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TENDON TRANSFERS

PREFACE

Tendon transfers have long been a valuable treatment modality for the impaired upper extremity. Many of the principles of tendon transfers were developed during the treatment of poliomyelitis, leprosy, and residual war injuries. These guidelines have been expanded to treat decits after peripheral nerve trauma, brachial plexopathy, spinal cord injury, brain injury, and congenital anomaly. This edition of the Atlas of the Hand Clinics is dedicated to tendon transfers for many of these difcult problems. The content is organized according to the underlying diagnoses to allow easy reference. A highly regarded ensemble of authors has been assembled with particular expertise in tendon transfers. Their contribution of time and effort has provided the substance to this monograph. The goal of this text is to present a variety of tendon transfer techniques specic to a particular problem. Each article focuses on the authors preferred method and provides specic technical details to perform the intended tendon transfer. This manner of organization facilitates the performance of the tendon transfer and improves the overall outcome. The ultimate goal, however, is to enhance function to the impaired limb and to improve the quality of life of the patient. I would like to thank A. Lee Osterman, MD, for the opportunity to serve as an editor for the Atlas of the Hand Clinics and all the contributors for their timely composition of superb manuscripts. In addition, this edition of Atlas of the Hand Clinics would not have been possible without the support of Deb Dellapena and the staff at W.B. Saunders who were instrumental to the completion of this text. Scott H. Kozin, MD
Guest Editor
Shriners Hospitals for Children 3551 North Broad Street Philadelphia, PA 19140

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Tendon Transfers for Thumb Opposition


Alexander Y. Shin, MD, and Khiem D. Dao, MD

On the length, strength, free lateral motion, and perfect mobility of the thumb, depends the power of the human hand.
SIR CHARLES BELL

The loss of thumb opposition, especially when associated with median nerve palsy or traumatic loss of the thenar musculature, results in a severe impairment of the function of the hand. The numerous publications and types of procedures describing the restoration of thumb opposition attest to the importance of the opposable thumb.* The earliest surgeries to restore thumb opposition focused on restoration of the short exors to the completely intrinsic-minus thumb.11,25,31,34 In 1924 Bunnell9 described an opponensplasty in which he passed a tendon through a constructed pulley at the level of the pisiform, subcutaneously tunneled it across the palm, and attached it to the dorsal ulnar aspect of the thumb metacarpal, allowing for mechanically superior opposition. Fourteen years later, Bunnell reported the results of this technique in 46 cases.8 That report underscored some of the basic principles of tendon transfers, including the appropriate direction of action, singular function, and sufcient muscle strength of the donor tendon-muscle unit. Using these precepts, Bunnell was able to achieve true opposition (thumb brought away from the ngers and pronated to oppose the ngers pulp to pulp) rather than short exor action. Since Bunnells report, a variety of tendon and muscles have been used to reconstruct opposition of the thumb. These tendon-muscle units include the exor digitorum supercialis of the long or ring nger,30,31 the extensor indicis proprius (EIP),10 the extensor pollicis longus,29 the extensor carpi ulnaris,21 the extensor carpi brevis longus,19 the extensor digitorum quinti,32 the palmaris longus,11 and the

The views expressed in this article are those of the authors and do not reect the ofcial policy of position of the Department of the Navy, Department of Defense, or the United States Government. *References 1 3, 5, 6, 9, 10, 13 15, 17 19, 21, 22, 24 29, 31, 32, 34, and 35. From the Division of Hand and Microvascular Surgery, Department of Orthopaedic Surgery, Naval Medical Center San Diego, San Diego, California (AYS, KDD); Division of Hand Surgery, Department of Orthopaedics, Mayo Clinic, Rochester, Minnesota

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abductor digiti quinti.24 A description of each of these tendon transfers is beyond the scope of this article. Herein, the technique of two tendon transfers that are commonly performed for the restoration of thumb opposition, that is, the (EIP), and the exor digitorum supercialis (FDS) of the ring nger, are described.

PRINCIPLES OF TENDON TRANSFER Prerequisites Before any tendon transfer, the surgeon and the patient must understand the functional and aesthetic goals along with the limitations and expectations of surgery. Once this understanding is established, several fundamental prerequisites are required when undertaking a tendon transfer.33 First and foremost, tissue equilibrium must be established. Inammation and edema must be subsided, joint contractures must be resolved, and a stable osseous framework must be present. Once these prerequisites are established, selection of a donor tendon and muscle is made based on a donor that is functional and expendable. These requirements provide adequate strength and amplitude without loss of function. The optimal donor tendon travels a straight route and performs a single function.

INDICATIONS FOR OPPONENSPLASTY The most common indication for opponensplasty is an isolated median nerve palsy. Median nerve paralysis is most frequently caused by penetrating or perforating injuries to the forearm or wrist, and typically involves damage to the exor tendon.10 Other indications include traumatic or developmental loss of the thenar musculature or ruptured or avulsed tendons or muscles.

TENDON TRANSFERS FOR THUMB OPPOSITION

METHODS OF DISTAL TENDON INSERTION Several options exist for attachment of the tendon transfer, all of which can be classied as single or dual insertions (Fig. 1).

Figure 1. Four common techniques for distal tendon attachment for opponensplasty. From Curtis RM: Opposition of the thumb. Orthop Clin North Am 5:314, 1974.

SHIN & DAO

Dual insertion techniques are designed to rotate (pronate) the thumb and either passively stabilize the metacarpophalangeal joint (MPJ) or minimize interphalangeal joint (IPJ) exion. This movement is theoretically benecial in patients with combined median and ulnar nerve decits who lack all thumb intrinsic function16; however, some surgeons question the utility of dual insertion techniques because the transfer will function predominantly on the tighter of the two insertions.16 Brands technique of distal tendon insertion involves splitting the tendon end into two slips. One slip is woven through the abductor pollicis brevis tendon and then passed distal to the MPJ and attached to the extensor pollicis longus tendon.7 The second slip is passed subcutaneously across the extensor mechanism dorsally and attached to the adductor pollicis on the ulnar side of the MPJ.15 This maneuver provides rotation of the thumb and stabilizes the MPJ, which is recommended in patients with complete loss of thenar musculature function and an unstable MPJ.15 Other options for distal attachment include the Royle-Thompson method, which also involves splitting the tendon into two slips.37 One slip is passed through a drill hole made in the metacarpal neck from radial to ulnar, with the metacarpal pulled into as much opposition as possible. This slip is tied to the other half that is initially passed dorsally over the extensor hood at the MPJ and through a small tunnel in the fascia and periosteum at the base of the proximal phalanx. The proximal insertion onto the metacarpal head assists in rotation of the thumb, and the distal insertion achieves slight rotation of the MPJ without causing its exion, an undesired effect.37 Riordans technique of attachment involves interweaving the transferred tendon into the abductor pollicis brevis tendon, with continuation onto the extensor pollicis longus tendon distal to the MPJ.30 This maneuver aids in extension of the terminal phalanx of the thumb in patients with exed posturing of the IPJ, as seen in combined median and ulnar nerve decits.15 In Littlers technique, the transferred tendon is attached into the abductor pollicis brevis tendon radially because Littler believes that the abductor pollicis brevis is the most important thenar musculature in normal opposition.23 Bunnells method involves passing the tendon through a small drill hole made at the proximal phalanx base from the dorsoulnar to palmar-radial direction to provide pronation of the thumb.8 The tendon may be secured by anchoring it to the periosteum on the radial side of the phalanx, sutured onto itself or secured with a pull-out suture.

TRANSFER TENSIONING Regardless of the attachment method selected, correct tensioning is imperative to achieve optimal results. Tensioning is achieved when the thumb is in maximal opposition with passive wrist extension and in maximal extension with passive wrist exion. The corollary dictates that the tension requires tightening if full thumb opposition is not obtained with maximal wrist extension, and loosening if full thumb extension is not obtained with maximal wrist exion. Provisional sutures are placed at the selected attachment sites, and the wrist is placed through a range of motion. Final sutures are placed to secure the transfer after the desired tension is achieved.

TENDON TRANSFERS FOR THUMB OPPOSITION

PULLEY PLACEMENT To determine the optimal direction of action or pulley location, Cooney and associates14 performed a cadaveric study that simulated tendon transfer to restore thumb opposition. The results indicated that any tendon transfer for thumb opposition required an adequate moment arm for the thumb trapeziometacarpal joint and the thumb MPJ. Furthermore, a pulley in the area of the pisiform restored the necessary direction of action of the thenar muscles and provided motion in the planes of abduction, exion, or combined abduction-exion (Fig. 2).

Figure 2. Pulley placement for thumb opposition tendon transfers includes pulleys proximal to the pisiform (extensor carpi ulnaris, extensor carpi radialis longus), rotated on the pisiform (abductor digiti quinti [muscle]), distal to the pisiform extensor indicis proprius (EIP), tendon loops of the exor carpi ulnaris (FCU) and the carpal tunnel (Camittransfer). (From Cooney WP, Linscheid RL, An KN: Opposition of the thumb: An anatomic and biomechanical study of tendon transfers. J Hand Surg 9A:3, 1984.)

SHIN & DAO

EXTENSOR INDICIS PROPRIUS TENDON TRANSFER The EIP opponensplasty was described in 1956 by Chouhy-Aguirre of Buenos Aires12 and was subsequently popularized by Burkhalter,10 who reported on a large series in 1973. This transfer is easy to perform, and the results of treatment have been uniformly good. The EIP opponensplasty has little, if any, donor-site morbidity and adequate strength to position the thumb. With the patient under regional or general anesthesia, the operative extremity is exsanguinated and an arm pneumatic tourniquet used. The incisions are outlined (Fig. 3A and B), and a longitudinal incision is made over the index MPJ.

Figure 3. An 18 year old mechanic whose hand was caught in the intake of a jet, with resultant traumatic loss of the thenar muscles and the motor recurrent branch of the median nerve. The patient underwent several debridements and wound coverage procedures, that left him with a sensate hand without thumb opposition. The preoperative incisions are drawn on the dorsal (A) and volar (B) aspects of the hand in preparation for an EIP opponensplasty. The dotted line represents the path of the tendon transfer.

TENDON TRANSFERS FOR THUMB OPPOSITION

The EIP tendon is identied ulnar to the extensor communis tendon (Fig. 4A, B, and C).

Figure 4. The EIP tendon at the metacarpophalangeal joint is the ulnarmost structure prior to the sagittal band (A). The EIP is isolated by dividing the sagittal band attachment and its attachment to the extensor digitorum communis (EDC) of the index nger (B). The harvested tendon is then tapered distally (C), and the sagittal band is reconstructed to the EDC tendon, closing the gap of the harvested tendon.

SHIN & DAO

An incision is made on the ulnar side of the EIP through the sagittal band, and extended distally. Similarly, an incision is made on the radial side of the EIP, separating it from the extensor digitorum communis and tapering to the distal incision on the ulnar side. The sagittal band is then reconstructed using nonabsorbable 4-0 sutures. Once the distal attachment of the EIP is released, a linear incision is made over the dorsal ulnar aspect of the distal forearm. The deep fascia is divided longitudinally, and the EIP tendon and muscle belly are identied and delivered into the proximal wound (Fig. 5).

Figure 5. A longitudinal incision is made along the dorso-ulnar aspect of the forearm, and the deep fascia divided longitudinally. The EIP muscle belly and tendon are identied and delivered from the wound.

TENDON TRANSFERS FOR THUMB OPPOSITION

Frequently, it is necessary to make a small transverse incision over the EIP tendon in the dorsum of the hand to free it from the extensor digitorum communis of the index nger (Fig. 6A and B).

Figure 6. A and B, Often, the EIP muscle belly and tendon cannot be delivered secondary to adhesions or connection of the EIP tendon in the dorsum of the hand. As such, an incision in the dorsum of the hand is often required to free the EIP tendon.

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A small longitudinal incision is made just distal to the pisiform, and a subcutaneous tunnel is created across the ulnar border of the forearm from the dorso-ulnar distal forearm incision to the incision distal to the pisiform (Fig. 7A, B, and C).

Figure 7. A small longitudinal incision is made just distal to the pisiform, and a subcutaneous tunnel across the ulnar border of the forearm is created from the dorso-ulnar distal forearm incision to the incision distal to the pisiform (A). The subcutaneous tunnel needs to be large enough to accept the muscle belly of the EIP, otherwise it may prevent full excursion of the donor tendon. The tendon is passed using a tendon passer or a hemostat (B and C).

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A large enough subcutaneous tunnel must be created to allow the entire EIP muscle belly to lie against the subcutaneous border of the ulna. The EIP tendon is passed through the tunnel and out the pisiform incision. A second subcutaneous tunnel is made across the palm to the thumb MPJ (Fig. 8A and B).

Figure 8. The line of pull of the donor tendon is estimated by placing the donor tendon to the proposed insertion site on the distal portion of the thumb metacarpal (A). A subcutaneous tunnel is then fashioned between the incision at the pisiform and the thumb MPJ (B), and the EIP tendon is passed through the tunnel.

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The method of attachment of the distal tendon transfer is controversial and has been discussed previously. Regardless of the method of distal attachment, the transferred EIP needs to be securely xed, either through bone tunnels or by weaving through the abductor pollicis brevis, EIP, or exor pollicis brevis (Fig. 9A and B). The thumb is placed into full opposition with the small nger, and the EIP transfer is tensioned and secured.

Figure 9. A and B, The EIP tendon is then weaved into the abductor pollicis brevis tendon and secured with nonabsorbable 3-0 suture with the thumb in maximal opposition to the small nger. Once this is completed, a bulky hand dressing maintains the position of maximal thumb opposition for 2 weeks, at which time the sutures are removed and a custom orthoplast splint is fabricated to hold the position of maximal opposition until 4 weeks after surgery.

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The tourniquet is released, hemostasis is obtained, and the wounds are meticulously closed. A bulky hand dressing with plaster splints is placed with the wrist in exion and the thumb in full opposition for 10 to 14 days, at which time the skin sutures are removed. Hand therapy is initiated to maintain motion in the ngers, and an orthoplast splint is fabricated to maintain wrist exion and full thumb opposition for a total of 4 weeks. At this time, range of motion exercises, tendon gliding exercises, and retraining of the transferred tendon and muscle begin (Fig. 10A, B, and C).

Figure 10. A C, At approximately 3 months after surgery, the patient demonstrated well healed wounds and excellent thumb opposition and strength.

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FLEXOR DIGITORUM SUPERFICIALIS TENDON TRANSFER Another common tendon transfer to restore thumb opposition is the exor digitorum supercialis tendon from the ring nger (FDS IV). This technique begins with a palmar transverse skin incision made over the MPJ of the ring nger (Fig. 11).

Figure 11. Skin incision markings for ring nger FDS tendon transfer. A The incision to harvest the FDS. B The incision to create the FCU pulley. C The incision to expose the new insertion of the transfered FDS. (From Jablon M: Oppensplasty with ring nger exor digitorum supercialis tendon. In Blair WF, Steyers CM (eds): Techniques in Hand Surgery. Baltimore, Williams and Wilkins, 1996, pp 675 681.)

The A1 pulley is identied and incised longitudinally, and the FDS tendon is identied. Passive pull on the tendon will ascertain whether the FDS IV tendon has been isolated. With the nger passively exed, the FDS tendon is divided transversely just proximal to its bifurcation.

TENDON TRANSFERS FOR THUMB OPPOSITION

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At this point, a pulley for the FDS IV tendon is constructed. A second curvilinear or zig-zag incision is made at the volar ulnar distal forearm in the region of the FCU tendon insertion (see Figure 11). The FCU and the FDS IV tendons are exposed while the ulnar nerve and artery are protected. The radial half of the FCU tendon is divided transversely approximately 4 cm proximal to its insertion onto the pisiform. The radial half of the tendon is separated longitudinally from the ulnar half, creating a distally based strip of tendon graft. The tendon graft is looped distally and passed through the distal portion of the FCU near the pisiform insertion and secured with nonabsorbable sutures (Fig. 12).

Figure 12. Pulley construction using the distally based radial half of the distal FCU tendon, with attachment onto the pisiform. Arrow indicates path of tendon through the FCU pulley. (From Jablon M: Oppensplasty with ring nger exor digitorum supercialis tendon. In Blair WF, Steyers CM (eds): Techniques in Hand Surgery. Baltimore, Williams and Wilkins, 1996, pp 675 681.)

The FDS IV tendon is isolated from the surrounding tendons at the wrist and delivered through the volar ulnar forearm incision. The FDS IV tendon is passed through the constructed pulley and wrapped in saline-soaked gauze to prevent desiccation. A third incision is made on the dorsum of the thumb MPJ, with care to prevent

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injury to branches of the supercial radial nerve (see Fig. 11). A subcutaneous tunnel is created between this incision and the wrist incision that is wide enough to accept the FDS IV tendon. The FDS IV tendon is passed through this tunnel to exit at the thumb incision. The thumb is placed into full opposition with the small nger, and the FDS IV tendon is secured with the surgeons preference for distal attachment of the tendon to the thumb. The postoperative course is similar to that described for the EIP opponensplasty.

RESULTS OF TREATMENT Burkhalter and associates10 reported excellent results in 57 of 65 patients undergoing EIP opponensplasty, dened as 75% function compared with the opposite/ normal thumb or less than 20 degrees difference between the plane of the opposite thumbnail and the plane of the palm with good power. Fair results were seen in four patients, and four others had complete failure (i.e., no rotation or opposition of the thumb). Extensor lag of the index nger was seen in one patient in this series. The preliminary results of FDS opponensplasty using the Royle-Thompson technique in nine patients (10 hands) were reported by Thompson.37 There were ve excellent, three good, one fair, and one poor result. Although an objective grading scheme was not provided, the good and excellent results exceeded expectations. Jacobs and Thompson20 reported their results for 96 patients (103 transfers) based on a grading scheme.36 A good or excellent result had at least 75% of the function of the opposite thumb or less than 20 degrees difference between the plane of the opposed thumbnail and the palm, with good power. A fair result had good rotation of thumb and poor power or less rotation and good power. Patients with a poor result had no thumb rotation or slight thumb rotation and poor power from the opponensplasty. All but three of the patients had opposition transfers for poliomyelitis. Using a variety of donor tendons (mainly, FDS IV and FDS III tendons), pulley designs, and insertion techniques (mainly, the Royle-Thompson attachment), 77 good/excellent, 9 fair, and 17 poor results were reported. Similar results were obtained with the FDS IV and FDS III tendons. Sundararaj and Mani36 reported their results in 20 patients using FDS IV (17) and FDS II (3) transfers for triple nerve palsies (radial, ulnar, and median) secondary to Hansens disease. Unfortunately, they did not elaborate on the methods of distal tendon insertion. Their results were classied as excellent if the pulp of the thumb could oppose to the pulp of the small or ring nger with the thumb IPJ extended, good if the pulp of the thumb could only touch the middle or index nger, fair if opposition was possible only with the thumb IPJ exed, and poor if no opposition was possible. Excellent or good results were obtained in 85% of cases. Anderson and associates2 compared 50 extensor indicis proprius with 116 FDS ring nger opponensplasties. Their analysis demonstrated that the EIP opponensplasty was best in supple hands, whereas the FDS opponensplasty was more suitable in less pliable hands. Complications were more frequent in the FDS group and included limitation of extension of the donor ring nger, exion contractures of the proximal interphalangeal joint, and radial migration of the transferred tendon in the wrist.

SUMMARY The choice of opponensplasty of the thumb should be based on the available donor muscle-tendon units, the overall condition of the hand, and a thorough discussion with the patient. Regardless of the muscle-tendon unit chosen, the principles of tendon transfer must be strictly adhered to to obtain optimal results.

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References
1. Anderson GA, Lee V, Sundararaj GD: Extensor indicis proprius opponensplasty. J Hand Surg 16B:334 338, 1991 2. Anderson GA, Lee V, Sundararaj GD: Opponensplasty by extensor indicis and exor digitorum supercialis tendon transfer. J Hand Surg 17B:611 614, 1992 3. Baek GH, Jung JM, Yoo WJ, et al: Transfer of extensor carpi radialis longus or brevis for opponensplasty. J Hand Surg 24B:50 53, 1999 4. Bell C: The Hand Its Mechanism and Vital Endowments as Evincing Design. The Bridgewater Treatises, vol. 4. London, William Pickering, 1833 5. Bindra RR, Bhandarkar DS, Taraporvala JC: Opponensplasty an experience of twentythree cases using three techniques. J Postgrad Med 36:9 12, 1990 6. Bourrel P, Courbil JL, Giraudeau P: Transplantation of the extensor indicis proprius for restoration of opposition of the thumb: Apropos of 15 cases. Ann Chir 32:597 600, 1978 7. Brand PW: Tendon transfers for median and ulnar nerve paralysis. Orthop Clin North Am 1:447 454, 1970 8. Bunnell S: Opposition of the thumb. J Bone Joint Surg 20A:269 284, 1938 9. Bunnell S: Reconstructive surgery of the hand. Surg Gynecol Obstet 39:259 279, 1924 10. Burkhalter W, Christensen RC, Brown P: Extensor indicis proprius opponensplasty. J Bone Joint Surg 55A:725 732, 1973 11. Camitz H: Uber die behandlung der oppositionslahmung. Acta Chir Scand 65:77 81, 1929 12. Chouhy-Aguirre S, Caplan S: Sobre secuelas de lesion alta e irreparable de nervios mediano y cubital, y su tratamiento. Prensa Med Argentina 43(31):2341 2346, 1956 13. Cooney WP: Tendon transfer for median nerve palsy. Hand Clin 4:155 165, 1988 14. Cooney WP, Linscheid RL, An KN: Opposition of the thumb: An anatomic and biomechanical study of tendon transfers. J Hand Surg 9A: 777 786, 1984 15. Curtis RM: Opposition of the thumb. Orthop Clin North Am 5:305 321, 1974 16. Davis TRC, Barton NJ: Median nerve palsy. In Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, vol. 2, ed 4. New York, ChurchillLivingstone, 1999, pp 1497 1525 17. Foucher G, Malizos C, Sammut D, et al: Primary palmaris longus transfer as an opponensplasty in carpal tunnel release: A series of 73 cases. J Hand Surg 16B:56 60, 1991 18. Goldner JL, Irwin CE: An analysis of paralytic thumb deformities. J Bone Joint Surg 32A:627 639, 1950 19. Henderson ED: Transfer of wrist extensors and brachoradialis to restore opposition of the thumb. J Bone Joint Surg 44A:513 522, 1962 Jacobs B, Thompson TC: Opposition of the thumb and its restoration. J Bone Joint Surg 42A:1015 1026, 1960 Kessler I: Transfer of extensor carpi ulnaris to tendon of extensor pollicis brevis for opponensplasty. J Bone Joint Surg 51A:1303 1308, 1969 Lin CH, Wei FC: Immediate Camitz opponensplasty in acute thenar muscle injury. Ann Plast Surg 44:270 276, 2000 Littler JW: Tendon transfers and arthrodesis in combined median and ulnar nerve paralysis. J Bone Joint Surg 31A:225 234, 1949 Littler JW, Cooley SGE: Opposition of the thumb and restoration by abductor digiti quinti transfer. J Bone Joint Surg 45A:1389 1396, 1963 Makin M: Translocation of the exor pollicis longus tendon to restore opposition. J Bone Joint Surg 49B:458 461, 1967 Mehta R, Malaviya GN: Evaluation of the results of opponensplasty. J Hand Surg 21B:622 623, 1996 Oberlin C, Alnot JY: Opponensplasty through translocation of the exor pollicis longus: Technique and indications. Ann Chir Main Memb Super 7:25 31, 1988 Ogino T, Minami A, Fukuda K: Abductor digiti minimi opponensplasty in hypoplastic thumb. J Hand Surg 11B:372 377, 1986 Riley WB, Mann RJ, Burkhalter WE: Extensor pollicis longus opponensplasty. J Hand Surg 5A:217 220, 1980 Riordan DC: Surgery of the Paralytic Hand. Instructional Course Lectures, The American Academy of Orthopaedic Surgeons, vol. 16. St. Louis, CV Mosby, 1959, pp 79 90 Royle ND: An operation for paralysis of the intrinsic muscles of the thumb. JAMA 612 613, 1938 Schneider LH: Opponensplasty using the extensor digiti minimi. J Bone Joint Surg 51A: 1297 1302, 1969 Smith RJ, Hasting H: Principles of Tendon Transfers to the Hand. Instructional Course Lectures, American Academy of Orthopaedic Surgeons, vol. 21. St. Louis, CV Mosby, 1980, pp 129 149 Steindler A: Flexor plasty of the thumb in thenar palsy. Surg Gynecol Obstet 50, 1930 Steindler A: Orthopedic operations for the hand. JAMA 71:1288 1291, 1918 Sundararaj GD, Mani K: Surgical reconstruction of the hand with triple nerve palsy. J Bone Joint Surg 66B:260 264, 1984 Thompson TC: A modied operation for opponens paralysis. J Bone Joint Surg 26A:632 640, 1942 Address reprint requests to Alexander Y. Shin, MD Department of Orthopaedic Surgery Division of Hand Surgery Mayo Clinic E14A 200 First Street SW Rochester, MN55905 shin.alexander@mayo.edu

20. 21.

22. 23. 24.

25. 26. 27.

28. 29. 30.

31. 32. 33.

34. 35. 36. 37.

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Tendon Transfers for Intrinsic Function in Ulnar Nerve Palsy


David M. Kalainov, MD, and Mark S. Cohen, MD

The ulnar nerve innervates approximately 80% of the intrinsic muscles in the hand. Consequently, loss of ulnar nerve function can be disabling. The lumbrical and interosseous intrinsic muscles are responsible for coordinated exion of the metacarpophalangeal (MCP) joints and extension of the interphalangeal (IP) joints. Although full nger exion and extension are still possible with intrinsic paralysis, the ngers tend to roll up during exion owing to asynchronous motion of the MCP and IP joints. The ability to position the hand effectively around objects such as a glass or door knob is impaired. In addition, grip and pinch strength are markedly diminished. Clinical features of ulnar nerve palsy include muscle wasting with atrophy of the hypothenar eminence and dorsal rst web space (Fig. 1A). The Froment sign is positive and involves hyperexion of the thumb IP joint during attempted key pinch (Fig. 1B). Concomitant hyperextension of the thumb MCP joint may develop owing to volar plate laxity and paralysis of the adductor pollicis muscle (Jeannes sign). Loss of the third volar interosseous muscle leads to an abduction deformity of the small nger from unopposed eccentric pull of the extensor digiti minimi (Wartenbergs sign) (Fig. 1C). Interosseous loss also impairs lateral nger movements, demonstrated by the cross-nger test (Fig. 1D). Clawing of the ring and small ngers typically ensues from unopposed actions of the extrinsic exor and extensor tendons (Fig. 1E). The small nger always exhibits a greater degree of clawing than the ring nger.

From the Department of Orthopaedic Surgery, Northwestern University Medical School (DMK), and Rush-Presbyterian St. Lukes Medical Center (MSC), Chicago, Illinois

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Figure 1. Ulnar paralysis leads to several deformities of the hand. A, Intrinsic muscle wasting is often best visualized in the rst web space. B, Froment sign involves thumb interphalangeal joint hyperexion during pinch. Illustration continued on opposite page

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Figure 1 (Continued). C, Wartenburgs sign is an abducted posture to the small nger due to loss of the third volar interosseous muscle and eccentric pull of the extensor digiti minimi. D, Loss of interosseous function also leads to an inability to cross the ngers. E, Clawing is most pronounced in the small nger and to a lesser degree in the ring nger.

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The index and long ngers may appear uninvolved if the median nerve remains functional owing to the intact rst and second lumbrical muscles. Although relatively weak, the lumbrical muscles often balance the radial digits and maintain synchronized joint motion. In 50% of individuals, the third lumbrical muscle is dually innervated (median and ulnar nerves), and the ring nger may be protected from clawing. When both the ulnar nerve and the distal median nerve are affected by disease or injury, claw deformities will develop in all ngers, with concomitant atrophy of the thenar and hypothenar muscles. The appearance is that of a simian hand. Variations in intrinsic muscle deciency are encountered occassionally with ulnar nerve palsy and often can be attributed to normal interconnections between the median and ulnar nerves. Crossover can occur between the anterior interosseous branch of the median nerve and the ulnar nerve in the forearm (Martin-Gruber communication) or between the motor branch of the median nerve and the ulnar nerve in the palm (Riche-Cannieu communication). Partial nerve injuries and high palsies of the median or ulnar nerves may also lead to different patterns of hand dysfunction. Effective management in each case requires an understanding of the anatomic lesions and the resultant motor and sensory decits. Numerous combinations of nerve palsies are possible. This article focuses on the management of intrinsic muscle paralysis from isolated ulnar nerve lesions.

ETIOLOGY Ulnar nerve motor decits most often result from direct trauma to the nerve or from long-standing nerve compression (e.g., cubital tunnel syndrome). The differential diagnosis in atraumatic cases includes cervical spine disease with impingement of the lower cervical nerve roots (C8-T1) and lesions of the brachial plexus. Cervical nerve root compression typically manifests as neck pain with radicular symptoms down the arm. Weakness and atrophy are expected in the thenar and hypothenar musculature, both of which are innervated by the lower cervical and rst thoracic nerve roots. Injury or compression of the lower elements of the brachial plexus (e.g., by a Pancoast tumor) may result in similar ndings. Other causes of peripheral nerve dysfunction can lead to a confusing clinical presentation, including leprosy (Hansens disease) and hereditary motor-sensory neuropathy (Charcot-Marie-Tooth disease). Intrinsic atrophy with or without sensory loss may be seen in syringomyelia or amyotrophic lateral sclerosis. These conditions often result in diffuse and symmetrical involvement of the upper extremities. In all cases, nerve conduction velocity and electromyogram studies may be helpful in localizing a suspected lesion and in excluding a more generalized nerve disorder.

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CONSERVATIVE TREATMENT Optimal treatment of the patient with ulnar nerve dysfunction requires the expertise and assistance of a hand therapist. Exercises are directed at maintaining or improving mobility of the nger joints. Fabrication of a hand-based orthosis is particularly useful to address the initial claw deformity and to prevent the development of xed joint contractures. A lumbrical bar splint ts over the dorsum of the metacarpal heads and proximal phalanges of the ring and small ngers (Figs. 2A and B).

Figure 2. A, Lumbrical bar splint frontal view. B, Lateral view. This splint blocks the claw deformity of the ring and small ngers, allowing the extrinsic extensor tendons to extend the interphalangeal joints. It will improve function and diminish the likelihood of xed contractures and attenuation of the central extensor tendons.

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The design protects the MCP joints from hyperextension without impending nger exion. The splint will not improve grip strength or correct asynchronous motion of the digits; however, by blocking the MCP joints, it enables the extrinsic extensor tendons to extend the IP joints more effectively. The patient will be able to manipulate the ngers around large objects and place the hand into tight spaces. Additionally, attenuation of the extensor tendons may be prevented.

SURGICAL TREATMENT Many surgical procedures have been described to treat functional decits resulting from intrinsic muscle paralysis in ulnar nerve palsy. Tendon transfers are available to correct the claw deformity, to improve integrated joint motion, and to increase grip and pinch strength. These transfers require a motivated patient and full passive mobility of the digits. The choice of transfer depends largely on the age and expectations of the patient, the availability of donor tendons, and the level of the ulnar nerve decit (high or low). Lack of protective sensation may adversely affect outcome. The differences between high and low ulnar nerve palsy are relatively few. In a proximal lesion, there is additional loss of the exor carpi ulnaris and the ring and small nger exor digitorum profundus muscles. Although the same tendon transfer techniques can be applied to both categories of ulnar nerve decit, consideration should be given to forearm level transfers of the ring and small nger exor digitorum profundus tendons to the adjacent profundus or supercialis tendons in high ulnar nerve palsy. This technique will balance nger exion and improve functional grasp. In addition, one should try to avoid using the exor carpi radialis tendon as a donor in a high ulnar nerve lesion given the absence of a functional exor carpi ulnaris muscle.

