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A new tendon transfer for ulnar paralytic clawhand, in which the palmaris longus with distal extensions of the palmar aponeurosis is passed under the transverse carpal ligament and fixed to the A-1 pulley of the small and ring fingers, is described. Advantages of the procedure are that there is no loss of function and free tendon grafts are not needed.
Simultaneous tendon transfer and dermofat graft augmentation of the first web space of the hand with intrinsic paralysis is described. Fifty per cent over-correction of the web space volume is recommended in anticipation of postoperative graft resorption. Other techniques of fat auto-transplantation are discussed.
Since 1959, 22 patients have had wrist extension restored by transfer of the pronator teres to the extensor carpi radialis longus and brevis, common finger extension by transfer of the superficialis of the long finger, independent thumb and index finger extension by transfer of the superficialis of the ring finger, and abduction of the thumb by transfer of the flexor carpi radialis at the wrist joint level. Twenty-one of 22 patients have been evaluated from 8 months to 15 years after operation, with an average follow-up of 4.5 years. By our new system of evaluation, there were 10 excellent results, six good results, five fair results, and all patients improved. Sixteen patients obtained full, independent thumb-index finger extension, three had fair function, and two obtained thumb-index extension by tenodesis of the transfer. This procedure allows full metacarpophalangeal extension independent of wrist position, provides thumb-index finger extension independent of the ulnar three digits, and maintains the dorsal-radial-to-volar-ulnar plane of functional motion of the wrist by retaining the flexor carpi ulnaris.
Rheumatoid arthritis is not as common a problem in Taiwan as it is in western countries. Compared with traumatic tendon rupture, tendon rupture in rheumatoid arthritis has its complex and peculiar pathophysiological mechanism which includes chemical erosion by hypertrophic synovium and mechanical attrition by deformed joints and bony spurs. In management, all these pathological foci must be eradicated to prevent recurrent failure. Tendon transfer is a simple and effective method for reconstructing lost tendon function.
We have studied the brachioradialis muscle both physiologically and clinically for its suitability for tendon transfer in the tetraplegic. Intraoperative measurements have shown that the muscle is strong, provides excellent excursion, and is commonly available for transfer in the absence of other candidate muscles. The anatomic features that limit its use can be overcome during the operation. Postsurgical assessment of the muscle using electromyography and muscle-force measurement have shown that the muscle is voluntarily activated and provides strength for the intended function. Our experience with transfer of the brachioradialis to the hand of a tetraplegic patient has been highly positive.
The authors show that extension of the elbow produces a traction on brachioradialis (BR) and extensor carpi radialis longus (ECRL): if their tendon is distally freed, it is pulled in the proximal direction when the elbow extends. This phenomenon provides tenodesis effects, especially after tendon transfer in tetraplegia. It has been assessed on 31 upper limbs of patients and fresh cadavers. The mean tendon excursion, between 90 degrees flexion and full extension of the elbow, was 32 mm for BR and 19 mm for ECRL. These tenodesis effects related to the extension of the elbow leads the authors to recommend three practices in tetraplegic patients: active extension of the elbow should be restored before rehabilitation of the hand, and a 90 degrees flexion of the elbow is the position in which BR and ECRL transfers should be set intraoperatively, as well as immobilized postoperatively.
Brachial plexus palsy at birth remains a serious problem. Although most cases resolve during the first few months by spontaneous regeneration, several operations have been used to correct the residual deformity. In the present study we describe the results of the latissimus dorsi and teres major tendons transfer on to the rotator cuff to improve shoulder function. Six patients were included in the study: three girls and three boys; four right shoulders, and two left. The types of palsy were four Erb's palsy (C5, C6) and two C5-C7 palsy. The median age at the time of operation was 11 years and 1 month and the median follow-up period was 54.2 months. Median preoperative passive external rotation was 51 degrees, and active abduction 67 degrees. Median postoperative active external rotation was 72 degrees, and postoperative active abduction 109 degrees. This procedure increased the ranges of external rotation and abduction, and provided considerable improvement in shoulder function.
