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PubMedDate not supplied

Immediate active mobilization versus immobilization for opposition tendon transfer in the hand.

PURPOSE: To test the hypothesis that immediate postoperative active mobilization of the hand after opposition tendon transfer will achieve outcomes similar to those of the standard practice of cast immobilization. METHODS: Five hands with isolated lower median nerve paralysis prospectively had opposition tendon transfer followed by immediate postoperative active mobilization for rehabilitation of the transfer. Historical records of 7 identical paralyses with opposition tendon transfers immobilized after surgery in a cast for 3 weeks were used for comparison. Outcomes were assessed by (1) the status of tendon transfer attachment to the thumb during immediate mobilization to detect tendon pullout, (2) the results of the opposition transfers for both groups using identical outcome measures (range of postoperative active abduction of the thumb, pinch pattern, pinch strength), and (3) comparison of the results from both groups. RESULTS: There were no incidences of tendon pullout during immediate active mobilization of opposition tendon transfer. There were no differences in outcome between the 2 groups at late follow-up evaluations, with all opposition transfers achieving good results. Immediate postoperative active mobilization reduced rehabilitation time by an average of 19 days. An earlier return to activities of daily living was a further benefit to patients. CONCLUSIONS: This study supports the hypothesis and suggests that similar outcomes can be achieved in reduced time by immediate active mobilization of opposition tendon transfer. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.

Activities of Daily Living↗
PubMed1988

Tendon transfers in surgery of the rheumatoid hand.

Tendon transfer procedures are used in the reconstructive surgery of the rheumatoid hand in cases of tendon ruptures, deformities, and compression neuropathies with subsequent muscle atrophy. The prerequisites and essential principles for tendon transfers are discussed, including the following: 1) correction of contractures, 2) adequate power of the muscle, 3) sufficient amplitude, 4) straight line of pull, and 5) maintenance of the integrity of the muscle.

Arthritis, Rheumatoid↗
PubMed1980

Tendon transfers for radial nerve palsy.

Outlined below are the tendon transfer procedures I have used in the treatment of 69 radial nerve palsy cases encountered during the past 25 years. The factors considered in determining which surgical procedure is to be performed are as follows: (i) neurorrhaphy is impossible; or (ii) neurorrhaphy would be possible, but useful recovery cannot be expected; (iii) signs of recovery cannot be seen six months after neurorrhaphy; or (iv) useful restoration cannot be expected because of scar formation or muscular atrophy in the surrounding area. In some cases, there may be some degree of functional restoration of extensor function, which is a welcome bonus, but tendon transfer is the most useful procedure to provide for a built-in dynamic splint in the hand. Therefore, so long as the correct indications for tendon transfer are carefully observed, this operation deserves to be used frequently.

Female↗
PubMed2003

Tendon transfer to reconstruct wrist extension in children with obstetric brachial plexus palsy.

This study reports on 20 children with obstetric brachial plexus palsy who underwent a tendon transfer to reconstruct wrist extension. The mean age at the time of tendon transfer was 8 years. There were seven patients with Erb's palsy and the remaining 13 had total palsy. The flexor carpi ulnaris was utilized 15 times and the flexor carpi radialis five times. The transferred tendon was sutured to the tendon of the extensor carpi radialis brevis. The result of the transfer was assessed according to a modified Medical Research Council (MRC) muscle grading system. A good result was obtained in 18 patients (modified MRC grade of 4) and a fair result (modified MRC grade of 3) in two. The choice of tendon transfer to reconstruct the wrist drop deformity in various conditions including adult traumatic brachial plexus injuries is discussed.

Adult↗
PubMed1985

Postoperative results of opponensplasty and flexor tendon transfer in patients with spinal cord injuries.

Key pinch, palmar pinch, and grasp strength were evaluated after opponensplasty and flexor tendon transfer in 24 patients who had suffered cervical spinal cord injuries during a 17-year period. The patients had 57 tendon transfers: 35 opponensplasties and 22 flexor tendon transfers. The average follow-up was 4.2 years. The brachioradialis and pronator teres were the most frequently used motors for the opponensplasty and flexor tendon transfer. Key pinch strength averaged 1.47 kg (range of 0.13 to 4.70 kg). Grasp strength averaged 2.81 kg (range of trace to 10.0 kg). Palmar pinch was obtained in 45% of the extremities; the overall result was 1.04 kg (range of 0.20 to 3.00 kg). In general, patients with higher functional classifications achieved better results. We believe that intraoperative length-tension studies were an important factor in improving the results. The choice of muscle for opponensplasty or flexor transfer when two different adequate motors were available did not seem to affect the outcome of key pinch or grasp. We believe that tendon transfers are beneficial and should be considered in all patients with spinal cord injuries regardless of age at injury if at least 1 year has elapsed since injury and the patients are neurologically stable and have participated in a rehabilitation program.