Integrated Finger Motion, Clawing, and Grasp Several techniques to correct these specic deciencies have been described, employing extrinsic muscles of the wrist and ngers as donor tendons. Two of the more commonly performed operations include transfer of a wrist motor with tendon graft extensions (four-tail graft) and transfer of one exor digitorum supercialis (FDS) from either the index or long nger (Stiles-Bunnell). Although both procedures rebalance the hand and improve asynchronous nger motion and clawing, only the addition of a wrist motor will increase grip strength. This use of a wrist motor usually is indicated for younger individuals and for persons with higher functional demands. Four-Tail Graft The extensor carpi radialis brevis (ECRB) is an ideal motor unit for tendon transfer in intrinsic paralysis. The exor carpi radialis can be substituted if the ECRB is absent or required for another procedure (e.g., thumb adductorplasty). Although clawing of the index and long ngers is typically absent in low ulnar nerve lesions, inclusion of all four ngers in the transfer is recommended for improved hand strength and dexterity. Four slips of tendon graft are required to prolong the ECRB for insertion into the proximal phalanges. The plantaris tendons from both lower extremities are readily accessible, and each will typically supply two tendon graft lengths. These slips are harvested through limited incisions using a tendon-stripping instrument. The long toe extensors may be used if the plantaris tendons are absent or of insufcient size.

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Preoperatively, the function of the ring and small nger extrinsic extensor tendons is assessed with the Bouvier test (Fig. 3)

Figure 3. The Bouvier test consists of blocking metacarpophalangeal joint hyperextension while the patient attempts digital extension. With supple interphalangeal joints, near complete active nger extension should be present if the central extensor tendons are competent.

If it is difcult to achieve active extension of supple proximal interphalangeal (PIP) joints with MCP hyperextension blocked, the central tendons have attenuated. In this setting, an improvement in active extension may be achieved by insertion of the transfers into the dorsal apparatuses rather than into the proximal phalanges; however, caution is advised with this variation in technique because PIP hyperextension and swan neck deformities may develop.

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For bony insertion, angled skin incisions approximately 2 cm in length are made at the radial bases of the middle, ring, and small ngers. A fourth angled incision is made at the ulnar base of the index nger (Fig. 4).

Figure 4. Proposed incisions for the extensor carpi radialis brevis four-tail tendon graft procedure.

The lateral bands are identied and retracted dorsally, exposing the proximal phalanges. A 2.0-mm transverse drill hole is made through each proximal phalanx at a point in the mid axiscorresponding to the second annular pulley. The near cortices are enlarged with a 2.7-mm drill bit or curette to accommodate insertion of the tendon grafts (Fig. 5).

Figure 5. Intraoperative view depicting drill hole in the proximal phalanx positioned near the midline (or slightly palmar) and approximately at the distal half of the second annular pulley.

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Two transverse skin incisions are made over the dorsal hand, one between the second and third metacarpals and one over the fourth metacarpal. The interosseous fascia is incised longitudinally between each metacarpal. Sutures are placed in the distal ends of all four tendon slips using a pull-through technique (Bunnell or Kessler). A Chevron incision approximately 8 cm in length is designed over the dorsoradial border of the extensor retinaculum. The insertion of the ECRB is released sharply from the base of the middle metacarpal, taking care to protect branches of the dorsal sensory radial nerve. The tendon is withdrawn proximally from beneath the extensor retinaculum. Two tendon grafts are passed through the interspace between the second and third metacarpals for the index and middle ngers. One graft is passed through the interspace between the third and fourth metacarpals and the other slip through the interspace between the fourth and fth metacarpals. Each graft must follow an unimpeded course through the interosseous muscles, under the transverse metacarpal ligament (through the lumbrical canal), and toward the prepared insertion site in the proximal phalanx. A curved tendon passer is helpful in this regard, and passage is aided by exion of the MCP joints. The tendons are seated securely by passing the attached sutures through the bone tunnels with Bunnell or Keith needles (Fig. 6).

Figure 6. Routing of the tendon graft extensions.

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The suture ends are tied snuggly over padded buttons on the opposite side of each digit. All four tendon grafts are tunneled through subcutaneous tissues proximally in a direct line toward the ECRB tendon (Fig. 7). Once this maneuver is accomplished, all distal wounds are closed.

Figure 7. Tendon grafts have been secured distally and are drawn in a straight-line path into the proximal wound. Note the closure of all distal wounds.

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The grafts are rst sutured to one another under appropriate balance. It is helpful to combine the ring and small and the index and middle grafts separately before joining all four grafts together. Care should be taken not to overtighten the index nger graft relative to the others, which can lead to an adduction contracture of the index nger and scissoring. Once balanced, the tendon mass is woven in a Pulvertaft fashion into the ECRB and secured (Fig. 8).

Figure 8. Tendon grafts have been sutured to the extensor carpi radialis brevis with a Pulvertaft weave.

Correct tensioning is achieved with the wrist held in full dorsiexion and the nger MCP joints in maximum exion, taking up approximately 50% of the excursion of the donor tendon. Following repair, the wrist is brought through a range of motion, demonstrating tenodesis of all nger MCP joints into exion with the wrist exed. Full passive MCP joint extension should be possible with the wrist extended. The wrist is immobilized postoperatively in approximately 45 degrees of extension, with the MCP joints exed 60 degrees and the IP joints extended.

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Flexor Digitorum Supercialis Transfer (Stiles-Bunnell) This procedure uses one exor digitorum supercialis (FDS) tendon as the donor transfer. The FDS tendon from either the index or middle nger is released and split. The two tendon slips are transferred through the lumbrical canals of the ring and small ngers and inserted most commonly into the lateral bands of the nger extensor mechanisms. Usually, the tendon slips are of adequate length and do not require tendon graft extensions. The goal is to rebalance the hand, correcting the claw deformities and improving a synchronous nger motion (Figs. 9A and B).

Figure 9. A, Follow-up revealing intrinsic plus posture with metacarpophalangeal exion and interphalangeal joint extension. B, Restoration of synchronous nger exion.

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No increase in strength is anticipated. Several variations of this technique have been described, including subdividing the long nger FDS into four slips for transfer to all four ngers, attachment of the tendon slips to the exor tendon sheaths, and attachment of the tendon slips to the proximal phalanges through bone tunnels as previously described. The middle nger FDS is harvested over the PIP joint palmarly, and both slips are released sharply, dividing Campers chiasm. A transverse incision is made in line with the distal palmar crease across the fourth metacarpal. The FDS tendon is withdrawn into the proximal wound, and the longitudinal split in the tendon is extended proximally to create two slips of equal caliber (Fig. 10).

Figure 10. Stiles-Bunnell transfer. Two slips of the middle nger exor digitorum supercialis are created and passed dorsal to neurovascular structures in preparation for transfer.

Sutures are placed into both distal tendon ends to assist in the transfer.

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Curvilinear or angled skin incisions approximately 2 cm in length are made at the dorsoradial bases of the ring and small ngers. The lateral band projecting to each extensor mechanism is identied. Both tendon slips must follow an unimpeded course through the hand, dorsal to common digital arteries and nerves and palmar to the transverse metacarpal ligaments. A tendon passer is used to create this path and to draw each tendon slip separately to the target nger (Fig. 11). The palmar wounds are closed.

Figure 11. The exor digitorum supercialis tendon slips are rerouted distally through the lumbrical canals and passed into the dorsal wounds.

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With the wrist positioned in neutral and the ring and small ngers in the intrinsic plus position, the tendon slips are sutured to the lateral bands, taking up 50% to 80% of allowable FDS excursion. Proper tensioning is tested with passive wrist motion. Flexion of the wrist should allow near full extension of the ring and small nger MCP joints, whereas extension of the wrist should lead to a normal cascade of MCP joint exion (Figs. 12A and B).

Figure 12. A, Following suture to the lateral bands, extension of the ring and small ngers is present with passive wrist exion that deactivates the transfer. B, Normal intrinsic plus cascade of metacarpophalangeal joint exion is seen with passive wrist extension.

The tendon junctions are loosened or tightened as deemed necessary. Postoperatively, the wrist is positioned in neutral to slight exion, with the MCP joints exed to approximately 60 degrees and the IP joints extended.

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KALAINOV & COHEN

Thumb Pinch Many procedures have been developed to restore thumb adduction in patients with ulnar nerve palsy. Most of these operations address balance and cosmetic issues rather than improved pinch and adduction strength. Similar to techniques addressing claw deformities in the ngers, a strong motor is necessary if enhanced power is to be expected. Adductorplasty with transfer of the ECRB has been shown to almost double thumb pinch strength. The operation entails lengthening the ECRB tendon with a graft to insert into the adductor pollicis tendon. A concomitant fusion of the thumb MCP joint is considered to augment pinch strength and improve longitudinal stability of the thumb. Not all patients with ulnar nerve palsy are appropriate candidates for adductor plasty and MCP joint fusion. Even with a weakened pinch, a patient may report minimal thumb decits. Extensor Carpi Radialis Brevis Thumb Adductorplasty A Chevron incision approximately 8 cm in length is made over the dorsoradial border of the extensor retinaculum. The insertion of the ECRB is released sharply from the base of the third metacarpal, and the tendon is withdrawn proximally from beneath the extensor retinaculum. A 2- to 3-cm transverse incision is made over the proximal aspect of the second intermetacarpal space, and the fascia overlying the second dorsal interosseous muscle is incised longitudinally. A subcutaneous tunnel is created with a curved clamp, connecting the dorsal wrist and hand wounds. A 2- to 3-cm curvilinear incision is then made along the dorsoulnar border of the thumb MCP joint, and the insertion of the adductor pollicis tendon is exposed. If fusion of the MCP joint is planned, then it is completed at this time. A curved clamp is passed through the second intermetacarpal space beneath the metacarpal and directed toward the thumb MCP joint in the interval between the adductor pollicis and rst dorsal interosseous muscles (Fig. 13).

Figure 13. Incisions and donor extensor carpi radialis brevis tendon for adductorplasty. A curved clamp is positioned in the interval between the adductor pollicis and rst dorsal interosseous muscles. Note plantaris tendon graft in the foreground.

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The ipsilateral palmaris longus tendon is harvested through two or three small transverse incisions or with the aid of a tendon stripper. A graft approximately 16 cm in length usually can be obtained. If the palmaris longus is absent or of insufcient size, other sources of autogenous tendon graft may be used (e.g., plantaris, long toe extensor). One end of the tendon graft is sutured to the adductor pollicis tendon at its bony insertion into the phalanx (Fig. 14).

Figure 14. The graft is rst secured to the adductor pollicis tendon at its bony insertion.

The free end of the graft is then withdrawn through the second intermetacarpal space with a curved clamp. The graft is then passed through the subcutaneous tunnel proximally, lying dorsal to the extensor retinaculum. The distal incisions are closed.

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KALAINOV & COHEN

With the wrist in neutral alignment and the thumb held tightly against the volar radial border of the index nger, the graft is woven into the ECRB, taking up 50% to 80% of the donor tendons excursion (Fig. 15).

Figure 15. The distal wounds are closed and the tendon graft is woven into the extensor carpi radialis brevis donor under the appropriate tension.

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When the wrist is placed in exion, the thumb should adduct rmly against the index metacarpal. With the wrist extended, the thumb should easily be abducted away from the palm (Figs. 16A and B).

Figure 16. A, Following transfer, passive exion of the wrist results in strong thumb adduction. B, Full palmar abduction is possible with wrist extension, which deactivates the transfer.

Postoperatively, the wrist is splinted in 45 degrees of extension with the thumb in palmar abduction. The thumb IP joint may be left free. Modications in the splint may be required to accommodate concomitant tendon transfers to the ngers.

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KALAINOV & COHEN

REHABILITATION In patients treated with an ECRB four-tail graft procedure, a short-arm dorsal splint is fabricated, which maintains the wrist in 45 degrees of extension and the MCP joints in 60 degrees of exion. Early active IP joint exion and extension are encouraged. Composite motion exercises of the wrist and digits are initiated out of the splint after 3 weeks, and the pull-out sutures are removed between 4 and 6 weeks postoperatively. The forearm splint may be converted to a smaller handbased lumbrical bar splint during that time period. Protective splinting is discontinued 6 to 8 weeks following surgery, and grip-strengthening exercises are added to the rehabilitation program. Unrestricted activities are permitted after 3 months. The forearm splint is modied for the Stiles-Bunnell procedure to position the wrist in neutral-to-slight exion. The MCP joints are maintained in 60 degrees of exion, and early IP nger motion exercises are encouraged. Composite motion of the wrist and ngers out of the splint is permitted 3 weeks postoperatively, and grip strengthening is initiated at 8 weeks. A hand-based lumbrical splint may be substituted for the forearm splint 3 weeks postoperatively and slowly weaned from use over a 2- to 4-week period. Unrestricted activities are allowed after 3 months. Following an ECRB adductorplasty, extension of the thermoplast splint to include the proximal phalanx of the thumb is indicated, and IP joint motion of the thumb is not restricted. The wrist should be positioned in neutral to 45 degrees of extension. A supervised range of motion program is initiated after 3 weeks and includes active thumb abduction with the wrist exed and extended and passive thumb adduction. Active thumb adduction exercises and strengthening are included in the rehabilitation program 6 weeks postoperatively. Protective splinting is discontinued at that time, with unrestricted activities permitted 4 to 6 weeks later.

SUMMARY Ulnar nerve dysfunction leads to sensory loss, a claw deformity with asynchronous nger motion, diminished digital abduction and adduction, and weakened grip and pinch strength. Often, the index and long ngers appear uninvolved. Various tendon transfers can effectively treat clawing and improve nger balance. Transfer of a wrist exor or extensor muscle-tendon unit will enhance grip strength and maximize hand coordination. Use of a nger exor for transfer simply redistributes balance within the hand and may diminish grip strength. Transfer selection is based on patient age, expectations, joint mobility, and tendon availability. Patient compliance with a postoperative rehabilitation program is important for an optimal outcome. Thumb adductorplasty is reserved for patients who are functionally impaired by weak thumb pinch. A concomitant MCP joint arthrodesis can be considered for improved longitudinal stability to the thumb.

References
1. Brand PW: Tendon transfers for correction of paralysis of intrinsic muscles of the hand. In Hunter JW, Schneider LH, Mackin EJ (eds): Tendon Surgery of the Hand. St. Louis, Mosby, 1987, pp 439 499 2. Brand PW: Ulnar nerve paralysis. In Chapman MW (ed): Operative Orthopaedics, ed 2. Philadelphia, JB Lippincott, 1993, pp 1477 1485 3. Burkhalter WE, Strait JL: Metacarpophalangeal exor replacement for intrinsic muscle paralysis. J Bone Joint Surg 55A:1667 1676, 1973 4. Hastings H II: Ulnar nerve paralysis. In Strickland JW (ed): The Hand. Philadelphia, Lippincott-Raven, 1998, pp 335 350 5. Hastings H II, Davidson S: Tendon transfers for ulnar nerve palsy: Evaluation of results and practical treatment considerations. Hand Clin 4:167 178, 1988 6. Hentz VR: Stiles-Bunnell tendon transfer for ulnar nerve palsy. Atlas of the Hand Clinics 5: 31 45, 2000 7. Jebson PJL, Steyers CM: Adductorplasty with

TENDON TRANSFERS FOR INTRINSIC FUNCTION IN ULNAR NERVE PALSY the extensor carpi radialis brevis. In Blair WF (ed): Techniques in Hand Surgery. Baltimore, Williams and Wilkins, 1996, pp 682 687 8. Omer GE Jr: Ulnar nerve palsy. In Green DP, Hotchkiss RN, Pederson WC (eds): Greens Operative Hand Surgery, ed 4. Philadelphia, Churchill Livingstone, 1999, pp 1526 1541 9. Smith RJ: ECRB tendon transfer for thumb adduction: A study of power pinch. J Hand Surg 8:4 15, 1983 10. Smith RJ: Tendon transfers to restore intrinsic muscle function to the ngers. In Tendon Transfers of the Hand and Forearm. Boston, Little, Brown, 1987, pp 103 133 Address reprint requests to David M. Kalainov, MD Northwestern Center for Orthopaedics 676 North St. Clair, Suite 450 Chicago, IL 60611 e-mail: dkalainov@aol.com

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TENDON TRANSFERS

1082 3131/02 $15.00 + .00

Tendon Transfer for Radial Nerve Palsy


Michael E. Rettig, MD, and Keith B. Raskin, MD

Complete injury to the radial nerve results in the inability to extend the wrist and ngers actively, resulting in a considerable impairment of hand function. Loss of active wrist extension impairs the ability to pick up objects and inhibits wrist stabilization for power grip. When an attempt is made to extend the digits, the wrist is simultaneously exed to use the tenodesis effect of wrist exion. Tendon transfers for radial nerve palsy must restore active wrist, nger, and thumb extension without sacricing key median nerve and ulnar nerve innervated motor units.

ANATOMY The radial nerve is the continuation of the posterior cord of the brachial plexus. It passes through the triangular space beneath the teres major muscle in the posterior aspect of the shoulder. In the arm, the nerve lies on the posterior humeral spiral groove, between the lateral and medial heads of the triceps muscle. After giving off branches to the lateral head of the triceps, the radial nerve penetrates the lateral intermuscular septum and enters the anterior compartment. After the nerve enters the anterior compartment, motor branches exit to the brachioradialis and the extensor carpi radialis longus (ECRL). The radial nerve traverses down the arm anterior to the elbow in the interval between the brachialis and the brachioradialis. It then divides into the posterior interosseous nerve (PIN), which enters the arcade of Froshe at the proximal edge of the supinator muscle and the supercial radial nerve. The PIN then innervates, in order, the supinator, extensor digitorum communis (EDC), extensor carpi ulnaris (ECU), extensor digiti quinti (EDQ), abductor pollicis longus (APL), extensor pollicis longus (EPL), extensor pollicis brevis (EPB), and extensor indicis proprius (EIP). The extensor carpi radialis brevis (ECRB) can receive its innervation from the radial nerve proper, supercial radial nerve, or PIN.1

From the Department of Orthopaedic Surgery, New York University Medical Center, New York, New York (MER, KBR)

ATLAS OF THE HAND CLINICS Volume 7 Number 1 March 2002

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RETTIG & RASKIN

Most injuries to the radial nerve occur distal to its innervation of the triceps. The nerve is vulnerable to injury from an adjacent fracture of the humerus typically at the junction of the middle and distal thirds of the humerus where the radial nerve can be tethered as it enters the lateral intermuscular septum. Many of these injuries are neurapraxias and spontaneously recover. The radial nerve also can be damaged by traumatic lacerations in this area, or during surgical procedures around the lateral aspect of the elbow and the posterior aspect of the proximal forearm.

GENERAL PRINCIPLES Tendon transfers to restore wrist and digit extension are performed when radial nerve recovery can no longer be expected or for wrist stabilization alone as an internal splint after radial nerve repair. Depending on the mechanism of injury and the time elapsed from injury, this damage can be determined by repeat physical examination in conjunction with electromyography of the radial nerve innervated muscles. General principles of tendon transfer must be followed to ensure a satisfactory functional outcome when performing tendon transfer for radial nerve palsy. A thorough examination of the upper extremity should be completed preoperatively to identify any previous lacerations that could adversely affect the tendon transfer procedure. Alternatively, previous surgical incisions can be used for tendon transfers as long as the basic principles of transfer are followed. Tendon transfer surgery should be performed only after tissue equilibrium has been reached. The skin and subcutaneous tissues must be pliable and soft, and all of the joints that will be motored by the tendon transfer need to be supple without contractures. The active range of motion achieved by the transfer will not exceed the preoperative passive range of motion. The strength and excursion of the potential donor tendons are tested. If the potential donor tendon has been injured, or if the nerve supplying innervation to the donor tendon has been traumatized, an alternative donor tendon should be considered. The donor tendon must be expendable without residual functional impairment. Planning of radial nerve tendon transfers can be facilitated by evaluating what decits need to be replaced and what donor tendons are available to transfer. In an upper extremity with an isolated injury to the radial nerve, all muscle-tendon units innervated by the median and ulnar nerve are potentially available to transfer for wrist and nger extension. One of the earliest descriptions of tendon transfer for radial nerve palsy was by Franke in 1899, who transferred the exor carpi ulnaris (FCU) to the EDC through the interosseous membrane. During the same year, Capellen reported transfer of the exor carpi radialis (FCR) to the EPL. Sir Robert Jones, regarded as one of the major contributors describing radial nerve tendon transfers, added the pronator teres (PT), ECRL and ECRB to these transfers. Jones made further modications in 1916 and again in 1921. In 1946 Zachary reported that the FCR should be preserved for wrist exion.38 Over 50 modications of tendon transfers have been described for radial nerve palsy. Three major groups of transfers have gained popularity. The FCU and the FCR transfer use the pronator teres to the ECRB and the palmaris longus to the rerouted EPL. These two transfers differ in the motor to the EDC, using either the FCU or the FCR. The major criticism of the FCU transfer is the detrimental loss of the major wrist exor and ulnar deviator of the wrist, the FCU being too short and too strong to be effective for nger extension, and the potential disabling radial deviation with wrist extension that can occur with loss of stabilization on the ulnar aspect of the wrist.58

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Boyes developed the supercialis transfer for digital extension.2 The supercialis tendons have a greater excursion than the FCU or FCR and are ideal motors for nger extension. The supercialis transfer uses the pronator teres to ECRL or ECRB, FDS III to EDC, FDS IV to EIP and EPL, and FCR to APL and EPB. The most common tendon transfer used for radial nerve palsy remains the pronator teres to ECRB, FCU to EDC, and a rerouted palmaris longus to EPL, despite the potential problems with the FCU transfer. Raskin and Wilgis demonstrated the long-term maintenance of wrist range of motion and power to perform daily activities and an overall excellent functional recovery with the FCU transfer. Furthermore, cadaver studies showed the ability to deviate the wrist despite loss of the FCU.4 The nal decision as to which transfer to perform ultimately depends on the requirements of the patient, the experience of the surgeon, and the available donor tendons. All of these tendon transfers adhere to the principles of one tendon one function, synergism, adequate excursion and strength of the donor tendon, and establishing a straight line of pull to the tendon insertion. Only when these concepts can be adhered to should surgery proceed to restore wrist and digit extension.

SURGICAL TECHNIQUE Tendon transfer for radial nerve palsy is performed as an outpatient procedure under either regional or general anesthesia. The arm is prepared and draped in the usual sterile fashion, and hemostasis is obtained through exsanguination and upper arm tourniquet elevation. Preoperative planning includes skin markings in the appropriate locations based on an accurate assessment of surface anatomy. Two incisions are used. For harvesting of the FCU and palmaris longus tendon, an inverted L-shaped incision is drawn out on the volar ulnar aspect of the distal forearm and wrist, extending from the transverse wrist crease along the ulnar border of the forearm. The insertion of the palmaris longus can be accessed through the most radial aspect of the transverse component of the incision. For exposure of the pronator teres and the insertion sites of the transfer, a Chevron incision with the apex ulnarly is drawn over the middle to distal forearm level, allowing the skin ap to be elevated to harvest the pronator teres with an extended strip of periosteum, as well as the performance of transfers into the EPL, EDC, and ECRB. Any previously healed surgical incisions should be evaluated and incorporated into these incisions.

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The incision over the volar ulnar aspect of the wrist is followed by elevation of the skin ap while cutaneous nerves are identied and protected. The FCU tendon is isolated and dissected in a distal-to-proximal direction. Protecting the ulnar nerve and artery, the surgeon transects the FCU at its insertion into the pisiform. The FCU tendon and its proximal muscle belly are dissected from surrounding fascial attachments in a distal-to-proximal direction while protecting the ulnar nerve and artery. This mobilization increases the FCU excursion and allows for adequate redirection of the tendon for transfer. The most distal muscle belly of the FCU can be trimmed to decrease the muscle bulk around tendon to improve coaptation to the EDC tendon. The FCU proximal muscle belly must be mobilized adequately. The fascial layer along the ulnar border of the forearm, between the FCU and the ECU, is excised to facilitate this mobilization and to ensure a straight line of pull to the EDC. Care is taken to avoid the motor branches of the ulnar nerve that enter the FCU distal to the medial epicondyle. The palmaris longus is located after identication and protection of the palmar cutaneous branch of the median nerve, transected at its distal insertion into the palmar fascia, and mobilized in a distal-to-proximal direction (Fig. 1A C).

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Palmar incision

FCU

PL

PT

FCU Ulnar n. Ulnar a.

FCU

B
Figure 1. A, Volar ulnar incision for exposure of exor carpi ulnaris (FCU) and palmaris longus (PL) tendon insertion. PT pronator teres. B, Transection of FCU at its insertion into the pisiform and proximal mobilization. Illustration continued on following page

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RETTIG & RASKIN

FCU Cutaneous branch of median n. PL

C
Figure 1 (Continued). C, Palmaris longus transected at its insertion into the palmar fascia.

Once both of these tendons have been prepared for transfer, the dorsal incision is made. The soft-tissue aps are carefully elevated. The wrist and nger extensor tendons are identied proximal to the extensor retinaculum. The tendon of the pronator teres is identied on the volar radial aspect of the forearm at its attachment to the radial shaft. The tendon insertion of the pronator teres is sharply elevated off of the radial shaft with a several-centimeter, broad-based strip of periosteum to ensure satisfactory length to complete the transfer to the ECRB. The tendon is then dissected in a distal-to-proximal direction to free the fascial attachments of the muscle to allow for a straight line for tendon transfer insertion. The periosteal strip is imbricated before completing the transfer to increase the strength of the distal aspect of the pronator teres (Fig. 2A C).

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Dorsal incision Radial view

Periosteal strip

Brachioradialis

Insertion of PT

Insertion of PT

Supinator

A
Dorsal view

Branches of radial sensory n.

Extensor retinaculum

Transect EPL

HA0203.12.02abc.lay
Figure 2. A, Dorsal Chevron incision for exposure of the extensor tendons and pronator teres (PT). B, Elevation of the PT tendon from the radial shaft with a periosteal strip. C, Rerouting of the extensor pollicis longus (EPL) from the extensor retinaculum after proximal transection.

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At the extensor retinaculum, the EPL is identied and rerouted out of the third compartment to the radial aspect of the thumb after transection of the most proximal end of the tendon at the musculotendinous junction. The distal stump of the EPL is now dorsal to the rst dorsal compartment. The terminal branches of the radial sensory nerve remain supercial to the EPL so they are not compressed by the tendon transfer. Subcutaneous tunnels are made in preparation for transfer. All of the donor tendons must be freed sufciently from the surrounding fascial and muscle attachments to allow a straight line of pull to their recipient tendon. The FCU is brought around the subcutaneous ulnar aspect of the forearm to the EDC with a tendon passer (Fig. 3).

Dorsal view

Branches of radial sensory n. Transected EPL above extensor retinaculum

Extensor retinaculum

FCU

PT with imbricated periosteal strip

Figure 3. Flexor carpi ulnaris is brought around ulnar forearm to the extensor digitorum comminus (EDC) tendons. Pronator teres periosteal sleeve imbricated in preparation for transfer.

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The EDC tendons are identied proximal to the extensor retinaculum. The EIP and EDQ, lying ulnar to the EDC to the index and little ngers, are not included in the transfer. The skin is elevated in the volar radial distal forearm for the palmaris longus tendon stump to be delivered to the EPL, and the pronator teres is tunneled to the ECRB, supercial to the brachioradialis and ECRL. Once the donor tendons are tunneled to their insertion sites and the three motor muscles are ready for transfer, the tourniquet can be deated. Hemostasis can be obtained before competing the transfers. The incision over the volar ulnar distal forearm can be repaired. Setting the proper tension for the transfer is one of the critical steps in the procedure. The tension must be enough to provide for sufcient extension of the wrist, ngers, and thumb, but not too tight to restrict wrist or digit exion. The tendon transfer tends to lose slight tension than that obtained intraoperatively; therefore the transfer is performed with a slightly increased tension. The tendon transfer for the thumb and ngers should be completed before the wrist transfer because the tenodesis effect through passive wrist exion and extension is used to gauge the tension of the thumb and nger extensor transfer. Once the wrist extensor tension is completed intraoperatively, wrist exion should be avoided. Transfer to the EDC is completed by using a No. 11 scalpel blade or tendon braider to fenestrate each of the EDC tendons, proximal to the extensor retinaculum. The FCU is then passed through each of the recipient EDC tendons in a slight oblique fashion from proximal ulnar to distal radial (Fig. 4A and B).

Fenestration of EDC tendons

FCU FCU

A B
Fenestration of EDC tendons EDC tendons EDC tendons

Figure 4. A and B, Flexor carpi ulnaris tendon transferred to fenestrated EDC recipient tendons in an oblique fashion proximal to extensor retinaculum.

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The transfer is set by placing the FCU under maximum tension and securing it to each of the EDC tendons individually with 4-0 nonabsorbable suture. The wrist is placed in slight extension and the metacarpophalangeal joints in full extension. The tension is then evaluated by passively exing and extending the wrist. With the wrist in 30 degrees of exion, the ngers should be in full extension; with the wrist fully extended, the ngers should be able to be exed passively into the palm. The ngers should all extend while maintaining a normal cascade. Once the appropriate tension is set, additional sutures between the FCU and each individual digital extensor tendon secure the repair. Intraoperative assessment of the completed transfer with wrist exion and extension must also include evaluating the line of pull and the excursion. The EDC tendons proximal to the transfer can be transected if their intact musculotendinous junction seems to be interfering with a direct line of pull to digit extension. If the excursion of the transfer is impeded by the proximal aspect of the extensor retinaculum, the leading edge of the retinaculum should be opened. The next transfer is the palmaris longus to the EPL. The transfer is dorsal to the extensor retinaculum overlying the rst dorsal compartment tendons. A Pulvertaft weave of three passes of the palmaris longus through the EPL is accomplished and secured with 4-0 nonabsorbable sutures (Fig. 5A and B).

EPL EPL

PL

FCU PL

EDC

Figure 5. A and B, PL woven into rerouted extensor pollicis longus (EPL) supercial to the extensor retinaculum.

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The palmaris longus is transferred under maximum tension, with the EPL also under maximum tension, with the wrist in neutral and the thumb extended and abducted in a radial direction. The tension is again evaluated by passively exing and extending the wrist. With the wrist in exion, the thumb extends and abducts. With the wrist in full extension, the thumb should be able to contact the radial border of the index nger at the interphalangeal joint. The pronator teres and periosteal extension are then woven into the ECRB, just distal to its musculotendinous junction with a Pulvertaft weave. If the periosteal strip is not substantial, part of the ECRB proximal to the weave can be divided and folded back on itself to improve the strength of the transfer. The transfer is sutured into position with the wrist in 60 degrees of extension and with maximum tension on the pronator teres. The ECRB tendon proximal to the transfer can be transected if its intact musculotendinous junction seems to be interfering with a direct line of pull to wrist extension (Fig. 6A and B).

ECRB ECRL

ECRB

PT PT

B
Figure 6. A and B, Transfer completed with the PT woven into the extensor carpi radialis brevis (ECRB) with the wrist in 60 of extension. ECRL extensor carpi radialis longus.

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After completion of the tendon transfers, the wrist and digits are supported and the dorsal wound approximated. The upper extremity is placed into a volar plaster splint maintaining the elbow exed at 90 degrees, the wrist in extension, and supporting the metacarpophalangeal joints in exion of approximately 30 to 45 degrees. The plaster splint maintains the thumb in an extended and abducted position. After suture removal, a berglass cast is applied and maintained for 4 to 6 weeks. The wrist and ngers are then placed into a volar orthoplast splint providing resting extension support. The splint is worn between occupational therapy sessions for an additional 4 weeks. A formal occupational therapy program is instituted for transfer training.