Two methods are used to route the tibialis posterior tendon anteriorly to achieve dorsiflexion: (1) around the medial side of the tibia, or the subcutaneous route; and (2) through the interosseous membrane, or the interosseous route. This study determined the effect of site of tendon insertion on ankle and foot motions and compared the efficacy of both routes. Eleven fresh normal cadaveric legs were used. The detached tibialis posterior tendon was transferred anteriorly through the interosseous membrane and anchored to the first cuneiform along the first metatarsal axis by a barbed staple. The specimen was mounted on a mechanical testing machine. Tension was applied to the tendon and ankle and foot motions were measured. The experimental procedure was repeated with tendon insertion along the second metatarsal axis and serially through to the fifth metatarsal axis. The entire experiment was repeated using the subcutaneous route. The interosseous route was more effective in achieving maximum dorsiflexion with minimal pronation. Shifting the insertion medially caused supination, whereas a more lateral insertion caused pronation.
Thirty-two children with hand dysfunction due to cerebral palsy were examined before tendon transfer and muscle release, and 9 months postoperatively. All children improved their performance regardless of the degree of impaired hand function. The main advantage of surgery was a more functional position of the hand with increased wrist extension and forearm supination. There were also increased functionality of handgrips, grip strength, and dexterity. Impaired sensibility before surgery did not influence the outcome. Individual goals were set preoperatively. Individual functional goals outlined before surgery were met by most children. Children identified as having mild impairments gained new functional skills related to everyday activity (self-care and leisure), while children with severely impaired hand function demonstrated enhanced grasping ability, as well as a better cosmetic appearance.
Muscles used for transfer ought to have adequate structural properties. The purpose of this study was to provide a database of potential excursion (muscle excursion without reference to connective tissue restraints) and relative tension (muscle physiologic cross-sectional area in percentage among a group) in shoulder girdle muscles. Thirteen muscles in 13 human cadavers aged 17 to 89 years at death were studied. Potential excursion ranged from 6.7 cm (supraspinatus) to 33. 9 cm (latissimus dorsi). Relative tension ranged from 1.7% (levator scapulae) to 20.9% (deltoid). Significant discrepancies were found between the properties of some of the muscles used as transfers around the shoulder and the properties of the muscles for which they are commonly used as substitutes. Despite the limitations of cadaveric studies and the fact that many other factors are involved in muscle transfers, this database of structural properties of shoulder girdle muscles may help when planning tendon transfers around the shoulder.
Fifteen cases of paralysis of the quadriceps muscles secondary to poliomyelitis were managed by hamstring tendon transfers with an average follow-up of 48 months. Results of 13.5% excellent, 73% good, and 13.5% fair were obtained, according to an objective scoring system. Significant improvement in gait pattern, relief from brace use, or "hand-on-thigh" ambulation was seen in all cases. A mean extension lag of 30 degrees was observed in patients examined in the sitting position. Lack of active terminal knee flexion, prohibiting comfortable floor sitting, was the main untoward effect and the source of complaint in four patients.
PURPOSE: This study was designed to investigate the efficacy of 3 different tendon transfer techniques in restoring grip strength, correcting claw hand deformity, and improving hand function after irreparable ulnar nerve palsy. METHOD: A total of 44 patients were assessed 14 to 96 months after surgery. Twenty-four patients were reconstructed with the flexor digitorum 4-tail (FDS 4-tail) procedure, 11 with the extensor carpi radialis 4-tail (ECRL 4-tail) procedure and 9 with Zancolli's Lasso procedure (ZLP) with mean paralysis times of 47, 51, and 32 months, respectively. Grip strength measurements, improvement in active range of motion at the PIP and wrist joints, patients' ability to fully open and close their hands, as well as the sequence of phalangeal flexion were analyzed. RESULTS: Age, sex, mean follow-up duration, and surgical technique did not relate statistically to the functional outcome. Preoperative extensor lag of the proximal interphalangeal (PIP) joint and mean paralysis time, however, significantly affected the functional outcome. The ZLP and the ECRL 4-tail were found to be the most effective technique in restoring grip strength. The FDS 4-tail procedure, however, was the most successful in correcting the claw hand deformity, especially in long-standing paralysis in which there was elongation of the extensor apparatus. CONCLUSIONS: In short-term paralysis in which patients predominantly need grip strength and claw finger deformity correction, the ZLP or ECRL 4-tail procedures are recommended. In long-standing cases with extensor lag, asynchronous finger motion should be corrected with the FDS 4-tail procedure.
The authors present a modified approach to addressing hallux abducto valgus. We have found that a combination of an adductor tendon transfer through a distal metaphyseal osteotomy is useful in the elderly patient with a high intermetatarsal angle, who might otherwise require a proximal-type procedure for optimal correction. The results of seven patients who underwent this surgical procedure are presented as a preliminary report.
