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PubMed2004

The uses of tendon transfers to correct paralytic deformity of the foot and ankle.

Tendon transfers for paralytic foot and ankle deformities can be rewarding in well-selected patients. The goal should be to achieve a stable plantigrade foot which optimally will not require a brace. This is possible if there is adequate preoperative tendon strength, adherence to the basic principles of tendon transfer during surgery, and intensive retraining of the muscle in the recovery phase. The optimal method of tendon fixation remains unclear.

Ankle↗
PubMed1999

Split flexor pollicus longus tendon transfer for stabilization of the thumb interphalangeal joint: a cadaveric and clinical study.

The split flexor pollicus longus (FPL) tendon transfer is a surgical technique using the radial half of the FPL tendon rerouted dorsally and inserted into the extensor pollicis longus tendon for correction of Froment's sign. A cadaveric model was designed to investigate the effects of the split FPL tendon transfer on pinch strength. Pinch strength was compared for extrinsic thumb flexion (1) without the split FPL and (2) with the split FPL, tensioned at 3 different positions (0 degrees flexion, 30 degrees flexion, and 60 degrees flexion). We report the clinical results of key pinch strength using split FPL tendon transfer as part of thumb reconstruction for 12 thumbs in 10 patients at an average follow-up time of 2 years. The cadaveric study showed no significant difference in pinch force between specimens with or without split FPL transfer or when comparing tensioning at 0 degrees versus 30 degrees versus 60 degrees. Froment's sign wa s reproduced in all cadavers with pinch activation without split FPL transfer and was eliminated in all specimens after the split FPL transfer. In the clinical portion of this study 12 transfers in 10 patients had an average follow-up pinch strength of 33.7 N (range, 18-80 N) and no evidence of Froment's sign. We conclude that the split FPL tendon transfer is an effective method for correction of Froment's sign due to intrinsic paralysis of the thumb.

Adult↗
PubMed1985

A laser diffraction method for measuring muscle sarcomere length in vivo for application to tendon transfers.

A technique that uses laser light diffraction to measure muscle sarcomere length allows direct determination of optimal muscle length during tendon transfers. Forearm muscle sarcomere length with the hand in the position of function is 2.4, and muscle length corresponds directly to sarcomere length. We have used these observations to restore optimal muscle length during tendon transfers. Standard high radial nerve tendon transfers in six fresh cadaver forearms demonstrated the efficacy of the laser diffraction method in accurately measuring sarcomere length. In two clinical trials with the laser, standard high radial nerve palsy tendon transfers were performed. In each case the clinical tendency was to overpull the muscle during the transfer. With the laser it was possible to identify excessive muscle stretch and restore optimal muscle length.

Forearm↗
PubMedDate not supplied

Outcomes of tendon transfer surgery and occupational therapy in a child with tetraplegia secondary to spinal cord injury.

OBJECTIVE: Tendon transfer surgery to augment hand function lost to spinal cord injury (SCI) has gained acceptance as a rehabilitation option for adults but has yet to be fully explored in children. In this study, hand function and performance of activities of daily living in an 11-year-old child with an SCI were evaluated before and after surgical transfers of the brachioradialis to the flexor pollices longus and the extensor carpi radialis longus to the flexor digitorum profundus. METHOD: With the use of a single-subject AB design, repeated measures of pinch force, the Jebsen Test of Hand Function for Children and the Grasp and Release Test were obtained before tendon transfer surgery and at 2 1/2 6, and 12 months after surgery. Activities of daily living were assessed with the Functional Independence Measure (FIM) and the Common Object Test (COT) before surgery and 12 months after surgery. RESULTS: Each assessment revealed a significant improvement in hand function after surgery. Pinch force was measurable only after tendon transfers and increased throughout the first year. By two standard deviation analyses, after surgery there were significantly more task completions for all Grasp and Release Test objects, and task completion times were shorter for the light and heavy objects of the Jebsen Test of Hand Function for Children. FIM results showed that self-catheterization and cutting food were possible only after surgery, and results of the COT revealed new unilateral and bilateral abilities that facilitated the client's independence in writing, eating, applying toothpaste, and brushing teeth. CONCLUSION: This single-subject study demonstrates the benefits of tendon transfers for active grasp in a child with an SCI.

