Department of Hand & Reconstructive Microsurgery TENDON TRANSFERS FOR THE HAND National Congress of Indonesian Surgery for Surgery of the Hand (HIPITA)

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


Definitions

• In a tendon transfer a tendon is transected and reinserted into a bone or another tendon.

• Tendon graft• Free muscle transfer


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


Programme

• Principles– Biomechanical– Surgical

• Tendon transfers in peripheral nerve injuries– Radial nerve


Length- tension curve


Muscle length- tension relationship

• The force developed by a muscle during contraction varies with its starting length.


Whole muscle architecture

• Two basic parameters: – Strength (maximum muscle force) Cross sectional

area (PCSA)

– Amplitude (Max muscle excursion) Fibre length



Upper limb muscles


Surgical principles

• Tissue equilibrium (Steindler)– No soft tissue induration– No reaction in the wounds– Joints supple– Scars soft


Choice of muscle

• Expendable• Working• Synergistic• Straight line of pull• One tendon one function


Transferred muscles

• Loss of power by one grade

• Adhesions



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)


Planning a tendon transfer

• What works

• What is available

• What is needed

• Matching

• Staging


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.


High radial nerve palsy


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


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


High radial nerve palsy- The standard transferIncisions for Tubiana Transfer


PT to ECRB Transfer


FCU to EDC Transfer





Immobilisation

• 3-4 weeks.


Thank you


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


Median nerve palsy


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.


Sensation

• Late nerve repair.

• Littler heterodigital neurovascular island flap from ring or little finger to thumb.


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.


Opposition

• Anteposition or abduction:– Tm joint mainly.

• Flexion:– All three joints.

• Pronation:– Tm jont.


Hands of man and monkeys


Feet of man and monkeys


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


Choice of trajectory of transferred muscle

• 1 when abduction is needed.

• 2 and 3 when deficit is in pronation and flexion.


EIP transfer (Burkhalter)

• Simple and efficient.• EIP harvested and

hood repaired.• Multiple vector

changing incisions.• EIP weaved into APB

insertion.


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.


Clinical result, FDS IV


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



Abductor digiti minimi (Huber)

• Difficult, the neurovascular pedicle must be dissected up till the Guyon canal.

• It forms the centre of rotation.



High median nerve paralysis

• Reanimation of thumb and index pinch:

• ECRL to FDP index.


Brachioradialis to FPL.


Ulnar nerve paralysis


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.


Restoration of pinch

• Littler technique using FDS IV.

• Angle of pull parallel to adductor pollicis fibers.



• Smith’s technique• ECRL can be used:

– Synergistic– Needs a graft

• Better for high palsies so as to preserve FDS tendons.



• Index abduction should be reconstructed to counter the increased thumb pinch.

• EPB biomechanically more logical than EIP(Bruner).


Restoration of ring and little finger flexion

• FDP III to FDP IV V

• FDS III to FDP IV V


Correction of claw deformity

• Results from interosseous paralysis.• 3 common techniques:

– Zancolli capsulodesis– Zancolli lasso transfer– Brand transfer


Bouvier manoeuvre

• To verify reducible claw.

• Passively reduce MCPJ hyperextension.

• If the fingers extend completely, tenodeses are sufficient to reduce the claw.


Zancolli capsulodesis

• For moderate deformities.

• A1 pulley cut.• U flap in volar plate

sutured proximally to flex MCPJ 30 degrees.


Zancolli lasso procedure

• FDS III divided into 3 slips and transferred to A1 pulley-MCPJ complex.


Brand technique

• ECRL extended with a graft and sutured to A1 pulleys aiming for 30 degrees of MCPJ flexion.


• If Bouvier’s manoeuvre is positive, the tendon slips should be passed to the intermetacarpal ligament and sutured to the lateral bands.



Finger adduction ( Wartenberg sign)

• Transfer of half of EDC IV to interosseous expansion.


Combined paralyses

• Deficit of muscle units.• Additional units can be freed by

arthrodesing certain joints.


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


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


Median and Radial nerves

• The most difficult to treat.• Classically:• Wrist fusion.• FCU to EDC and EPL.• Thumb IPJ fusion.• Huber transfer.


Fusion, FDP LF to FPL, split FCU to EPL and EDC


Thank you


Documents

Department of Hand & Reconstructive Microsurgery TENDON TRANSFERS FOR THE HAND National Congress of Indonesian Surgery for Surgery of the Hand (HIPITA)