References
1. Adams RA, Ziets RJ, Lieber RL, et al: Anatomy of the radial nerve motor branches in the forearm. J Hand Surg 22A:232 237, 1997 2. Chiunard RG, Boyes JH, Stark HH, et al: Tendon transfers for radial nerve palsy: Use of supercialis tendons for digital extension. J Hand Surg 3:560 570, 1978 3. Jones R: Tendon transplantation in cases of musculospiral injuries not amenable to suture. Am J Surg 35:333 335, 1921 4. Raskin KB, Wilgis EFS: Flexor carpi ulnaris transfer for radial nerve palsy: Functional testing of long-term results. J Hand Surg 20A:737 742, 1995 5. Riordan DC: Tendon transfers in hand surgery. J Hand Surg 8:748 753, 1983 6. Riordan DC: Radial nerve paralysis. Orthop Clin North Am 5:283 287, 1974 7. Smith RJ: Tendon transfers to restore wrist and digit extension. In Tendon Transfers of the Hand and Forearm. Boston, Little, Brown, 1987, pp 35 56 8. Strickland JW, Kleinman WB: Tendon transfers for radial nerve paralysis. In Strickland JW: The Hand. Philadelphia, Lippincott-Raven, 1998, pp 303 318

Address reprint requests to Michael E. Rettig, MD Department of Orthopedic Surgery New York University Medical Center 317 East 34th Street, 3rd Floor New York, NY 10016

TENDON TRANSFERS

1082 3131/02 $15.00 + .00

Tendon Transfers for Elbow Flexion


Scott H. Kozin, MD

A brachial plexus injury, central nervous system lesion (e.g., spinal cord injury), or birth anomaly (e.g., arthrogryposis) can result in impaired function of the limb. Restoration of elbow exion is a main priority to increase the available workspace and allow hand-to-mouth function.5,10 The goal of tendon transfer for elbow exion is to regain a functional elbow range of motion, which is from 30 to 130 degrees.5,9 The conditions of the adjacent shoulder, forearm, wrist, and hand are important considerations during formulation of a comprehensive surgical plan. In general, tendon transfers proceed from proximal to distal to restore a stable foundation and fulcrum for hand use. Additional transfers about the forearm and hand may be necessary to optimize use of the limb fully after restoration of elbow exion. The preoperative evaluation is critical and should include subjective and objective measures. This process ensures realistic goals and expectations before surgical intervention.

PATIENT SELECTION Appropriate patient selection is critical to any tendon transfer. The patient should be stable from an emotional and physical standpoint. The patient must be able to undergo a prolonged operative procedure and to comply with a rigorous postoperative regimen.5 Realistic goals and expectations are prerequisites to tendon transfer because no operation will restore the limb to normalcy. The examination begins with an assessment of the overall limb posture and status of the surrounding soft tissues. A poor soft-tissue envelope and cicatrix must be corrected before transfer. Supple soft-tissue coverage along the arm and across the antecubital fossa is a requirement before tendon transfer. Preliminary soft-tissue reconstruction may be required using aps (local, regional, or distant) or tissue expanders for coverage.

From the Department of Orthopaedic Surgery, Temple University and Shriners Hospitals for Children, Philadelphia, Pennsylvania

ATLAS OF THE HAND CLINICS Volume 7 Number 1 March 2002

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The active and passive motion of the joints within the limb is assessed, beginning at the shoulder and progressing in a distal direction. Passive motion of the elbow is carefully recorded because the transfer can only restore the amount of available motion. A exion contracture greater than 30 degrees warrants preliminary treatment to regain elbow extension before tendon transfer. Similarly, an extension contracture with inadequate passive exion must be corrected before tendon transfer. Manual muscle testing of all the prime movers about the shoulder, elbow, forearm, wrist, and hand is performed. Each muscle is graded from 0 to 5 according to the Medical Research Council Scale.5 This information provides a baseline assessment of motion (active and passive) and strength of the muscles throughout the limb. A comprehensive plan for reconstruction of the impaired limb can be formulated, including secondary tendon transfers to improve wrist and hand function following restoration of elbow exion. The degree of stability about the shoulder girdle requires careful consideration because scapulothoracic or glenohumeral instability or both negatively affect limb positioning and control. Scapulothoracic instability secondary to dysfunction of the long thoracic nerve causes medial winging and can create a treatment dilemma. A tendon transfer to the scapula or a scapulothoracic fusion may be required before management of the elbow deciency. Glenohumeral instability can be mild or marked depending on the status of the rotator cuff and deltoid muscle. Mild instability can be improved during tendon transfer for elbow exion by attaching the proximal aspect of the transfer to the clavicle or acromion. This procedure provides an anterior support to the anterior glenohumeral joint and can improve shoulder stability. Frank shoulder instability may require formal arthrodesis as part of the upper extremity reconstruction as long as adequate scapular muscles are present.7 Insufcient scapular motors are a contraindication to shoulder fusion because scapular winging will increase, which worsens scapulothoracic dysfunction. The selection of an appropriate muscle to transfer for elbow exion requires an understanding of potential donors.9,10 Potential candidates include the pectoralis major muscle, the latissimus dorsi muscle, the triceps muscle, and the exor-pronator group (Steindler transfer).19,11 Many factors must be considered when choosing the donor muscle, including the strength of the proposed muscle, the line of pull for elbow exion, available excursion, and donor morbidity.5,9 In addition, the overall plan for limb reconstruction must be reviewed to ensure that secondary transfers do not intend to use similar muscles. A proposed donor muscle must have normal or near-normal strength (grade 4 to 5) to achieve a grade 3 or better elbow exion strength. A weaker muscle should not be used because functional range of motion against gravity will not be attained. The advantages and disadvantages of the potential donor muscles must be considered during the decision-making process. The triceps muscle should not be transferred in individuals who rely on elbow extension for propulsion (e.g., wheelchair users or crutch ambulators).3 The Steindler transfer often results in weak elbow exion and a limited arc of active motion, which makes this transfer less preferable.8 The pectoralis major muscle can be transferred using a unipolar or bipolar method.1,2,4 The unipolar technique detaches the origin or insertion and transfers this portion to the biceps tendon.2 This procedure also results in weak elbow exion through an incomplete range. The bipolar technique transfers the origin and insertion of the pectoralis major muscle.4 The insertion is attached to the acromion, clavicle, or both while the origin is secured to the biceps tendon. The bipolar pectoralis major muscle transfer provides adequate range and strength for elbow exion. The disadvantage of this transfer is the extensive incision across the chest that is required for muscle harvest.

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The latissimus dorsi is the authors preferred donor muscle for tendon transfer to restore elbow exion.5,11 The latissimus dorsi has unique attributes that make this transfer preferable, including a minimal functional loss and an exceptional excursion to generate a functional arc of elbow exion. This muscle can be transferred using a unipolar or bipolar technique. The unipolar method transfers the origin of the latissimus dorsi muscle along with a strip of attached thoracolumbar fascia to the biceps tendon. The insertion site into the humerus is not disturbed. The bipolar method detaches the origin and insertion of the latissimus dorsi muscle and transfers the entire muscle within the arm.11 The tendon of insertion is secured to the clavicle, acromion, or both while the facial origin is woven into the biceps tendon. The underlying neurovascular pedicle (i.e., thoracodorsal nerve, artery, and veins) must be carefully preserved during bipolar transfer. The bipolar technique is preferred over the unipolar method for restoration of elbow exion. The bipolar transfer repositions the latissimus dorsi muscle in line with the innate elbow exor muscles, provides a superior line of pull, and takes advantage of the substantial excursion of the latissimus dorsi muscle.

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TREATMENT Restoration of Passive Elbow Motion Adequate passive range of motion must be present before muscle transfer (Fig. 1).

Figure 1. A 10-year-old patient with residual left obstetric brachial plexus palsy. Full passive range of motion is present before muscle transfer.

Because functional elbow motion ranges from 30 to 130 degrees, this amount of passive movement is the goal. A joint exion contracture greater than 30 degrees is treated before tendon transfer. The management depends on the cause of contracture, with consideration of soft-tissue or bony abnormalities. A soft-tissue contracture is initially treated by stretching, heat, and serial casting. Failure to achieve an adequate correction or the presence of an underlying bony problem requires initial surgical release before tendon transfer.

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Latissimus Dorsi Transfer The patient is placed in the lateral decubitus position, and all bony prominences are padded. A beanbag facilitates positioning of the patient. The entire extremity, hemithorax, and ipsilateral thigh are prepared and draped for the procedure (Fig. 2).

Figure 2. The patient is placed in the lateral decubitus position and the entire extremity, hemithorax, and ipsilateral thigh are prepared and draped for the procedure.

Contrary to described techniques, the author prepares the shoulder, elbow, and thigh before dissection of the latissimus dorsi muscle. This sequence allows preparation of the origin and insertion sites without the fear of jeopardizing the latissimus dorsi muscle or pedicle.

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A deltopectoral approach is performed across the anterior shoulder with mobilization of the cephalic vein in a medial direction. The incision is extended in a proximal direction to expose the distal clavicle by reection of the deltoid origin. Deep to the deltopectoral interval, the underlying conjoined tendon is traced to the coracoid process. The proximal third of the pectoralis muscle insertion into the humerus is released to facilitate passage of the latissimus dorsi muscle from the back of the thorax to the front of the arm. The latissimus dorsi transfer can be attached to either the distal clavicle or the coracoid. The specic site varies according to the resting length of the muscle and the stability of the shoulder. Coracoid xation is easier to accomplish and avoids additional stretch to the neurovascular pedicle; however, the muscle may not expand to its optimal resting length when attached to the coracoid. In contrast, linkage to the clavicle enhances tension across the muscle bers and augments anterior shoulder stability; therefore, clavicle attachment is more commonly performed and xation accomplished by sutures placed through the clavicle (Fig. 3).

Figure 3. Proximal xation accomplished by nonabsorbable sutures placed through the clavicle.

Drill holes are made through the clavicle with a malleable retractor placed beneath the clavicle for protection. Three drill holes are made and nonabsorbable sutures passed using a suture passer.

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The biceps tendon is exposed via a transverse incision across the antecubital fossa. Occasionally, a longitudinal extension along the medial aspect of the arm is performed when a concomitant humeral osteotomy is required (Fig. 4).

Figure 4. Isolation of the biceps tendon is exposed by way of an incision across the antecubital fossa.

The biceps tendon is isolated with careful protection of the lateral antebrachial cutaneous nerve and the medial neurovascular bundle (median nerve and brachial artery). The neurovascular bundle resides directly beneath the lacertus brosus (bicipital aponeurosis). A subcutaneous tunnel is made between the antecubital incision and the deltopectoral interval. This tunnel must be large enough to accommodate the latissimus dorsi muscle.

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A 10-cm lateral incision from the greater trochanter toward the knee provides ample exposure for fascia lata harvest (Fig. 5).

Figure 5. Lateral incision along the thigh for fascia lata harvest.

Sharp dissection is performed directly to the fascia lata, which is isolated along the length of the incision. A 10-cm by 3-cm strip of fascia is removed and rolled into a long tube to create a tissue of considerable caliber. This wound is closed over a suction drain after the fascia has been removed.

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The operating table is rotated away from the surgeon to ease harvest of the latissimus dorsi muscle. A long posterior incision is made from the posterior axillary fold to the thoracolumbar area. The skin and subcutaneous tissue are elevated over the latissimus dorsi muscle to the midline. A Teon-coated electrocautery facilitates dissection. The lateral border of the latissimus dorsi muscle is identied and elevated from the underlying serratus anterior muscle (Fig. 6).

Figure 6. The lateral border of the latissimus dorsi muscle is identied and elevated from the underlying serratus anterior muscle.

The neurovascular bundle (thoracodorsal artery, veins, and nerve) is carefully isolated at the junction of the proximal one third and distal two thirds of the muscle (Fig. 7).

Figure 7. The neurovascular bundle (i.e., thoracodorsal artery, veins, and nerve) is isolated carefully.

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This pedicle is mobilized into the axilla to increase its length and to prevent a kink during transfer. The vascular pedicle is traced back to the subscapular artery with ligation of the branch to the serratus anterior muscle (Fig. 8).

Figure 8. The vascular pedicle is traced back to the subscapular artery with ligation of the branch to the serratus anterior muscle.

The entire latissimus dorsi muscle is harvested on the thoracodorsal pedicle with division of the origin and insertion (Fig. 9).

Figure 9. The entire latissimus dorsi muscle is harvested on the thoracodorsal pedicle with division of the origin and insertion.

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The humeral insertion release must include the latissimus dorsi tendon for proximal xation within the arm. The thoracodorsal origin release attempts to include a portion of the fascia for attachment into the biceps tendon (Fig. 10).

Figure 10. The thoracodorsal origin is released including a portion of the thoracolumbar fascia.

The latissimus dorsi muscle is then transferred from the back of the thorax to the front of the arm through the deltopectoral interval (Fig. 11).

Figure 11. The latissimus dorsi muscle is transferred from the back of the thorax to the front of the arm.

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The thoracodorsal origin is passed rst and the neurovascular bundle monitored during passage. Subsequently, the humeral insertion is passed through the interval and the neurovascular bundle reassessed. Any undue tension across the neurovascular bundle must be resolved, usually by additional dissection within the axilla. The operating table is rotated toward the surgeon to facilitate attachment of the latissimus dorsi muscle along the anterior arm. The fascia lata is woven through the thoracodorsal origin using a tendon braider and leaving the ends of the fascia lata protruding from the muscle for attachment into the biceps tendon (Figs. 12 and 13).

Figure 12. The fascia lata is rolled to form a long strip of tissue with considerable caliber.

Figure 13. The fascia lata is woven through the thoracodorsal origin, and the ends of the fascia lata are left protruding from the muscle for attachment into the biceps tendon.

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The muscle and fascia are then passed through the subcutaneous tunnel and into the antecubital incision. The muscle must pass easily to allow gliding within the arm. The fascia is woven through the biceps tendon using a tendon braider and secured with nonabsorbable sutures. The antecubital incision is then closed before proximal xation. This maneuver allows the incision to be sutured and dressed with the elbow extended. The elbow is placed in full exion and the latissimus dorsi tendon of insertion attached to the clavicle using the previously placed transosseous sutures. The shoulder and back incision are closed in layers, and two suction drains are placed within the thoracic wound. The arm is positioned in full exion, and a posterior plaster splint is applied. The arm is also immobilized to the chest and trunk using a cotton and Ace wrap. POSTOPERATIVE CARE Immediate Intravenous antibiotics are continued for 24 hours, and the patient is placed on adequate pain medications, usually patient-controlled analgesia (i.e., pain pump). The position of immobilization is maintained for 6 weeks from the time of surgery. The suction drain from the leg is removed 1 to 2 days after surgery. The drains along the back are left in place for up to 1 week because of the large dead space created by latissimus dorsi harvest, which is prone to seroma formation. These drains should not be removed until the patient is ambulatory to ensure a rm seal between the chest wall and overlying tissues. Therapy After 6 weeks of strict immobilization, the patient is initiated on a therapy program. A static splint is fabricated to maintain the arm in 90 to 100 degrees of elbow exion. Modalities to reduce scar formation along the incisions are instituted, and tendon transfer retraining is initiated. The patient is educated on maneuvers to activate the latissimus dorsi muscle to produce elbow exion. This transfer is usually not difcult for the patient to activate and retrain. The splint is remolded weekly over the subsequent 6 weeks to allow progressive extension while protecting the transfer. Some patients have difculty with activation of the transfer or co-contraction of the surrounding muscles. This problem can be treated with biofeedback, which enhances stimulus to the patient and increases selective muscle activation. OUTCOME The Steindler and unipolar transfers often result in a limited arc of active motion and weak elbow exion.5,9 The results after bipolar tendon transfer to restore elbow exion are favorable.14,6,8,9,11 Most patients regain the ability to ex the arm against gravity, which results in an improvement in function; however, these transfers are weak and provide limited lifting strength, which must be discussed with the patient before surgery. COMPLICATIONS A tendon transfer to restore elbow exion is a demanding procedure. Complications can occur despite careful surgical technique. During bipolar transfer, the

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neurovascular pedicle must be carefully isolated and protected to prevent injury, which could cause ischemia or denervation of the muscle. Any injury to the neurovascular pedicle during surgery must be recognized and repaired immediately. Specic complications are related to the donor site of the fascia lata and muscle. Harvest of the fascia creates a hernia along the lateral thigh and allows the muscles to bulge through this rent. Usually, this creates some mild temporary discomfort occurs along the lateral thigh that resolves over time. This discomfort is best treated by symptomatic measures, such as compression wraps or neoprene supports. The lateral thigh and muscle donor site are prone to seroma and hematoma formation. This donor-site morbidity is especially true after bipolar transfer of the latissimus dorsi or pectoralis major. Drainage of these sites will decrease the incidence of uid collection. Drains are placed deep within the dead space and not removed until the patient is ambulatory. This step promotes drainage of any uid and prevents unwanted accumulation. One of the most prevalent and disappointing complications is decient motion against gravity or weakness. This problem is multifactorial and can be related to attenuation of the origin or insertion site, scarring about the transfer, and transfer of a muscle with unrecognized denervation. Attenuation about the transfer can be lessened by the use of fascia lata augmentation and meticulous preparation of the origin and insertion sites. Inadvertent transfer of a weak muscle is less likely after careful preoperative manual muscle testing supplemented by electrophysiologic testing. Unfortunately, scar formation is unavoidable after tendon transfer. Healing of the coaptation sites is required for function; excessive scar proliferation will impede tendon transfer gliding and limit motion. The early detection of motion-limiting scar can be helped by therapeutic modalities, including formal therapy, ultrasound, and biofeedback. Established dense scar is difcult to manage with therapy or surgery. Tenomyolysis of the transfer is indicated for scar recalcitrant to therapy, although this technique is not uniformly successful in restoration of motion.

References
1. Beaton DE, Dumont A, Mackay MB, et al: Steindler and pectoralis major exorplasty: A comparative analysis. J Hand Surg 20A:747 756, 1995 2. Brooks DM, Seddon HJ: Pectoral transplantation for paralysis of the exors of the elbow. J Bone Joint Surg 41B:36 50, 1959 3. Carroll RE, Hill NA: Triceps transfer to restore elbow exion: A study of fteen patients with paralytic lesions and arthrogryposis. J Bone Joint Surg 52A:239 244, 1970 4. Carroll RE, Kleinman WB: Pectoralis major transplantation to restore elbow exion to the paralytic limb. J Hand Surg 4:501 507, 1979 5. Kozin SH: Injuries of the brachial plexus. In Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, Lippincott Williams & Wilkins, 1999, pp 847 880 6. Marshall RW, Williams DH, Birch R, et al: Operations to restore elbow exion after brachial plexus injuries. J Bone Joint Surg 70B:577 582, 1988 7. Richards RR, Waddell JP, Hudson AR: Shoulder arthrodesis for the treatment of brachial plexus palsy. Clin Orthop 198:250 258, 1985 8. Steindler A: Tendon transplantation of the upper extremity. Am J Surg 44:534, 1939 9. Stern PJ, Caudle RJ: Tendon transfers for elbow exion. Hand Clin 4:297 307, 1988 10. Van Heest A, Waters PM, Simmons BP: Surgical treatment of arthrogryposis of the elbow. J Hand Surg 23A:1063 1070, 1998 11. Zancolli E, Mitre H: Latissimus dorsi transfer to restore elbow exion: An appraisal of eight cases. J Bone Joint Surg 55A:1265 1275, 1973

Address reprint requests to Scott H. Kozin, MD Shriners Hospitals for Children 3551 North Broad Street Philadelphia, PA 19140 e-mail:skozin@shrinenet.org

TENDON TRANSFERS

1082 3131/02 $15.00 + .00

Tendon Transfers for Lateral Pinch


Albert A. Weiss, MD, and Scott H. Kozin, MD

The paralyzed hand that could benet from transfers to restore lateral pinch is seen in an impaired individual who is nearly always tetraplegic, although such paralysis can conceivably be caused by a combination of peripheral nerve lesions or incomplete brachial plexus palsy. The additional independence gained from this transfer affords a monumental leap in functional capabilities, often providing the ability to self-feed, independently catheterize, and seek employment.1,4 The restoration of lateral pinch also allows activities of daily living without brace encumbrance, which blocks sensory feedback.

HISTORY Early writings on the restoration of prehensile function in the paralyzed hand focused on peripheral nerve injuries or brachial plexus palsies. Survival rates for cervical spinal cord injury were low, owing largely to the challenges in nursing care, dysautonomia, and genitourinary system complications. The Symposium on Reconstructive Surgery of the Paralyzed Upper Limb of the Royal Society of Medicine in 1949 made no mention of the treatment of paralysis secondary to spinal cord injury.3 A exor hinge splint to restore grasp in patients with intact wrist extensors was introduced, although this device found little acceptance until the general care of quadriplegics improved in the early 1960s.10 Bunnell2 described a exor tenodesis in 1948, and Lipscomb and coworkers6 published a series in 1958 in which transfers were used for what was termed thumb opposition, which was actually lateral pinch. In many early reports, the terms thumb opposition or adduction opposition were used to refer to what is currently dened as lateral pinch, key pinch, or lateral grasp.

From the Department of Orthopaedic Surgery, MCP Hahnemann University (AAW); Temple University; and Shriners Hospital for Children (SHK), Philadelphia, Pennsylvania

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PATIENT SELECTION Tetraplegia secondary to spinal cord injury is dened according to the American Spinal Injury Association or the International Classication of Surgery of the Hand in Tetraplegia (ICSHT).7 The ICSHT is designed to guide surgical reconstruction of the upper limb in tetraplegia (Table 1).
Table 1. INTERNATIONAL CLASSIFICATION OF SURGERY OF THE HAND

IN TETRAPLEGIA
Sensibility O on Cu* Group 0 1 2 3 4 5 6 7 8 9 X
*O

Motor Characteristics No muscle below elbow suitable for transfer Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis Pronator teres Flexor carpi radialis Finger extensors Thumb extensor Partial digital exors Lacks only intrinsics Exceptions

Description of Function Flexion of elbow Extension of the wrist (weak or strong) Extension of the wrist Pronation of the wrist Flexion of the wrist Extrinsic extension of the ngers Extrinsic extension of the thumb Extrinsic exion of the ngers (weak) Extrinsic exion of the ngers

occular (visual) sensibility only; Cu

cutaneous sensibility -visual.

Persons with high-level tetraplegia (ICSHT groups 0) have insufcient available innervated motors for restoration of lateral pinch using tendon transfer without supplemental electrical stimulation. Persons with lower-level tetraplegia (ICSHT 2 and greater) have enough available motors to reconstruct lateral pinch and other grasp patterns (e.g., palmar grasp). In activities of daily living, more tasks are performed with lateral pinch compared with palmar grasp, which underscores the importance of pinch reconstruction. Utensils such as a toothbrush, pen, fork, oppy disk, and compact disc are acquired and manipulated with lateral pinch, unless a more sophisticated precision pinch (opposition or pulp-to-pulp) is available. Opposition pinch requires an opposable thumb with good control and sensibility, which is often beyond the scope of conventional transfer restorability. Candidates for a tendon transfer to restore lateral pinch must have an absence of contracture, control of spasticity, and the capability of undergoing postoperative rehabilitation (i.e., without chronic pain or psychiatric disorders).

CATEGORIES OF PINCH RECONSTRUCTION Passive Effective lateral pinch can be restored by tenodesis of the exor pollicis longus, as long as a grade 3 or better volitional wrist extension is present. Active wrist extension produces tension in the exor pollicis longus tendon and positions the thumb against the index nger. The preferred point of contact is the index proximal interphalangeal joint. The magnitude of wrist extension and the tautness of the exor pollicis longus directly affect pinch strength. In patients in ICSHT group 1, active wrist extension can be achieved by transfer of the brachioradialis to the extensor carpi radialis brevis (Fig. 1A). The brachioradialis must be freed from its

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insertion into the radial styloid and forearm fascia to maximize available excursion. Because the need to mobilize proximally is critical, the passive amplitude of excursion should be measured repeatedly until 2.0 to 2.5 cm of excursion is evident (Fig. 1B).

Figure 1. A, Brachioradialis tendon harvested and transferred to extensor carpi radialis brevis. B, Brachioradialis excursion can be increased by proximal dissection of muscle belly.

Mobilization proximal to the musculotendinous junction is required, which ensures adequate excursion to provide sufcient amplitude for wrist extension and concomitant tension within the tenodesis.

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Technique Preoperatively, the overall thumb posture must be evaluated when planning lateral pinch reconstruction. The rst ray must be positioned sufciently to allow the thumb to contact the index proximal interphalangeal joint. This requires some thumb carpometacarpal joint stability and mild pronation. An unstable thumb carpometacarpal joint or supinated posture will result in malpositioning during attempted lateral pinch. A thumb carpometacarpal joint capsulodesis or arthrodesis may be required to rectify this problem. Through a longitudinal volar incision just radial to the exor carpi radialis tendon, the exor pollicis longus tendon is exposed and divided from its muscle as far proximally in the forearm as possible (Fig. 2A). Two holes are drilled in the metaphysis of the palmar radius, separated by a bony bridge (Fig. 2B).

Figure 2. A, Longitudinal incision and exposure of exor pollicis longus tendon. B, Drill holes in distal radius for passage of exor pollicis longus tendon.

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The holes are enlarged to accept the exor pollicis longus tendon. The tendon is passed into a hole, under the bony bridge, out the other hole, and then secured back to itself around the bony bridge. This maneuver provides a stable anchor of xation for the tenodesis that is secure enough to permit rapid postoperative use. Tension is set such that lateral pinch is achieved with the wrist positioned in extension, and thumb extension is attained with the wrist placed in exion. Tenodesis of the extensor pollicis longus may be necessary to enhance thumb extension and facilitate release; however, the extensor pollicis longus has an unwanted adduction vector and must be rerouted into the vicinity of the rst dorsal compartment before tenodesis. Interphalangeal joint stabilization is routinely performed to maximize effective contact between the thumb and index nger and is performed before tensioning. Criticisms of the exor pollicis longus tenodesis are related to stretching of the tenodesis over time and ineffective pinch strength. Currently, passive pinch is reserved for ICSHT group 1, when functional electrical stimulation is not a viable alternative.

Active Patients with strong active wrist extension but absent thumb exion can regain active lateral pinch using a tendon transfer. Depending on the patients motor inventory, options for powering the exor pollicis longus include the brachioradialis or the pronator teres (elongated with radial periosteum). Technique The skin incision varies slightly according to the chosen motor and concomitant tendon transfers. A longitudinal radial incision allows access to the exor pollicis longus tendon and the brachioradialis and pronator teres (Fig. 3A). The harvested tendon is woven into the exor pollicis longus using a three-pass Pulvertaft weave technique. This method provides enough integral strength to allow early active use of the transfer without fear of transfer dehiscence. Similar to passive pinch, proper tension of the transfer is determined by placing the wrist in exion and extension and gauging tenodesis lateral pinch position and thumb release, respectively.

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As is true in passive tenodesis, the interphalangeal joint of the thumb is stabilized before tensioning the transfer. A split exor pollicis longus transfer is performed, which preserves some interphalangeal joint mobility. This joint stabilization maximizes the lever arm for pinch strength and avoids unwanted interphalangeal exion, which would compromise the lateral pinch pattern (Fig. 3B).

Figure 3. A, Longitudinal radial incision to expose brachioradialis, extensor carpi radialis brevis, exor pollicis longus, and pronator teres tendons. B, Inefcient pinch pattern following tendon transfer to restore lateral pinch without concomitant interphalangeal joint stabilization.

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Functional Electrical Stimulation Specic selection criteria for functional electrical stimulation are beyond the scope of this article. The general selection criterion for functional electrical stimulation (FES) is high-level tetraplegia (ICSHT groups 0 and 1) without considerable denervation (i.e., lower motor neuron injury).5 Functional electrical stimulation controlled lateral pinch can be superb, with better strength than many active transfers; however, FES often limits applicability and requires caregiver support. Ideal conditions for functional electrical stimulation restored lateral pinch allow implantation of electrodes into the exor pollicis longus and the adductor pollicis muscles. Interphalangeal joint stabilization with or without carpometacarpal joint capsulodesis or arthrodesis is also required. Denervation of the exor pollicis longus or the adductor pollicis muscles precludes a usable response to stimulation and requires transfer of other paralyzed but not denervated muscles to provide an electrically controllable lateral pinch. Determination of a viable motor for transfer requires an inventory of all paralyzed muscles that can be stimulated. The ability to stimulate indicates an intact reex arc (upper motor neuron injury) without injury to the anterior horn cells (lower motor neuron injury). General principles of tendon transfer surgery apply, except that synergy of action (desirable in volitional transfers) is irrelevant with computer-controlled transfers. The exor carpi radialis normally would not be an ideal substitute motor for the exor pollicis longus because wrist exion and thumb exion are not synergistic acts. Nevertheless, the paralyzed but not denervated exor carpi radialis would work well by transfer to the exor pollicis longus with electrical control. Surgical approaches for these procedures are dependent on the total number and location of motor points to be supplied with electrodes, along with consideration for any necessary tendon transfers. Typically, a longitudinal incision is needed on the volar and dorsal forearm, as well as incisions for hand electrodes (thumb abductor and adductor muscles).

Interphalangeal Joint Stabilization Moberg3 recognized the need to block interphalangeal joint exion during exor pollicis longus tenodesis to achieve an effective pinch against the index nger (Fig. 3B). He further recognized the potential dissatisfaction with stiff joints in persons with tetraplegia. Provisional Kirschner wire xation across the interphalangeal joint provided immediate stability for lateral pinch and offered reversibility. If the patient sensed that the loss of exibility outweighed the gain in pinch strength, simple wire removal could be performed; however, these pins often migrated, broke, or caused pain, which necessitated a second procedure for their removal and overall dissatisfaction with an unstable interphalangeal joint.

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The split exor pollicis longus transfer described by Mohammed and colleagues9 offered a solution to retain a supple joint and still provide an improved lateral pinch pattern (Fig. 4).

Figure 4. Split exor pollicis longus tendon transfer to provide stability to lateral pinch.

Technique A radial midaxial incision is developed on the thumb. The neurovascular bundle is retracted in a palmar direction and the exor sheath incised to expose the exor pollicis longus tendon (Fig. 5A). The tendon is divided in its midline and in a longitudinal direction. The radial half of the tendon is incised at its insertion point on the distal phalanx and pulled into the midaxial region of the thumb (Fig. 5B). A dorsal ap is elevated to expose the extensor hood and terminal tendon. The cut half of the exor pollicis longus tendon is passed through a slit in the midportion of the extensor hood and sutured back to itself (Fig. 5C). The proximal end of the slit in the extensor hood is reinforced with a suture to prevent proximal propagation of the slit and the transfer further secured to the extensor tendon directly. A longitudinal Kirschner wire is passed retrograde across the interphalangeal joint to provide temporary stabilization and protection of the transfer and to allow early motion (Fig. 5D). This pin is removed 4 to 5 weeks after surgery.

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Figure 5. A, Radial mid-axial incision to expose exor pollicis longus tendon. B, Radial half of exor pollicis longus incised at distal phalanx insertion. Illustration continued on following page

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Figure 5 (Continued). C, Radial half of exor pollicis longus routed in a dorsal direction and passed through extensor hood. D, Longitudinal Kirschner wire passed across interphalangeal joint to protect split exor pollicis longus transfer.

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Carpometacarpal Joint Stabilization The thumb position can adversely affect transfers for lateral pinch. In the absence of an opponens muscle, supination of the thumb ray often develops, which places the thumb pulp poorly on the index nger. This malrotation is further compromised when combined with a thumb adduction contracture. The thumb ray can be repositioned by osteotomy, capsulodesis, or arthrodesis. A soft-tissue procedure (i.e., capsulorrhaphy) tends to stretch over time, and an osteotomy does not prevent continued supination; therefore, arthrodesis of the rst carpometacarpal joint is preferred to provide a stable platform for the rst ray and simultaneous correction of any rst web space malposition. A dorsal approach between the rst and third compartments is used to expose the carpometacarpal joint. The articular surface is removed with a saw and rigid xation accomplished with plate and screws (e.g., minicondylar plate). Interphalangeal joint stabilization is still necessary to prevent unwanted interphalangeal joint exion, which leaves only the metacarpophalangeal joint for motion.

