon Or Bone To
Replace The Function Of A Paralyzed Muscle
Or Injured Tendon

3. Tendon Transfers
• Indications
1) Restore Function To A Muscle Paralyzed As
A Result Of Injury Of The Peripheral Nerves,
Brachial Plexus Or Spinal Cord
2) To Restore Function After Closed Tendon
Ruptures Or Open Injuries To The Tendons
Or Muscles
3) Restore Balance To A Hand Deformed From
Neurological Conditions

4. Tendon Transfers
• General Principles
1) Straight Line Of Pull
2) Expendable Donor
3) Adequate Strength
4) Correction Of Contracture
5) One Tendon – One Function
6) Amplitude Of Motion
7) Synergism
8) Tissue Equilibrium

5. Tendon Transfers
1) Correction Of Contracture
– Keep All Joints Supple
• Soft Tissue Contracture Easier To Prevent Than
Correct
Stiff Joints Will Not Move!!

6. Tendon Transfers
2) Adequate Strength
– Donor Strength Must Be
Adequate To Perform
New Function In Its
Altered Position
• Work Of Muscle Related
To Muscle Volume
– Transferred Muscles Lose
One Grade Of Strength

7. Tendon Transfers
3) Amplitude Of Motion
– Wrist Flexors And Extensors
• 33mm
– Finger Extensors And EPL
• 50mm
– Finger Flexors
• 70mm

8. Tendon Transfers
3) Amplitude Of Motion
– Augmentation Of Effective Amplitude
a) Convert From Monarticular To Multiarticular –
Utilize Tenodesis
b) Dissection Of Surrounding Fascial Attachments

9. Tendon Transfers
4) Straight Line Of Pull
– Most Efficient Transfer
5) One Tendon – One Function
– Single Tendon Cannot Perform Two Opposite
Functions Simultaneously
– May Insert Into More Than One Tendon
• FCU  EDC

10. Tendon Transfers
6) Synergism
– Easier To Retrain
7) Expendable Donor
– Use Of Muscle Must Not Result In Unacceptable
Functional Loss
8) Tissue Equilibrium
– No Transfer Should Be Done Unless Tissues In
Optimal Condition
• Scars Soft, No Induration

11. Tendon Transfers
• Surgical Principles
– Carefully Planned Incisions
• Tendons Should Not Lie Beneath Scars
– Careful Mobilization Of Muscles
• Prevent Neurovascular Pedicle Damage
– Subcutaneous Tunneling Of Transfers
• No Small Fascial Windows

12. Radial Nerve Palsy

13. Tendon Transfers
Radial Nerve Palsy
• Functional Deficits
– Wrist Extension
– Finger Extension
– Extension And Radial Abduction Of The
Thumb

14. Tendon Transfers
Radial Nerve Palsy
• Timing Of Tendon Transfers
– Controversial
• Early
– Internal Splint At Time Of Nerve Repair
• Conventional
– Performed After Reinnervation Of Paralyzed Muscles
Fails To Occur By 3 Months After Expected
• Late

15. Tendon Transfers
Radial Nerve Palsy
• Early Transfer
– Pronator Teres to ECRB
– Temporary Substitute Until Reinnervation
– Suboptimal Reinnervation – Acts To Augment
Function

16. • Historical Perspective
– Evolved During The Two World Wars
– Classic Jones Transfer (1916)
• PT  ECRL and ECRB
• FCU  EDC III-V
• FCR  EIP, EDC II, and EPL
Tendon Transfers
Radial Nerve Palsy

18. Tendon Transfers
Radial Nerve Palsy
FCU Transfer

20. • Incision 1:
– FCU And PL Transected Proximally
– FCU Freed Up Proximally
• Incision 2:
– Deep Fascia Overlying FCU Incised And Muscle Freed
Proximally
– Limit – Neurovascular Pedicle
• Incision 3:
– Insertion Of PT Freed With Strip Of Periosteum
– EPL Tendon Identified
Tendon Transfers
Radial Nerve Palsy

25. Tendon Transfers
Radial Nerve Palsy
• Setting The Proper Tension
– Err On Suturing Extensor Tendons Tightly
– PT  ECRB
• Wrist 45° Extension
• Tendon Sutured With Maximal Tension
– FCU  EDC
• Wrist and MP Joints In Neutral
• Adjust EDC Tension Individually
• +/- EDM