Activities of Daily Living↗
PubMed1999

Results of flexor-to-extensor and extensor brevis tendon transfer for correction of the crossover second toe deformity.

Between 1990 and 1995, 38 patients (42 feet) underwent repair for crossover toe deformity, 31 (35 feet) of whom returned for final examination at an average of 51.6 months (range, 24-81 months). Causes included trauma, iatrogenic, and unknown. Presenting complaints included dorsal pain with either metatarsalgia or joint pain, isolated metatarsophalangeal (MP) joint pain, metatarsalgia, painful plantar callus, metatarsalgia and joint pain, and painful dorsal callus. All patients were treated with one of two operative techniques, either the flexor-to-extensor tendon transfer or the extensor brevis tendon transfer. Choice of procedure depended on the stage of preoperative deformity. Twenty-four patients were completely satisfied with the surgical correction, 6 were satisfied with reservations, and 1 was dissatisfied. The average postoperative AOFAS score for all patients was 85 points (range, 54-100 points), which correlated strongly with patient satisfaction. Twenty-two patients stated that they had no postoperative pain, 8 reported some pain, and 1 had frequent pain at the corrected toe. In 30 feet, there was no recurrence; three patients had mild residual crossover toe deformity, and two patients had recurrent deformity, although all MP joints were stable. Follow-up radiographs demonstrated substantial reduction in MP joint angles in both the AP (from 7 degrees to -1 degree) and lateral (from 45 degrees to 25 degrees) projections. This article reviews the surgical technique of both procedures, proposes specific indications for each, and presents outcomes. Based on our findings, the extensor brevis tendon transfer is appropriate for stage 1, stage 2, and flexible stage 3 deformities. Flexor-to-extensor tendon transfer is appropriate for rigid stage 3 and stage 4 deformities and for all patients with a symptomatic neuroma of the second web space (where the extensor brevis transfer is not possible). Stiffness of the MP joint is a potential problem with the flexor-to-extensor tendon transfer.

Adult↗
PubMed2002

Problems and solutions in palliative tendon transfer surgery for radial nerve palsy.

Palliative tendon transfer procedures for radial nerve palsy are continuing to evolve. The main modifications have concerned the operative techniques and the choice of procedures to adapt surgery to the needs of the patient. A study of all the elements of tendon transfer has been undertaken and has gradually led us to describe two basic methods of transfer either using or not using the flexor carpi ulnaris for transfer. The essential consideration is the avoidance of radial deviation of the wrist by centralizing the insertion of the extensor carpi radialis longus.

Journal Article↗
PubMed2002

Tendon transfers as applied to tetraplegia.

The techniques of the tendon transfers that are used primarily for the functional rehabilitation of upper limbs in tetraplegia are described in this article. The restoration of active elbow extension can be obtained either by biceps-to-triceps or by deltoid-to-triceps transfers. Grasp and key grip can be restored either by active or by passive tendon transfers. The usual motors of active transfer are the BR and ECRL. The usual tenodesis involve the FDS (via lassos), EDC, EPL, FPL, and APL.

Arm↗
PubMed1998

Flexor carpi ulnaris tendon transfers in cerebral palsy.

Flexor carpi ulnaris tendon transfer to either the extensor carpi radialis longus or extensor carpi radialis brevis has become a standard procedure to improve function in patients with cerebral palsy. In this retrospective study of the procedure, we have compared preoperative and postoperative wrist position, analysed potential outcome predictors and assessed function by objective and subjective measures. Sixteen children, with flexor carpi ulnaris transfer to extensor carpi radialis longus or brevis or extensor digitorum, were tested at an average follow-up of 4 years (range, 1-9). General resting position improved and the centre of the arc of motion averaged 6 degrees pronation and 9 degrees extension. Subjectively, 14 of 16 parents felt there was an improvement in function, 16 of 16 felt that cosmesis was improved, 14 of 16 would recommend the procedure to others, and 15 of 16 were satisfied overall.

Adolescent↗
PubMed2001

Long-term results of tibialis posterior tendon transfer for drop-foot.