Anatomic and biomechanical properties of the passive brachioradialis muscle were investigated to understand the limited excursion of this muscle seen during tendon transfer surgery. First, architectural measurements were performed on three fiber bundles obtained from four regions of the brachioradialis (10 specimens) chosen to represent the range of muscle fiber lengths across the brachioradialis. Next, in separate specimens (eight specimens), passive excursion was measured by securing the distal tendon stump to a servomotor. A constant load of 4.9 N was applied to the tendon, while the distal tendon was released from the surrounding tissue in 3-cm increments. Within the four regions studied, muscle fiber length varied significantly from 104.2 +/- 6.2 mm to 179.8 +/- 6.1 mm. As the brachioradialis was released, an average of 3 mm of mobility was obtained for each interval whereas for the succeeding three intervals, an average of 5.3 mm of mobility was obtained. This resulted in 22.2 +/- 2.3 mm of mobility when each specimen was fully released. These data show that there is no intrinsic muscle fiber length limitation to excursion, but that excursion is limited by other intermuscular connections to adjacent connective tissue and other muscles.
Seventeen hands in 15 patients with posttraumatic tetraplegia had transfers of the brachioradialis tendon to the flexor pollicis longus in an attempt to create an active lateral pinch. In addition, interphalangeal joint fixation with a Moberg screw was performed in 16 thumbs and tenodesis of the extensor pollicis longus and brevis tendons to the metacarpal was performed in 11 patients. Average patient age was 32 years, time from onset of tetraplegia to operation was 5.3 years, and postoperative follow-up was 2.3 years. Functional improvement was noted in 15 hands and 80% of the patients could name at least four activities of daily living that were now possible or made more efficient as a result of surgery. With the elbow flexed to 90 degrees, the average lateral pinch was 3.9 pounds with the wrist extended 30 degrees, 4 pounds with the wrist in the neutral position, and 2.3 pounds with the wrist flexed 30 degrees. There was a direct correlation between pinch strength and the amount of residual triceps and wrist extensor strength.
During the last few years the author has used a new surgical method of treating subcutaneous ruptures of the Achilles tendon. This is particularly appropriate in severe cases where the gap resulting from the rupture of degenerated tissue does not permit direct suture. The method has been used in ten cases. It consists of splitting the tendons of tibialis posterior and peroneus brevis and using the freed hemitendons as pedicled transplants. The plantaris tendon is used as a reinforcement. The operation is completed by folding down a flap of the superficial aponeurosis of the gastrocnemius. The results have been consistently good.
Thirty-eight patients with cerebral palsy had tendon transfers to improve extension of the wrist and fingers. The 10 patients who had poor hand placement, sensibility, or motor control failed to improve in functional grasp or release. The remaining 28 patients, with better preoperative criteria, had improved function. On long-term follow-up, 5 of the 12 patients with transfers to the wrist extensor had extension contractures with difficulty in release, and in seventeen patients transfers to the finger extensors resulted in improved finger extension and release, with no sacrifice in the ability to grasp.
This commentary reviews musculotendon architecture and the relation between architectural parameters and the force, speed, and excursion capacity of musculotendon units. It is hoped that this review will help provide the framework within which to appreciate the importance of the data presented by Lieber et al. Muscle fiber pennation hardly affects musculotendon output of forearm and hand muscles. Instead, physiologic cross-sectional area and muscle fiber length affect force capacity and speed and excursion capacity, respectively. How muscles with equal mass can have different force, speed, and excursion capacities is explained. Since the moment arm of a muscle (the shortest distance from the musculotendon unit to the joint center of rotation) transforms muscle output into musculotendon output, it is shown why the capacity for a muscle to exert force on an object, as during grasping, is directly proportional to its moment arm and why the range of joint movement and speed over which muscles exert force is inversely proportional to the moment arm. Finally, tendon, being not stiff in forearm and hand musculotendon units, also affects their output. Criteria are given for designing tendon transfer reconstructions from architectural data and moment arm data to best replicate the biomechanical function of the replaced muscle. To have the same capacity for imparting movement to objects and exerting force on them, the donor muscle should have the same moment arm/physiologic cross-sectional area product, the same fiber length/moment arm ratio, and the same tendon length/muscle fiber length ratio as the replaced muscle.