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PubMed1988

Tendon transfer for median nerve palsy.

A large number of tendon transfers have been described that restore opposition to the thumb and provide thumb and finger flexion. To provide optimal results following tendon transfers, one needs to follow the principles of tendon transfer: normal tissue equilibrium, movable joints, and a scar-free bed. Once these are present, we must look to available tables to determine an appropriate tendon transfer, matching up the lost muscle mass, fiber length, and cross-sectional area and then pick out muscle-tendon units of similar size, strength, and potential excursion. For low median nerve palsy (Table 4), we have found from our experimental and clinical studies that the FDS of the long and ring fingers or the wrist extensors (ECR or ECRL) best approximate the force and motion required for full thumb opposition and strength. These transfers are preferred in median nerve palsy or combined median ulnar nerve palsy when both strength and motion are required. In circumstances where only thumb mobility is desired, the EIP is an ideal transfer. Also, the extensor digitorum quinti (EDQ) and ADQ have sufficient mean fiber length (muscle excursion) to provide full thumb opposition. The palmaris longus transfer (Camitz transfer) is an abduction rather than an opposition transfer and should be reserved for selected cases of long-term carpal tunnel syndrome. For high median nerve palsy (Table 5), transfers of the brachioradialis or ECRL to restore lost thumb flexion (FPL) and side-to-side transfer of the FDP of the index finger are generally sufficient. A separate transfer to restore independent flexion of the index finger could be performed by utilizing the pronator teres or extensor carpi radialis ulnaris tendon muscle units. As they combine a proper direction of action, pulley location, and tendon insertion, tendon transfers for median nerve palsy are usually quite successful. In considering any of these elective procedures, however, it is important to remember that tendon transfers are muscle balance operations. The effect of transfer on restoring function must be carefully studied to assess the loss of function that such a transfer may endure.

Hand↗

PubMed2006

Repair of large supraspinatus rotator-cuff defects by infraspinatus and subscapularis tendon transfers in a cadaver model.

Transosseous repair of a supraspinatus tendon (SSP) defect (Patte size II) can be difficult if the tendon is retracted and the muscle atrophied. In this situation alternatives are margin convergence techniques, local tendon transfers or distant tendon transfers in massive tears. The object of this study was to compare two local tendon transfers in terms of the feasibility of the shift, the area covered by the shift and the force needed to accomplish the shift. Thirteen fresh-frozen cadaver shoulders were used. First a supraspinatus defect extending to the apex of the humeral head (Patte size II) was created. Transosseous repair was attempted with the infraspintus (ISP) and with the subscapularis (SCP) in all cases; repair was successful in all ISP cases, while use of the SCP resulted in a successful repair in only 8 of the 13 (61.5%). A significantly (P=0.012) larger defect area was covered by the ISP transfer than by the SCP shift: 89.7+/-8.5% versus 31.2+/-31.1% of the original defect, respectively. The tensile force needed to accomplish the shift was significantly (P=0.004) lower when the ISP was used (15+/-11 N) than with the SCP (37.1+/-15 N). In this cadaver model the ISP shift proved more favourable than the SCP shift for covering a Patte size II SSP defect.

Aged↗

PubMed1995

Tendon transfer combined with calcaneal osteotomy for treatment of posterior tibial tendon insufficiency: a radiological investigation.

We present the radiographic results after flexor digitorum longus tendon transfer combined with a medial displacement calcaneal osteotomy for the treatment of posterior tibial tendon insufficiency. Eighteen patients with posterior tibial tendon insufficiency were reviewed from 12 to 26 months after surgery. The 15 women and 3 men had a mean age of 54 years (range, 38-72 years). The talar-first metatarsal and talonavicular coverage angles were measured before and after surgery on the anteroposterior weightbearing radiographs. The mean preoperative talar-first metatarsal and talonavicular coverage angles were 21 degrees (range, 3-45 degrees) and 34 degrees (range, 0-55 degrees), respectively. The mean postoperative values for these angles were 8.5 degrees (range, 0-35 degrees) and 21 degrees (range, -30-45 degrees), respectively. The mean talar-first metatarsal angle decreased from 21 degrees to 8.5 degrees, a mean improvement of 12.5 degrees, and the mean talonavicular coverage angle decreased from 34 degrees to 21 degrees, a mean improvement of 13 degrees. On the lateral weightbearing radiographs, the talar-first metatarsal angle and the distance from the medial cuneiform to the floor were measured before and after surgery. The mean preoperative values were -22 degrees (range, -10 to -40 degrees) and 9 mm (range, 1-19 mm), respectively. The mean postoperative values were -9 degrees (range, +5 to -25 degrees) and 16 mm (range, 10-28 mm), respectively. The mean talar-first metatarsal angle decreased from -22 to -9 degrees (a mean improvement of 13 degrees), and the distance from the medial cuneiform to the floor increased from 9 to 16 mm (a mean improvement of 7 mm). We conclude that the use of a combined medial displacement osteotomy of the calcaneus with a tendon transfer for treatment of posterior tibial tendon insufficiency may offset the inherent weakness of the flexor digitorum longus transfer by reducing the antagonistic deforming force of heel valgus.