References
1. Allieu Y, Coulet B, Chammas M: Functional surgery of the upper limb in high-level tetraplegia. Techniques in Hand and Upper Extremity Surgery 4:50 68, 2000 2. Bunnell S: Bunnells Surgery of the Hand. Philadelphia, JB Lippincott, 1948 3. DAubigne RM: Treatment of residual paralysis after injuries of the main nerves (superior extremity). (Symposium on Reconstructive Surgery of the Paralyzed Upper Limb): Proceedings of the Royal Society of Medicine XLII: 831 844, 1949 4. House J, Gwathmey FW, Lundsgaard DK: Restoration of strong grasp and lateral pinch in tetraplegia due to cervical spinal cord injury. J Hand Surg 1:152 159, 1976 5. Kilgore KL, Peckman PH, Keith MW, et al: An implanted upper-extremity neuroprosthesis: Follow-up of ve patients. J Bone Joint Surg 79A:533 541, 1997 6. Lipscomb PP, Elkins EC, Henderson ED: Tendon transfers to restore function of hands in tetraplegia, especially after fracture-dislocation of the sixth cervical vertebra on the seventh. J Bone Joint Surg 40A:10 58, 1958 7. McDowell CL, Moberg EA, House JH: The second international conference on surgical rehabilitation of the upper limb in tetraplegia (quadriplegia). J Hand Surg 11A:604 608, 1986 8. Moberg E: The Upper Limb in Tetraplegia. Stuttgart, Georg Thieme Publishers, 1978 9. Mohammed KD, Rothwell AG, Sinclair SW, et al: Upper limb surgery for tetraplegia. J Bone Joint Surg 74B:873 882, 1992 10. Nickel VL, Perry J, Garrett AL: Development of useful function in the severely paralyzed hand. J Bone Joint Surg 45A:933, 1963

Address reprint requests to Albert A. Weiss, MD MCP Hahnemann University 230 N. Broad Street Philadelphia, PA 19102 e-mail: bertieweiss@hotmail.com

TENDON TRANSFERS

1082 3131/02 $15.00 + .00

Tendon Transfers for Restoration of Active Grasp


Allan E. Peljovich, MD, MPH

Traumatic tetraplegia represents about one-half of all spinal cord injuries, and the C5 and C6 levels are the most commonly injured. As such, the common cervical level spinal injury leaves patients with some shoulder and elbow function and perhaps minimal wrist function. This pattern translates into a weak tenodesis grasp and release in C6 level patients but no effective grasp ability in C5 patients. Lower cervical injury in which patients retain some hand function is uncommon, as is high-level injury that leaves patients ventilator dependent. Among the most disabling aspects of traumatic tetraplegia is the loss of hand and upper extremity function. Previous study has demonstrated that restoration of hand and upper extremity function is rated above bowel/bladder control, sexual function, and ambulation among patients and caregivers alike. Surgery to restore hand function can thus have a signicant impact on the quality of life of tetraplegic patients. Most activities of daily living are performed through two fundamental grasp patterns: (1) lateral thumb pinch and release (key pinch) and (2) palmar grasp and release. The author typically prioritizes key pinch and restores palmar grasp and release when sufcient donor muscles exist. Enhancing the natural wrist tenodesis effect through orthotics or passive tenodesis procedures or through voluntary tendon transfers is the means by which function is restored. A novel method to restore palmar grasp and release not discussed herein is through neuroprosthetic implantation (NeuroControl Freehand; NeuroControl Corp., Valley View, OH), typically reserved for American Spinal Injury Association (ASIA) C5 and C6 patients, or International Classication of Surgery of the Hand in Tetraplegia (ICSHT) groups 0 to 2. Grasp and release restoration must be viewed from the larger perspective of upper extremity restoration. Not all tetraplegic patients are good candidates for surgical intervention. Among the criteria listed below perhaps the most important is that the patients desires and goals from surgery are realistic.

From the Shepherd Center; The Hand Treatment Center, PC; the Department of Orthopaedic Surgery, Atlanta Medical Center; and Emory University, Atlanta, Georgia

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Patient Criteria for Surgical Consideration in Tetraplegic Hand Restoration Indications Neurologic stability (at least 10 12 months from injury) Motivation and desire Realistic goals Good cognition Good general health Wheelchair/trunk stability Supple/pain-free upper extremity (consider other injuries sustained during trauma) Minimal to no problem with recurrent pressure sores Good support systems (family, friends, attendants) Suitable physical examination for tendon transfer or neuroprosthetic Minimal to no problems with upper extremity spasticity Contraindications Unrealistic expectations Uncontrollable upper extremity spasticity Upper extremity pain Signicant upper extremity or hand contractures or both In addition, the ability to grab and manipulate an object is enhanced by the ability to be able to reach out with ones arm; therefore, restoration of palmar grasp and release is most efcacious when other functions are present or provided, namely, key pinch, supple pronosupination, and elbow extension. Often, multiple procedures are combined in a single or a staged series of operations to minimize the disabling downtime tetraplegic patients face after surgery.

INTERNATIONAL CLASSIFICATION In 1984 at the First International Conference on Surgical Rehabilitation of the Upper Limb in Tetraplegia held in Edinburgh, a classication system was devised by a group of experienced surgeons, which has since been modied for the tetraplegic hand. The system categorizes patients by the most distally innervated voluntary muscle with grade 4 British Medical Research Council (BMRC) strength or greater (Table 1).
Table 1. THE INTERNATIONAL CLASSIFICATION FOR SURGERY OF THE HAND IN TETRAPLEGIA Group 0 1 2 3 4 5 6 7 8 9 X Motor None Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis Pronator teres Flexor carpi radialis Extrinsic nger extensors Extrinsic thumb extensors Radial extrinsic digital exors Complete digital exion (thumb included) Incomplete/exceptions Function Elbow exion and supination Elbow exion and supination, pronation with neutral forearm position Wrist extension Strong wrist extension Active forearm pronation Wrist exion Partial or complete digital extension Thumb extension Partial digital exion Intrinsic minus hand Unpredictable

BMRC British Medical Research Council; ECRB extensor carpi radialis brevis. Note: System only applies to muscles of the forearm and hand. Upper extremity function is not included but becomes increasingly functional as the group level increases. Sensibility is based on the presence of thumb/index two-point discrimination of 10 mm. If present, the classication has the prex Cu (cutaneous), such as Cu 4. If two-point discrimination is greater than 10 mm, the classication has the prex O (ocular), such as O 1. Motor is based on the presence of at least grade 4 BMRC strength. Weaker voluntary function may be present, such as a weak ECRB in a group 2 patient.

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Unlike in the ASIA system, its utility is that the groupings provide information concerning which specic muscles are voluntary and sufciently strong, thereby giving the treating physician concise information regarding surgical options for the patient. For example, a group 3 patient has a voluntary strong brachioradialis (BR), extensor carpi radialis longus (ECRL), and extensor carpi radialis brevis (ECRB). This observation suggests that group 3 patients have three potential donor muscles for transfer. On the other hand, an ASIA C6 patient who also has voluntary wrist extension may or may not have a strong and voluntary ECRB. The International Classication is more useful when describing hand function and is used throughout this article. SURGICAL PRINCIPLES Successful restoration of palmar grasp and release involves addressing four phases: (1) object acquisition, (2) grasp, (3) hold/manipulation, and (4) object release. Each phase must be attended to for the best results as follows: 1. Object acquisition: The patient must be able to acquire the object he or she desires to manipulate. This ability involves coordinated upper extremity motion, such as elbow extension and forearm rotation, for wrist positioning in space in addition to digital extension to reach around an object. 2. Grasp: In the second phase, the hand must grasp the object through digital exion. The mass of the object the patient can grasp is proportionate to the strength of digital exion and wrist stability, whereas the size of the object is proportionate to digital extension. Another factor in the size of the object is the type of exion that a patient achieves. A curl or hook grasp, in which there is hyperexion of the interphalangeal joints with relative extension of the metacarpophalangeal (MCP) joint, would be effective for small objects and power. On the other hand, a balanced grasp with exion of all of the phalangeal joints allows grasp of a larger object, such as a book or cup. The latter grasp pattern is more versatile for activities of daily living, whereas the former is fairly inefcient. 3. Hold and manipulate: The patient must then be able to hold and manipulate the object. This ability is correlated with endurance of digital exion strength and upper extremity coordination. 4. Object release: The patient must be able to release the object to its desired location effectively. The ngers and thumb must extend in a coordinated fashion. The muscle functions addressed in reconstruction of palmar grasp and release include the exor digitorum profundus (FDP), extensor digitorum communis (EDC), extensor pollicis longus (EPL), abductor pollicis longus (APL), exor pollicis longus (FPL), and, occasionally, the exor digitorum supercialis (FDS) and intrinsic hand muscles. For the sake of economy in these patients, the FDP is prioritized for digital exion because its action results in exion of all of the interphalangeal joints as opposed to the FDS. When muscles are available as donors to be transferred to power grasp, the author usually prioritizes FDP activation as opposed to EDC activation to provide strength for grasp and hold/manipulation phases, expecting tenodesis nger extension that is passively associated with gravity-produced wrist exion to provide sufcient acquisition and release phases. If the FPL is activated as well, which is often true if a motor is available to power the FDP because key pinch restoration is prioritized, grasp is even stronger. Tendon transfers to activate digital extension are performed when there are sufcient donor muscles available, that is, the patient is in group 4 or higher, and EDC, EPL, and APL activation can be achieved with a single donor motor.

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General principles of tendon transfer are often extended in this population of patients. Regardless of the technique or procedure, ideal patients have supple joints, are motivated, are healthy, and have sufcient cognition to understand, and cooperate in their postoperative therapy. Transferring strong muscles that are under voluntary control is the norm; however, occasionally, muscles with grade 3 strength are used, that is, transfer of the ECRB to FDP through interosseous membrane in group 2 patients. Donor muscles must have sufcient amplitude of motion, especially considering that the excursion for the FDP is approximately 7 cm. Of course, the function of the donor muscle must be expendable; and the BR, one of the two radial wrist extensors (ECRL preferred over the ECRB) and pronator teres (PT) meet this criterion best. The author preserves the exor carpi radialis when present (group 5) because, usually, sufcient donor muscles are available to restore meaningful function, and voluntary wrist exion generally produces better tenodesis digital extension than gravity alone. Use of the ECRB is limited to the previous example; otherwise, the ECRL is the prime wrist extensor used for transfer if the ECRB is under voluntary control and is of sufcient strength. Sensation is not critical because the goal is restoration of fundamental grasp patterns that can be controlled visually. If touch, stereognosis, and proprioception were criteria for surgery, almost no tetraplegic patients would qualify for surgery, and this requirement belies experience with the success of surgery. Synergism as achieved with an ECRL to FDP transfer is ideal but not required.

RESTORATIVE LADDER The foundation for palmar grasp and release restoration lies in the presence or provision of wrist extension, which powers the passive tenodesis coupling of wrist extension/digital exion and gravity-produced wrist exion/digital extension. Once adequate and voluntary wrist extension is present, a tenodesis grasp and release can be enhanced as necessary through therapy, orthotics, or surgery. Some patients are satised with tenodesis grasp alone. Most patients desire to become brace free and to have a stronger grasp and key pinch. Restorative or reconstructive surgery is then based on transferring and tightening tendons along with judicious use of joint stabilization, whether through capsulodesis or arthrodesis. Patients with group 0 function do not have wrist motion or a suitable donor muscle for transfer into the hand and wrist. As such, restoration of hand function is achievable only through neuroprosthetic implantation, which is primarily used for patients in groups 0 to 3. In group 1 patients, the BR is available for transfer into the ECRB, thereby providing wrist extension. Palmar grasp and release is then enhanced as necessary with orthotics or tendon tenodesis, if necessary. Key pinch restoration alone is more commonly performed in this group. In group 2 patients, the ECRL is sufciently strong. Key pinch is still prioritized and powered with transfer of the BR to FPL, in addition to other thumb-stabilizing procedures. Palmar grasp and release is enhanced as necessary with tenodesis procedures, or can be prioritized over key pinch and restored with a BR to FDP transfer. Some group 2 patients retain a present but weak ECRB (BMRC 3 strength). This weak ECRB can be passed through the interosseous membrane to act as a strong tenodesis transfer without sacricing critical wrist extension. In group 3 patients, palmar grasp and release can be restored without sacricing key pinch and is activated by transferring the ECRL into the FDP; EDC tenodesis is used to balance the nger. Two-stage exor/extensor reconstructions are often performed in patients who function at a group 3 level or higher but are more commonly used in patients who are at least group 4. In group 4 and 5 patients, options depend on the choice of thumb reconstruction, and available donor motors to power the FDP include the PT and ECRL. At this level, the BR is potentially available to power nger/thumb extension, again depending on the choice of thumb/key pinch reconstruction. In group 6 patients,

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some digital extension is present, and the EPL alone is activated in addition to nger exion. In group 7 patients, only exion activation is required. In group 8 patients, there may be good exion of the radial digits. In this circumstance, the ECRL can be used to power some or all of the FDS. In patients at group 4 level or higher, and in some patients of higher-level cervical tetraplegia, consideration of intrinsic balance is included in the surgical plan.

Two-Stage Flexion and Extension Reconstruction Patients who can undergo restoration of active exion as well as lateral pinch should be considered for two-stage reconstructions (group 3 or greater) (Table 2) because joint balancing enhances digital restoration. Unopposed or unbalanced function can result in inefcient function, long-term contractures, and failure of transfers, such as nger exion contractures following isolated activation of the FDP. Either active transfer or, more commonly, tenodesis of the antagonist achieves balance. In this fashion, EDC/EIP tenodesis or activation balances function gained through FDP activation. At the same time, intrinsic reconstruction also achieves digital balance. The problem is that the rehabilitation for exion restoration is contradictory and endangers the rehabilitation for extension restoration; therefore, restoration is performed in two stages, one for exion and a second for extension. The higher the group level, the more functional the hand. The details of such procedural algorithms are found in texts written by House and Zancolli and are outlined in Table 2.3,7
Table 2. EXAMPLES OF TWO-STAGE FLEXION AND EXTENSION RECONSTRUCTIONS Zancolli Method (2 6 months between stages) 1. Extensor reconstruction a. EDC/EPL/APL tenodesis versus BR to EDC/EPL transfer b. Thumb CMC arthrodesis c. Zancolli lasso 2. Flexor reconstruction a. BR to FDP transfer versus ECRL to FDP and ECRB/ FPL synchronization b. BR to FPL versus FPL tenodesis c. PT to FCR for group 4 House Method (2 6 months between stages) For groups 4 5 1. Flexor reconstruction a. ECRL to FDP transfer b. PT to FPL transfer c. BR to adductor pollicis/opponens transfer (via FDS graft) 2. Extensor reconstruction a. EDC synchronization and tenodesis b. EPL/APL tenodesis c. Free graft intrinsic index/long tenodesis For group 6 1. Flexor reconstruction a. ECRL to FDP transfer b. BR or PT to FPL transfer c. Zancolli lasso 2. Extensor reconstruction a. Thumb CMC arthrodesis b. EDC and EPL tenodeses versus BR to EDC/EPL

BR brachioradialis; ECRL extensor carpi radialis longus; EDC extensor digitorum communis; ECRB extensor carpi radialis brevis; EPL extensor pollicis longus; APL abductor pollicis longus; CMC carpo metacarpal; FDP flexor digitorum profundus; FPL flexor pollicis longus; PT pronator teres; FCR flexor carpi radialis; FDS flexor digitorum supercialis.

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TENDON SYNCHRONIZATION Tendon synchronization is a useful technique whereby all of the FDP or EDC/EIP tendons, respectively, are sutured to each other to create efciency and economy. It is impossible to activate exor or extensor function individually for each digit independently in the setting of traumatic tetraplegia. In this technique, either the FDP or EDC is transformed into a single tendon unit. In both procedures, the natural cascade of the ngers is ignored, and the synchronization is set such that all the ngers ex and extend level to each other (Fig. 1).

Figure 1. Synchronization of the exor digitorum profundus (FDP) and the extensor digitorum communis converts four independent tendons into one mass that allows for efcient control of nger motion. Synchronization is performed by tying the tendons in a side to side fashion using at least three horizontal mattress sutures. At least three sutures are required to control relative translation between the tendons themselves. Note that the ngers are synchronized in a straight, equal fashion, rather than in the natural cascade. This reverse cascade improves grasp and release ability. The proximal muscle would be transected if a tenodesis procedure were being performed as well.

At least three interrupted nonabsorbable sutures are used to tie the tendons to each other to create translational control of the mass. This suturing is carried out proximal to the retinaculum on the extensor surface, such that the sutures do not enter the extensor compartments. With this reverse cascade, force is applied through all of the ngers equally and with equal motion, thereby maximizing the size of an object that can be grasped or manipulated. Synchronization is routinely performed when individual nger motion is not already present, that is, at less than group 6 function. A minimum of 3 weeks of immobilization is required before sufcient healing occurs to allow therapy.

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TENODESIS TECHNIQUE Tenodesis refers to tightening tendons to phases of motion, in this case, tightening the extrinsic nger muscles in sync with wrist motion to strengthen or enhance a function that occurs naturally. Finger exion can be enhanced with wrist extension by tightening the FDP. Finger extension can be enhanced with gravity-induced wrist exion by tightening the EDC/EIP. Tenodesis procedures are used when donor muscles are absent, and the natural tenodesis effect achieved through the wrist is inadequate. Another circumstance in which tenodesis commonly is applied is when joint balancing is necessary. For example, it is desirous to perform tenodesis of the EDC when activating the FDP to prevent late exion deformities. The problem with tenodesis is that it is generally weak and can stretch with time. For exor tenodesis, exposure of the FDP is achieved depending on other simultaneously performed procedures. This maneuver can be performed through a radial approach (approach of Henry), or a more radial, near-midaxial approach (Fig. 2).

Figure 2. The surgical approaches for most reconstructive procedures for palmar grasp and release vary from volar and dorsal combinations to single utilitarian approaches. This view demonstrates two alternative utilitarian exposures. One single straight incision can be created just volar to the midaxial line of the forearm (near-midaxial). Alternatively, a single lazy-S incision can be created in a similar location. Mobilization of full-thickness soft tissue aps and rotation of the forearm provide excellent access to the three forearm compartments during tetraplegia reconstruction.

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Any of these latter approaches are fairly utilitarian because they provide exposure for other simultaneous procedures, such as key pinch restoration. If EDC/EIP tenodesis or any other extensor-sided procedure is desired, whether at the same setting or in a staged fashion, a lazy-S shaped or straight radial, near-midaxial incision is ideal because access to extensors and exors is provided through a single approach; otherwise, a separate dorsal approach may be required. Ulnar-sided forearm exposures are not useful because the access to muscles and tendons that will be manipulated is more limited. FDP synchronization in a reverse cascade is performed, and the tendons are transected at the musculotendinous junction. The length of tendon required for proper tension is estimated because the tendon unit will be anchored to bone via a corticotomy. Wrist extension will pull on the FDP, tensioning the ngers into exion. The surgeon must choose the appropriate tension based on factors such as the patients wrist extension strength and motion and passive digital motion. A simple guideline is to adjust tension such that the ngers are maximally exed at about 30 to 45 degrees of extension. In this manner, further wrist extension produces more tension than excursion, adding strength of grasp. Because the corticotomy is a xed distance from the radiocarpal joint, shortening the tendon mass by trimming the proximal edge sharply sets tension. This tension is estimated and completed before securing the tenodesis. The corticotomy performed about the diaphyseal/metaphyseal junction must be large enough to accommodate the synchronization mass (1 2 cm diameter). The corticotomy can be created with drill holes and osteotomies or a high-speed burr. Once created, the corticotomy is deepened with curettes or a burr to create a sizeable cavity large enough to accommodate the proximal FDP tendon unit. Three drill holes are then made proximal to the corticotomy, leaving a sufcient bone bridge in between and connected to the cavity just created. Mimicking the created tenodesis effect using hemostats and temporary sutures allows for nal adjustments. Once the tendon mass is appropriately shortened for proper tension, a locking whipstitch is secured to the outer margins of the proximal synchronization mass using large-caliber nonabsorbable suture (no. 3 or 5). A more centrally placed locking suture is applied as well, leaving four free strands of suture through which the tendon mass will be anchored. The tendon unit is attached to the volar aspect of the distal radius similar to reattachment of a distal biceps tendon rupture (Fig. 3A).

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Figure 3. Passive tenodesis procedures. A, For the exor side, the exor digitorum profundus (FDP) is rst synchronized, then secured to the volar distal radial surface through a bone tunnel or defect. B, For the extensor side, a similar procedure is performed using the extensor digitorum communis (EDC / the EIP), but proximal to the extensor retinaculum. If necessary, the proximal 1/3 to 1/2 of the retinaculum can be excised to create room for the synchronized EDC mass in order to avoid adhesions under the fourth dorsal extensor compartment that could reduce the effective excursion achieved during surgery.

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The sutures are passed through the cavity and out the proximal drill holes, and the tendon mass is snugged down into the cavity and secured by tying the sutures together. Gravity-induced wrist exion extends the digits, which can be equally affected via tenodesis of the EDC. This form of tenodesis is more commonly performed when restoring palmar grasp and release when wrist exion fails to result in adequate nger extension, or when a tendon transfer powers the FDP to achieve better digital balance. As in the FDP tenodesis, the EDC is synchronized and secured proximal to the wrist joint through a corticotomy (Fig. 3B). The corticotomy should be performed proximal to the extensor retinaculum to prevent postoperative scarring within the dorsal extensor compartments. If signicant adhesions already exist with the extensor tendons within the retinaculum, the tendons can be removed from the retinaculum and tenodesis performed supercially. The proximal portion of the retinaculum can be removed to avoid adhesions between the tendons now synchronized and the fourth dorsal extensor compartment. Tension is set such that nger extension is full by about 30 to 45 degrees of exion and should be individualized to the patient. Consideration should be given to EPL/APL tenodesis. Thumb extension is part of palmar grasp release. The wrist and ngers are immobilized in a relaxed neutral position for a minimum of 3 weeks. Afterward, rehabilitation is started, consisting of tendon-gliding exercises. Passive motion is not generally used to avoid stretching the tenodesis.

TENDON TRANSFERS FOR FINGER FLEXION When activating nger exion, the typical donor muscle is the ECRL. The ECRL has sufcient excursion and power and is a synergistic transfer. Despite its availability, the BR usually used to restore key pinch through transfer into the FPL. In patients having group 4 or greater function, in whom two-stage exor and extensor reconstruction is often performed, the PT is an available donor muscle and can be used to power the FDP or, more commonly, thumb motion. For the ECRL, exposure must be extensive enough to allow mobilization of the muscle to reroute it volarly and to provide sufcient passive excursion to be an effective transfer for the FDP. One can use separate incisions to release, mobilize, and transfer the tendon volarly, or a longer utilitarian single radial incision, which is especially useful if other simultaneous procedures are performed.

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The donor muscle is released from its insertion and freed from any fascial or intermuscular connections to maximize excursion. The FDP is identied, and a reverse cascade tenodesis is performed. The donor tendon is then routed volarly around the radial aspect of the forearm suprafascially and subcutaneously, when using the ECRL, and attached to the FDP in the tenodesis zone using a standard Pulvertaft weave (the author generally passes the tendon a minimum of three times through the recipient tendon) (Fig. 4).

Figure 4. The extensor carpi radialis longus (ECRL) to exor digitorum profundus (FDP) transfer. The ECRL is mobilized and transferred radially to the exor side of the forearm and transferred into the FDP. The FDP is initially synchronized, and the ECRL is weaved into the synchronized mass, or just proximal to it. A standard Pulvertaft weave is used to attach the ECRL into the FDP.

If the PT is chosen, it is released from its long insertion on the radius along with a continuous strip of periosteum to maximize length for tendon weaving (Fig. 4). The tendon is then weaved into the FDP tendon unit after it is released and sufciently freed. Regardless of the donor motor chosen, tension is set in a similar fashion. The resting tension of the transfer is set such that the ngers are exed with the wrist in about 30 to 45 degrees of extension. Finger extension with the wrist exed must be present or provided by tenodesis to optimize digital balance and prevent late nger exion contractures. The wrist and ngers are immobilized in a relaxed neutral position for a minimum of 3 weeks. Training exercises are then begun, along with the use of a removable splint.

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TENDON TRANSFERS FOR FINGER EXTENSION Finger extension is not powered unless there are sufcient donor muscles available. The ideal patient for consideration is in group 5 or higher; group 4 patients can be considered. In this circumstance, the BR is chosen as the donor muscle; the PT and ECRL are used to power thumb pinch and nger exion using a two-stage reconstruction. Given the presence of three potentially good donor muscles, one can rely on tenodesis procedures to power nger and thumb extension, use the ECRL to power nger exion, and use the BR and PT to restore thumb mobility elegantly. Selection of the specic method must be individualized to the patients goals and desires and based on the hand function before surgery. This decision is also based on the surgeons experience. Appropriate descriptions by House and Zancolli should be reviewed, and there is no gold standard.3,7 The BR can be mobilized from the same radial, near-midaxial incision described earlier. To increase the passive excursion of the BR sufciently, which is typically about 4 cm, its long expansive tendon must be freed of its more proximal fascial and intermuscular attachments to increase its passive excursion to up to 8 cm (Fig. 5).

Figure 5. The brachioradialis must be both released and freed from its intramuscular and intrafascial attachments to create sufcient excursion to be a suitable donor motor. A, The brachioradialis is identied by the top forceps. The proximity of the median nerve is shown through the bottom forceps. B, Extensive mobilization of the brachioradialis is required to create the sufcient amount of excursion to make it a more suitable donor motor. The forceps at the top right points to the supercial sensory branch of the radial nerve that should be protected during the dissection.

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The incision should reach proximally enough to allow the surgeon to mobilize this muscle fully. Once freed, it is transferred suprafascially to a synchronized EDC/EIP proximal to the extensor retinaculum (Fig. 6).

Figure 6. Brachioradialis (BR) to extensor digitorum communis (EDC) transfer. The BR is extensively mobilized and routed subcutaneously and dorsally into the synchronized EDC. A Pulvertaft weave is used.

The EPL and APL can also be incorporated into this transfer to provide active thumb extension as opposed to a tenodesis. Tension is set such that the ngers are extended with the wrist in about 30 degrees of exion. The elbow should be exed about 70 to 90 degrees as well because the BR crosses two joints. In fact, transfer of the BR in general is more effective when the elbow is also stabilized, that is, a deltoid or biceps to triceps transfer. Immobilization is for 3 to 4 weeks. Training is then begun and is aided by stabilizing the elbow with a brace, especially if a simultaneous elbow extension transfer has been performed, and the patient is not yet able to ex the elbow for fear of overstretching the triceps transfer.

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INTRINSICS Intrinsic reconstruction should be considered in patients undergoing two-stage reconstructions because the restoration of nger exion and extension could be hampered by the lack of intrinsic balance (group 4 patients or higher). Strong candidates are patients who will have both the nger exors and extensors activated by tendon transfer. The intrinsic minus hand that can result produces an inefcient and progressively weakening curl grasp. Other situations in which intrinsic reconstruction should be considered include patients with hyperextensible MCP joints, which will weaken grasp, and proximal interphalangeal (PIP) joint extensor lags. Patients who exhibit index hyperexion with the wrist extended may have an impaired key pinch, and this effect could be reversed by intrinsic reconstruction. A nal patient in whom intrinsic reconstruction should be considered as part of grasp restoration is the rare group 8 patient who is hampered by intrinsic minus hand function. Two passive tenodesis techniques have been developed to balance the intrinsics, one proposed by Zancolli and one by House. Both techniques are effective, and the relative merits are discussed in the literature.3,7 The author favors the Zancolli method but recognizes that postoperative nger stiffness may result; therefore, in a two-stage reconstruction, the technique should be performed during the exor phase to minimize scarring.

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The lasso method described by Zancolli involves a tenodesis of the FDS to the A1 pulley, thereby mimicking intrinsic function with wrist extension. Inducing slight MCP joint exion and preventing interphalangeal hyperexion with the wrist extended improve grasp posturing. Signicant PIP lag should be treated simultaneously by a tenodesis of the central slip and by temporarily pinning the PIP joint in near extension for 2 to 3 weeks. The FDS to each nger is approached by an oblique incision extending from the distal palmar crease to the radial border of the MCP exion crease. If necessary, the incision for each digit can be extended distally in a zigzag fashion. The A1 pulley is identied but not transected, but the proximal portion of the A2 pulley can be incised for exposure. The FDS is transected proximal to the chiasm or distal to it if length is required. It is then routed out of the A1/A2 pulley interval. The transected FDS tail is then sewn to itself proximal to the A1 pulley (Fig. 7A).

Figure 7. Examples of intrinsic reconstruction. A, The Zancolli method. The exor digitorum sublimus (FDS) is transected between the A1 and A2 pulley, routed over the A1 pulley, and sutured to itself. B, The House method. A graft of palmaris longus is woven into each of the radial lateral bands and central slips of the index and long nger, and under the extensor communis of the index nger.

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The alternative method described by House involves tenodesis of the index and long nger alone. A palmaris longus tendon graft is woven into the radial lateral band/central slip of the index nger and then passed deep through the lumbrical canal of the index nger, under the index extensor mechanism ulnarly, and deep through the lumbrical canal of the long nger, and woven into the radial lateral band/central slip of the long nger (Fig. 7B). This weave now links MCP motion to PIP motion. MCP joint hyperextension is prevented because, when the nger exes with the wrist extended, PIP exion results in MCP exion. Finger extension is also enhanced as both joints extend with EDC tenodesis or activation. Balanced nger exion occurs as PIP exion initiated through an active FDP transfer results in MCP exion, thereby preventing excessive curling. House recommends that this transfer be performed during the extensor phase of a two-stage reconstruction.3

SURGICAL ALTERNATIVES Almost no standards exist in approaching restoration in patients with traumatic tetraplegia. Although several studies demonstrate the improvements in function and strength following surgery, few compare one method with another. Most recommendations are based on sound knowledge of pathophysiology, anatomy, biomechanics, and accrued experience. With regard to tenodesis, any one of a number of techniques for anchoring the tendon to bone is likely to be effective. Many surgeons advocate that the tendons be anchored using a horseshoe corticotomy. In addition, and depending on the patients hand, one can choose to perform exor tenodesis using the FDS. The author prefers a fairly standard, albeit technically involved method. Another important alternative to strengthen exor tenodesis can be performed in group 2 patients with a voluntary but weak ECRB. Because the ECRB is not a useful wrist extender in this particular circumstance but retains some function and strength, it can be transferred through the interosseous membrane to the FDP to create a strong FDP tenodesis. This is useful in a patient who might otherwise be limited to a thumb key pinch restoration, and the presence of a weak but voluntary ECRB should be determined. Options exist with regard to the choice of donor muscle for transfer and, perhaps, the priorities for which functions are restored rst. The author gives priority to lateral pinch and release and prioritizes activating nger exion when restoring palmar grasp and release. Depending on the patient, these priorities may be changed, and individualizing treatment to the patients goals and needs is one of the important concepts in treating tetraplegic patients. For group 4 or higher patients undergoing two-stage reconstruction, various alternative schemes have been presented based on the choice of thumb (lateral pinch) restoration. When activating nger exion, the ECRL can be transferred into the FDP of the index and long ngers and the FDS of the little and ring ngers because, occasionally, there is excess curling of the ulnar ngers. In such a circumstance, tendon synchronization would match the FDP of the index and long ngers with the FDS of the ring and little ngers. The FDS can be chosen as the exor activated in restoring nger exion, but one loses the hooking effect on an object achieved by distal interphalangeal exion. With intrinsic reconstruction, especially in the presence of a concurrent PIP lag, the Stiles-Bunnell technique is a useful alternative. In this procedure, the FDS distal to the chiasm is transected, and the slips are woven into the radial lateral band to address intrinsic dysfunction by creating simultaneous MCP exion and PIP extension moments.