26. Tendon Transfers
Radial Nerve Palsy
• Setting The Proper Tension
– PL  EPL
• Wrist In Neutral
• Maximal Tension On EPL And PL
• Test Passive ROM
– Wrist In Extension
• Passively Flex Fingers Into Palm
– Wrist In Flexion
• MP Joints In Full Extension
• Should Not Hyperextend

27. Tendon Transfers
Radial Nerve Palsy
• Postoperative Management
– Splint For 4 Weeks
• Wrist 15-30° Pronation
• Forearm 45° Extension
• MP Joints Slight Flexion (10-15°)
• Thumb – Maximal Extension And Abduction
• PIP Joints – Left Free
– 4 To 6 Weeks
• Removable Splint
• Planned Exercise Program – With Therapist

28. Tendon Transfers
Radial Nerve Palsy
• Potential Problems
– Excessive Radial Deviation
– From Removing FCU
– Further Aggravated If PT Inserted Into ECRL
– Problem With PIN Palsy
• Solutions
– FCU Transfer Contraindicated With PIN Palsy
– Reinsert ECRL Into 4th
Metacarpal
– Bowstringing Of EPL
• Solution
– Hook EPL Around Insertion Of APL

29. Tendon Transfers
Radial Nerve Palsy
• Potential Problems
– Absence Of Palmaris Longus
• Solutions
– Include Thumb Extrinsics In FCU  EDC Transfer
» Violates One Tendon – One Function Principle
– Use Brachioradialis
» Possible Only With PIN Palsy
» Requires Extensive Freeing Up
» More Difficult To Reeducate
– Use FDS III Or IV

30. Tendon Transfers
Radial Nerve Palsy
FCR Transfer
(Starr, Brand, Tsuge)

31. Tendon Transfers
Radial Nerve Palsy
• FCR  EDC
• PT  ECRB, When Required
– Performed As Before
• PL  EPL
– Performed As Before
– If Absent
• EPL Joined With EDC To FCR Transfer

32. Tendon Transfers
Radial Nerve Palsy
• Incision – Between FCR And PL
• FCR Freed To Middle Of Forearm
• FCR Passed Around Radial Border
– Subcutaneous Tunnel
• Two Best Tendons Sutured To FCR
– Other Two Sutured To Neighbors
Sutured With Wrist & MP’s In Neutral

34. Tendon Transfers
Radial Nerve Palsy
Superficialis Transfer
(Boyes)

35. Tendon Transfers
Radial Nerve Palsy
• PT  ECRB
• FDS III  EDC III,IV,V
• FDS IV  EIP & EPL
• FRC  APL & EPB

36. Tendon Transfers
Radial Nerve Palsy
• PT Tendon Exposed
– Volar – Radial Incision
• Sublimis Tendons Exposed
– Transverse Incision Palm
– Divided Proximal To Chiasm
Pass Tendons Through Interosseous Membrane Or
Around Radial And Ulnar Borders

37. Tendon Transfers
Radial Nerve Palsy
• Potential Problems
– Protect Anterior And Posterior Interosseous
Arteries
• One Opening On Either Side Of The Artery
– Avoid Kinking The Median Nerve
• FDS III Routed To The Radial Side Of Profundus
– Between FDP And FPL
• FDS IV Routed To The Ulnar Side Of Profundus

38. Tendon Transfers
Radial Nerve Palsy
• Transfer
– FDS III
• EDC (Long, Ring and Little)
– FDS IV
• EIP and EPL
Advantages
– Independent Motion Of Thumb And Index
– Palmaris Absent

40. Median Nerve Palsy

41. Tendon Transfers
Median Nerve Palsy
• Reconstructive Goals
– Thumb Opposition
– FPL Function
– Index FDP Function
• Sensation
– Prime Determinant In Hand Function
– Restoration Of Sensation Abandoned
• Neurovascular Island Flaps

42. Tendon Transfers
Median Nerve Palsy
• Classification
1) High
• Above Origin Of Anterior Interosseous Nerve
• Pronator Teres And Quadratus, FCR, FDS (II –
V), FDP(II & III) And FPL Paralyzed
2) Low
• Thenar Intrinsic Muscles Paralyzed
– Abductor Pollicis Brevis, Opponens Pollicis, And
Superficial Head Of Flexor Pollicis Brevis

