View
219
Download
1
Category
Tags:
Preview:
Citation preview
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
TENDON TRANSFERS FOR THE HAND
National Congress of Indonesian Surgery for Surgery of the Hand (HIPITA)2nd Flap dissection course and workshop
Surabaya, March 31-April 2, 2005
Aymeric Lim Department of Hand & Reconstructive Microsurgery,
National University Hospital
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Definitions
• In a tendon transfer a tendon is transected and reinserted into a bone or another tendon.
• Tendon graft• Free muscle transfer
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Indications– Paralysed muscle:
– Peripheral nerve injuries– Quadriplegia– Brachial plexus injuries– Peripheral nerve
compression
– Muscle loss:– Rheumatoid arthritis– Congenital deformities– Severe trauma
– Restoration of muscle balance:
– Cerebral palsy– Stroke
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Programme
• Principles– Biomechanical– Surgical
• Tendon transfers in peripheral nerve injuries– Radial nerve
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Length- tension curve
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Muscle length- tension relationship
• The force developed by a muscle during contraction varies with its starting length.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Whole muscle architecture
• Two basic parameters: – Strength (maximum muscle force) Cross sectional
area (PCSA)
– Amplitude (Max muscle excursion) Fibre length
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Upper limb muscles
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Surgical principles
• Tissue equilibrium (Steindler)– No soft tissue induration– No reaction in the wounds– Joints supple– Scars soft
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Choice of muscle
• Expendable• Working• Synergistic• Straight line of pull• One tendon one function
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Transferred muscles
• Loss of power by one grade
• Adhesions
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Synergy
• Synergistic muscles contract simultaneously to achieve the desired effect
• Finger flexors with wrist extensors• Finger extensors with wrist flexors• Considered important consideration by
some surgeons (Littler)
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Planning a tendon transfer
• What works
• What is available
• What is needed
• Matching
• Staging
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Timing
• Bevin (Hand 1976):• 12 radial nerve repairs compared with 13
tendon transfers.• Tendon transfer group returned to work in
8 weeks.• Nerve repair group returned to work at 8
months.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
High radial nerve palsy
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
High radial nerve palsy
• What works:• All median and ulnar innervated muscles
• What is available:• All except FDP, FPL
• Needed:• Wrist extension• Finger extension• Thumb extension
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Donor Insertion Function Reference
PTFCRFCU
ECRL & ECRB EPL, EPB,APL, EDCEDC
Wrist ext.Thumb ext, abd. Index.Finger ext.
Jones, 1921
PTFDS(mid)FCU
ECRBEPLEDC
Wrist ext.Thumb ext, abd.Finger ext.
Goldner, 1974
PTPLFCR
ECRBEPLEDC
Wrist ext.Thumb ext.Finger ext.
Brand, 1975
PTFCRFDS (ring)FDS (middle)
ECRL and ECRBAPL & EPBEPL and EIPEDC
Wrist ext.Thumb abd.Thumb & index ext.Finger ext.
Boyes 1970
PTPLFDS (little)FDS (ring)
ECRBAPLEPLEDC
Wrist ext.Thumb abd.Thumb ext.Finger ext.
Beasley 1970
PTPTFCU
ECRLEPL (rerouted)EDC
Wrist ext.Thumb ext.Finger ext.
Riordan 1964
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
High radial nerve palsy- The standard transferIncisions for Tubiana Transfer
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
PT to ECRB Transfer
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
FCU to EDC Transfer
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Immobilisation
• 3-4 weeks.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Thank you
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
The three most common variants
Function Tubiana Smith Boyes
Finger extension
FCU FCR FDS IV
Thumb extension
PL PL FDS IIIPL to APL
Wrist extension
PT PT PT
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Median nerve palsy
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Principles
• Replace lost nerve function:– Motor and sensory.
• Low median nerve palsy:– Sensation in the radial 3 fingers.– Thumb opposition.
• High median nerve palsy:– Sensation in the radial 3 fingers.– Thumb opposition.– Flexion in the radial 3 fingers.– Flexion in the thumb.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Sensation
• Late nerve repair.
• Littler heterodigital neurovascular island flap from ring or little finger to thumb.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Thumb opposition
• The action of bringing the pulp of the thumb into contact with the pulp of one of the other fingers.