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SUMMARY Restoration of hand function in the setting of traumatic tetraplegia is challenging but extremely rewarding for the patient. Previous outcomes research has demonstrated signicant gains in function, use, and subjective improvement following such surgery. The key lies in proper patient selection, understanding what goals are reasonable and achievable, and individualizing the surgical plan to t the patient.

References
1. Gonzalez E, Keith MW: Surgical management of the upper limb in tetraplegia. In Lee, Ostrander (eds): The Spinal Cord Injured Patient. Demos Medical Publishing, New York 2. Haque MA, Keith MW, Bednar M, et al: Clinical results of ECRB to FDP transfer through the interosseous membrane to restore nger exion, in Press 3. House JH, Shannon MA: Restoration of strong grasp and lateral pinch in tetraplegia: A comparison of two methods of thumb control in each patient. J Hand Surg 10A:21 29, 1985 4. Keith MW, Lacey SH: Surgical rehabilitation of the tetraplegic upper extremity. Journal of Neurology and Rehabilitation 5:75 87, 1991 5. McCarthy CK, House JH, Van Heest A, et al: Intrinsic balancing in reconstruction of the tetraplegic hand. J Hand Surg 22A:596 604, 1997 6. Peljovich AE, Kucera K, Gonzalez E, et al: Rehabilitation of the hand and upper extremity in tetraplegia. In Mackin EJ, Callahan AD, Skirven T, et al (eds): Hunter, Mackin, Callaghan Rehabilitation of the Hand and Upper Extremity, ed 5. St. Louis, Mosby, 2002 7. Zancolli EA: Functional restoration of the upper limb in traumatic quadriplex. In Structural and Dynamic Basis of Hand Surgery, ed 2. Philadelphia, JB Lippincott, 1979, pp 229 262

Address reprint requests to Allan Peljovich, MD, MPH The Hand Treatment Center, PC Suite 1020 980 Johnson Ferry Road Atlanta, GA 30342 e-mail: apeljovich@mindspring.com

TENDON TRANSFERS

1082 3131/02 $15.00 + .00

Tendon Transfers for Restoration of Active Grasp


Allan E. Peljovich, MD, MPH

Traumatic tetraplegia represents about one-half of all spinal cord injuries, and the C5 and C6 levels are the most commonly injured. As such, the common cervical level spinal injury leaves patients with some shoulder and elbow function and perhaps minimal wrist function. This pattern translates into a weak tenodesis grasp and release in C6 level patients but no effective grasp ability in C5 patients. Lower cervical injury in which patients retain some hand function is uncommon, as is high-level injury that leaves patients ventilator dependent. Among the most disabling aspects of traumatic tetraplegia is the loss of hand and upper extremity function. Previous study has demonstrated that restoration of hand and upper extremity function is rated above bowel/bladder control, sexual function, and ambulation among patients and caregivers alike. Surgery to restore hand function can thus have a signicant impact on the quality of life of tetraplegic patients. Most activities of daily living are performed through two fundamental grasp patterns: (1) lateral thumb pinch and release (key pinch) and (2) palmar grasp and release. The author typically prioritizes key pinch and restores palmar grasp and release when sufcient donor muscles exist. Enhancing the natural wrist tenodesis effect through orthotics or passive tenodesis procedures or through voluntary tendon transfers is the means by which function is restored. A novel method to restore palmar grasp and release not discussed herein is through neuroprosthetic implantation (NeuroControl Freehand; NeuroControl Corp., Valley View, OH), typically reserved for American Spinal Injury Association (ASIA) C5 and C6 patients, or International Classication of Surgery of the Hand in Tetraplegia (ICSHT) groups 0 to 2. Grasp and release restoration must be viewed from the larger perspective of upper extremity restoration. Not all tetraplegic patients are good candidates for surgical intervention. Among the criteria listed below perhaps the most important is that the patients desires and goals from surgery are realistic.

From the Shepherd Center; The Hand Treatment Center, PC; the Department of Orthopaedic Surgery, Atlanta Medical Center; and Emory University, Atlanta, Georgia

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Patient Criteria for Surgical Consideration in Tetraplegic Hand Restoration Indications Neurologic stability (at least 10 12 months from injury) Motivation and desire Realistic goals Good cognition Good general health Wheelchair/trunk stability Supple/pain-free upper extremity (consider other injuries sustained during trauma) Minimal to no problem with recurrent pressure sores Good support systems (family, friends, attendants) Suitable physical examination for tendon transfer or neuroprosthetic Minimal to no problems with upper extremity spasticity Contraindications Unrealistic expectations Uncontrollable upper extremity spasticity Upper extremity pain Signicant upper extremity or hand contractures or both In addition, the ability to grab and manipulate an object is enhanced by the ability to be able to reach out with ones arm; therefore, restoration of palmar grasp and release is most efcacious when other functions are present or provided, namely, key pinch, supple pronosupination, and elbow extension. Often, multiple procedures are combined in a single or a staged series of operations to minimize the disabling downtime tetraplegic patients face after surgery.

INTERNATIONAL CLASSIFICATION In 1984 at the First International Conference on Surgical Rehabilitation of the Upper Limb in Tetraplegia held in Edinburgh, a classication system was devised by a group of experienced surgeons, which has since been modied for the tetraplegic hand. The system categorizes patients by the most distally innervated voluntary muscle with grade 4 British Medical Research Council (BMRC) strength or greater (Table 1).
Table 1. THE INTERNATIONAL CLASSIFICATION FOR SURGERY OF THE HAND IN TETRAPLEGIA Group 0 1 2 3 4 5 6 7 8 9 X Motor None Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis Pronator teres Flexor carpi radialis Extrinsic nger extensors Extrinsic thumb extensors Radial extrinsic digital exors Complete digital exion (thumb included) Incomplete/exceptions Function Elbow exion and supination Elbow exion and supination, pronation with neutral forearm position Wrist extension Strong wrist extension Active forearm pronation Wrist exion Partial or complete digital extension Thumb extension Partial digital exion Intrinsic minus hand Unpredictable

BMRC British Medical Research Council; ECRB extensor carpi radialis brevis. Note: System only applies to muscles of the forearm and hand. Upper extremity function is not included but becomes increasingly functional as the group level increases. Sensibility is based on the presence of thumb/index two-point discrimination of 10 mm. If present, the classication has the prex Cu (cutaneous), such as Cu 4. If two-point discrimination is greater than 10 mm, the classication has the prex O (ocular), such as O 1. Motor is based on the presence of at least grade 4 BMRC strength. Weaker voluntary function may be present, such as a weak ECRB in a group 2 patient.

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Unlike in the ASIA system, its utility is that the groupings provide information concerning which specic muscles are voluntary and sufciently strong, thereby giving the treating physician concise information regarding surgical options for the patient. For example, a group 3 patient has a voluntary strong brachioradialis (BR), extensor carpi radialis longus (ECRL), and extensor carpi radialis brevis (ECRB). This observation suggests that group 3 patients have three potential donor muscles for transfer. On the other hand, an ASIA C6 patient who also has voluntary wrist extension may or may not have a strong and voluntary ECRB. The International Classication is more useful when describing hand function and is used throughout this article. SURGICAL PRINCIPLES Successful restoration of palmar grasp and release involves addressing four phases: (1) object acquisition, (2) grasp, (3) hold/manipulation, and (4) object release. Each phase must be attended to for the best results as follows: 1. Object acquisition: The patient must be able to acquire the object he or she desires to manipulate. This ability involves coordinated upper extremity motion, such as elbow extension and forearm rotation, for wrist positioning in space in addition to digital extension to reach around an object. 2. Grasp: In the second phase, the hand must grasp the object through digital exion. The mass of the object the patient can grasp is proportionate to the strength of digital exion and wrist stability, whereas the size of the object is proportionate to digital extension. Another factor in the size of the object is the type of exion that a patient achieves. A curl or hook grasp, in which there is hyperexion of the interphalangeal joints with relative extension of the metacarpophalangeal (MCP) joint, would be effective for small objects and power. On the other hand, a balanced grasp with exion of all of the phalangeal joints allows grasp of a larger object, such as a book or cup. The latter grasp pattern is more versatile for activities of daily living, whereas the former is fairly inefcient. 3. Hold and manipulate: The patient must then be able to hold and manipulate the object. This ability is correlated with endurance of digital exion strength and upper extremity coordination. 4. Object release: The patient must be able to release the object to its desired location effectively. The ngers and thumb must extend in a coordinated fashion. The muscle functions addressed in reconstruction of palmar grasp and release include the exor digitorum profundus (FDP), extensor digitorum communis (EDC), extensor pollicis longus (EPL), abductor pollicis longus (APL), exor pollicis longus (FPL), and, occasionally, the exor digitorum supercialis (FDS) and intrinsic hand muscles. For the sake of economy in these patients, the FDP is prioritized for digital exion because its action results in exion of all of the interphalangeal joints as opposed to the FDS. When muscles are available as donors to be transferred to power grasp, the author usually prioritizes FDP activation as opposed to EDC activation to provide strength for grasp and hold/manipulation phases, expecting tenodesis nger extension that is passively associated with gravity-produced wrist exion to provide sufcient acquisition and release phases. If the FPL is activated as well, which is often true if a motor is available to power the FDP because key pinch restoration is prioritized, grasp is even stronger. Tendon transfers to activate digital extension are performed when there are sufcient donor muscles available, that is, the patient is in group 4 or higher, and EDC, EPL, and APL activation can be achieved with a single donor motor.

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General principles of tendon transfer are often extended in this population of patients. Regardless of the technique or procedure, ideal patients have supple joints, are motivated, are healthy, and have sufcient cognition to understand, and cooperate in their postoperative therapy. Transferring strong muscles that are under voluntary control is the norm; however, occasionally, muscles with grade 3 strength are used, that is, transfer of the ECRB to FDP through interosseous membrane in group 2 patients. Donor muscles must have sufcient amplitude of motion, especially considering that the excursion for the FDP is approximately 7 cm. Of course, the function of the donor muscle must be expendable; and the BR, one of the two radial wrist extensors (ECRL preferred over the ECRB) and pronator teres (PT) meet this criterion best. The author preserves the exor carpi radialis when present (group 5) because, usually, sufcient donor muscles are available to restore meaningful function, and voluntary wrist exion generally produces better tenodesis digital extension than gravity alone. Use of the ECRB is limited to the previous example; otherwise, the ECRL is the prime wrist extensor used for transfer if the ECRB is under voluntary control and is of sufcient strength. Sensation is not critical because the goal is restoration of fundamental grasp patterns that can be controlled visually. If touch, stereognosis, and proprioception were criteria for surgery, almost no tetraplegic patients would qualify for surgery, and this requirement belies experience with the success of surgery. Synergism as achieved with an ECRL to FDP transfer is ideal but not required.

RESTORATIVE LADDER The foundation for palmar grasp and release restoration lies in the presence or provision of wrist extension, which powers the passive tenodesis coupling of wrist extension/digital exion and gravity-produced wrist exion/digital extension. Once adequate and voluntary wrist extension is present, a tenodesis grasp and release can be enhanced as necessary through therapy, orthotics, or surgery. Some patients are satised with tenodesis grasp alone. Most patients desire to become brace free and to have a stronger grasp and key pinch. Restorative or reconstructive surgery is then based on transferring and tightening tendons along with judicious use of joint stabilization, whether through capsulodesis or arthrodesis. Patients with group 0 function do not have wrist motion or a suitable donor muscle for transfer into the hand and wrist. As such, restoration of hand function is achievable only through neuroprosthetic implantation, which is primarily used for patients in groups 0 to 3. In group 1 patients, the BR is available for transfer into the ECRB, thereby providing wrist extension. Palmar grasp and release is then enhanced as necessary with orthotics or tendon tenodesis, if necessary. Key pinch restoration alone is more commonly performed in this group. In group 2 patients, the ECRL is sufciently strong. Key pinch is still prioritized and powered with transfer of the BR to FPL, in addition to other thumb-stabilizing procedures. Palmar grasp and release is enhanced as necessary with tenodesis procedures, or can be prioritized over key pinch and restored with a BR to FDP transfer. Some group 2 patients retain a present but weak ECRB (BMRC 3 strength). This weak ECRB can be passed through the interosseous membrane to act as a strong tenodesis transfer without sacricing critical wrist extension. In group 3 patients, palmar grasp and release can be restored without sacricing key pinch and is activated by transferring the ECRL into the FDP; EDC tenodesis is used to balance the nger. Two-stage exor/extensor reconstructions are often performed in patients who function at a group 3 level or higher but are more commonly used in patients who are at least group 4. In group 4 and 5 patients, options depend on the choice of thumb reconstruction, and available donor motors to power the FDP include the PT and ECRL. At this level, the BR is potentially available to power nger/thumb extension, again depending on the choice of thumb/key pinch reconstruction. In group 6 patients,

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some digital extension is present, and the EPL alone is activated in addition to nger exion. In group 7 patients, only exion activation is required. In group 8 patients, there may be good exion of the radial digits. In this circumstance, the ECRL can be used to power some or all of the FDS. In patients at group 4 level or higher, and in some patients of higher-level cervical tetraplegia, consideration of intrinsic balance is included in the surgical plan.

Two-Stage Flexion and Extension Reconstruction Patients who can undergo restoration of active exion as well as lateral pinch should be considered for two-stage reconstructions (group 3 or greater) (Table 2) because joint balancing enhances digital restoration. Unopposed or unbalanced function can result in inefcient function, long-term contractures, and failure of transfers, such as nger exion contractures following isolated activation of the FDP. Either active transfer or, more commonly, tenodesis of the antagonist achieves balance. In this fashion, EDC/EIP tenodesis or activation balances function gained through FDP activation. At the same time, intrinsic reconstruction also achieves digital balance. The problem is that the rehabilitation for exion restoration is contradictory and endangers the rehabilitation for extension restoration; therefore, restoration is performed in two stages, one for exion and a second for extension. The higher the group level, the more functional the hand. The details of such procedural algorithms are found in texts written by House and Zancolli and are outlined in Table 2.3,7
Table 2. EXAMPLES OF TWO-STAGE FLEXION AND EXTENSION RECONSTRUCTIONS Zancolli Method (2 6 months between stages) 1. Extensor reconstruction a. EDC/EPL/APL tenodesis versus BR to EDC/EPL transfer b. Thumb CMC arthrodesis c. Zancolli lasso 2. Flexor reconstruction a. BR to FDP transfer versus ECRL to FDP and ECRB/ FPL synchronization b. BR to FPL versus FPL tenodesis c. PT to FCR for group 4 House Method (2 6 months between stages) For groups 4 5 1. Flexor reconstruction a. ECRL to FDP transfer b. PT to FPL transfer c. BR to adductor pollicis/opponens transfer (via FDS graft) 2. Extensor reconstruction a. EDC synchronization and tenodesis b. EPL/APL tenodesis c. Free graft intrinsic index/long tenodesis For group 6 1. Flexor reconstruction a. ECRL to FDP transfer b. BR or PT to FPL transfer c. Zancolli lasso 2. Extensor reconstruction a. Thumb CMC arthrodesis b. EDC and EPL tenodeses versus BR to EDC/EPL

BR brachioradialis; ECRL extensor carpi radialis longus; EDC extensor digitorum communis; ECRB extensor carpi radialis brevis; EPL extensor pollicis longus; APL abductor pollicis longus; CMC carpo metacarpal; FDP flexor digitorum profundus; FPL flexor pollicis longus; PT pronator teres; FCR flexor carpi radialis; FDS flexor digitorum supercialis.

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TENDON SYNCHRONIZATION Tendon synchronization is a useful technique whereby all of the FDP or EDC/EIP tendons, respectively, are sutured to each other to create efciency and economy. It is impossible to activate exor or extensor function individually for each digit independently in the setting of traumatic tetraplegia. In this technique, either the FDP or EDC is transformed into a single tendon unit. In both procedures, the natural cascade of the ngers is ignored, and the synchronization is set such that all the ngers ex and extend level to each other (Fig. 1).

Figure 1. Synchronization of the exor digitorum profundus (FDP) and the extensor digitorum communis converts four independent tendons into one mass that allows for efcient control of nger motion. Synchronization is performed by tying the tendons in a side to side fashion using at least three horizontal mattress sutures. At least three sutures are required to control relative translation between the tendons themselves. Note that the ngers are synchronized in a straight, equal fashion, rather than in the natural cascade. This reverse cascade improves grasp and release ability. The proximal muscle would be transected if a tenodesis procedure were being performed as well.

At least three interrupted nonabsorbable sutures are used to tie the tendons to each other to create translational control of the mass. This suturing is carried out proximal to the retinaculum on the extensor surface, such that the sutures do not enter the extensor compartments. With this reverse cascade, force is applied through all of the ngers equally and with equal motion, thereby maximizing the size of an object that can be grasped or manipulated. Synchronization is routinely performed when individual nger motion is not already present, that is, at less than group 6 function. A minimum of 3 weeks of immobilization is required before sufcient healing occurs to allow therapy.

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TENODESIS TECHNIQUE Tenodesis refers to tightening tendons to phases of motion, in this case, tightening the extrinsic nger muscles in sync with wrist motion to strengthen or enhance a function that occurs naturally. Finger exion can be enhanced with wrist extension by tightening the FDP. Finger extension can be enhanced with gravity-induced wrist exion by tightening the EDC/EIP. Tenodesis procedures are used when donor muscles are absent, and the natural tenodesis effect achieved through the wrist is inadequate. Another circumstance in which tenodesis commonly is applied is when joint balancing is necessary. For example, it is desirous to perform tenodesis of the EDC when activating the FDP to prevent late exion deformities. The problem with tenodesis is that it is generally weak and can stretch with time. For exor tenodesis, exposure of the FDP is achieved depending on other simultaneously performed procedures. This maneuver can be performed through a radial approach (approach of Henry), or a more radial, near-midaxial approach (Fig. 2).

Figure 2. The surgical approaches for most reconstructive procedures for palmar grasp and release vary from volar and dorsal combinations to single utilitarian approaches. This view demonstrates two alternative utilitarian exposures. One single straight incision can be created just volar to the midaxial line of the forearm (near-midaxial). Alternatively, a single lazy-S incision can be created in a similar location. Mobilization of full-thickness soft tissue aps and rotation of the forearm provide excellent access to the three forearm compartments during tetraplegia reconstruction.

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Any of these latter approaches are fairly utilitarian because they provide exposure for other simultaneous procedures, such as key pinch restoration. If EDC/EIP tenodesis or any other extensor-sided procedure is desired, whether at the same setting or in a staged fashion, a lazy-S shaped or straight radial, near-midaxial incision is ideal because access to extensors and exors is provided through a single approach; otherwise, a separate dorsal approach may be required. Ulnar-sided forearm exposures are not useful because the access to muscles and tendons that will be manipulated is more limited. FDP synchronization in a reverse cascade is performed, and the tendons are transected at the musculotendinous junction. The length of tendon required for proper tension is estimated because the tendon unit will be anchored to bone via a corticotomy. Wrist extension will pull on the FDP, tensioning the ngers into exion. The surgeon must choose the appropriate tension based on factors such as the patients wrist extension strength and motion and passive digital motion. A simple guideline is to adjust tension such that the ngers are maximally exed at about 30 to 45 degrees of extension. In this manner, further wrist extension produces more tension than excursion, adding strength of grasp. Because the corticotomy is a xed distance from the radiocarpal joint, shortening the tendon mass by trimming the proximal edge sharply sets tension. This tension is estimated and completed before securing the tenodesis. The corticotomy performed about the diaphyseal/metaphyseal junction must be large enough to accommodate the synchronization mass (1 2 cm diameter). The corticotomy can be created with drill holes and osteotomies or a high-speed burr. Once created, the corticotomy is deepened with curettes or a burr to create a sizeable cavity large enough to accommodate the proximal FDP tendon unit. Three drill holes are then made proximal to the corticotomy, leaving a sufcient bone bridge in between and connected to the cavity just created. Mimicking the created tenodesis effect using hemostats and temporary sutures allows for nal adjustments. Once the tendon mass is appropriately shortened for proper tension, a locking whipstitch is secured to the outer margins of the proximal synchronization mass using large-caliber nonabsorbable suture (no. 3 or 5). A more centrally placed locking suture is applied as well, leaving four free strands of suture through which the tendon mass will be anchored. The tendon unit is attached to the volar aspect of the distal radius similar to reattachment of a distal biceps tendon rupture (Fig. 3A).

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Figure 3. Passive tenodesis procedures. A, For the exor side, the exor digitorum profundus (FDP) is rst synchronized, then secured to the volar distal radial surface through a bone tunnel or defect. B, For the extensor side, a similar procedure is performed using the extensor digitorum communis (EDC / the EIP), but proximal to the extensor retinaculum. If necessary, the proximal 1/3 to 1/2 of the retinaculum can be excised to create room for the synchronized EDC mass in order to avoid adhesions under the fourth dorsal extensor compartment that could reduce the effective excursion achieved during surgery.

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The sutures are passed through the cavity and out the proximal drill holes, and the tendon mass is snugged down into the cavity and secured by tying the sutures together. Gravity-induced wrist exion extends the digits, which can be equally affected via tenodesis of the EDC. This form of tenodesis is more commonly performed when restoring palmar grasp and release when wrist exion fails to result in adequate nger extension, or when a tendon transfer powers the FDP to achieve better digital balance. As in the FDP tenodesis, the EDC is synchronized and secured proximal to the wrist joint through a corticotomy (Fig. 3B). The corticotomy should be performed proximal to the extensor retinaculum to prevent postoperative scarring within the dorsal extensor compartments. If signicant adhesions already exist with the extensor tendons within the retinaculum, the tendons can be removed from the retinaculum and tenodesis performed supercially. The proximal portion of the retinaculum can be removed to avoid adhesions between the tendons now synchronized and the fourth dorsal extensor compartment. Tension is set such that nger extension is full by about 30 to 45 degrees of exion and should be individualized to the patient. Consideration should be given to EPL/APL tenodesis. Thumb extension is part of palmar grasp release. The wrist and ngers are immobilized in a relaxed neutral position for a minimum of 3 weeks. Afterward, rehabilitation is started, consisting of tendon-gliding exercises. Passive motion is not generally used to avoid stretching the tenodesis.

TENDON TRANSFERS FOR FINGER FLEXION When activating nger exion, the typical donor muscle is the ECRL. The ECRL has sufcient excursion and power and is a synergistic transfer. Despite its availability, the BR usually used to restore key pinch through transfer into the FPL. In patients having group 4 or greater function, in whom two-stage exor and extensor reconstruction is often performed, the PT is an available donor muscle and can be used to power the FDP or, more commonly, thumb motion. For the ECRL, exposure must be extensive enough to allow mobilization of the muscle to reroute it volarly and to provide sufcient passive excursion to be an effective transfer for the FDP. One can use separate incisions to release, mobilize, and transfer the tendon volarly, or a longer utilitarian single radial incision, which is especially useful if other simultaneous procedures are performed.

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The donor muscle is released from its insertion and freed from any fascial or intermuscular connections to maximize excursion. The FDP is identied, and a reverse cascade tenodesis is performed. The donor tendon is then routed volarly around the radial aspect of the forearm suprafascially and subcutaneously, when using the ECRL, and attached to the FDP in the tenodesis zone using a standard Pulvertaft weave (the author generally passes the tendon a minimum of three times through the recipient tendon) (Fig. 4).

Figure 4. The extensor carpi radialis longus (ECRL) to exor digitorum profundus (FDP) transfer. The ECRL is mobilized and transferred radially to the exor side of the forearm and transferred into the FDP. The FDP is initially synchronized, and the ECRL is weaved into the synchronized mass, or just proximal to it. A standard Pulvertaft weave is used to attach the ECRL into the FDP.

If the PT is chosen, it is released from its long insertion on the radius along with a continuous strip of periosteum to maximize length for tendon weaving (Fig. 4). The tendon is then weaved into the FDP tendon unit after it is released and sufciently freed. Regardless of the donor motor chosen, tension is set in a similar fashion. The resting tension of the transfer is set such that the ngers are exed with the wrist in about 30 to 45 degrees of extension. Finger extension with the wrist exed must be present or provided by tenodesis to optimize digital balance and prevent late nger exion contractures. The wrist and ngers are immobilized in a relaxed neutral position for a minimum of 3 weeks. Training exercises are then begun, along with the use of a removable splint.

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TENDON TRANSFERS FOR FINGER EXTENSION Finger extension is not powered unless there are sufcient donor muscles available. The ideal patient for consideration is in group 5 or higher; group 4 patients can be considered. In this circumstance, the BR is chosen as the donor muscle; the PT and ECRL are used to power thumb pinch and nger exion using a two-stage reconstruction. Given the presence of three potentially good donor muscles, one can rely on tenodesis procedures to power nger and thumb extension, use the ECRL to power nger exion, and use the BR and PT to restore thumb mobility elegantly. Selection of the specic method must be individualized to the patients goals and desires and based on the hand function before surgery. This decision is also based on the surgeons experience. Appropriate descriptions by House and Zancolli should be reviewed, and there is no gold standard.3,7 The BR can be mobilized from the same radial, near-midaxial incision described earlier. To increase the passive excursion of the BR sufciently, which is typically about 4 cm, its long expansive tendon must be freed of its more proximal fascial and intermuscular attachments to increase its passive excursion to up to 8 cm (Fig. 5).

Figure 5. The brachioradialis must be both released and freed from its intramuscular and intrafascial attachments to create sufcient excursion to be a suitable donor motor. A, The brachioradialis is identied by the top forceps. The proximity of the median nerve is shown through the bottom forceps. B, Extensive mobilization of the brachioradialis is required to create the sufcient amount of excursion to make it a more suitable donor motor. The forceps at the top right points to the supercial sensory branch of the radial nerve that should be protected during the dissection.

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The incision should reach proximally enough to allow the surgeon to mobilize this muscle fully. Once freed, it is transferred suprafascially to a synchronized EDC/EIP proximal to the extensor retinaculum (Fig. 6).

Figure 6. Brachioradialis (BR) to extensor digitorum communis (EDC) transfer. The BR is extensively mobilized and routed subcutaneously and dorsally into the synchronized EDC. A Pulvertaft weave is used.

The EPL and APL can also be incorporated into this transfer to provide active thumb extension as opposed to a tenodesis. Tension is set such that the ngers are extended with the wrist in about 30 degrees of exion. The elbow should be exed about 70 to 90 degrees as well because the BR crosses two joints. In fact, transfer of the BR in general is more effective when the elbow is also stabilized, that is, a deltoid or biceps to triceps transfer. Immobilization is for 3 to 4 weeks. Training is then begun and is aided by stabilizing the elbow with a brace, especially if a simultaneous elbow extension transfer has been performed, and the patient is not yet able to ex the elbow for fear of overstretching the triceps transfer.

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INTRINSICS Intrinsic reconstruction should be considered in patients undergoing two-stage reconstructions because the restoration of nger exion and extension could be hampered by the lack of intrinsic balance (group 4 patients or higher). Strong candidates are patients who will have both the nger exors and extensors activated by tendon transfer. The intrinsic minus hand that can result produces an inefcient and progressively weakening curl grasp. Other situations in which intrinsic reconstruction should be considered include patients with hyperextensible MCP joints, which will weaken grasp, and proximal interphalangeal (PIP) joint extensor lags. Patients who exhibit index hyperexion with the wrist extended may have an impaired key pinch, and this effect could be reversed by intrinsic reconstruction. A nal patient in whom intrinsic reconstruction should be considered as part of grasp restoration is the rare group 8 patient who is hampered by intrinsic minus hand function. Two passive tenodesis techniques have been developed to balance the intrinsics, one proposed by Zancolli and one by House. Both techniques are effective, and the relative merits are discussed in the literature.3,7 The author favors the Zancolli method but recognizes that postoperative nger stiffness may result; therefore, in a two-stage reconstruction, the technique should be performed during the exor phase to minimize scarring.

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The lasso method described by Zancolli involves a tenodesis of the FDS to the A1 pulley, thereby mimicking intrinsic function with wrist extension. Inducing slight MCP joint exion and preventing interphalangeal hyperexion with the wrist extended improve grasp posturing. Signicant PIP lag should be treated simultaneously by a tenodesis of the central slip and by temporarily pinning the PIP joint in near extension for 2 to 3 weeks. The FDS to each nger is approached by an oblique incision extending from the distal palmar crease to the radial border of the MCP exion crease. If necessary, the incision for each digit can be extended distally in a zigzag fashion. The A1 pulley is identied but not transected, but the proximal portion of the A2 pulley can be incised for exposure. The FDS is transected proximal to the chiasm or distal to it if length is required. It is then routed out of the A1/A2 pulley interval. The transected FDS tail is then sewn to itself proximal to the A1 pulley (Fig. 7A).

Figure 7. Examples of intrinsic reconstruction. A, The Zancolli method. The exor digitorum sublimus (FDS) is transected between the A1 and A2 pulley, routed over the A1 pulley, and sutured to itself. B, The House method. A graft of palmaris longus is woven into each of the radial lateral bands and central slips of the index and long nger, and under the extensor communis of the index nger.

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The alternative method described by House involves tenodesis of the index and long nger alone. A palmaris longus tendon graft is woven into the radial lateral band/central slip of the index nger and then passed deep through the lumbrical canal of the index nger, under the index extensor mechanism ulnarly, and deep through the lumbrical canal of the long nger, and woven into the radial lateral band/central slip of the long nger (Fig. 7B). This weave now links MCP motion to PIP motion. MCP joint hyperextension is prevented because, when the nger exes with the wrist extended, PIP exion results in MCP exion. Finger extension is also enhanced as both joints extend with EDC tenodesis or activation. Balanced nger exion occurs as PIP exion initiated through an active FDP transfer results in MCP exion, thereby preventing excessive curling. House recommends that this transfer be performed during the extensor phase of a two-stage reconstruction.3

SURGICAL ALTERNATIVES Almost no standards exist in approaching restoration in patients with traumatic tetraplegia. Although several studies demonstrate the improvements in function and strength following surgery, few compare one method with another. Most recommendations are based on sound knowledge of pathophysiology, anatomy, biomechanics, and accrued experience. With regard to tenodesis, any one of a number of techniques for anchoring the tendon to bone is likely to be effective. Many surgeons advocate that the tendons be anchored using a horseshoe corticotomy. In addition, and depending on the patients hand, one can choose to perform exor tenodesis using the FDS. The author prefers a fairly standard, albeit technically involved method. Another important alternative to strengthen exor tenodesis can be performed in group 2 patients with a voluntary but weak ECRB. Because the ECRB is not a useful wrist extender in this particular circumstance but retains some function and strength, it can be transferred through the interosseous membrane to the FDP to create a strong FDP tenodesis. This is useful in a patient who might otherwise be limited to a thumb key pinch restoration, and the presence of a weak but voluntary ECRB should be determined. Options exist with regard to the choice of donor muscle for transfer and, perhaps, the priorities for which functions are restored rst. The author gives priority to lateral pinch and release and prioritizes activating nger exion when restoring palmar grasp and release. Depending on the patient, these priorities may be changed, and individualizing treatment to the patients goals and needs is one of the important concepts in treating tetraplegic patients. For group 4 or higher patients undergoing two-stage reconstruction, various alternative schemes have been presented based on the choice of thumb (lateral pinch) restoration. When activating nger exion, the ECRL can be transferred into the FDP of the index and long ngers and the FDS of the little and ring ngers because, occasionally, there is excess curling of the ulnar ngers. In such a circumstance, tendon synchronization would match the FDP of the index and long ngers with the FDS of the ring and little ngers. The FDS can be chosen as the exor activated in restoring nger exion, but one loses the hooking effect on an object achieved by distal interphalangeal exion. With intrinsic reconstruction, especially in the presence of a concurrent PIP lag, the Stiles-Bunnell technique is a useful alternative. In this procedure, the FDS distal to the chiasm is transected, and the slips are woven into the radial lateral band to address intrinsic dysfunction by creating simultaneous MCP exion and PIP extension moments.