Adult↗

PubMed1997

Intraoperative measurement and biomechanical modeling of the flexor carpi ulnaris-to-extensor carpi radialis longus tendon transfer.

Sarcomere length was measured intraoperatively in five patients undergoing tendon transfer of the flexor carpi ulnaris (FCU) to the extensor carpi radialis longus (ECRL) for radial nerve palsy. All measurements were made with the elbow in 20 deg of flexion. Prior to tendon transfer, FCU sarcomere length ranged from 2.84 +/- .12 microns (mean +/- SEM) with the wrist flexed to 4.16 +/- .15 microns with the wrist extended. After transfer into the ECRL tendon, sarcomere length ranged from 4.82 +/- .11 microns with the wrist flexed (the new longest position of the FCU) to 3.20 +/- .09 microns with the wrist extended, resulting in a shift in the sarcomere length operating range to significantly longer sarcomere lengths (p < 0.001). At these longer sarcomere lengths, the FCU muscle was predicted to develop high active tension only when the wrist was highly extended. A biomechanical model of this tendon transfer was generated using normative values obtained from previous studies of muscle architectural properties, tendon compliance, and joint moment arms. Predicted sarcomere lengths pre- and post-tendon transfer agreed well with intraoperative experimental measurements. The theoretical wrist extension moment-wrist joint angle relationship was also calculated for a variety of values of FCU muscle length. These different lengths represented the different conditions under which the FCU could be sutured into the ECRL tendon. Variation in FCU muscle length over the range 200 mm to 260 mm resulted in large changes in absolute peak moment produced as well as the angular dependence of peak moment. This was due to the change in the region of FCU operation on its sarcomere length-tension curve relative to the magnitude of the ECRL moment arm. These data demonstrate the sensitivity of a short-fibered muscle such as the FCU to affect the functional outcome of surgery. In addition, we demonstrated that intraoperative sarcomere length measurements, combined with biomechanical modeling provide the surgeon with a powerful method for predicting the functional effect of tendon transfer surgery.

Adult↗

PubMed2004

Biomechanical analysis of tendon transfers for massive rotator cuff tears.

OBJECTIVE: To determine why certain tendon transfers are mechanically more effective than other tendon transfers for the treatment of a massive rotator cuff tear. DESIGN: A tendon transfer procedure of latissimus dorsi, teres major or a combination of these two to the insertions of either teres minor, infraspinatus, supraspinatus, or subscapularis is simulated using a biomechanical musculoskeletal model of the upper extremity. BACKGROUND: Massive rotator cuff tears are not easily repaired. To compensate for the loss of rotator cuff function, techniques such as muscle transfers are developed. METHODS: Three range of motion tasks were used as input to the Delft shoulder and elbow model. The muscle parameters of the Delft shoulder and elbow model were modified to simulate a rotator cuff tear. A biomechanical analysis of the transferred muscles was performed, taking outcome variables such as moment arms, muscle length and muscle force into account. RESULTS: Due to the massive rotator cuff tear, an elevation and external rotation moment is lost. When the tendon was transferred to the insertions of infraspinatus or supraspinatus, the humerus was capable of elevating and externally rotating. CONCLUSIONS: On the basis of mechanical parameters such as moment arms, muscle length and force it can be concluded that a tendon transfer of the teres major to the supraspinatus insertion will produce the best functional outcome in the treatment of massive rotator cuff tears. RELEVANCE: To find biomechanical evidence for an optimal tendon transfer that will lead to improved treatment of patients with a massive rotator cuff tear.