• Opposition cones:– 199, greater cone,
Bunnell.– 200, lesser cone.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Opposition
• Anteposition or abduction:– Tm joint mainly.
• Flexion:– All three joints.
• Pronation:– Tm jont.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Hands of man and monkeys
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Feet of man and monkeys
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Mechanism of opposition
• The thumb is opposed when its pulp is parallel to the pulp of the middle finger:– 1 pronation– 2 flexion– 3 abduction
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Choice of trajectory of transferred muscle
• 1 when abduction is needed.
• 2 and 3 when deficit is in pronation and flexion.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
EIP transfer (Burkhalter)
• Simple and efficient.• EIP harvested and
hood repaired.• Multiple vector
changing incisions.• EIP weaved into APB
insertion.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
FDS IV (Royle)• Originally, the distal edge was
used as the pulley.• 15 different trajectories
proposed.• Merle uses pisiform.• Short transverse incision for
harvesting.• Insertion onto EPL and APB.• Tension: thumb in complete
abduction with wrist flexed 30 degrees.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Clinical result, FDS IV
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Palmaris longus transfer (Camitz)
• Simple with minimal donor site morbidity.
• Can be combined with carpal tunnel release.
• Fascial extension necessary.
• Angle of insertion is primarily for abduction
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Abductor digiti minimi (Huber)
• Difficult, the neurovascular pedicle must be dissected up till the Guyon canal.
• It forms the centre of rotation.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
High median nerve paralysis
• Reanimation of thumb and index pinch:
• ECRL to FDP index.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Brachioradialis to FPL.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Ulnar nerve paralysis
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Loss• Pinch• MCPJ flexion leading to
claw hand• Loss of finger abduction
and adduction• Flattening of the arch• FDP flexion of ring and
little fingers.• Loss of FCU• Sensation on ulnar border
of hand.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Restoration of pinch
• Littler technique using FDS IV.
• Angle of pull parallel to adductor pollicis fibers.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Restoration of pinch
• Smith’s technique• ECRL can be used:
– Synergistic– Needs a graft
• Better for high palsies so as to preserve FDS tendons.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Restoration of pinch
• Index abduction should be reconstructed to counter the increased thumb pinch.
• EPB biomechanically more logical than EIP(Bruner).
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Restoration of ring and little finger flexion
• FDP III to FDP IV V
• FDS III to FDP IV V
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Correction of claw deformity
• Results from interosseous paralysis.• 3 common techniques:
– Zancolli capsulodesis– Zancolli lasso transfer– Brand transfer
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Bouvier manoeuvre
• To verify reducible claw.
• Passively reduce MCPJ hyperextension.
• If the fingers extend completely, tenodeses are sufficient to reduce the claw.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Zancolli capsulodesis
• For moderate deformities.
• A1 pulley cut.• U flap in volar plate
sutured proximally to flex MCPJ 30 degrees.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Zancolli lasso procedure
• FDS III divided into 3 slips and transferred to A1 pulley-MCPJ complex.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Brand technique
• ECRL extended with a graft and sutured to A1 pulleys aiming for 30 degrees of MCPJ flexion.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
• If Bouvier’s manoeuvre is positive, the tendon slips should be passed to the intermetacarpal ligament and sutured to the lateral bands.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Finger adduction ( Wartenberg sign)
• Transfer of half of EDC IV to interosseous expansion.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Combined paralyses
• Deficit of muscle units.• Additional units can be freed by
arthrodesing certain joints.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Ulnar and median nerves
• ECRB to FDP• BR to FPL• EIP to thumb for opposition• ECU to A1 pulleys for claw correction• MP thumb fusion
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Radial and ulnar nerves
• Better prognosis because hand sensation is preserved palmarly.
• PT to ECRL.• PL to EPL.• FDS III to EDC.• FDP IV V to III.• Zancolli capsulodesis
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Median and Radial nerves
• The most difficult to treat.• Classically:• Wrist fusion.• FCU to EDC and EPL.• Thumb IPJ fusion.• Huber transfer.
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Fusion, FDP LF to FPL, split FCU to EPL and EDC
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Thank you
Department of Hand & Reconstructive MicrosurgeryDepartment of Hand & Reconstructive Microsurgery
Recommended