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SUMMARY Restoration of hand function in the setting of traumatic tetraplegia is challenging but extremely rewarding for the patient. Previous outcomes research has demonstrated signicant gains in function, use, and subjective improvement following such surgery. The key lies in proper patient selection, understanding what goals are reasonable and achievable, and individualizing the surgical plan to t the patient.

References
1. Gonzalez E, Keith MW: Surgical management of the upper limb in tetraplegia. In Lee, Ostrander (eds): The Spinal Cord Injured Patient. Demos Medical Publishing, New York 2. Haque MA, Keith MW, Bednar M, et al: Clinical results of ECRB to FDP transfer through the interosseous membrane to restore nger exion, in Press 3. House JH, Shannon MA: Restoration of strong grasp and lateral pinch in tetraplegia: A comparison of two methods of thumb control in each patient. J Hand Surg 10A:21 29, 1985 4. Keith MW, Lacey SH: Surgical rehabilitation of the tetraplegic upper extremity. Journal of Neurology and Rehabilitation 5:75 87, 1991 5. McCarthy CK, House JH, Van Heest A, et al: Intrinsic balancing in reconstruction of the tetraplegic hand. J Hand Surg 22A:596 604, 1997 6. Peljovich AE, Kucera K, Gonzalez E, et al: Rehabilitation of the hand and upper extremity in tetraplegia. In Mackin EJ, Callahan AD, Skirven T, et al (eds): Hunter, Mackin, Callaghan Rehabilitation of the Hand and Upper Extremity, ed 5. St. Louis, Mosby, 2002 7. Zancolli EA: Functional restoration of the upper limb in traumatic quadriplex. In Structural and Dynamic Basis of Hand Surgery, ed 2. Philadelphia, JB Lippincott, 1979, pp 229 262

Address reprint requests to Allan Peljovich, MD, MPH The Hand Treatment Center, PC Suite 1020 980 Johnson Ferry Road Atlanta, GA 30342 e-mail: apeljovich@mindspring.com

TENDON TRANSFERS

1082 3131/02 $15.00 + .00

Elbow Extension Tendon Transfer


Ann E. Van Heest, MD

Elbow extension transfers provide signicant improvement in upper extremity function for patients disabled by spinal cord injury. Active elbow extension assists the patient in reaching objects above shoulder levels and while lying down, improves the ability to drive safely, aids in wheelchair propulsion, permits pressure relief, and facilitates independent transfer.1,6,25,26 Additionally, active elbow extension provides an antagonist to elbow exion, which allows improved function after hand reconstruction that uses the brachioradialis as a tendon transfer.2 Surgical reconstruction of the upper extremity in tetraplegia involves two priorities: (1) to establish elbow extension and (2) to establish grasp, pinch, and release. The level of spinal cord injury dictates the muscle deciencies present and the muscle donors available. A historical review reveals that surgical reconstruction for the upper extremity is relatively new for patients with spinal cord injury. Before the 1960s, the poor survival and poor prognosis after spinal cord injury precluded the need for upper extremity reconstruction. By the 1970s, the surgical management of upper extremity paralysis due to spinal cord injury using tendon transfers became more claried, including its indications and goals and its differences from tendon transfers for other paralytic events, such as cerebral palsy, peripheral nerve injuries, or polio. In the twenty-rst century, patients and physicians have become enthusiastic about the benets that can be achieved through a well-designed and well-executed surgical reconstructive plan. In a survey of adult men with spinal cord injury, most would have chosen to restore hand function before bowel, bladder, sexual function, or walking ability.10

From the Department of Orthopedic Surgery, University of Minnesota; Twin Cities Shriners Hospital; and Gillette Childrens Specialtycare Hospital, Minneapolis, Minnesota

ATLAS OF THE HAND CLINICS Volume 7 Number 1 March 2002

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PATIENT ASSESSMENT Patients are candidates for surgical reconstruction of the upper extremity using tendon transfer surgery based on an assessment of the following elements: 1. Stabilization of return of motor function can be achieved following injury. Motor recovery after spinal cord injury commonly occurs up to 6 months after injury, usually stabilizes by 1 year after injury, but can continue to occur up to 2 years after injury.5 Reconstructive surgery of the upper extremity is not recommended until the patients return of motor strength has plateaued for at least 2 months; this period usually ranges from 6 to 12 months after injury. 2. The patient is stable medically and psychologically. Medical treatment is necessary for bowel and bladder function, blood pressure control, avoidance of decubitus ulcers, and eradication of bladder infections. Psychologic stability implies that the patient has accepted his or her injury, has realistic expectations of the surgery, and has the mental stamina to complete the postoperative rehabilitation program. 3. The upper limb must: be free of severe contracture, have no grossly unstable joints or signicant spasticity, and be pain free. Most spinal cord injury centers have immediate upper extremity range of motion and splinting programs to prevent contracture; however, if a patient presents with considerable contracture, the limb should be splinted and stretched before surgical reconstruction. For elbow tendon transfer, the elbow must be stable. Because many spinal cord injury patients have had concomitant fractures or dislocations, a preoperative radiograph of the elbow (including the humerus and forearm) should be obtained. Spasticity can also compromise tendon transfer results, but this problem occurs primarily in the forearm and hand when assessing for grasp, pinch, and release reconstructions. Pain in the limb will not be alleviated with tendon transfer, a fact that should be addressed before intervention.

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MOTOR ASSESSMENT In 1978 the First International Conference on Surgical Rehabilitation of the Upper Limb in Tetraplegia proposed a motor classication for patients with spinal cord injury. This system was modied in 1984 at the Second International Conference and has now become the gold standard (Table 1).
Table 1. INTERNATIONAL CLASSIFICATION Group 0 1 2 3 4 5 6 7 8 9 Muscle Characteristics None BR BR and ECRL BR, ECRL, ECRB BR, ECRL, ECRB, PT BR, ECRL, ECRB, PT, FCR BR, ECRL, ECRB, PT, FCR, nger extensors BR, ECRL, ECRB, PT, FCR, ngers and thumb extensors Group 7 muscles partial digital exors Lacks only intrinsics

BR brachioradialis; ECRL extensor carpi radialis longus; ECRB extensor carpi radialis brevis; PT pronator teres; FCR flexor carpi radialis. Data from McDowell CL, Moberg AE, House JH: Second International Conference on surgical rehabilitation of the upper limb in tetraplegia. J Hand Surg 11A:604608, 1986.

Because of the variability in the number and strength of functioning muscles at each cervical level, the International Classication requires precise identication of the number of muscles functioning below the elbow at grade 4 strength or greater. The system also recognizes the sensibility deciencies associated with spinal cord injury and requires classication of hand sensibility as O (ocular) for vision as the only afferent versus Cu (cutaneous) if the patient has useful cutaneous sensibility (usually 10 cm two-point discrimination in the thumb). Unfortunately, the International Classication does not assess elbow function for the patients overall ability to position the hand in space. Such an assessment is a necessary part of combining the two goals of upper limb reconstruction in spinal cord injury, that is, elbow extension and hand function. These goals need to be integrated as part of the overall upper extremity reconstructive plan. Because of the segmental innervation of the upper extremity from the spinal cord, spinal cord injury produces a predictable pattern of paralysis depending on the level of the injury. As shown in Table 2, the biceps and deltoid are innervated from the spinal cord at a higher level than the triceps. For the typical International Classication level 4 patient, a biceps to triceps or posterior deltoid to triceps tendon transfer can be performed to provide active elbow extension.

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VAN HEEST Table 2. SEGMENTAL INNERVATION OF UPPER EXTREMITY MUSCLES Segment C7

C5 Biceps Brachialis Brachioradialis Supinator

C6

C8

T1

ECRL ECRB Pronator teres FCR Triceps EDC EDQ EIP EPL Pronator quadratus FDP FPL FCU Lumbricals FDS Thenars Adductor Interossei Hypothenar
ECRL extensor carpi radialis longus; ECRB extensor carpi radialis brevis; FCR flexor carpi radialis; EDC extensor digitorum communis; EDQ extensor digiti quinti; EIP extensor indicis proprius; EPL extensor pollicis longus; FDP flexor digitorum profundus; FPL flexor pollicis longus; FCU flexor carpi ulnaris; FDS flexor digitorum supercialis. Data from Zancolli E: Functional restoration of the upper limbe in traumatic quadriplegia. In Zancolli E (ed): Structural and Dynamic Bases of Hand Surgery, ed 2. Philadelphia, Lippincott, 1979, pp 274280.

BICEPS TO TRICEPS TENDON TRANSFER The biceps to triceps tendon transfer uses the biceps as a donor tendon. The procedure requires verication that the brachialis will remain as an active elbow exor (such that elbow exion will not be lost) and the supinator as an active forearm supinator (such that forearm supination will not be lost). In reviewing the segmental motor innervation from the spinal cord (Table 2), the biceps is noted to be innervated above the same level as the brachialis and the supinator. If the patient has intact and strong wrist extension, then biceps, brachialis, and supinator function should be strong. Additionally, the muscles can be palpated and observed, teaching the patient to relax the biceps differentially, and still ex the elbow and supinate the forearm, verifying that loss of the donor muscle with the biceps to triceps transfer will not lead to a functional loss. Electromyography or peripheral nerve blocks can be used to differentiate between biceps and supinator function in patients in whom it cannot be determined clinically. The biceps to triceps tendon transfer can be performed using a medial12,24 or a lateral7,9,21 routing technique. The lateral technique was rst described by Friedenberg in 1954. Two bilateral cases were reported, with complete range of motion in one and a 30-degree extensor lag in the other. Signicant functional improvements were noted. The lateral technique was also performed by Zancolli,27 who reported six cases in 1979 and 13 cases in 198728 with no poor results. No loss of active elbow exion was noted, although exor strength diminished by 24%. In 1988 Ejeskar7 reported his results using the lateral routing technique for biceps to triceps transfer in ve patients, including the rst complication of radial nerve palsy. The devastating complication of radial nerve palsy was subsequently noted by others using this technique, and a medial routing is now preferred.

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The operative technique preferred by the author uses medial routing. The patient is placed supine on the operating table with the limb draped free using a sterile tourniquet. An anterior incision (Fig. 1) is used to harvest the biceps tendon from its insertion, starting along the medial border of the biceps at the midhumeral level, extending obliquely across the antecubital fossa, and distally centering over the biceps insertion on the radial tuberosity.

Figure 1. An anterior incision (heavy line) is used starting along the medial border of the biceps at the midhumeral level, extending obliquely across the antecubital fossa, and distally centering over the biceps insertion on the radial tuberosity. (From Kuz J, Van Heest A, House J: Biceps to triceps transfer in tetraplegic patients: report of the medial routing techniques and follow-up of three cases. J Hand Surg [Am] 24:165 170, 1999)

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The musculocutaneous nerve is identied and protected as dissection is carried down onto the biceps muscle belly, freeing it from its fascial insertions medially and laterally. As the biceps tendon is dissected down onto its insertions, the lacertus brosus is dissected off the forearm fascia and preserved as a second tail of tendon for subsequent weaving. The biceps tendon is sharply dissected off its radial tuberosity insertion and is tagged with a No. 5 nonabsorbable locked grasping suture. The lacertus brosus is tagged with a No. 0 nonabsorbable locked grasping suture, as shown in Figure 2.

BT

BA MCN

Pronator teres

Figure 2. The bicipital tendon and lacertus brosus have been harvested off their insertion and tagged, with careful protection of the musculocutaneous nerve (MCN). BT biceps tendon; BA biceps aponeurosis. (From Kuz J, Van Heest A, House J: Biceps to triceps transfer in tetraplegic patients: report of the medial routing techniques and follow-up of three cases. J Hand Surg [Am] 24:165 170, 1999)

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A second posterior incision is made over the distal one third of the triceps and laterally past the tip of the olecranon (Fig. 3).

Figure 3. A second posterior incision (heavy line) is made over the distal one third of the triceps and laterally past the tip of the olecranon. The incision is based laterally to allow an adequate skin bridge from the anterior incision, and to avoid a wound directly over the olecranon that may be subject to pressure and breakdown. (From Kuz J, Van Heest A, House J: Biceps to triceps transfer in tetraplegic patients: report of the medial routing techniques and follow-up of three cases. J Hand Surg [Am] 24:165 170, 1999)

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The incision is based laterally to allow an adequate skin bridge from the anterior incision and to avoid a wound directly over the olecranon that may be subject to pressure and breakdown. A subcutaneous tunnel is made medially from the anterior wound to the posterior wound in a line of pull that would be straight and free for the biceps transfer into the triceps insertion. The biceps tendon is passed supercial to the ulnar nerve from the anterior wound, into the posterior wound, and woven into the triceps tendon. Length will usually allow two to three weaves with the end of the biceps tendon placed into a drill hole into the olecranon. A 4-mm unicortical drill hole is placed on the tip of the olecranon to receive the terminal end of the biceps tendon. Two small drill holes are placed through the opposite cortex to allow the No. 5 grasping suture to be passed out on Keith needles, tying the No. 5 grasping suture over bone (Fig. 4).

BA

BT Bone tunnel entrance

Figure 4. The biceps tendon is woven two or three times through the triceps tendon, delivering the distal end to the tip of the olecranon. A 4-mm unicortical drill hole is placed on the tip of the olecranon to receive the terminal end of the biceps tendon. Two small drill holes are placed through the opposite cortex to allow the No. 5 grasping suture to be passed out on Keith needles, tying the No. 5 grasping suture over the bone. The transfer is tensioned to allow 90 of elbow exion. When proper tension has been achieved with test sutures, a nal suturing is done, including interweaving of the lacertus brosus through the biceps-to-triceps weaves in order to interlock the position. (From Kuz J, Van Heest A, House J: Biceps to triceps transfer in tetraplegic patients: report of the medial routing techniques and follow-up of three cases. J Hand Surg [Am] 24:165 170, 1999)

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The transfer is tensioned to allow up to 90 degrees of elbow exion. When proper tension has been achieved with test sutures, a nal suturing is done, including interweaving of the lacertus brosus through the biceps to triceps weaves to interlock the position. The incisions are then closed in layers. Postoperatively, after surgery the elbow is casted in about 30 degrees of exion for 3 weeks. A exion-blocking splint is then used on a full-time basis to prevent elbow exion beyond 45 degrees, which is progressively increased by 15 degrees per week. Initially, the biceps is trained to extend the elbow with gravity eliminated using a powder board (a horizontal board to eliminate gravity and powdered to eliminate friction). The medially routed biceps can be palpated along the medial humerus to assess for control and allow patient feedback. If muscle control is achieved, strengthening against resistance begins at 8 to 10 weeks, with the patient wearing the splint for protection only (e.g., transfers). When sufcient strength and range of motion have been achieved, use of the splint is discontinued. Excellent antigravity strength can be achieved, allowing signicant improvement in transfers, driving, pressure relief, and use of the arms when supine (Fig. 5).

Figure 5. Medially routed biceps can be seen as the patient actively extends his elbow while lying supine. (From Kuz J, Van Heest A, House J: Biceps to triceps transfer in tetraplegic patients: report of the medial routing techniques and follow-up of three cases. J Hand Surg [Am] 24:165 170, 1999)

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POSTERIOR DELTOID TO TRICEPS TRANSFER The posterior deltoid to triceps transfer uses the posterior third and the posterior half of the middle third of the deltoid muscle as a donor, with an interpositional tendon graft bridging to its insertion into the triceps tendon as shown in Figure 6A C.

Figure 6. Posterior deltoid to triceps transfer. The posterior one third of the deltoid is harvested with its periosteal insertion off the deltoid tubercle, with careful protection of the axillary nerve and of the insertion of the middle and anterior deltoid insertions (A). Toe extensors are used as intercalary grafts with intertendinous weaves through both the deltoid insertion and the triceps tendon (B). The fascia lata is used as intercalary graft with a large surface area sewn onto the deltoid tendon, and woven distally through the triceps tendon and into bone tunnels in the olecranon (C).

The posterior deltoid is easily tested by supporting the limb in 90 degrees of shoulder abduction and testing strength of shoulder extension while palpating the posterior deltoid, verifying bulk and selective control. Scapular stabilization and control are necessary to maximize the effectiveness of the transfer. The procedure is performed with the patient in a supine position with the shoulder forequarter draped free. A deltoid incision is made from the tip of the posterior corner of the acromion distally to the deltoid tubercle insertion. Dissection along the posterior border of the deltoid down to its insertion onto the humerus is developed. The demarcation between the posterior and middle one third of the humerus is then dened, usually, best delineated in the proximal aspect of the muscle. The axillary nerve courses about 5 cm distal to the acromion on the deep surface of the deltoid. The axillary nerve is protected as the plane between the

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posterior and the posterior half of the middle third of the deltoid is developed down to the deltoid insertion. The insertion of the anterior deltoid is protected, whereas the posterior portion is harvested in a full-thickness manner including the periosteal attachment. A separate triceps incision is made over the distal one third of the humerus with exposure of the triceps tendon. A subcutaneous tunnel is made connecting the two incisions for placement of the interpositional graft. Several alternatives have been described for the interpositional graft bridging the posterior deltoid to the triceps. As originally suggested by Moberg,19 toe extensors from the second, third, and fourth toes allow at least three weaves at each attachment site. Alternative graft materials include fascia lata,11 tibialis anterior,13,15 extensor carpi ulnaris,14 or Dacron.16 Additionally, a method described by CastroSierra and Lopez-Pita3 uses the central one third of the triceps as the graft. In this method, a 1-cm strip from the central one third of the triceps is harvested from its periosteal insertion in a retrograde manner, mobilizing it proximally to allow sufcient length for a woven end-to-end anastomosis with the posterior deltoid. The graft is tensioned with the shoulder in 30 to 40 degrees of abduction and no forward exion so that the elbow can ex 30 to 60 degrees with moderate exion. Posterior deltoid to triceps transfers have been compromised by several factors.22,23 The most common problem following this procedure has been elongation of the tendon graft.4,20 Friden and collegues8 used intraoperative stainless steel sutures in six patients to measure tendon elongation, which averaged 2.3 cm over a 2-year period. They employed a postoperative armrest to maintain the elbow in 20 degrees of exion and prevent shoulder adduction. Using this armrest in ve subsequent patients, tendon elongation using the same markers averaged 0.8 cm. Modication of the postoperative rehabilitation plan to prevent tendon elongation may be necessary to maintain strength.

SUMMARY At the First and Second International Conferences on surgical rehabilitation of the upper limb in tetraplegia,17,18 the consensus among surgeons was that, for the tetraplegia patient with paralysis of elbow extension, the rst and fundamental intervention for reconstruction of the limb is tendon transfer for elbow extension. This article describes the posterior deltoid to triceps transfer, which has been used extensively over the last 30 years, and the medially routed biceps to triceps transfer, which has been described more recently.

References
1. Betz RR: Upper extremity management. In Betz RR, Mulcahy MJ (eds): The Child with a Spinal Cord Injury: Symposium: Phoenix, Arizona, December 8 11, 1994. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 373 458 2. Brys D, Waters RL: Effect of triceps function on the brachioradialis transfer in quadriplegia. J Hand Surg 12A:237 239, 1987 3. Castro-Sierra A, Lopez-Pita A: A new surgical technique to correct triceps paralysis. Hand 15: 42 46, 1983 4. DeBenedetti M: Restoration of elbow extension power in the tetraplegic patient using the Moberg technique. J Hand Surg 4A:86 89, 1979 5. Ditunno JFJ, Stover SL, Freed MM: Motor and sensory recovery following incomplete tetraplegia: A multi-center study. Arch Phys Med Rehabil 73:4431 4436, 1992 6. Dunkerley AL, Ashburn A, Stack EL: Deltoid triceps transfer and functional independence of people with tetraplegia. Spinal Cord 38:435 441, 2000 7. Ejeskar A: Upper limb surgical rehabilitation in high-level tetraplegia. Hand Clin 4:585 599, 1988 8. Friden J, Ejeskar A, Dahlgren A, et al: Protection of the deltoid to triceps tendon transfer repair. J Hand Surg 25A:144 149, 2000 9. Friedenberg ZB: Transposition of the biceps brachii for triceps weakness. J Bone Joint Surg 36A:656 658, 1954 10. Hanson RW, Franklin MR: Sexual loss in relation to other functional losses for spinal cord injured males. Arch Phys Med Rehabil 57:291 293, 1976 11. Hentz VR, Brown M, Keoshian LA: Upper limb reconstruction in quadriplegia: Functional

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VAN HEEST assessment and proposed treatment modications. J Hand Surg 8A:119 131, 1983 Kuz JE, Van Heest AE, House JH: Biceps-totriceps transfer in tetraplegic patients: Report of the medial routing technique and follow-up of three cases. J Hand Surg 24A:161 172, 1999 Lacey SH, Wilber RG, Peckham PH, et al: The posterior deltoid to triceps transfer: A clinical and biomechanical assessment. J Hand Surg 11A:542 547, 1986 Lamb DW, Chan KM: Surgical reconstruction of the upper limb in traumatic tetraplegia: A review of 41 patients. J Bone Joint Surg 65B: 291 298, 1983 LeClerq S, McDowell CL: Fourth International Conference on surgical rehabilitation of the upper limb in tetraplegia. Ann Chir Main Memb Super 10:258 260, 1991 McDowell CL, House JH: Tetraplegia. In Green DP, Hotchkiss RN, Pederson WC (eds): Greens Operative Hand Surgery, ed 4. New York, Churchill Livingstone, 1999 McDowell CL, Moberg AE, House JH: Second International Conference on surgical rehabilitation of the upper limb in tetraplegia. J Hand Surg 11A:604 608, 1986 McDowell CL, Moberg EA, Smith AG: First International Conference on surgical rehabilitation of the upper limb in tetraplegia. J Hand Surg 4A:604 608, 1979 Moberg E: Surgical treatment for absent singlehand grip and elbow extension in quadriplegia. J Bone Joint Surg 57A:196 206, 1975 20. Moberg EA, Lamb DW: Surgical rehabilitation of the upper limb in tetraplegia. Hand 12:209 213, 1980 21. Moberg E, McDowell CL, House JH: Third International Conference on surgical rehabilitation of the upper limb in tetraplegia (quadriplegia). J Hand Surg 14A:1064 1066, 1989 22. Rabischong E, Benoit P, Benichou M, et al: Length-tension relationship of the posterior deltoid to triceps transfer in C6 tetraplegic patients. Paraplegia 31:33 39, 1993 23. Raczka R, Braun R, Waters RL: Posterior deltoid-to-triceps transfer in quadriplegia. Clin Orthop 187:163 167, 1984 24. Revol M, Briand E, Servant JM: Biceps-to-triceps transfer in tetraplegia: The medial route. J Hand Surg 24B:235 237, 1999 25. Richards RR: Soft Tissue Reconstruction in the Upper Extremity. New York, Churchill Livingstone, 1995 26. Smith RJ: Tendon Transfers of the Hand and Forearm, ed 1. Boston, Little, Brown, 1987, p 337 27. Zancolli E: Functional restoration of the upper limbs in traumatic quadriplegia. In Zancolli E (ed): Structural and Dynamic Bases of Hand Surgery, ed 2. Philadelphia, Lippincott, 1979, pp 229 262 28. Zancolli EA: Tetraplegia. In McFarlane RM (ed): Unsatisfactory Results in Hand Surgery. The Hand and Upper Limb. New York, Churchill Livingstone, 1987, pp 274 280 Address reprint requests to Ann E. Van Heest, MD Department of Orthopaedic Surgery 420 Delaware Street SE MMC 492 Minneapolis, MN 55455 e-mail: girar008@tc.umn.edu

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Tendon Transfers During Index Finger Pollicization


Gary M. Lourie, MD
HISTORICAL PERSPECTIVE The creation of an opposable thumb through pollicization of the index nger remains one of the most demanding yet rewarding procedures performed by the hand surgeon. Over 130 years ago, the challenge to reconstruct the decient thumb began with Huguier,5 who reported on the deepening of the web space between a damaged index nger and partial thumb amputations. Signicant efforts by Nicoladoni,12 Luksch,10 Joyce,6 and Guermonprez4 in the early 1900s advocated the principle of distant pedicle aps to reconstruct the decient thumb. Before World War II, osteoplastic reconstruction provided the technique of staged pedicle coverage followed by corticocancellous grafting for bony support. The overwhelming upper extremity trauma seen in World War II sparked intense progress in hand reconstruction. In 1949 Gosset3 was one of the rst surgeons to recommend transfer of an index nger on its neurovascular pedicle to reconstruct the decient hand. Littler9 and others rened the index nger neurovascular pedicle transfer in thumb reconstruction. These principles gradually found their way into reconstructive schemes for the congenitally deprived thumb.

From the Department of Orthopaedics, Emory University, The Hand Treatment Center, Atlanta, Georgia

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The misguided use of thalidomide in Europe accelerated the need for pollicization as a sudden overwhelming population of children were born with congenital deciencies of the upper and lower extremities. Buck-Gramcko1 published 100 cases of pollicization of the index nger. With signicant contributions by Littler,9 Riordan,13 and others, this procedure has become the technique of choice in reconstruction of congenital hypoplasia or complete absence of the thumb (Figs. 1A, and B).

Figure 1. A and B, Postoperative pollicization utilizing principles of Buck-Gramcko.

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POLLICIZATION GOALS Strict adherence to the principles of pollicization is vital and requires creation of a scar-free rst web space, adequate skeletal shortening, preservation of the neurovascular pedicle, proper positioning, and intrinsic tendon transfer to motor and stabilize the created thumb. The goal is to provide a sensate, stable, opposable thumb for prehensile pinch and grasp. This article discusses the details of intrinsic tendon transfer at the time of pollicization.

TECHNIQUE The technique of tendon transfer in pollicization of the index nger has evolved as the overall reconstructive method has advanced. Gossets initial procedure of reconstruction following traumatic thumb loss recommended transfer of the extensor pollicis longus to the index lateral band and the extensor pollicis brevis to the central slip.3 Also primarily describing reconstruction following traumatic loss, Littler recommended transfer of the rst dorsal interossei to provide abduction and retention of the uninjured adductor pollicis to allow continued adduction of the created thumb. The rst volar interossei was excised, the extensor pollicis longus was sutured to the extensor digitorum communis to the index nger to provide extension, and the extensor indicis proprius was transferred to the ulnar lateral band.9 Zancollis technique provided abduction of the newly created thumb by releasing the origin of the rst dorsal interossei and then reattaching it to the fascia of the hypothenar muscles on the ulnar border of the hand.14 Carroll2 advocated transfer of the rst dorsal interossei and rst volar interossei to the index middle phalanx to restore abduction and adduction, respectively, in the pollicized digit. All of these contributions added greatly to the success in motoring the pollicized digit, and additional renements made by Kleinman,7,8 Manske,11 Riordan,13 and Buck-Gramcko1 have established the current method of choice in tendon transfer. The success of each step in the pollicization is predicated on adequate completion of the preceding task. Proper placement of the skin incision not only creates a scan-free rst web space but also identies the neurovascular bundles. Identication of the palmar neurovasular structures helps to visualize the exor tendons to the index nger, along with the rst dorsal interossei. The common digital artery and nerve to the index nger middle web space helps to locate the intermetacarpal ligament, which, when incised, allows one to visualize the rst volar interossei. The dorsal dissection is equally as important. Proper preservation of the dorsal veins allows for unimpeded venous outow of the pollicized digit and identies the extensor digitorum communis and the extensor indicis proprius tendons. Successful completion of the dissection over the proximal phalanx of the index nger exposes the radial and ulnar lateral bands along with the intrinsic muscle contribution. Each musculotendinous structure must be carefully preserved. After proper skeletal shortening, these structures will be used for tendon transfer to stabilize and motor the newly created thumb.

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The standard transfers adopted by Buck-Gramcko and rened by others include transfer of the rst dorsal interossei for abduction and transfer of the rst volar interossei for adduction. The extensor digitorum communis to the index nger serves as the abductor pollicis longus; the extensor indicis proprius becomes the extensor pollicis longus1 (Fig. 2). Anatomic variation can exist, and modication of these transfers may be necessary.

Figure 2. Bony realignment and tendon transfer used to motor the created thumb. DIP distal interphalangeal; PIP proximal interphalangeal; MP metacarpophalangeal; IP interphalangeal; CM carpometacarpal. (From Kleinman WB: Management of thumb hypoplasia. Hand Clin 6:628 630, 1990.)

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The insertions of the rst dorsal interossei and the rst volar interossei are incised at the level of the proximal phalanx. Careful dissection off the shaft of the metacarpal is necessary to preserve each muscle belly. With proper skeletal shortening, each interossei can be transferred distally into the radial and ulnar lateral band of the index digit, previously separated from the extrinsic extensor. The lateral bands are passed through the tendinous portion of the interossei and sutured back to allow for abduction (dorsal interossei) and adduction (volar interossei) (Fig. 3).

Figure 3. A and B, Tendon transfers. Radial and ulnar lateral bands routed through tendinous portion of interossei to provide for abduction and adduction. 1 volar interossei; 2 dorsal interossei; 3 radial lateral bond; 4 metacarpal; asterisk neurovascular bundles. (From Kleinman WB, Strickland JW: Thumb reconstruction. In Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, Churchill Livingstone, 1993, p 2068.)

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The extensor digitorum communis will act as the abductor pollicis longus. The extensor indicis proprius will become the extensor pollicis longus. Buck-Gramcko1 and Kleinman7,8 advocated shortening these two extensors a segment equal to the length of metacarpal resected. Other surgeons disagree with shortening of the extensors and recommend leaving the tendons alone, which allows equilibration and retention of proper excursion over time. This technique has been supported by Manske and McCarroll.11 There is no disagreement regarding the exor tendons. They are not shortened and will readjust quickly to the effective lengthening caused by the skeletal shortening. The A1 pulley is released, which improves the vector for more efcient exion of the newly created thumb. The transferred index digit is stabilized anterior to the index base with two to three transosseous sutures and, along with the intrinsic transfers, positions the thumb in 40 degrees of abduction, 15 degrees of extension, and initial pronation of 160 degrees, which will lessen to a nal resting posture of 120 degrees.

Figure 4. Stability provided by strategically placed sutures to create new carpometacarpal joint. Abduction, 40 ; extension, 15 ; pronation, 120 . (From Kleinman WB: Management of thumb hypoplasia. Hand Clin 6:628 630, 1990.)

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ALTERNATIVE TRANSFERS Kleinman7,8 has found that, in as many as 50% of his cases, the rst dorsal interossei has been hypoplastic and in some cases absent. To allow for abduction in the pollicized digit, he has recommended detaching and transferring the extensor digitorum communis more distal and volar on the index proximal phalanx (Fig. 5).

Figure 5. Kleinmans technique to provide for abduction of thumb in the face of an absent rst dorsal interossei. The extensor digitorum communis is redirected more distal and volar on the index proximal phalanx. EPL (EIP) extensor pollicis turns into extensor indicis proprius; AbPL (EDCII). (From Kleinman WB: Management of thumb hypoplasia. Hand Clin 6:628 630, 1990.)

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If this maneuver proves inadequate, a staged procedure, such as an opponensplasty, can be performed. This procedure can be accomplished by using the abductor digiti quinti (Huber), the exor digitorum supercialis of the ring nger, or other proven donors (Fig. 6).

Figure 6. Huber transfer. The abductor digiti quinti is mobilized and transfered across the palm to provide for abduction.

Another technique to provide for adduction of the thumb has been described by Kleinman.7,8 To simplify dissection about the proximal phalanx, he advocated leaving the insertion of the rst volar interossei intact, detaching the muscle belly origin, and transferring it to the periosteum of the third metacarpal. This maneuver not only precludes the need for extensive dissection of the index proximal phalanx but can minimize skin incisions dorsally, which protects venous outow.