Biomechanical Phenomena↗

PubMed1993

Functional outcome of upper limb tendon transfers performed in children with spastic hemiplegia.

Children with spastic hemiplegia often present with upper limb muscle imbalance. The purpose of this paper was to determine whether reconstructive surgery improved their functional ability. 17 children under the age of 16 years with spastic hemiplegia underwent reconstruction that included tendon transfers, tendon lengthenings and thumb metacarpophalangeal fusion. They were assessed pre-operatively and at an average follow-up period of 2.6 years. Children's abilities were classified according to House's functional rating scale. Tendon transfers improved functional grading by two grades, from good passive assist to fair active assist. Improvement in the arc of wrist motion and forearm rotation was also seen. Parental satisfaction was high. Reconstructive surgery improved the functional abilities in this group of children with spastic hemiplegia.

Adolescent↗

PubMed2003

Motor unit properties in the soleus muscle after its distal tendon transfer to the plantaris muscle tendon in the rat.

The aim of this study was to evaluate how a modification in the mechanical conditions under which a muscle is used could induce changes in the characteristics and the spinal drive of its motor units (MU). The distal tendon of the soleus muscle of Wistar rats was transferred to the distal stump of the plantaris muscle tendon. The EMG activity of the soleus was chronically recorded for 8 weeks, every other day, during a 1-min treadmill walk. After spinal ventral root splitting, individual MU contractile properties were measured in control soleus (102 MUs) or in transposed soleus muscles after 4 weeks (41 MUs) or 8 weeks (28 MUs). Muscle/body weight ratio did not vary after transposition, nor did MU tetanic forces. A decrease in MU twitch contraction times and in their half relaxation times was observed at weeks 4 and 8. MU tension-frequency curves varied significantly after tendon transfer, becoming closer to the curves of the fast MUs of the control group. During locomotion, we observed no change in the amplitude of rectified-filtered electromyographic activity, but a significant decrease in mean burst duration and an increase in the median frequency of the power density spectrum. Tendon transposition of the soleus muscle brought about adaptations in MU contractile properties and soleus spinal control.

Animals↗

PubMed2001

Peroneus brevis tendon transfer in neglected tears of the Achilles tendon.

BACKGROUND: We present the results of a single-center, single-surgeon study in 59 patients with a fresh (4 women and 23 men; mean age, 43.6 +/- 8.8 years) or a neglected (1 woman and 21 men; mean age, 41.3 +/- 7.4 years) Achilles tendon rupture. METHODS: Patients with a fresh rupture were operated on using end-to-end suture, and patients with a neglected rupture received the tendon of the peroneus brevis as an autologous graft. Patients were assessed during the sixth postoperative week, and during the sixth postoperative month. They were discharged within 1 year after the operation, and were reviewed at an average of 53 +/- 13 months after surgery. RESULTS: Patients were generally satisfied with the procedure, but those with a neglected rupture tended to have a greater postoperative complication rate, greater loss of isokinetic strength variables at high speeds, and greater loss of calf circumference. CONCLUSION: The management of acute and neglected subcutaneous tears of the Achilles tendon by peroneus tendon transfer is safe but technically demanding. It affords good recovery, even in patients with a neglected rupture of 6 weeks' to 9 months' duration. Patients with a neglected rupture are at a slightly greater risk of postoperative complications, and their ankle plantar flexion strength can be reduced.

Achilles Tendon↗

PubMed1991

[Development of the techniques of tendon transfers for radial paralysis].

The techniques of tendon transfer for radial palsy are continually evolving. The technique of R. Merle d'Aubigné partly inspired by that of Robert Jones clearly represented an advance, but a study of the results has shown several imperfections. The techniques of Brand, Tsuge, or Boyes more recently, have also brought improvements, but are not entirely satisfactory. A study of all the elements of tendon transfers schemes leads us to describe two basic schemes for tendon transfers either using F.C.U. or not, which can be adapted to the patient's particular needs. The essential point for success is the centralization of extensor carpi radialis longus at its insertion.

Hand↗

PubMed1995

Perimalleolar tendon transfer to the os calcis for triceps surae insufficiency in patients with postpolio syndrome.