Twelve patients with drop-foot secondary to sciatic or common peroneal nerve palsy treated with transfer of the tibialis posterior tendon were followed-up for a mean of 90 (24-300) months. In 10 patients the results were 'excellent' or 'good'. In 11 patients grade 4 or 5 power of dorsiflexion was achieved, although the torque, as measured with a Cybex II dynamometer, and generated by the transferred tendon, was only about 30% of the normal side. Seven patients were able to dorsiflex their foot to the neutral position and beyond. The results appeared to be better in men under 30 years of age with common peroneal palsies. A painful flatfoot acquired in adulthood does not appear to be a significant long-term complication despite the loss of a functioning tibialis posterior tendon.

Adolescent↗
PubMed2001

Changes in muscle moment arms following split tendon transfer of tibialis anterior and tibialis posterior.

Moment arms of tibialis anterior (TA) and tibialis posterior (TP) about the subtalar and talocrural joint axes were measured in anatomic specimens both before and after split tendon transfers. These procedures are commonly performed to correct hindfoot varus, a gait deformity that is often seen in patients with cerebral palsy, stroke, and brain injury. Split tendon transfer significantly reduced the inversion moment arms of tibialis anterior and tibialis posterior at all subtalar joint angles except for the most everted position in the case of TA. Changes in subtalar joint moment arms produced by split tendon transfer, especially those seen in TA, were variable, suggesting that the procedure may be susceptible to technical errors, especially related to balancing tensions in the medial and lateral tendon halves. Talocrural joint moment arms of both muscles were preserved following split tendon transfer. This study presents the first measurements of the moment arms of split transferred muscles. These characterizations of the mechanics of split tendon transfer will aid in the planning and assessment of these procedures.

Adult↗
PubMed1988

Combined anteroposterior tibial tendon transfer in post-traumatic peroneal palsy.

Posterior tibial tendon transfer to the dorsum of the foot for correction of traumatic paralytic peroneal palsy is a well-accepted treatment option. A careful review of the literature reveals that the results of treatment in this specific patient group are not always encouraging. This paper reports the results of a combined anteroposterior tibial tendon transfer in nine patients with traumatic paralytic peroneal palsy who initially used an ankle-foot orthosis to ambulate. Percutaneous tendo achillis lengthening to correct fixed ankle equinus was performed in six of the patients. At a minimal 24-mo follow-up (range, 24-56), all nine patients were brace free and subjectively felt that the surgery was successful. While the surgery was initially planned to provide an active "tenodesis" of the ankle to resist passive ankle equinus during swing phase of gait, walking electromyography revealed "retraining" of the transferred posterior tibial muscle to function as an active swing-phase ankle dorsiflexor muscle in seven of the nine patients.

Adult↗
PubMed1993

Flexor digitorum longus tendon transfer.

A retrospective evaluation consisting of a written survey and physical examination was completed on flexor digitorum longus tendon transfer patients. The tendon transfer is used to alleviate symptoms and address imbalance of extrinsic and intrinsic muscles. The authors present an evaluation of 110 procedures with an average follow-up period of 65.7 months (range 7 to 198 months). A literature review, discussion of a new theory as to the etiology of hammer toes, and criteria for using the procedure are included.

Follow-Up Studies↗
PubMed1987

Posterior tibial-tendon transfer in patients with cerebral palsy.

The results of fifty-seven posterior tibial-tendon transfers through the interosseous membrane to the dorsum of the foot that were performed in fifty-one patients who had cerebral palsy, and who were followed for a mean of 9.3 years (range, five to twenty-six years), were evaluated in terms of pattern of gait, alignment of the foot, formation of callus on the sole of the foot, and requirements for bracing. A good or excellent result was achieved in twenty-seven of thirty feet in the hemiplegic patients, twelve of sixteen feet in the paraplegic patients, and two of eleven feet in the quadriplegic patients. We found that in order for the tendon transfer to be successful the foot had to be passively correctable to at least a neutral position and that the tendon had to be passed superficial to the extensor retinaculum and inserted into the lateral cuneiform bone. The heel cord should be lengthened before the tendon transfer.

Adolescent↗
PubMed2003

Flexor hallucis longus tendon transfer: evaluation of postoperative morbidity.