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SUMMARY Pollicization of an index nger is an exacting procedure that requires strict attention to detail. Integral to its success is the completion of tendon transfers to balance, stabilize, and motor the newly created thumb. This article has described the method of choice for tendon transfer.
ACKNOWLEDGMENTS
The author thanks William B. Kleinman, MD, not only for his guidance on work for this article but also for his continued commitment to teaching in the eld of hand surgery.

References
1. Buck-Gramcko D: Pollicization of the index nger: Method and results in aplasia and hypoplasia of the thumb. J Bone Joint Surg 53A: 1605 1617, 1971 2. Carroll RE: Pollicization. In Green DP (ed): Operative Hand Surgery, ed 2. New York, Churchill Livingstone, 1988, pp 2263 2280 3. Gosset J: La pollicization de lindex (technique chirurgicale). J Chir (Paris) 65:403, 1949 4. Guermonprez F, Derode G: Notes sur les Indications de la Restauration du Ponce. Toulouse, Imprinerie Pinel, 1889 5. Huguier PC: Replacement du pouce par son metacarpien, par Landgradissement du premier espace interosseous: Arch Gen Med (Paris) 1:78, 1874 6. Joyce JL: A new operation for substitution of a thumb. J Bone Joint Surg 5:499 504, 1917 1918 7. Kleinman WB: Management of thumb hypoplasia. Hand Clin 4:617 641, 1990 8. Kleinman WB: Thumb reconstruction. In Green DP (ed): Operative Hand Surgery. New York, Churchill Livingstone, 1992, pp 2043 2073. 9. Littler JW: On making a thumb: One hundred years of surgical effort. J Hand Surg 1:35 51, 1976 10. Luksch I: Uber eine nene methode zum ersatz des verlorenen daumens. Verh Dtsch Ges Chir 32:22, 1903 11. Manske PR, McCarroll HR Jr: Abductor digiti minimi opponensplasty in congenital radial dysplasia. J Hand Surg 3:552 559, 1978 12. Nicoladoni C: Daumen Plastik. Wien Klein Wochenschr 10:663, 1897 13. Riordan DC: Congenital absence of the radius. J Bone Joint Surg 37A:1129 1140, 1976 14. Zancolli E: Transplantation of the index nger in congenital absence of the thumb. J Bone Joint Surg 42A:658 660, 1960 Address reprint requests to Gary M. Lourie, MD The Hand Treatment Center 980 Johnson Ferry Road Suite 1020 Atlanta, GA 30342 e-mail: GMLHTC@aol.com

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Tendon Transfers for Thumbin-Palm Deformity


Michelle Gerwin Carlson, MD, and Catherine Brooks, OT, CHT

Cerebral palsy is a musculoskeletal deformity caused by a static perinatal brain injury. The extent of involvement of motor function and sensibility is variable. Motor involvement may take the form of spasticity, accidity, or athetosis (uctuating between spasticity and accidity). Frequently, spastic involvement of a muscle is accompanied by accidity of its antagonist, often necessitating not only release of the spastic muscle but transfers to augment the antagonist. Identication of upper limb dysfunction usually is noted by 1 year of age. At this point normal infant achieves a rened pinch with opposition of the thumb tip to the index nger. Infants with cerebral palsy do not reach this milestone, although they may have a more primitive key pinch (thumb to side of index nger).

Work for this article was supported by a grant from the Tow Foundation and the Farbman Foundation. From The Hospital for Special Surgery; and The Cornell University Medical College, New York, New York

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The thumb is responsible for 40% of the function of the hand, and the thumbin-palm deformity seen in cerebral palsy signicantly affects the function of the hand. There are two important aspects of thumb-in-palm deformity: (1) the position of the thumb in the palm during sting, and (2) the inability to abduct the thumb when opening the hand. This inability to get the thumb out of the palm, with loss of the rst web space, when trying to grasp an object is the true obstacle to use of the hand (Fig. 1).

Figure 1. Thumb adduction during grasp prevents this patient from being able to hold a bottle. (Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

Even in the setting of an adequate web space, abduction of the thumb is necessary to allow for visualization of the thumb, especially if the forearm is pronated. Visualization is important to assist function in a sensory or functionally limited hand. Abduction of the thumb requires strength in the abducting muscles and relaxation of the adducting muscles. Additionally, the skin of the rst web space must be redundant enough to allow abduction. The primary muscle responsible for abduction of the thumb is the extensor pollicis brevis (EPB). This muscle abducts the thumb carpometacarpal (CMC) joint and the metacarpophalangeal (MP) joint. The extensor pollicis longus (EPL) tendon is responsible for extension of the terminal phalanx in this abducted position. EPL ring alone will produce adduction of the thumb ray owing to its line of pull around Listers tubercle.7 For full thumb abduction, the EPL and EPB must function. The abductor pollicis longus (APL), although named an abductor, has little thumb abduction function and actually is more responsible for wrist radial deviation than thumb abduction. The adducted posture of the thumb is caused by spasticity in the adductor pollicis and the rst dorsal interosseous muscle. In most cases, release of these muscles is necessary to improve abduction of the thumb. Additionally, the skin of the rst web space contracts over time and usually needs to be released. The exor pollicis longus (FPL) muscle may also be spastic and should be checked for tightness.

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EXAMINATION OF THE THUMB Physical examination of the spastic upper extremity can be difcult. Despite their best efforts, patients often have difculty cooperating with the examination. Often, it is helpful for the patient to perform the requested activities with both extremities simultaneously to ensure that the patient understands the requested task. There are four keys to evaluating the adducted deformity of the thumb: (1) spasticity of the exors and adductors, (2) accidity of the extensors and abductors, (3) hypermobility of the MP joint, and (4) web space skin contracture. The exors and adductors are the FPL, the exor pollicis brevis (FPB), the adductor pollicis, and the rst dorsal interosseous. With use, the thumb metacarpal will assume an adducted position if there is spasticity of the adductor and rst dorsal interosseous, and the MP joint will ex with spasticity of the FPB. These muscles can be palpated in the rst web space. FPL spasticity should be evaluated with the wrist at neutral and the thumb held radial to the index nger. If the interphalangeal (IP) joint of the thumb sits in a xed exed position, the FPL will need to be lengthened also. Extension and abduction of the thumb are performed by the EPB and EPL. Often, the EPL will function well with the thumb in the adducted position, creating IP joint hyperextension. Passive or active MP joint hyperextension should be identied and addressed at the time of surgery; otherwise, tendon transfers to abduct the thumb ray may produce unwanted MP joint hyperextension. Additionally, the skin in the rst web space may similarly become contracted and need to be addressed at the time of surgical correction.

OPERATIVE PROCEDURES Operative treatment is directed at the four causes of deformity previously described. Spasticity of the thumb intrinsics is present in almost all thumb-in-palm deformities. Attention should primarily be addressed to the adductor pollicis and rst dorsal interosseous muscles; less frequently, the FPB is involved. Release of the adductor can be performed at its origin1,46,8,11,13 or its insertion.2,46,8,12 The FPL should be lengthened or released if it is spastic. Augmentation of thumb abduction has been performed using a variety of tendon transfers, including brachioradialis,9 palmaris longus,6 exor carpi radialis and exor carpi ulnaris,6,11 extensor carpi radialis longus and brevis,8 and exor digitorum supercialis.1,3 Rerouting of the EPL, FPL abductorplasty, and APL and EPB imbrication also have been described.1,3,710 Rerouting of the EPL allows the tendon to become a thumb abductor instead of an adductor and extensor. Of these procedures, the author has found rerouting of the EPL tendon, or a brachioradialis to EPB transfer to be the most effective. If the EPL is strong and if good extension of the IP joint is possible with the wrist in netural, EPL rerouting is performed as described in the following sections. If the EPL is not strong, brachioradialis to EPB transfer is performed. One must examine the thumb MP joint prior to transfer; otherwise, the transfer may produce unwanted MP joint hyperextension. A capsulodesis of the MP joint can be performed at the time of the procedure if necessary.

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Adductor Release and MP Joint Capsulodesis Adductor Release Release of the adductor is performed at its insertion on the ulnar thumb sesamoid and metacarpal through the rst web space. Through a double opposing Zplasty of the rst web space (Fig. 2), the adductor tendon and muscle are released from their insertion on the metacarpal, extensor hood, and sesamoid, and reattached proximally to periosteum in the midshaft of the metacarpal with a 4-0 nonabsorbable braided suture (Fig. 3).

Figure 2. The rst web space is opposed through a double opposing Z-plasty incision. This allows for excellent visualization of the adductor and rst dorsal interosseous and improvement of the skin contracture in the web space. (Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

Figure 3. The adductor is taken down from its insertion on the thumb metacarpal and sesamoid. (Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

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Subperiosteal release of the rst dorsal interosseous from the thumb metacarpal is performed proximally. Care is taken to avoid injury to the princeps pollicis artery as it ascends from the base of the web space along the ulnar border of the rst metacarpal. After release of the rst dorsal interosseous, the FPL tendon should be checked with the wrist in a neutral position. If full abduction and extension of the thumb is not possible, the FPL tendon will need to be released, usually by fractional lengthening. MP Joint Capsulodesis If there is passive hyperextension of the thumb MP joint of more than 20 degrees, a capsulodesis can be performed through this incision. The volar capsule is taken down from its origin on the metacarpal along its ulnar side, leaving it attached to the ulnar sesamoid. The capsule is then pulled down securely and sutured more proximally to the periosteum of the rst metacarpal. Performing this capsular advancement only on the ulnar side of the MP joint is secure enough to prevent MP joint hyperextension after tendon transfer. The MP joint should be held in 10 degrees of exion for 4 weeks after surgery with a 0.035-inch Kirschner wire.

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Abduction Augmentation Abduction augmentation is primarily accomplished by one of two procedures. If the EPL can fully extend the thumb IP joint with the wrist in neutral (either held actively or passively), it is rerouted to become an abductor. If the EPL is not functional with the wrist in neutral, the brachioradialis is transferred to the EPB or rerouted EPL. EPL Rerouting Through a transverse incision over the third dorsal compartment, proximal to Listers tubercle, the retinaculum of the third dorsal compartment is incised. The EPL is removed from its tunnel and allowed to migrate radially (Fig. 4A and B).

Figure 4. The third dorsal compartment is opened over the extensor pollicis longus tendon to allow it to migrate radially. (Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

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Through a second transverse incision just distal to the rst dorsal compartment, a distally based slip of APL is harvested (Fig. 5).

Figure 5. A and B, The most volar slip of the abductor pollicis longus (APL) tendon is transected distally to create a radial pulley for the extensor pollicis longus (EPL) tendon. EPB extensor pollicis brevis. (Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

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A radial pulley is created with the abductor slip as it is wrapped around the EPL tendon, pulling it radially. The abductor slip is sutured to the most volar aspect of the retinaculum of the rst dorsal compartment, or radial periosteum (Fig. 6A and B).

Figure 6. A and B, The extensor pollicis longus (EPL) tendon is rerouted radially and volarly through the abductor pollicis longus (APL) pulley. (Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

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The adequacy of the radial pulley is checked intraoperatively by traction on the EPL at the wrist, producing thumb abduction instead of extension and adduction (Fig. 7A and B).

Figure 7. A, Traction on the EPL in its anatomic position produces extension and adduction of the thumb. B, After rerouting of the EPL, traction produces abduction of the thumb. (Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

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If hyperextension of the MP joint is noted preoperatively, a capsulodesis of the MP joint is concurrently performed. The rst web space is held in abduction with a percutaneous 0.045-inch Kirschner wire, and a nonremovable thumb spica splint is applied for 4 weeks. Postoperatively at 4 weeks, the Kirschner wire is removed, the thumb is placed in a removable thumb spica splint, and therapy is begun. Thumb position in the splint is midante/retropulsion and not pure opposition in an attempt to encourage more radial abduction. The splint is worn at all times with the exception of bathing and therapy. Silicone scar management is placed in the web space of the splint for nighttime wear. Scar massage is recommended for 3 to 5 minutes daily for 6 weeks. Therapy lasting 3 months postoperatively is recommended. The initial postoperative therapy goal is an active attempt by the patient to inhibit any thumb adduction during the performance of proximal exercises. This action is assessed and achieved before active EPL/EPB ring is attempted, usually within 2 weeks after splint removal. Therapy then progresses to include light cylindrical grasp and lateral or opposed light pinch of 1-inch size objects, with a focus on the use of balanced palmar and radial abduction. Squeezing and tight pinch are avoided for the rst 3 weeks of therapy to avoid the thumb adduction pattern. If the patient cannot inhibit involuntary adduction, squeezing and tight grasp are limited in the therapy program but included as needed for activities of daily living. Three weeks after cast removal, activities of daily living are encouraged, including tasks with pinch and grasp. Activities of daily living are then progressed as tolerated, and the splint is discontinued 4 weeks after cast removal. Brachioradialis to EPB Transfer A 2-cm transverse incision is made 3 cm proximal to the tip of the radial styloid. The subcutaneous tissues are spread bluntly with care taken to avoid injury to the supercial branches of the radial nerve. The brachioradialis tendon is identied and released from its insertion on the distal radius as distal as possible. The EPB tendon is identied in the distal aspect of the wound as the more ulnar of the tendons in the rst dorsal compartment. Its identity can be conrmed with retraction of the two tendons. The APL will only abduct the rst metacarpal at the CMC joint, with no effect at the MP joint. The EPB tendon will extend the MP joint. The EPB tends to be a small tendon. If it is too small, the rerouted EPL described previously can be used instead. The EPB is transected as proximal as possible, and the tendon is woven into the brachioradialis tendon in a Pulvertaft fashion (Fig. 8A and B).

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Figure 8. A and B, The brachioradialis tendon is transected distally and the EPB proximally and woven in a Pulvertaft fashion into the brachioradialis. (Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

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Maximum tension is placed on the two tendons with the wrist in neutral during the weave. The tension can be checked after repair. Wrist dorsiexion should allow the thumb to rest on the radial aspect of the index nger, and wrist volar exion should abduct the thumb. The postoperative regimen is the same as for EPL rerouting.

SUMMARY Treatment of the thumb-in-palm disorder usually requires release of the pathologic adduction and augmentation of thumb abduction. Release of the thumb adductor and rst dorsal interosseous along with EPL rerouting or brachioradialis to EPB transfer reliably provide excellent results in improvement of grasp of the hand (Fig. 9A and B).

Figure 9. Release of the adductor and rst dorsal interosseous and rerouting of the EPL. A, Preoperatively attempted abduction of the thumb produces adduction of the rst metacarpal. B, Postoperatively a 60 web space is maintained actively. (Courtesy of Michelle Gerwin Carlson, MD, New York, New York)

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References
1. Gelberman RH: Cerebral palsy. In Gelberman RH (ed): Operative Nerve Repair and Reconstruction. Philadelphia, JB Lippincott, 1991, pp 1455 1475 2. Goldner JL: Reconstructive surgery of the hand in cerebral palsy and spastic paralysis resulting from injury to the spinal cord. J Bone Joint Surg 37A: 1141 1154, 1955 3. Goldner JL: Upper extremity tendon transfers in cerebral palsy. Orthop Clin North Am 5: 389 414, 1974 4. Goldner JL, Koman LA, Gelberman RH, et al: Arthrodesis of the metacarpophalangeal joint of the thumb in children and adults: Adjunctive treatment of thumb-in-palm deformity in cerebral palsy. Clin Orthop 253:75 89, 1990 5. Hoffer MM, Perry J, Garcia M, et al: Adduction contracture of the thumb in cerebral palsy: A preoperative electromyographic study. J Bone Joint Surg 65A:755 759, 1983 6. House JH, Gwathmey FW, Fidler MO: A dynamic approach to the thumb-in-palm deformity in cerebral palsy: Evaluation and results in fty-six patients. J Bone Joint Surg 63A:216 225, 1981 7. Manske PR: Cerebral palsy of the upper extremity. Hand Clin 6:697 709, 1990 8. Matev I: Surgical treatment of spastic thumbin-palm deformity. J Bone Joint Surg 45B:703 708, 1963 9. McCue FC, Honner R, Chapman WC: Transfer of the brachioradialis for hands deformed by cerebral palsy. J Bone Joint Surg 52A:1171 1180, 1970 10. Sakellarides HT, Matza RA, Mital MA: The surgical treatment of the different types of thumb-in palm deformities in cerebral palsy. J Dev Med Child Neurol 21:116, 1979 11. Swanson AB: Surgery of the hand in cerebral palsy. Surg Clin North Am 44:1061 1070, 1964 12. Szabo RM, Gelberman RH: Operative treatment of cerebral palsy. Hand Clin 1:525 543, 1985 13. Zancolli EA, Goldner JL, Swanson AB: Surgery of the spastic hand in cerebral palsy: Report of the Committee on Spastic Hand Evaluation. J Hand Surg 8A:766 772, 1983

Address reprint requests to Michelle Gerwin Carlson, MD Hospital for Special Surgery 523 East 72nd Street New York, NY 10021

TENDON TRANSFERS

1082 3131/02 $15.00 + .00

Tendon Transfer for Wrist Flexion Deformity in Cerebral Palsy


Thomas W. Wright, MD

Patients with cerebral palsy commonly position their wrist in a palmar-exed, ulnar-deviated, and pronated position (Fig. 1). This position is assumed because of increased exor tone of the wrist and nger exors when compared with the extensors. Grip is markedly weakened by a wrist in a signicant palmar-exed position. This deformity may become a xed contracture if the patient has poor motor control and if no program of passive stretching is initiated. This article focuses on the pathophysiology of cerebral palsy associated wrist exion deformity, treatment rationale, surgical technique, rehabilitation, complications, and results. The treatment of wrist pronation contracture or the multiple other procedures performed for patients with cerebral palsy are not discussed.

From the Department of Orthopaedic Surgery, University of Florida, Gainesville, Florida

ATLAS OF THE HAND CLINICS Volume 7 Number 1 March 2002

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Figure 1. A, The typical position of the wrist in a functional patient with cerebral palsy shows a palmar exed, ulnar deviated, and pronated position. B and C, The Pulvertaft weave tenorrhaphy (long arrow) and the transferred FCU (asterisk). D, The wrist is near neutral when it is tested against gravity.

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Multiple tendon transfers have been proposed for treatment of the wrist exion deformity in functional patients with cerebral palsy and other brain injury patients. The transfers proposed include exor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB) (i.e., the Green transfer),3 FCU to extensor digitorum communis (EDC), pronator teres to ECRB,2 extensor carpi ulnaris (ECU) to ECRB, and brachioradialis to ECRB.4 The normal pattern of grasp and release is mandatory for a functional hand. A wrist in considerable palmar exion has inadequate grasp because the nger exors are at a mechanical disadvantage from relative shortening. The nger exors are generally strong in patients with cerebral palsy, but, with the wrist in substantial exion, the ngers will appear to be weak, and the patient will have difculty holding onto objects. If the wrist is corrected manually or with the use of a splint to the neutral position, nger exion will be strong, and, often, the patient will lose his or her ability to release an object (inadequate release pattern). This problem of inadequate release is as much a functional concern as weak grasp and must be addressed at the same time the wrist exion deformity is corrected. Strategies for treating this problem are presented herein. Patients with the most severe deformity may also have a xed wrist exion contracture and not just a deformity secondary to a dynamic imbalance of the wrist exors and nger exors. The FCU is the largest contributor to the exed and ulnar-deviated wrist position. This xed deformity is seen predominantly in the severely involved patient with cerebral palsy. Slow passive stretch with correction to neutral may not be possible in these patients. Higher-functioning patients generally have a passively correctable deformity that can be positioned in at least neutral. Two general groups of patients with cerebral palsy are treated for wrist exion deformities. One group includes high-functioning patients. The other group contains low-functioning, severely involved patients with cerebral palsy. Treatment of these two groups of patients is different with respect to surgical decision making. Much of the treatment described herein can also be applied to patients with other types of brain injuries and wrist exion deformities.

EVALUATION The evaluation of the patient with a wrist exion deformity secondary to cerebral palsy must take into account the entire patient and not just the deformity. Patients selected for a functional-type tendon transfer should have good cognitive skills, fair limb placement, and some cortical sensation. The presence of athetosis is not a contraindication to tendon transfer, but the complication rate may be higher.8 Procedures for the severely involved patient with cerebral palsy are entirely different and are directed at hygiene rather than function. On examination, the overall posture of the wrist is noted. The medical record should include a notation of whether the deformity is passively correctable. When the wrist position is corrected between 20 degrees of palmar exion and neutral, are the nger extensors strong enough to extend the ngers (Zancolli type 1)?10 A Zancolli type 2 patient cannot extend the metacarpophalangeal (MP) joints with the wrist in neutral but can actively extend the joints with the wrist in greater than 20 degrees of palmar exion. If the MP joints cannot be actively extended in any wrist position, a transfer directed at strengthening the nger extensors may be indicated (Zancolli type 3).10 Radiographs should be obtained at the time of consideration of denitive treatment of the wrist to assess for any bony deformity. An association between cerebral palsy and Kienbock disease has been reported. Dynamic electromyography is time consuming, difcult in the young child, and not performed in many centers but may provide valuable information as to the phasic pattern of a particular muscle. In the authors original evaluation, different

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patterns of spasticity were found from patient to patient, but, most consistently, the FCU and brachioradialis were active through grasp and release. It is not known whether their phasic activity would change with transfer, but this effect is unlikely.

Treatment Plan Functional Patients Functional patients who have cerebral palsy with wrist exion deformity are good candidates for tendon transfer. In most cases, this transfer must be combined with a need for weakening the nger exors and sometimes the remaining wrist exors. If a transfer is performed without addressing the exor side, frequently, the patient will have an inadequate release pattern. In patients with Zancolli type 1 deformity (active MP joint extension with the wrist in less than 20 degrees of exion), weakening of the nger and wrist exors by fractional lengthening may be all that is required; these cases are the exception. Most functional patients with cerebral palsy have deformities in the category of Zancolli type 2 (active MP joint extension with the wrist in greater than 20 degrees of exion). These patients are treated with an FCU to ECRB transfer in addition to fractional lengthening of the nger exors and wrist exors. The FCU transfer has a second benecial effect of increasing supination when routed along the ulnar border of the forearm.1 In Zancolli type 3 deformity (no active MP joint extension at any position of the wrist), the FCU is transferred to the EDC, and the wrist and nger exors undergo fractional lengthening. An alternative transfer for weak wrist extension is the pronator teres transferred to the ECRB. In the authors opinion, this procedure is a distant second choice to the FCU transfer because of the greater strength of the tenorrhaphy, removal of a considerable deforming force, and the supination effect of the FCU transfer.

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Treatment Plan Low/Nonfunctional Patients The treatment of wrist exion deformities in patients with a low level of function is directed at hygiene concerns (Fig. 2).

Figure 2. A, Wrist exion deformity in a patient with severe cerebral palsy. B and C, The patient underwent a profundus to supercialis transfer, Z-lengthening of exor carpi radialis and exor carpi ulnaris, and a proximal row carpectomy. Note the markedly improved wrist and nger posture in this patient postoperatively.

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Although most of these patients require no surgery, some patients with severe wrist exion deformities that are xed contractures may require operation for hygiene reasons. The ngers may be positioned in a clenched st, creating concerns about palm hygiene (this concern is actually less common if the wrist exion contracture is severe). If the wrist deformity is corrected, the nger in palm position will be exacerbated unless the procedure is combined with a supercialis to profundus tendon transfer. Another option is proximal row carpectomy, which obtains a relative lengthening of the exors of approximately 1 cm. The wrist xed contracture is corrected by the proximal row carpectomy, although a wrist fusion may still be required near skeletal maturity. Wrist exors are tenotomized or Z-lengthened when a supercialis to profundus transfer is performed (Fig. 3).

Radius

Flexor digitorum superficialis

Ulna

Flexor digitorum profundus tendons

Figure 3. A exor digitorum supercialis transfer to the exor digitorum profundus. (From Hisey MS, Keenan MA: Orthopaedic management of upper extremity dysfunction following stroke or brain injury. In Green DP, Hotchkiss RN, Pederson WC (eds): Greens Operative Hand Surgery, ed. 4. New York, Churchill Livingstone, 1999, pp 287 325; with permission.)

In the authors experience, in patients requiring surgery for hygiene issues, a proximal row carpectomy combined with a wrist fusion is a more predictable procedure than a tendon transfer (see Fig. 2B and C).

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SURGICAL TECHNIQUE IN FUNCTIONAL PATIENTS Flexor Carpi Ulnaris to Extensor Carpi Radialis Brevis The FCU to ECRB transfer is performed in functional patients with cerebral palsy who have a passively correctable deformity and some active MP joint extension with the wrist positioned in greater than 20 degrees of exion. These Zancolli type 2 patients are the most common group seen. The FCU to ECRB transfer is performed under general anesthesia with the arm placed on an arm table. Spastic elbow contractures improve dramatically under anesthesia, making positioning easier. The procedure is performed with an upper arm tourniquet. A long longitudinal incision is started 1 mm proximal to the proximal wrist exion crease and continued in a proximal direction over the FCU for the distal one third to one half of the forearm (Fig. 4).

Figure 4. The procedure is performed with an upper arm tourniquet. A long longitudinal incision is started 1 mm proximal to the proximal wrist exion crease and continues in a proximal direction over the exor carpi ulnaris for the distal one third to one half of the forearm. Extensive insertion of the exor carpi ulnaris (FCU) muscle on surronding fascia. It is mandatory to make this long incision and dissect the FCU to the proximal edge of the incision. This dissection obtains the correct line of pull and adequate excursion of the transferred tendon.

The distal FCU tendon is isolated and tenotomized just proximal to the pisiform insertion. The ulnar neurovascular bundle is encountered radial to the tendon at the wrist level and protected. The dissection is continued in a proximal direction, releasing the FCU muscle and tendon from the fascia and the periosteum of the ulna. Because of the extensive insertion of the FCU muscle on surrounding fascia, it is mandatory to make this long incision and dissect the FCU to the proximal edge of the incision. This dissection obtains the correct line of pull and adequate excursion of the transferred tendon.

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A second 4-cm oblique incision is made proximal to the extensor retinaculum over the ECRB tendon (Fig. 5).

Figure 5. A second 4-cm oblique incision is then made proximal to the extensor retinaculum over the extensor carpi radialis brevis tendon.

The ECRB is ulnar to the extensor carpi radialis longus (ECRL) and is carefully separated. The ECRB is a better wrist extender than the ECRL, which is a better radial deviator. A large window is created in the ulnar forearm fascia adjacent to the FCU at the proximal edge of the ulnar wound. The FCU is then transferred subcutaneously using a Bunnell tendon passer. Using a Dieter-Buck Gramco tendon passer, a Pulvertaft weave is created by passing the FCU through the ECRB (Fig. 6).

Figure 6. Strong Pulvertaft weave tenorrhaphy. (From Gelberman RH: Cerebral palsy. In Gelberman RH (ed): Operative Nerve Repair (vol. 2). Philadelphia, JB Lippincott, 1991, pp 1455 1475, with permission.)

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Appropriate tensioning of the transfer is performed by placing the wrist in maximum extension, retracting the ECRB proximally, pulling distally on the FCU to its full length, and then backing off 1 to 2 mm before passing the suture. A 3-0 nonabsorbable suture is passed through both tendons at the tenorrhaphy site in a horizontal mattress fashion. This preliminary tensioning is tested by holding the wrist horizontal and noting whether the transfer will hold the wrist in near neutral against gravity. If the wrist exes greater than 20 degrees, the transfer is not tensioned tight enough and must be revised. If the wrist is held in dorsiexion, it is overtensioned and must be adjusted appropriately. Although it is possible to overtension the transfer and create a dorsiexed wrist deformity, in the authors experience, overtension is difcult to achieve. Once the correct tension is obtained, an additional one or two passes of the FCU tendon through the ECRB are performed, and the tendon is sutured in place. Excess FCU tendon is then cut and removed. Figure 7A shows the volar forearm and the approach for harvesting the FCU. Figure 7B shows the dorsum of the forearm and the Pulvertaft weave of the FCU and ECRB.

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Ulnar a. and n.

FDS

FDP

FCU

EPL EPB ECRB ECRL

APBL

B
Figure 7. Flexor carpi ulnaris to carpi radialis brevis (ECRB) transfer. A, Volar forearm and the approach for harvesting the FCU. FDP exor digitorium profundus, FDS exor digitorum supercilias. B, Dorsum of the forearm and the Pulvertaft weave of the FCU and ECRB. EPL extensor pollicus longus, EPB extensor pollicus brevis, ECRB extensor carpi radialis brevis, ECRL extensor carpi radialis longus, APBL abductor pollicus brevis. (From Gelberman RH: Cerebral palsy. In Gelberman RH (ed): Operative Nerve Repair (vol. 2). Philadelphia, JB Lippincott, 1991, pp 1455 1475, with permission.)

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Alternatively, the FCU may be transferred through the interosseous membrane, but this route is not recommended. Such a transfer is at greater risk for adhesion formation. This route will also lose the benecial supination effect that occurs when the tendon is transferred around the ulnar border of the forearm. The FCU to ECRB tendon transfer is almost always performed with a concomitant fractional lengthening of the exors.

Flexor Carpi Ulnaris to Extensor Digitorum Communis Tendon Transfer The FCU transfer to the EDC tendons (Fig. 8) is performed when there is no active extension of the MP joints in any wrist position (Zancolli type 3).

EDC

FCU

Figure 8. Flexor carpi ulnaris to extensor digitorum communis transfer. (From Gelberman RH: Cerebral palsy. In Gelberman RH: Operative Nerve Repair (vol. 2). Philadelphia, JB Lippincott, 1991, pp 1455 1475, with permission.)

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The FCU is transferred in a similar method as previously described, but is passed through all four EDC tendons instead of the ECRB tendon. The dorsal incision is 4 to 5 cm proximal to the extensor retinaculum and oblique in orientation. The EDC tendons are exposed and sutured side-to-side with the MP joints in the normal cascade. A Pulvertaft weave is created by passing the FCU through each of the EDC tendons with the EDC tendons pulled proximally, the wrist in maximum extension, and the FCU pulled out to full length and then allowed to shorten 1 to 2 mm. Preliminary suture with a nonabsorbable 3-0 material is performed. The appropriate tension is checked against gravity, which should not allow the wrist to ex beyond 20 degrees with the MP joints at 0 degrees. Once the tension is appropriate, a second pass of the FCU is made through each of the EDC tendons and sutured in place. Excess FCU is removed. Care must be taken to ensure this tenorrhaphy does not bind on the extensor retinaculum. If the transfer impinges on the retinaculum, the proximal half of the retinaculum can be released. Alternatively, the tenorrhaphy may be moved more proximally. In both of the described FCU transfers, there is almost always a need to weaken the nger exors and sometimes the FCR as well. A third volar longitudinal incision about 4 to 6 cm in length is made over the middle third of the forearm. Alternatively, the proximal aspect of the incision for harvesting the FCU may be curved in a radial direction, allowing access to the myotendinous junctions of the nger exors. The palmaris longus is encountered and the underlying median nerve gently retracted. The palmaris longus tendon is incised and retracted. The myotendinous junctions of all the nger exors are exposed. Each nger exor tendon that is tight with the wrist in neutral is lengthened fractionally by carefully cutting through the tendon and not disturbing the surrounding muscle (Fig. 9). A fractional lengthening gains about 3 to 5 mm of length. In the patient who has a severely contracted nger exor, a second more proximal cut may be performed to gain additional length. Occasionally, the FCR may require fractional lengthening, but care should be taken not to overlengthen. If the FCR is lengthened too much, the wrist may become unbalanced, and a reversed dorsiexion deformity may be created. Fractional lengthening of the nger and wrist exors should be performed before the wrist or nger extension transfer so as to not disrupt the tenorrhaphy site.

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FCR FDS

Ulnar neurovasacular bundle

FCR FCU FDS

Ulnar neurovasacular bundle

FCU

C
Figure 9. A fractional lengthening. (From Gerwin M: Cerebral palsy. In Green DP, Hotchkiss RN, Pederson WC (eds): Greens Operative Hand Surgery, ed 4. New York, Churchill Livingstone, 1999, pp 287 325.)