43. Tendon Transfers
Low Median Nerve Palsy
• Deficit And Deformity
– Abduction And Opposition Frequently
Retained
• Due To Diverse Innervation Of Intrinsics
– Median And Ulnar Nerves

44. Tendon Transfers
Low Median Nerve Palsy
• Prevention Of Contractures
– Good Therapy And Splinting
– Position Of Thumb
• Supinated And Adducted
• Contracted First Web Space
– Correct Contracture Before Opponensplasty
• Release Fascia Over Adductor Pollicis And First
Dorsal Interosseous

46. Tendon Transfers
Low Median Nerve Palsy
• Pulley Design
– Straight Line Of Pull
• Reduced Friction And
Work
• Tendon Migrates To
Run In Straight Line

47. Tendon Transfers
Low Median Nerve Palsy
• Opponensplasty Insertions
– Abductor Pollicis Brevis
• Radial Aspect Of Thumb
• Produces Good Opposition
– Dual Insertions
• Probably Unnecessary
• Attempt Opposition Plus
Stabilization

49. Tendon Transfers
Low Median Nerve Palsy
• Standard Opponensplasties
1) FDS Opponensplasty
• Royle-Thompson Technique
• Bunnell Technique
2) Extensor Indicis Proprius Opponensplasty
3) Huber Transfer
• Abductor Digiti Minimi
4) Camitz Procedure
• Palmaris Longus

50. Tendon Transfers
Low Median Nerve Palsy
1) FDS Opponensplasty – Royle-Thompson
– FDS Brought Around Ulnar Border Of
Palmar Aponeurosis
– FDS Has A Large Potential Excursion
• Adjusting Tension Not As Critical
• Margin For Error

51. Tendon Transfers
Low Median Nerve Palsy
1) FDS Opponensplasty – Bunnel Technique
– Ring Finger FDS Divided
– FCU Exposed
• 4cm Proximal To Pisiform Insertion
– Tendon Split Into Two Halves
– Free End Looped Back Onto Its Base
• Ensure Loop Not Too Tight

54. Tendon Transfers
Low Median Nerve Palsy
• Sublimis Tendon Harvest
– Ring Finger Commonly Used As Motor
• May Weaken Power Grip
• Some Surgeons Prefer Middle Finger
– Recommend Division Proximal To Bifurcation
• Avoids Destruction To Vincula
• Does Not Disrupt Blood Supply To FDP
• Avoids Injury At The Level Of The PIP
– Possible Stiffness

55. Tendon Transfers
Low Median Nerve Palsy
• Sublimis Tendon Harvest
– Potential Complications
• Swan-Neck Deformity
– Suture Distal Ends Of Tendon Across Palmar Plate –
Prevent Hyperextension
• DIP Joint Extension Lags

56. Tendon Transfers
Low Median Nerve Palsy
2) Extensor Indicis Proprius Opponensplasty
– Popular In High Median Nerve Palsy
• Ring And Middle FDS Unavailable
– Does Not Weaken Grip
– Tendon Must Be Superficial To FCU
• Avoid Compression To Ulnar Nerve

58. Tendon Transfers
Low Median Nerve Palsy
3. Huber Transfer
– Difficult Procedure
• Neurovascular Pedicle Easily Damaged
– Dorsoradial Aspect
• Insertions Divided
– Base Of Prox. Phalynx And Ext. Apparatus
• Freed Off Pisiform
– Attachments To FCU Retained
• Attached To Abductor Pollicis Brevis Insertion

60. Tendon Transfers
Low Median Nerve Palsy
4) Camitz Procedure
– Usually For Complication Of Severe Carpal
Tunnel Syndrome
• Performed At Same Time As Carpal Tunnel
Release
• Restores Palmar Abduction
– Rather Than Opposition
• Not Recommended With Traumatic Median Nerve
Injuries
– Palmaris Longus Usually Scarred

62. Tendon Transfers
Low Median Nerve Palsy
• Other Options For Opponensplasty
– Extensor Carpi Ulnaris
– Extensor Carpi Radialis Longus
– Extensor Digiti Minimi
– Flexor Pollicis Longus
– Extensor Pollicis Longus

63. Tendon Transfers
High Median Nerve Palsy
• Deficit
– All Flexor Compartment Forearm Muscles
• Apart From Ulnar-Innervated FCU And FDP
• Aim Of Tendon Transfers
– Flexion Of Index And Thumb
– Opposition
• Potential Motors
– Brachioradialis  FPL
– ECRL  Index FDP