Clinical and pedobarograph evaluation was performed on 16 patients following flexor hallucis longus (FHL) tendon transfers to determine the resulting morbidity due to the loss of FHL function. All patients underwent FHL tendon transfer for either chronic tendon Achilles rupture or chronic Achilles tendinosis. Clinical evaluation of hallux function was performed using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale, the SF-36 score, and a clinical questionnaire to assess alteration in the clinical function of the hallux during activities of daily living. Pedobarography was carried out using the Musgrave pedobarograph system to detect changes in forefoot loading in comparison to the contralateral normal foot. Fourteen of the 16 patients scored maximally on the hallux metatarsophalangeal-interphalangeal scale and none of the patients noticed functional weakness of the hallux during activities of daily living at a mean follow-up of 43.6 months (range, 5-120 months). Pedobarograph readings showed a trend toward reduction in peak pressure loading on the distal phalanx, but this was not significant for the numbers of patients studied. There was no significant increase in loading of the first or second metatarsophalangeal joints to suggest that transfer metatarsalgia may complicate FHL tendon transfer. According to the results of the study morbidity from FHL transfer should be clinically insignificant.

Achilles Tendon↗
PubMedDate not supplied

A prospective evaluation of upper extremity tendon transfers in children with cervical spinal cord injury.

Three children (five hands) between 6 and 11 years of age with cervical level spinal cord injuries underwent tendon transfers to restore voluntary lateral pinch. Repeated measures of pinch force and the Grasp and Release Test (GRT) were obtained before surgery and at regular intervals after tendon transfers. The Functional Independence Measure (FIM) was administered before surgery and at 12 months after surgery. Responses to open-ended questions were used to supplement the FIM data at 1 year after surgery. Before surgery, no measurable force was obtained in any hand; after tendon transfers, pinch and finger flexion forces increased throughout the follow-up period. On the GRT, manipulation of the heavy objects was possible only after tendon transfers. Improvements were realized in feeding, grooming, bladder management, play, and school tasks. Each child requested surgery to restore pinch in the nondominant hand. Two hands required tenolysis procedures. Despite capsulotomies and aggressive therapy, three hands continued to have range limitations at the metacarpophalangeal joints.

Activities of Daily Living↗
PubMed1995

Tendon transfer for rupture of the extensor pollicis longus.

Reviewing the history and etiology of extensor pollicis longus tendon rupture shows the most compelling mechanism of rupture apparently is interruption of the tendon's vascularity secondary to hemorrhage and pressure, which causes the damaged tendon to be more susceptible to rupture secondary to late ischemic necrosis and attrition. Treatment options tried have included direct repair, tendon grafting, and tendon transfer. The authors recommend the extensor indicis proprius tendon transfer as the most predictable procedure to restore the original function of the EPL. This technique can be performed reliably, requires little postoperative re-education, and has few associated complications.

Adult↗
PubMed1996

Treatment of posterior tibial tendon dysfunction with flexor digitorum longus tendon transfer and calcaneal osteotomy.

We treated 32 patients with stage-II posterior tibial tendon dysfunction with calcaneal osteotomy and flexor digitorum longus tendon transfer. These 32 patients (29 women, 3 men) had an average age of 58 years (range, 46 to 73 years) and had been symptomatic for an average of 2.5 years (range, 1 to 8 years) before surgical correction. The indication for surgery was the presence of medial foot pain refractory to nonoperative treatments, including shoewear modifications, orthoses, and bracing. All patients were examined at a mean of 20 months (range, 14 to 48 months) after surgery. Functional and radiographic examinations were performed for each patient and the American Orthopaedic Foot and Ankle Society (AOFAS) foot rating scale was used. Of the 32 patients, 30 were satisfied with the outcome of surgery, had improved function, and exhibited radiographic correction of the foot deformity. The AOFAS score improved from a preoperative mean of 48 points (range, 23 to 76) to a postoperative mean of 84 points (range, 68 to 92). In one patient, treatment failed, necessitating a triple arthrodesis for worsening deformity. The short-term results of this procedure are encouraging. Most patients (94%) experienced pain relief, had improvement in the arch of the foot, and were able to wear regular shoes without orthotic support. In order to correct deformity and provide substantial relief of foot pain and dysfunction, a medial translational calcaneal osteotomy was performed in addition to a flexor digitorum longus tendon transfer for management of stage-II posterior tibial tendon dysfunction.

Aged↗
PubMed1986

Indications for tendon transfers to the hand.

In view of the potential problems with tendon transfers, the surgeon must consider another major alternative of treatment for the paralyzed patient: neurorrhaphy. The advantages and risks of tendon transfer and neurorrhaphy are compared in this article.

Child↗