Adult↗
PubMed2005

The response of the flexor digitorum longus and posterior tibial muscles to tendon transfer and calcaneal osteotomy for stage II posterior tibial tendon dysfunction.

BACKGROUND: The purpose of this prospective study was to evaluate the response of the flexor digitorum longus (FDL) and posterior tibial (PT) muscles to FDL tendon transfer and medial displacement calcaneal osteotomy for stage II posterior tibial tendon dysfunction (PTTD). METHODS: Twelve patients were divided into two groups, depending on whether the PT tendon was excised (Excised Tendon Group) or left intact (Intact Tendon Group). The muscle volumes of the FDL and PT muscles in both legs were measured and compared, using cross-sectional area (CSA) analysis of preoperative and postoperative MRI. RESULTS: Preoperatively, there was an average 11% reduction in the PT muscle volume and a 17% increase in the FDL muscle volume from the normal contralateral side in both groups. One year after surgery (average 13.4 months) in both groups, the FDL muscle volume had increased by an average of 27% and the PT muscle volume had decreased by 23% compared to the contralateral normal side. The FDL volume increased by 44% in the Excised Tendon Group compared to 11% in the Intact Tendon Group. The PT muscle volumes were not assessed in the Excised Tendon Group because all PT muscle had been replaced by fatty infiltration. The PT volumes in the Intact Tendon Group decreased further from a 6% reduction preoperatively to a 23% reduction postoperatively compared to the normal contralateral side. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores increased from 50 preoperatively to 88 at 1 year after surgery. There was no difference in the scores between the Excised Tendon (47 to 87) and Intact Tendon (53 to 89) groups. CONCLUSION: We concluded that the FDL muscle hypertrophies in response to a failing PT muscle. This hypertrophy continues after FDL transfer and medial displacement calcaneal osteotomy. With excision of the PT tendon, the FDL undergoes greater hypertrophy than if the tendon is left attached. The PT muscle continues to atrophy and undergoes complete fatty replacement if the tendon is excised. Transfer of the FDL and medial displacement calcaneal osteotomy produce a satisfactory improvement in hindfoot function; the outcome was the same whether the PT tendon was sacrificed or left intact.

Adult↗
PubMed1998

Increasing the moment arm of the tibialis anterior induces structural and functional adaptation: implications for tendon transfer.

Previous studies on the functional effects of tendon transfer have not examined possible muscle adaptation following transfer. The purpose of the present study was to test the hypothesis that muscle adapts to increased moment arm and excursion such that joint torque is maintained near normal levels. The moment arm and excursion of the tibialis anterior (TA) were increased by releasing the TA from its retinacular restraint at the ankle joint in growing (4-week-old) rabbits. Twelve weeks post-release, in vivo TA force during hopping was smaller in released compared with control rabbits, compensating for the increased moment arm, and thus TA torque at the ankle joint was not significantly different between groups. Physiological cross-sectional area was smaller, and the number of sarcomeres in series was larger, in the released TA compared with the control TA. These adaptations may result from chronically decreased in vivo TA force production, and chronically increased TA excursion, respectively. In addition, these adaptations were consistent with the smaller in vivo force for the released TA. Comparisons between control and sham-operated rabbits showed no significant differences for in vivo TA force, torque, or muscle architecture. Thus, muscle appears capable of adapting to increased moment arm and excursion such that joint torque is maintained near normal levels. These findings have important implications for tendon transfer procedures that increase the moment arm and/or excursion of the released muscle.

Adaptation, Physiological↗
PubMed1996

Human wrist motors: biomechanical design and application to tendon transfers.