64. Tendon Transfers
High Median Nerve Palsy
• Timing Of Transfers
– Dependent On Prognosis
• Sensory Deficit Most Important Disability
• Early Transfers
– Should Be Attached End-To-Side – If Reinnervation
Expected
– Act As Internal Splint

65. Tendon Transfers
High Median Nerve Palsy
• Extrinsic Transfers
– Restoration Of Index Function
• ECRL  Index FDP
• Side-To-Side Suturing Of Profundus Tendons
– Restores Range Of Motion
– Strength Is Not Restored
– Restoration Of Thumb Function
• Brachioradialis  FPL

68. Tendon Transfers
High Median Nerve Palsy
• Thumb Opposition
– Early Transfer
• Allows Pronation Of Hand
– Compensates For Loss Of Sensation
– Possible Transfers
• EIP
• EPL
• Extensor Digiti Minimi
• FCU – Eliminates Only Functioning Wrist Flexor

71. Ulnar Nerve Palsy

72. Tendon Transfers
Ulnar Nerve Palsy
• Classification
1) Low
• Below Innervation To FCU And FDP (III & IV)
• Affected Muscles
– Seven Interossei, Ulnar Two Lumbricals, Hypothenar
Muscles, And Adductor Pollicis
• “Claw Deformity”
2) High
• FCU And FDP (III & IV) Affected

73. Tendon Transfers
Ulnar Nerve Palsy
• Clawing Of Fingers
– Surgical Options
• Capsulodesis
– Prevent MCP Hyperextension
– Described By Zancolli
• Static Tenodesis (Parkes)
– Prevents MCP Hyperextension
– Provides IP Extension
– Free Tendon Graft: Radial Lateral Band  Dorsal
Expansion

76. Tendon Transfers
Ulnar Nerve Palsy
• Clawing Of Fingers
– Dynamic Tenodesis
(Fowler)
• Free Tendon Graft
• Wrist Movement 
Grafts Tighten 
Active MCP Flexion &
IP Extension

77. Tendon Transfers
Ulnar Nerve Palsy
• Superficialis Transfer
– FDS – Long Split Into
Four Slips
– Passed Through
Lumbrical Canal
– Attached To Radial
Lateral Band – Dorsal
Apparatus
– Alternate – Flexor
Sheath

78. Tendon Transfers
Ulnar Nerve Palsy
• Wrist Motors For Proximal Phalanx Power
– Muslces Available
• ECRL
• ECRB
• Brachioradialis
• FCR
– Gross Grip Power Improved

80. Tendon Transfers
Ulnar Nerve Palsy
• Riordan
– For Palmar Flexion
Deformity
• Repeated Attempts To
Extend Clawed Fingers
– FCR Passed To Dorsal
Forearm
– FCR In Phase For IP
Extension
• Minimal Rehab Required

81. Tendon Transfers
Ulnar Nerve Palsy
• Thumb-Index Key Pinch
– Requires Thumb Adduction And Flexion
• Loss Of Adductor And Interossei
• FPL And EPL Contribute
– Lesser Extent
• 75 – 80% Loss With Ulnar Nerve Palsy
Arthrodesis Of MCP & IP Joints Of Thumb An Option

85. Tendon Transfers
High Ulnar Nerve Palsy
• Significant Deficit
– FCU And FDP Paralysis
• Decreased Power Grip
• Options
– FDP Paralysis
• Tenodesis Of Profundus Tendons
– FCU Paralysis
• Consider Transfer FCR To FCU

87. Tendon Transfers
Ulnar Nerve Palsy
• Preferred Transfers
1) Thumb Adduction
• ECRB  Adductor Tubercle Thumb
• FDS (Long)  Adductor Tubercle Thumb
2) Thumb-Index Tip Pinch
• APL  First Dorsal Interosseous & Arthrodesis
Thumb MP
• EPB  First Dorsal Interosseous & Arthrodesis
Thumb MP

88. Tendon Transfers
Ulnar Nerve Palsy
• Preferred Transfers
3) Clawed Fingers
• ECRL – Four Tailed Tendon Graft
• FCR – If Wrist Flexion Contracture
4) Distal Finger Flexion (High Palsy)
• FDP (Long) Tenodesed To FDP (Ring & Little)
5) Radial Wrist Flexion (High Palsy)
• FCR  FCU

89. THE END