Twelve patients (14 feet) with the diagnosis of postpolio syndrome underwent patients-specific transfer of perimalleolar tendons to the os calcis for triceps surae insufficiency. One to 5 tendons were transferred, for a resulting mean muscle strength of Grade 3 at a mean followup of 2.7 years. At final followup, 7 patients were restudied with ankle plantar flexion torque measurements, range of motion, and gait analysis. Patients reported subjective improvements in endurance (86%), pain (90%), and ambulatory distance (50%). No progression of foot deformity was noted. Three of 5 patients became brace free. After tendon transfer, patients recorded increased ankle plantar flexion torque strength (80%) and an increase in 1 grade of muscle strength (29%). There was no significant change in gait velocity, stride length, or heeloff time between pre- and postoperative gait analysis. No tenodesis effect was observed. In conclusion, perimalleolar tendon transfers for triceps surae insufficiency in postpolio patients was effective in decreasing subjective complaints, arresting progressive foot deformity caused by muscle imbalance, and increasing plantar flexion strength, whereas the results of gait analysis failed to show significant improvement.

Adult↗

PubMed2002

Tendon transfer surgery: clinical implications of experimental studies.

Tendon transfers commonly are used to restore arm and hand function after injury to the main motor nerves or after spinal cord injury. Surgeons traditionally use passive tension to determine the length at which a muscle should be attached during tendon transfer. The principles used to choose the length at which the transferred muscle should be attached still are relatively vague and have not been examined thoroughly. Misunderstanding of the sarcomere length-passive tension relationship can result in severe overstretch of the muscle and poor function. Upper extremity muscles have operating ranges that vary between synergists and antagonists, and recent architectural and biochemical data suggest that upper extremity muscles are designed to provide optimal control of joint position and stability. It is hypothesized that a significant functional improvement will be realized when muscles are reattached during tendon transfer procedures at the appropriate length and tension.

Adaptation, Physiological↗

PubMed1991

Combined split anterior tibial-tendon transfer and intramuscular lengthening of the posterior tibial tendon. Results in patients who have a varus deformity of the foot due to spastic cerebral palsy.

Twenty patients who had a varus deformity of the foot secondary to spastic cerebral palsy had twenty-two operations involving combined split anterior tibial-tendon transfer and intramuscular lengthening of the posterior tibial tendon, with and without concomitant lengthening of the Achilles tendon. Preoperatively, all patients had had a dynamic varus deformity of the hindfoot and adduction of the forefoot in both the stance phase and the swing phase of gait. At an average follow-up of 6.2 years (range, 2.3 to 8.8 years), there were fourteen excellent, four good, and four poor clinical results. Two patients who had a fixed varus deformity of the hindfoot and one patient who had a very weak anterior tibial muscle had a poor result. We concluded that the combined procedure is effective for correction of a flexible varus deformity of the foot in patients who have spastic cerebral palsy.

Adolescent↗

PubMed2003

Tendon transfers for failed nerve reconstruction.

There are few reconstructive procedures in the upper extremity that are as helpful to patients as a tendon transfer. Successful tendon transfer requires the marriage of anatomic knowledge, surgical judgment, and rehabilitative expertise. Frequently, the improvement in function can be dramatic. By the same token, an unsuccessful tendon transfer wastes a normal muscle-tendon unit in the hand and leaves the patient withless function than what was present preoperatively.

Arm↗

PubMed1991

Tendon transfers in traumatic foot.

A clinical review was performed of 11 cases of traumatic foot treated by tendon transfer. Among 11 patients, there were eight males and three females, ranging from four to 36 years of age. The anterior tibial tendon was used in six cases for tendon transfer and among these, split anterior tibial tendon was used in three cases in children. The posterior tibial tenodn was used in two cases and the extensor digitorum longus tendon of the foot was in three cases. In six cases of soft tissue injury where tendon transfer was impossible, microvascular free cutaneous flap transplantation was combined with the tendon transfer. Follow-up results were obtained from 25 months to nine years. Excellent results were obtained in eight cases and satisfactory results in three cases. For the correction of function loss in traumatic foot, tendon transfere were a useful method for the recovery of active motion of the foot. For the restoration of function loss in the traumatic foot, there are several methods of treatment such as tendon transfer, arthrodesis and tenodesis, but for recovery of the active motion of the foot, tendon transer is the only useful method.

Adolescent↗

PubMed1975

[Restoration of grip by means of repair of the injured peripheral nerve and/or muscle-tendon transfer (author's transl)].

