DALHOUSIEPLASTIC Tendon Transfers Doug Humphreys Division of Plastic Surgery Dalhousie University Halifax, Nova Scotia Tendon Transfers • Definition – The Detachment Of A Functioning MuscleTendon Unit From Its Insertion And Reattachment To Another Tendon Or Bone To Replace The Function Of A Paralyzed Muscle Or Injured Tendon Tendon Transfers • Indications 1) 2) 3) Restore Function To A Muscle Paralyzed As A Result Of Injury Of The Peripheral Nerves, Brachial Plexus Or Spinal Cord To Restore Function After Closed Tendon Ruptures Or Open Injuries To The Tendons Or Muscles Restore Balance To A Hand Deformed From Neurological Conditions Tendon Transfers • General Principles 1) 2) 3) 4) 5) 6) 7) 8) Straight Line Of Pull Expendable Donor Adequate Strength Correction Of Contracture One Tendon – One Function Amplitude Of Motion Synergism Tissue Equilibrium Tendon Transfers 1) Correction Of Contracture – Keep All Joints Supple • Soft Tissue Contracture Easier To Prevent Than Correct Stiff Joints Will Not Move!! . 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 . Tendon Transfers 3) Amplitude Of Motion – Wrist Flexors And Extensors • – Finger Extensors And EPL • – 33mm 50mm Finger Flexors • 70mm . Tendon Transfers 3) Amplitude Of Motion – Augmentation Of Effective Amplitude a) b) Convert From Monarticular To Multiarticular – Utilize Tenodesis Dissection Of Surrounding Fascial Attachments . Tendon Transfers 4) Straight Line Of Pull – 5) Most Efficient Transfer One Tendon – One Function – Single Tendon Cannot Perform Two Opposite Functions Simultaneously – May Insert Into More Than One Tendon • FCU EDC . No Induration .Tendon Transfers 6) Synergism – 7) Expendable Donor – 8) Easier To Retrain Use Of Muscle Must Not Result In Unacceptable Functional Loss Tissue Equilibrium – No Transfer Should Be Done Unless Tissues In Optimal Condition • Scars Soft. 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 . Radial Nerve Palsy . Tendon Transfers Radial Nerve Palsy • Functional Deficits – Wrist Extension – Finger Extension – Extension And Radial Abduction Of The Thumb . 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 . Tendon Transfers Radial Nerve Palsy • Early Transfer – Pronator Teres to ECRB – Temporary Substitute Until Reinnervation – Suboptimal Reinnervation – Acts To Augment Function . Tendon Transfers Radial Nerve Palsy • Historical Perspective – Evolved During The Two World Wars – Classic Jones Transfer (1916) • PT ECRL and ECRB • FCU EDC III-V • FCR EIP. and EPL . EDC II. . Tendon Transfers Radial Nerve Palsy FCU Transfer . . Tendon Transfers Radial Nerve Palsy • 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 . . . . . EDM .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 • +/. 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 . 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 . 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 . 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 . Tendon Transfers Radial Nerve Palsy FCR Transfer (Starr. Tsuge) . Brand. 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 . 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 . . Tendon Transfers Radial Nerve Palsy Superficialis Transfer (Boyes) . V FDS IV EIP & EPL FRC APL & EPB .Tendon Transfers Radial Nerve Palsy • • • • PT ECRB FDS III EDC III.IV. 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 . 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 . 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 . . • Indian J Orthop. 45(6): 558–562. 2011 Nov-Dec. and Ali Karbalaeikhani1 . • Outcome of tendon transfer for radial nerve paralysis: Comparison of three methods • Alia Ayatollahi Moussavi. Alireza Saied. • 41 pacientes / 3 Grupos • FCU Extensión dedos – PL EPL (Abducción y extensión D1) • FCR Extensión dedos – PL EPL (Abducción y extensión D1) • FDS 3º Extensión dedos – FDS 4º EPL • En todos si se necesitaba restaurar extension muñeca: PT ECRB • Si no tenian PL. eran excluidos . • Postop – Valva ABP con muñeca y dedos en extensión por 4 semanas – Luego 3 meses nocturna – Fisioterapia desde el 1º mes . • Grupo 1 – 18 Pacientes • Grupo 2 – 10 Pacientes • Grupo 3 – 13 Pacientes . • Resultados . • Resultados . . dedos – DASH: 35 / 38 / 30 • 95% Se volveria a operar • Extension simultanea de muñeca-dedos – Solo 4 del grupo 3 • Contractura en flexion – 3 pacientes del grupo 3 • Pronosupinacion conservada en todos . D1.• Sin diferencias: – ROM muñeca. • Varios presentaron disminución flexion muñeca – Ninguno lo reporto • Todos lograron buen grip – No fue medido por falta de instrumentos • Sin desviaciones radiales .