Moment arm, muscle architecture, and tendon compliance in cadaveric human forearms were determined and used to model the wrist torque-joint angle relation (i.e. wrist torque profile). Instantaneous moment arms were calculated by differentiating tendon excursion with respect to joint rotation. Maximum isometric tension of each wrist muscle-tendon unit was predicted based on muscle physiological cross-sectional area. Muscle forces were subsequently adjusted for sarcomere length changes resulting from joint rotation and tendon strain. Torque profiles were then calculated for each prime wrist motor (i.e. muscle-tendon unit operating through the corresponding moment arm). Influences of moment arm, muscle force, and tendon compliance on the torque profile of each motor were quantified. Wrist extensor motor torque varied considerably throughout the range of motion. The contours of the extensor torque profiles were determined primarily by the moment arm-joint angle relations. In contrast, wrist flexor motors produced near-maximal torque over the entire range of motion. Flexor torque profiles were less influenced by moment arm and more dependent on muscle force variations with wrist rotation and with tendon strain. These data indicate that interactions between the joint, muscle, and tendon yield a unique torque profile for each wrist motor. This information has significant implications for biomechanical modeling and surgical tendon transfer.

Biomechanical Phenomena↗
PubMed1995

[Changes in muscle power following tendon lengthening and tendon transfer].

Each muscle consists of a tendon, the aponeuroses and the muscle fibers. Because of the anatomical architecture a force functionally adapted to the joint motion is generated by the muscle. If the functional length changes, the muscle adapts by altering the number of sarcomeres in a series. If the tendon is elongated without changing the functional range of motion at which the muscle is active on the joint, the passive tension is decreased. As a result, the number of sarcomeres in a series is reduced. The muscle produces less force and the range of active force production is narrowed. If by elongating the tendon, however, the functional range of motion of the muscle at the joint is moved and the tension remains unchanged, the muscle force can be preserved. A tendon transfer affects the muscle in a similar way. If the length of the muscle (and the tension) remains unchanged, the muscle force will be preserved. This prerequisite is fulfilled even better the more the architecture of the replacing muscle equals what is being replaced.

Biomechanical Phenomena↗
PubMed2001

Outcome following addition of peroneus brevis tendon transfer to treatment of acquired posterior tibial tendon insufficiency.

The flexor digitorum longus, the tendon most often used for transfer in posterior tibial tendon insufficiency, is one-half to one-third the size of the posterior tibial tendon. Occasionally it may be particularly small or may have been previously used for transfer. In these cases, the senior author has felt that the addition of a transfer of the Peroneus Brevis (PBr) tendon may be helpful in maintaining sufficient tendon and muscle mass to rebalance the foot. Thirteen patients who underwent this procedure were retrospectively identified and matched by age and length of follow-up to patients who underwent a more standard tendon transfer operation minus the addition of the PBr transfer. Pain and functional status were then assessed by the American Orthopaedic Foot and Ankle Society's ankle/hindfoot rating scale. Each patient was tested by an independent physical therapist to evaluate inversion and eversion strength. The mean duration of follow-up was 20.6 months (12 to 34 months). The average AOFAS score of the PBr group was 75.8 compared to 71.5 for the standard control group. There was no significant difference between the groups when inversion or eversion strengths were compared. Inversion strength and eversion strength was rated good or excellent (4 or 5) in 12 out of 13 of the PBr transfer group patients. No major complications were encountered in either group. Although it does not increase inversion strength, a PBr transfer can be used to augment a small FDL without causing significant eversion weakness. This can be useful when the FDL is particularly small or in revision surgery.

Calcaneus↗
PubMed2004

Effectiveness of tendon transfers for massive rotator cuff tears: a simulation study.

UNLABELLED: OBJECTIVE To determine what the most effective tendon transfer is in the case of a dysfunctional rotator cuff. 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 this loss of rotator cuff function other techniques like muscle transfers are developed. METHODS: Three range of motion tasks and six activities of daily living of 24 subjects were measured. Kinematics from these 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 and the ability to perform the measured tasks with and without simulated transfer procedures was checked. RESULTS: The highest improvements (28-30%, P = 0.00 ) in the ability to perform tasks were observed after a simulated tendon transfer of either both muscles or teres major alone attached to the supraspinatus or infraspinatus insertion. Although all transfer procedures produce significant improvements (P = 0.00 ), there is a significant difference between the procedures (Chi square=58.8, P = 0.00 ) dependent on attachment site. CONCLUSIONS: According to the simulation procedure used in the current study, a tendon transfer of teres major and latissimus dorsi or teres major alone to the supraspinatus insertion appears to be the most effective procedure in the case of a dysfunctional rotator cuff. Practical factors, like subacromial space, volume of the muscles and tendons, tensile properties and the ability to split the muscles, will finally determine which is the preferred transfer option.