Muscle or tendon transfers are indicated after lesions of peripheral nerves if regeneration does not occur or remains incomplete after nerve repair or if the paralyzed muscles themselves are damaged. In long-standing cases the authors try nerve repair to attain adequate sensitivity, and perform the tendon transfer independently. The different techniques are discussed; transfer of the brachialis muscle to replace deficient flexor muscles is described and nerve-into-muscle implantation is mentioned.

Brachial Plexus↗

PubMed2006

[EEG spectral coherence at patients submitted to tendon transfer surgery: study pre- and post-surgery].

Tendon transfer of the tibiliais posterior muscle is a surgical intervention widely employed in orthopedics for the correction of drop foot caused by leprosy. However, few models have proposed a thorough investigation of the brain plasticity phenomenon during tendon transfer. Thus, the present study aimed at analyzing EEG spectral coherence (SC) in patients submitted to tendon transfer of the tibiliais posterior muscle by Srinivasan's technique and quantitative EEG (EEGq). The sample consisted of four subjects with drop foot caused by leprosy. The SC parameter was evaluated in two experimental moments: pre and post-surgery. Results demonstrated a main moment effect for the C3-CZ electrode pair. Specifically, a significant increase in coherence values was observed. However, the ANOVA did not indicate a significant band/moment interaction. It can be assumed that coherence augmentation indicates that functional rehabilitation promoted by this specific surgery yields cortical alterations.

Adult↗

PubMed1995

Early active mobilization after tendon transfers using mesh reinforced suture techniques.

23 tendon transfers in the hand and forearm were performed using a polyester mesh sleeve to reinforce conventional suture techniques. All transfers were mobilized with active flexion and extension within 3 days of operation. Excluding one rupture (due to extreme unintentional loading) and depending on the type of transfer used, a mean of between 69% and 78% of the final active range of motion was obtained 1 month post-operatively. With the exception of transfers for wrist extension, the mean final active range of motion amounted to between 91% and 100% of the available passive range of motion and between 75% and 100% of the corresponding "normal" active range of motion in the opposite hand. The mean final active range of motion after reconstructions for wrist extension amounted to 85% of the passive range of motion and to at least 80% of the maximum range of motion potentially available with the transfers used. The results indicate that early active mobilization after tendon transfers may offer significant advantages in terms of quicker and simpler rehabilitation as well as improved results.

Adolescent↗

PubMed1996

Sarcomere length changes after flexor carpi ulnaris to extensor digitorum communis tendon transfer.

Sarcomere length was measured intraoperatively on five patients undergoing tendon transfer of the flexor carpi ulnaris (FCU) to the extensor digitorum communis (EDC) for radial nerve palsy. The most significant result was that the absolute sarcomere length and sarcomere length operating range of the FCU increased after transfer into the EDC (p < .001). Preoperatively, with the wrist fully extended and fingers flexed, FCU sarcomere length was 4.22 +/- .24 microns and decreased to 3.19 +/- .05 microns as the wrist was fully flexed. This represented an overall sarcomere length range of 1.03 microns. After the tendon transfer using standard recommended techniques, all sarcomere lengths were significantly longer (p < .001). Specifically, sarcomeres were 0.74 +/- .14 microns longer with the muscle in its fully lengthened position (4.96 +/- .43 microns with the wrist and digits flexed) and 0.31 +/- .16 microns longer with the FCU in the fully shortened position (3.50 +/- .06 microns with the wrist and digits extended). At these sarcomere lengths, the FCU muscle was predicted to develop relatively high force only during movement involving synergistic wrist flexion and finger extension. Under the conditions of the procedures performed, the transferred FCU muscle was predicted to produce maximum force over the range of about 30 degrees of wrist flexion and 0 degree of finger flexion to 70 degrees of wrist extension and 90 degrees of finger flexion. While this is acceptable, a more desirable result was predicted to occur if the muscle was transferred at a longer length. In this latter case, greater stretch of the FCU during transfer (increasing sarcomere length to about 5 microns) was predicted to improve the transfer. The more highly stretched FCU was predicted to result in maximum force as the wrist and fingers progressed from about 60 degrees of wrist extension and 0 degree of finger flexion to 80 degrees of wrist extension and 70 degrees of finger flexion. These results quantify the relationship between the passive tension chosen for transfer, sarcomere length, and the estimated active tension that can be generated by the muscle. The results also demonstrate the feasibility of using intraoperative laser diffraction during tendon transfer as a guide for optimal placement of the transferred muscle.

Adolescent↗