Analysis of Variance↗
PubMed2004

The correction of ulnar claw fingers: a follow-up study comparing the extensor-to-flexor with the palmaris longus 4-tailed tendon transfer in patients with leprosy.

PURPOSE: The extensor to flexor 4-tailed tendon transfer (EF4T) and the palmaris longus 4-tailed tendon transfer (PL4T) are 2 surgical procedures used to correct intrinsic paralysis of the hand in leprosy. The EF4T traditionally is the more common procedure and requires the transfer of a wrist extensor muscle. The PL4T requires the transfer of the palmaris longus and morbidity is expected to be lower. A follow-up study was performed to determine whether the clinical outcome of the PL4T is superior to the EF4T procedure in leprosy patients with ulnar claw fingers that are considered mobile before surgery. METHODS: Fifty-five patients presented 65 affected hands, of which 40 hands had the PL4T and 25 had the EF4T procedure. Each hand was assessed before surgery and at follow-up evaluation by predetermined angle measurements, standardized photographs, mechanical function, and patient satisfaction. Each hand was given an overall technical grade according to previously published standards. RESULTS: After an average follow-up period of 33 months there was no statistically significant difference in the technical outcome or patient satisfaction between the 2 tendon transfer procedures. CONCLUSIONS: Whenever the palmaris longus is available it may be considered to be the motor tendon of choice to undertake a many-tailed procedure for claw finger reconstruction in mobile hands paralyzed by leprosy. The palmaris longus should be considered as a possible motor tendon when correcting intrinsic muscle paralysis of the hand.

Adolescent↗
PubMed1998

Tendon transfer with a microvascular free flap for injured feet in children.

We reviewed 11 patients who had been treated between January 1986 and June 1994 for severe foot injuries by tendon transfer with microvascular free flaps. Their mean age was 5.6 years (3 to 8). Five had simultaneous tendon transfer and a microvascular free flap and six had separate operations. The mean interval between the tendon transfer and the microvascular free flap was 5.8 months (2 to 15) and the mean time between the initial injury and the tendon transfer was 9.6 months (2 to 21). The anterior tibial tendon was split in five of six cases. The posterior tibial tendon was used three times and the extensor digitorum longus tendon twice. The mean follow-up was 39.7 months (24 to 126). There were nine excellent and two good results. Postoperative complications included loosening of the transferred tendon (2), plantar flexion contracture (1) mild flat foot deformity (1) and hypertrophic scars (2). We recommend tendon transfer with a microvascular free flap in children with foot injuries combined with nerve injury and extensive loss of skin, soft tissue and tendon.

Ankle Joint↗
PubMed1979

The role of muscle reeducation in dynamic tendon transfer surgery of the hand.

Tendon transfers are used commonly to improve function following damage to major nerve trunks. For the transfer to function dynamically and in harmony with other active hand muscles, proper integration of the action of the transfer into the available hand movements is essential. This concept is discussed together with the rationale and methods of pre and postoperative training that contribute immensely to the success of such operative procedures.

Body Image↗
PubMed1995

Assessment of eversion and plantar flexion strength after repair of Achilles tendon rupture using peroneus brevis tendon transfer.

Eight patients with Achilles tendon ruptures, one of which was a late discovery, underwent peroneus brevis tendon transfers to repair their injuries. Subsequently, both the repaired and normal extremities of all eight patients were tested for eversion and plantar flexion strength. The Cybex 340 isokinetic system (Lumex Corp, Bayshore, New York) was used at both 30 degrees per second and 120 degrees per second. Patients' affected sides were then assessed subjectively for function compared with their opposite normal sides. Results for eversion strength showed a 17.4% deficit at 30 degrees per second and a 14.9% deficit at 120 degrees per second on the repaired extremity. Only the group with the 14.9% deficit showed a statistically significant difference using the paired t test (P < 0.05). Results for plantar flexion strength showed a 1.5% difference at 30 degrees per second and a 5.8% difference at 120 degrees per second. None of these differences were statistically significant. Subjective assessment showed no functional compromise in eversion strength, plantar flexion strength, activities of daily living, or ankle stability. Conclusions are that mild objective eversion weakness and no objective plantar flexion weakness can be expected after this procedure; however, subjective assessment reveals no functional compromise.

Achilles Tendon↗
PubMedDate not supplied

Mechanical strength of latissimus dorsi tendon transfer with Teflon felt augmentation.

Tensile properties of Teflon felt augmentation after latissimus dorsi tendon transfer to rotator cuff defect were examined in dog cadaver shoulders. Two experimental groups with latissimus dorsi tendon transfer were designed. In group 1 (right shoulders, n = 7) the tendon ends of latissimus dorsi were sutured to the greater tuberosity. In group 2 (left shoulders, n = 7) the repair was augmented with Teflon felt at the suture site. The ultimate tensile force and stiffness of each specimen in group 2 were individually compared with those in group 1. The average increases in ultimate tensile force and stiffness in group 2 were 53.8% and -3.7%, respectively. The individual value of ultimate tensile force in group 2 was significantly greater than that in group 1. These results demonstrate that augmentation at the repair site is mechanically effective latissimus dorsi tendon transfer. The augmentation procedure may provide protection during the healing period because of this and a surrounding fibrous tissue reaction.

Animals↗
PubMed1996

Measurement of isometric elbow and shoulder moments: position-dependent strength of posterior deltoid-to-triceps muscle tendon transfer in tetraplegia.

This report describes an apparatus which has been developed to measure several isometric elbow and shoulder forces and moments simultaneously and also allows this characterization to be performed across a range of shoulder and elbow joint angles in a horizontal plane. This apparatus was used to characterize the elbow extension strength in individuals with tetraplegia resulting from cervical level spinal cord injury. In all of these individuals, voluntary elbow extension was provided exclusively by the posterior deltoid muscle, which had previously been surgically transferred to the tendon of the paralyzed triceps muscle. Elbow extension is essential for many daily activities, such as reaching above shoulder level and pushing objects away from the body; the widely used posterior deltoid-to-triceps muscle tendon transfer surgery restores some degree of voluntary control to this important function. The apparatus contained a six-axis force-moment transducer to which the arm of each subject was attached. The six outputs of the transducer were transformed to correspond to physiological elbow and shoulder moments and forces. A customized table allowed the shoulder and elbow angles of the subject to be varied over a wide range in a horizontal plane so that the effects of posterior deltoid muscle length could be characterized over the likely functional range of the subject within this plane. It was found that elbow extension strength varied widely across subjects with C5 or C6 tetraplegia, from quite weak to strong enough to propel a manual wheelchair. Furthermore, the elbow extension strength of most subjects showed a strong dependence on both elbow and shoulder angles. Elbow extension was typically weak when the upper arm was elevated to shoulder level at the side, which unfortunately corresponds to the position often adopted by these individuals due to shoulder weakness.

Elbow Joint↗
PubMedDate not supplied

Effect of attachment site and routing variations in split tendon transfer of tibialis posterior.

Spastic equinovarus is a condition that commonly affects the gait of children with cerebral palsy. Split tendon transfers of the tibialis posterior (TP) are often performed to eliminate the excessive hindfoot inversion present in equinovarus. TP muscle moment arms were computed before and after three variations of split TP tendon transfer to assess the effectiveness of each. The three surgeries tested were (1) the original split TP transfer to the distal peroneus brevis tendon routing behind the lateral malleolus; (2) an attachment variation in which the transferred tendon half was attached to the proximal peroneus brevis tendon rather than to the distal site; and (3) a routing variation in which the transferred tendon half was passed through a window in the interosseous membrane and attached to the distal peroneus brevis tendon. Tendon tension was controlled for in these experiments because improper tensioning is often cited as a reason for poor outcomes. All three surgeries significantly reduced the ability of TP to invert the hindfoot, thus eliminating a potential deforming force, but the reduction following interosseous routing was significantly less than that found for the other two transfer procedures. Routing through the interosseous membrane also reduced the ability of the TP to plantarflex the foot, but ankle actions were preserved following the other two surgeries. Routing through the interosseous membrane to an anterior attachment site resulted in a muscle with minimal potential to create or resist action about the ankle joint. Similar moment arms were measured when the attachment site on the peroneus brevis tendon was located either proximally or distally, suggesting that this choice does not appear to significantly affect the mechanical outcome.

Aged↗