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OTHER TRANSFER OPTIONS In a few patients, the ECU can be transferred to the ECRB. The specic patient who might benet from this transfer has a good grasp and release pattern and falls into palmar exion and ulnar deviation during grasp. This patient may also benet from an ECU transfer to the ECRB along with a fractional lengthening of the FCU. The surgical technique for ECU transfer consists of a dorsal oblique incision about 8 cm in length. Through this incision, the ECU and the ECRB can be exposed. The ECU is tenotomized distal to the retinaculum. It is then rerouted to the ECRB where a tenorrhaphy is performed with a Pulvertaft weave. A fractional lengthening of the wrist exors and possibly the nger exors may be required. The pronator teres transfer to the ECRB (Fig. 10) has been reported to provide wrist extension with good functional results in two thirds of the transfers.2 The pronator transfer has the advantage of removing one deforming force, the pronator, and applying this force to the ECRB. The disadvantage is that, unlike in previously described FCU transfers, it does not alleviate the deforming ulnar deviation force at the wrist. Also, the strength of the tenorrhaphy site is less than in the FCU to ECRB transfer.

EDC

A
ABPL ECRL ECRB Brachioradialis

ABPL

Supinator Pronator teres ECRB and ECRL

B D

ECRB ECRL PT ECRB ECRL

C
Figure 10. Pronator teres time to extensor carpi radialis brevis transfer. (From Gelberman RH: Cerebral palsy. In Gelberman RH (ed): Operative Nerve Repair (vol. 2). Philadelphia, JB Lippincott, 1991, pp 1455 1475.)

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The technique for pronator teres transfer to the ECRB begins with a 6-cm incision over the pronator insertion in the middle third of the radial forearm. The supercial radial nerve is exposed and gently retracted and the pronator insertion exposed. The pronator teres is elevated along with a strip of periosteum so as to lengthen the tendon. The muscle is circumferentially mobilized in a proximal direction. The tendon with its attached periosteum is then passed supercial to the ECRB, and a tenorrhaphy is performed using a Pulvertaft weave. Postoperative rehabilitation is essentially the same as described in the next section. The brachioradialis has been used as a transfer for wrist extension with good results.5 The disadvantage of this transfer is that the dissection to mobilize the brachioradialis and obtain the appropriate amount of excursion is extensive. The brachioradialis is a powerful muscle that is often severely spastic in patients with cerebral palsy. If this transfer is overly tensioned it can create an opposite wrist extension deformity. Currently, this transfer is used rarely for a wrist deformity secondary to cerebral palsy. The surgical technique for brachioradialis transfer to ECRB consists of an incision along the entire length of the radial forearm. The radial sensory nerve is encountered deep to the brachioradialis and is protected. The brachioradialis is elevated from its insertion on the radial aspect of the distal radius. It is then mobilized in a proximal direction, past its musculotendinous junction, circumferentially around its muscle belly. The fascial attachments must be incised to obtain any signicant excursion. The brachioradialis is then transferred to the ECRB using a Pulvertaft tenorrhaphy.

Surgical Postoperative Rehabilitation Patients who have undergone an FCU transfer to the ECRB are treated with a splint applied in the operating room with the wrist in 20 to 30 degrees of extension. Two weeks after surgery, the splint is changed to a fabricated cast in this same position. Six weeks following surgery, the cast is removed and an orthoplast splint placed. The splint is worn full-time for an additional month but can be removed several times a day for active range of motion of the wrist. Splint wear is weaned to a night splinting program by 3 months after surgery. Some patients with signicant exor tone may require a night splinting program on a long-term basis. This additional splinting may be particularly important during periods of growth. Patients who have undergone an FCU to EDC tendon transfer are placed in a splint that blocks the MP joints at 0 degrees and holds the wrist in 20 to 30 degrees of extension. Two weeks after surgery, a cast is placed that holds the same position an additional 2 weeks. Four weeks after surgery, an orthoplast splint is truncated with the wrist in extension and a removable MP joint exion block. The MP joint component of the splint is removed several times a day for active range of motion and training of the transfer. Six weeks after surgery, the wrist splint is removed several times a day to perform active range of motion. Composite nger and wrist exion should be avoided. Three months following the procedure, splint wear is weaned to a wrist control splint at night only. In cases with persistent signicant exor tone, it may be necessary to continue night splinting indenitely. Most patients undergoing the previous transfers will also have a nger exor fractional lengthening. In that situation, in addition to the immobilization for the transfer, the ngers are splinted in full extension to the nger tip. The ngers are held in full extension for 4 to 6 weeks, at which time the cast is removed, and an orthoplast splint holding the ngers is made. The splint is removed several times a day to initiate active range of motion. If considerable exor tone is present, a night splinting program may be necessary.

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AUTHORS PREFERRED METHOD OF TREATMENT FOR THE FUNCTIONAL PATIENT WITH CEREBRAL PALSY The author prefers to use the FCU transfer in all functional patients with cerebral palsy who have wrist exion deformities and some ability to extend the MP joints actively at any wrist position (most common group). This procedure is almost always accompanied by a fractional lengthening of the nger exors, tenotomy of the palmaris longus, and, possibly, a careful fractional lengthening of the FCR. If the patient has no ability to extend the MP joints actively even with wrist exion, the FCU is transferred to the EDC. This procedure is rarely needed because, in most instances, spasticity of the nger exors, not pure EDC weakness, overpowers the nger extensors and limits MP joint extension. Fractional lengthening of the tight nger and wrist exors is important. Patients with a weak grip who drift into palmar exion when trying to sustain a hard grasp are treated by weakening the exor side rather than performing a tendon transfer. A fractional lengthening of the wrist exors and possibly the nger exors is performed.

COMPLICATIONS The most signicant and common complication of the FCU to ECRB and FCU to EDC transfers is over- or undertensioning the transfer. With undertensioning, the patients ability to extend the wrist to neutral may be compromised, possibly necessitating functional wrist bracing or revision of the procedure. The opposite situation of overtensioning is less common in the authors experience but, when present, is a signicant problem often leading to the need for revision surgery. Thometz and coworkers6 had two extension contractures in a series of 25 wrists that underwent an FCU to ECRB transfer.

RESULTS Beach and co-workers1 reported on the results of FCU to ECRB transfer. They found that although the total arc of wrist motion did not change, but the arc was now centered around neutral rather than exion. Cosmetic improvement was seen in 88% of patients, 79% had functional improvement, and no patient lost function. Athetosis did not adversely affect the outcome in this series. Thometz and coworkers6 reported on 25 patients with FCU to ECRB transfer with an average follow-up of 8 years, 7 months. Mean active wrist extension was 44 degrees and palmar exion 19 degrees. There were nine good, ve fair, and ve poor results noted by the modied Green grading system. Other reported series employing this transfer have noted an improvement of wrist extension ranging from 34 to 44 degrees.6,7 The average resting wrist position after an FCU to ECRB transfer is 11 degrees of exion.1,5,9

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The FCU to ECRB transfer (Fig. 11), when routed the usual way around the ulnar aspect of the forearm, may improve forearm supination an average of 22 degrees.1 This range of motion can be signicantly improved by the addition of a pronator rerouting.

Figure 11. A E, A patient who is 9 months postoperative after a exor carpi ulnaris to extensor carpi radialis brevis transfer and fractional lengthening of the nger exors. The ability to extend ngers and grasp an object with the wrist in neutral is shown. Illustration continued on following page

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Figure 11. (Continued)

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SUMMARY The treatment of wrist exion deformities secondary to cerebral palsy can be gratifying from both an appearance and functional standpoint. The mainstay of treatment in the functional patient with cerebral palsy who has some active MP extension is the FCU to ECRB transfer with fractional nger exor lengthening. For the low/nonfunctional patient with cerebral palsy, the treatment goal is to improve hygiene and is best served without surgery or by a proximal row carpectomy/wrist fusion and profundus to supercialis transfer. Despite the lack of treatment options for the brain injury, a balanced wrist with an improved grasp and release pattern can go a long way toward helping patients with activities of daily living and improved self-esteem.

References
1. Beach WR, Strecker WB, Coe J, et al: Use of the Green transfer in treatment of patients with spastic cerebral palsy: 17 years experience. J Pediatr Orthop 11:731 736, 1991 2. Colton CL, Ransford AO, Lloyd-Roberts GC: Transportation of the tendon of the pronator teres in cerebral palsy. J Bone Joint Surg 58B: 220 223, 1976 3. Gerwin M: Cerebral palsy. In Green DP, Hotchkiss RN, Pederson WC (eds): Greens Operative Hand Surgery, ed 4. New York, Churchill Livingstone, 1999, pp 259 286 4. Green WT, Banks HH: Flexor carpi ulnaris transplant and its use in cerebral palsy. J Bone Joint Surg 44A:1343 1352, 1962 5. McCue FC, Honner R, Chapman WC: Transfer of the brachioradialis for hands deformed by cerebral palsy. J Bone Joint Surg 52A:1171 1180, 1970 6. Roth JH, OGrady SE, Richards RS, et al: Functional outcome of upper limb tendon transfers performed in children with spastic hemiplegia. J Hand Surg 18B:299 303, 1993 7. Thometz JG, Tachdjian M: Long-term followup of the exor carpi ulnaris transfer in spastic hemiplegic children. J Pediatr Orthop 8:407 412, 1988 8. Tonkin M, Gschwind C: Surgery for cerebral palsy. Part 2. Flexor deformity of the wrist and ngers. J Hand Surg 17B:396 400, 1992 9. Wenner SM, Johnson KA: Transfer of the exor carpi ulnaris to the radial wrist extensors in cerebral palsy. J Hand Surg 13A:231 233, 1988 10. Zancolli EA, Zancolli ER: Surgical management of the hemiplegic spastic hand in cerebral palsy. Surg Clin North Am 61:395 406, 1981

Address reprint requests to Thomas W. Wright, MD Department of Orthopaedic Surgery University of Florida Box 100246 Gainesville, FL 32610 e-mail: Thomas-wright@u.edu

TENDON TRANSFERS

1082 3131/02 $15.00 + .00

Supercialis to Profundus Tendon Transfer


Douglas A. Palma, MD, David A. Fuller, MD, and Mary Ann E. Keenan, MD

Spasticity in the upper extremity can produce severe exion contractures in the wrist and hand in patients with injury to the upper motor neuron system. The exion contractures can lead to difculties with positioning, dressing, and hygiene and are frequently painful. Skin maceration, pressure ulcerations, and nail deformities are common with advanced deformity. Surgery is the treatment of choice. A exor digitorum supercialis (FDS) to exor digitorum profundus (FDP) tendon (STP) transfer is indicated to treat severe spastic exion contractures of the hand. The hand is repositioned to relieve pain, improve hygiene, and ease activities of daily living for patients and caregivers. The STP transfer has been advocated as treatment in the nonfunctional hand with a spastic clenched st deformity. The goal of surgery is to rebalance the muscle forces around the wrist and hand. If the exor tendons to the ngers and wrist are simply released, with time, the unopposed tone in the extensors can produce an extension deformity of the ngers and wrist. Over the last 10 years, the authors have performed over 75 STP transfers and have found the procedure to be an effective, predictable, and safe operation.

NONOPERATIVE MANAGEMENT Nonoperative treatment of the spastic clenched st may be useful for early or mild deformity. Passive modalities include stretching, splinting, and custom orthoses. These modalities should be performed in conjunction with an experienced occupational therapist and can risk pressure ulceration and iatrogenic fracture. Systemic medications and local neuromuscular blocking agents such as botulinum toxin A can be helpful in controlling spasticity in a dynamic deformity. Despite appropriate nonoperative treatment, deformity can progress over time. Advanced deformities do not respond to nonoperative treatment, including stretching, therapy, splinting, antispasticity medications, or intramuscular injections.

From the Department of Orthopaedic Surgery, Albert Einstein Medical Center; and Thomas Jefferson University, Philadelphia, Pennsylvania (DAP, DAF, MAEK)

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PREOPERATIVE EVALUATION The spastic clenched st deformity is common in brain injury or stroke. This pattern results from unmasking of the primitive grasp reex. The ngers are typically clasped into the palm, and the ngernails may be embedded into the palmar skin. Appropriate access to the palm for washing may also be compromised. Skin maceration, breakdown, and malodor may occur in the chronically contracted hand. Figure 1 illustrates a full-thickness skin ulceration due to pressure in the hand from untreated spastic contractures.

Figure 1. Intraoperative full-thickness skin breakdown and hygiene problems resulting from severe exion contracture. The exor tendons have already been released to allow nger extension.

Signs and symptoms of pain may be elicited from the patient when caregivers attempt to pry ngers open to gain palmar access. The examination begins with an assessment of the passive range of motion. Following this determination, the patient is asked to open and close the ngers and to ex and extend the wrist. If no active wrist or nger extension is seen, one must assess whether there is active control of nger exion. The degree of motor control may be masked by the severe amount of tone present in the nger exors. Often, an increase in the pressure of grasp can be felt during attempted nger exion, indicating underlying muscle control. Spastic nger exors may override and mask the patients potential to extend the ngers. A temporary lidocaine nerve block of the exor muscles can help to identify potential extensor muscle activity. Muscles that contribute to the clenched st deformity include the FDS and FDP. If the proximal interphalangeal (PIP) joints ex while the distal interphalangeal (DIP) joints remain extended, spasticity of the FDS rather than FDP is suspected. Despite the marked increase in tone, there often exists some underlying volitional control in either or both sets of extrinsic nger exors. The FDP typically has less spasticity and better volitional control than the FDS. The intrinsic muscles may be also be spastic but an intrinsic plus posture (i.e., combined metacarpophalangeal [MCP] exion and PIP extension) is often not seen because spastic extrinsic exors dominate by exing the PIP joints. Some degree of contracture of the intrinsic muscles is typical of the chronically clenched st.

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OPERATIVE MANAGEMENT The patient is positioned supine. A hand table is recommended. Contractures at the shoulder and elbow can make positioning of the extremity difcult and may need to be corrected at the same time. Perioperative antibiotics are recommended as a prophylactic measure against infection. Frequently, the skin in a severe clenched st deformity will be colonized with organisms resistant to multiple antibiotics because of the patients exposure to bacteria in multiple institutions. General anesthesia and tourniquet hemostasis are routine. The preoperative position of the wrist and hand in a patient sustaining a traumatic brain injury is depicted in Figure 2.

Figure 2. Preoperative spastic hand and wrist with no active function. The wrist exors and extrinsic nger exors are contracted. An intrinsic plus position is also apparent.

Flexion contractures of the wrist exors, extrinsic nger exors, and intrinsic nger exors all contribute to the position. The ngers often manifest contractures at the PIP and DIP joints as well, although not seen in this patient.

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A volar incision is drawn extending from the palm into the mid forearm as shown in Figure 3.

Figure 3. Intraoperative skin incision.

The incision is made straight across the wrist exion crease. A simultaneous wrist arthrodesis was planned for the patient in Figure 3, eliminating the concern for scar contracture across the wrist exion crease. The incision needs to be proximal enough to allow the release of the profundus tendons from their muscles and distal enough to release the carpal tunnel. It is often difcult to incise the palm owing to the severity of the nger exion contractures. The entire incision may not be completed until the nger exor tendons are released.

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After incising the skin, the median and ulnar nerves along with the ulnar and radial arteries are identied and protected. The median nerve is often draped across the taut FDS tendons at the level of the wrist, showing stricture indicative of nerve compression. Peripheral compression of the median nerve is typically caused by bowstringing of the supercial nger exors, which lift the nerve from its bed and can press it against the proximal edge of the transverse carpal ligament. Figure 4 shows a vessel loop around the stenotic median nerve as it crosses over the tight FDS tendons.

Figure 4. Intraoperative exor digitorum supercialis (FDS) tendons with a blue vessel loop around the median nerve. The median nerve chronically compressed by the contracted nger exors against the transverse carpal ligament.

The four FDS tendons are isolated as distally in the palm as possible and sutured together with nonabsorbable material. The authors use a 1-0 braided polyester suture as shown in Figure 5.

Figure 5. Intraoperative with an clamp around the exor digitorum supercialis (FDS) tendons that are under tension to the exor digitorum profundus tendons. The FDS tendons are sutured en masse distally in the wound.

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Maximum length of the FDS tendons is desired so that when the transfer is performed, there will be adequate length in the transferred tendons. The FDS tendons are then transected distal to the suture site. Once the FDS tendons have been cut distally, they can be elevated out of the wound to allow visualization as shown in Figure 6.

Figure 6. Intraoperative exor digitorum supercialis (FDS) tendons transected and retracted proximally. In the proximal wound, the exor digitorum profundus (FDP) tendons are sutured en masse before transection.

The four FDP tendons are sutured together proximally using nonabsorbable material, with all of the ngers placed in a balanced position so that, after the transfer, the ngers will be in an acceptable cascade. Once sutured together, the four FDP tendons are released from their proximal muscles.

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After the FDS and FDP tendons have been released, the wrist and ngers should be brought to a neutral position. Wrist exors often need to be released or lengthened to bring the wrist to a neutral position. The exor pollicis longus is also released from its proximal muscle to allow the thumb to be extended. Skin and neurovascular structures need to be closely observed during this extension maneuver. Volar skin can be torn or ischemia created in the digits owing to excessive tension on the soft tissues. The position of the FDS and FDP tendons is shown after the straightening maneuver in Figure 7.

Figure 7. Intraoperative transected sutured exor digitorum supercialis (FDS) and exor digitorum profundus (FDP) tendons, along with exor pollicis longus prior to transfer. Fingers and wrist are extended. FPL exor pollicis longus

Joint contractures at the PIP and DIP joints often need to be manipulated gently to achieve passive nger extension.

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With the wrist positioned in neutral and the ngers fully extended, the length and tension of the transfer are estimated. Depending on the length of the transected tendon stumps, the STP transfer is completed with an end-to-end or side-to-side transfer. Some activity of the FDS muscle proximally is to be expected, which will potentially ex the ngers to a limited extent. To reduce the risk of recurrent deformity, the muscle activity should be considered when tensioning the transfer. The supercialis and profundus tendons are secured together using a 1-0 nonabsorbable suture. The tourniquet is often deated before wound closure to assess the vascularity of the ngers as shown in Figure 8.

Figure 8. Intraoperative completed FDS to exor digitorum profundus (FDP) transfer. Flexor pollicis longus has been incorporated separately. The tourniquet is deated to assess vascularity and provide hemostasis.

Total tourniquet time is generally about 30 minutes. Electrocautery is used for hemostasis. Drains are not routinely used. The skin is closed with an absorbable suture in the subcutaneous tissue and a nylon suture in the skin. The postoperative position of the wrist and hand is shown in Figure 9.

Figure 9. Intraoperative nal hand position after closure. Skin is under moderate tension in this closure. Metacarpophalangeal joints can be fully extended passively and an intrinsic release was not performed.

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In addition to the tendon transfer, a carpal tunnel release, ulnar motor neurectomy, and wrist arthrodesis were performed. Postoperative position is maintained with a forearm-based volar plaster splint extending to the nger tips. The wrist is held in about 15 degrees of extension, and the ngers are fully extended.

POSTOPERATIVE CARE Postoperative care begins with an overnight stay in the hospital for analgesia, elevation, and neurovascular checks. The patient is usually discharged on the rst postoperative day unless problems arise. A follow-up examination is scheduled approximately 14 days after surgery for wound check, removal of sutures, and casting. A short arm cast with the wrist in neutral and the ngers fully extended is applied for an additional 4 weeks to allow healing of the arthrodesis. The cast is removed at 6 weeks, and a removable night splint is worn for an additional 6 weeks. Figure 10 shows the hand and wrist at the 6-week follow-up visit.

Figure 10. Six week postoperative view showing healed wounds. The intrinsic plus position has resolved. The ngers are nicely extended and the wrist is in a neutral, stable position. Little chance for recurrence of deformity exists for this hand and wrist.

The intrinsic plus position of exion at the MCP joint has resolved, with elimination of the intrinsic tone owing to the ulnar motor neurectomy and the stretching in the cast.

COMPLICATIONS Complications have included supercial wound infections, abnormal swelling, hardware failures, and pulmonary complications.14 Review of the authors experience has revealed other complications, including deep infection, arterial laceration, and recurrence of deformity. In addition to the potential complications related to the procedure, many patients have multiple medical problems. Urinary retention and urinary tract infections are common. Gastrointestinal dysmotility and ileus are also common in this patient population. Pulmonary toilet is essential because these patients are at risk for aspiration and pneumonia. Skin integrity elsewhere in the body, such as the sacrum and heel, needs to be monitored vigorously periopera-

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tively. Nutrition should be optimized to promote healing after surgery. Patients are often on a plethora of medications, and diligence is required to prevent medication errors. DISCUSSION The authors recommend performing an ulnar motor neurectomy at the same time as the STP procedure, even if the intrinsic plus position is not evident before surgery. Intrinsic spasticity can present after the STP procedure if the ulnar motor neurectomy is not performed. Intrinsic spasticity will compromise the result of the STP procedure and lead to an intrinsic posture of the hand. If intrinsic spasticity has been present for a prolonged time, the exion at the MCP joint may be rigid, and release of the intrinsics at the same time as the STP procedure may be required. In addition to the ulnar motor neurectomy, the authors routinely perform a wrist arthrodesis to control the position of the wrist. Without stabilizing the wrist, release of the wrist exors can cause a hyperextension deformity and subluxation of the carpus. A carpal tunnel release is also routinely performed. Release of the carpal tunnel allows maximizing the length of the supercialis tendons for transfer by providing access to the tendons distally in the palm. Substantial length is required to straighten the ngers fully. In addition to achieving greater tendon length, release of the carpal tunnel will fully decompress the median nerve and provide pain relief. Profound swelling can be encountered with such extensive surgery at the wrist and hand, making it difcult to close the surgical wounds. The volar wrist skin is at greatest risk for problems with wound healing because this tissue is often thin and can be under signicant tension. This tension can be lessened by shortening the carpus at the time of wrist arthrodesis with a proximal row carpectomy. SUMMARY The STP transfer is a safe and reliable operation to reposition the hand with advanced exion contractures. Surgery is often performed in combination with other procedures to provide a permanent and predictable correction of the hand and wrist position. A high rate of satisfaction has been reported by patients and caregivers.

References
1. Botte MJ, Keenan MA, Korchek JI, et al: Modied technique for the supercialis-to-profundus transfer in the treatment of adults with spastic clenched st deformity. J Hand Surg 12A:639 640, 1987 2. Braun RM, Vise GT, Roper B: Preliminary experience with the supercialis-to-profundus tendon transfer in the hemiplegic upper extremity. J Bone Joint Surg 56A:466 472, 1974 3. Keenan MA, Korchek JI, Botte MJ, et al: Results of transfer of the exor digitorum supercialis tendons to the exor digitorum profundus tendons in adults with acquired spasticity of the hand. J Bone Joint Surg 69A:1127 1132, 1987 4. Keenan MA, Waters RL: Surgical treatment of the upper extremity after stroke and brain injury. In Chapman M (ed): Operative Orthopedics, ed 2. Philadelphia, JB Lippincott, 1993, pp 1529 1544 5. Pomerance JF, Keenan MA: Correction of the severe spastic exion contractures in the nonfunctional hand. J Hand Surg 21A:828 832, 1996 Address reprint requests to Douglas A. Palma, MD Department of Orthopaedic Surgery Albert Einstein Medical Center Willow Crest Building, 4th oor 5501 Old York Road Philadelphia, PA 19141 e-mail: Dapsurfer@aol.com

TENDON TRANSFERS

1082 3131/02 $15.00 + .00

Functional Free Gracilis Transfer for Upper Extremity Reconstruction


Milan Stevanovic, MD, and Frances Sharpe, MD

Functional free muscle transfer was rst reported in an animal model by Tamai and co-workers14 in 1970. This technique was successfully applied in humans by Harii and co-workers6 using a functional free gracilis transfer for reconstruction of facial paralysis in 1976. Manktelow and Zucker8,11 popularized the use of functional free muscle transfers for reconstruction of functional decits, including those of the upper extremity.

PRINCIPLES OF MUSCLE TRANSPLANTATION IN THE UPPER EXTREMITY When possible, functional loss due to nerve or muscle injury should be reconstructed with a tendon transfer or with functional muscle rotational aps. When these procedures are not feasible owing to unavailability of an appropriate donor, functional free microneurovascular muscle transfer should be considered.15,8,10,12 To perform a successful free microneurovascular muscle transfer, several conditions should be met at the recipient site. These conditions include the availability of an undamaged motor nerve; adequate soft-tissue coverage at the recipient site, especially in the distal portion of the recipient site; full passive range of motion of the joint(s) in which function is to be restored; and a clean, infection-free, soft-tissue bed. For reconstruction of nger exion or extension, the exor or extensor tendons should be intact from 2 cm proximal to the wrist joint to their distal insertions, and the tendons should glide freely.

From the Department of Orthopedics, Keck School of Medicine, University of Southern California Los Angeles County Medical Center, Los Angeles (MS); and Kaiser Permanente, Fontana (FS), California

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MUSCLE SELECTION Several muscles have been used successfully in upper extremity reconstruction. These muscles include the latissimus dorsi, serratus anterior, rectus femoris, tensor fascia lata, and gracilis. The donor muscle selected for reconstruction should t certain criteria. The muscle should have sufcient strength to replace the lost function and adequate excursion to maximize joint range of motion. Other requirements are a single neurovascular pedicle and tendon origin and insertion of sufcient size to allow proper reattachment to the muscle. Adequate antagonist muscle function must be present. The hand should be sensate, and the patient must be motivated. When a soft-tissue defect is present, the donor muscle should be of ample size to ll the area of defect and provide coverage for underlying bone, tendons, and neurovascular structures. Whenever possible, the donor muscle should be harvested as a musculofasciocutaneous ap to allow better muscle gliding below the skin. The donor muscle should not result in a signicant functional or cosmetic decit at the donor site.

GRACILIS MUSCLE The gracilis muscle is a strap muscle that is broad proximally and that tapers distally, with an average length ranging from 35 to 40 cm. The tendinous portion averages around 6 cm in length. It is supercially located on the medial aspect of the thigh and functions to adduct and medially rotate the thigh. It also acts as a weak knee exor. It is the weakest of the adductors, and its removal does not result in signicant functional loss. The muscle origin is from the body of the pubis and adjacent ramus of the ischium. Its well-dened tendon inserts into the medial surface of the proximal tibia, distal to the tibial tubercle. The insertion of the gracilis lies between the insertions of the sartorius (anteriorly) and the semitendinosis (posteriorly). Stimulation of the gracilis will shorten the muscle length by over 50%, which produces approximately 15 cm of muscle excursion.8 The blood supply to the gracilis is through several pedicles. The dominant pedicle enters the muscle between 8 and 12 cm from the muscle origin. The length of the pedicle ranges from 4 to 6 cm. The arterial diameter is 1 to 2 mm, and the two concomitant veins can range from 1 to 4 mm in diameter. Manktelow described one case in which the superior pedicle was a double pedicle, with two arteries and four concomitant veins. In that case, the muscle circulation proximal to the pedicle was supplied by one artery, and the muscle circulation distal to the pedicle was supplied by the other artery. The gracilis also has two or three more distally lying smaller vascular pedicles. These pedicles can be ligated without compromising the muscle because the larger proximal pedicle provides adequate circulation for the entire muscle. If the muscle is dissected with a skin paddle, only the skin paddle overlying the proximal half of the muscle is reliable. The skin paddle is supplied by a constant single perforating vessel that enters the skin paddle at the level of the dominant muscle vascular pedicle. Because the skin paddle relies on a single perforating vessel, it is more susceptible to injury, particularly from shearing forces. The skin paddle on the medial thigh is often thick and bulky, and it is easier for this bulky tissue to produce high shear forces at the fasciocutaneous perforator. The nerve supply to the gracilis is from a single motor branch of the obturator nerve that enters the muscle immediately proximal to the vascular pedicle. The nerve branch is composed of two to three fascicles surrounded by an abundance of fat tissue. The fascicles can be easily separated from the fat tissue and individually stimulated. A single fascicle can control 20% to 50% of the anterior portion of the muscle; the remaining portion of the muscle is controlled by the other fascicles. This

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territorial distinction can be useful when trying to reconstruct independent thumb and nger exion.9 PREOPERATIVE PLANNING Recipient Site Planning Before considering functional muscle transplantation, several criteria must be met with respect to the recipient site. The patient should have sufcient passive range of motion of the joints for which the function is to be restored; an undamaged motor nerve with a cross-sectional area similar in size to the motor nerve of the gracilis should be available as a donor; and skin coverage of the distal half of the gracilis and the site of tendon repair should be adequate for tendon gliding to assure a good functional outcome. Only the proximal half of the gracilis can be reliably covered by harvesting the gracilis with an overlying skin paddle. In general, the authors recommend this maneuver to allow for proximal muscle gliding and to enable monitoring of the transferred tissue. In patients who have sustained a signicant soft-tissue injury or a Volkmanns ischemic contracture associated with functional loss, preoperative planning may include angiography or MR angiography with gadolinium to better identify the recipient vessels. Operating Room Planning When possible, the procedure should be performed in a two-team approach. Appropriate microsurgical instruments and an operating microscope should be available. The room temperature should be between 75 and 80 F, at least until the patients core temperature has stabilized around 98.6 F. A pathologist experienced in neurohistochemical staining should be available if there is a question regarding the suitability of the recipient site donor nerve. SURGICAL TECHNIQUE Even when a two-team approach is used, the recipient site should be explored and a suitable recipient artery, vein, and nerve identied. If there is a question regarding the recipient nerve, further investigation must be performed before harvesting the gracilis. Investigation may include examination under the microscope, frozen section, or histochemical identication of the sensory and motor fascicles of a mixed nerve. These studies may take up to 2 hours. Awake nerve stimulation may also be used to distinguish motor from sensory fascicles. This technically demanding procedure is best indicated for separating motor from sensory bers for the axillary and musculocutaneous nerves. When these structures are adequately identied, simultaneous preparation of the recipient site and dissection of the gracilis muscle can proceed with two surgical teams. Preparation of the Recipient Site Preparation of the recipient site begins with elevation of skin aps. The distal tendons of the muscles in which function is to be restored are identied and evaluated for their ability to glide within their soft-tissue bed. Dissection for the transplanted gracilis muscle origin is carried out. The operating microscope is then brought to the operating eld, and the previously identied artery, vein, and nerve are prepared.

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Gracilis Muscle Dissection Dissection of the gracilis begins with identication of the tendon distally through either a transverse or a longitudinal incision just proximal to the adductor tubercle. The tendon lies between the muscle of the sartorius and musculotendinous region of the semitendinosus. When the tendon is identied distally, a half-inch Penrose drain is placed below the tendon. Tension is applied to the Penrose drain to allow identication of the muscle proximally and to plan the proximal skin incision and paddle. After the skin paddle is designed, the proximal dissection is carried out. The proximal incision and dissection should extend distally to the level of the musculotendinous junction. The posterior limb of the skin paddle and the posterior margin of the gracilis should be dissected rst because the neurovascular pedicle is located anteriorly. During dissection of the skin paddle, the subcutaneous tissue layer is beveled away from the paddle, creating a wider base for supplying the skin ap and to minimize the risk of injury to the perforating branches. The skin paddle should be secured to the muscle fascia to prevent shearing injuries to the perforating branches. The anterior limb of the skin paddle and the anterior margin of the gracilis are dissected. To measure the correct resting length of muscle, the thigh is abducted and the knee extended (Fig. 1A). A ruler is used to measure 5-cm increments from the muscle origin to the distal aspect of the musculotendinous junction. These increments are marked with a 4-0 silk suture through the muscle belly. The gracilis may be supplied by several pedicles. The proximal vascular pedicle is dominant and should be meticulously dissected. The smaller more distally lying pedicles should be ligated. The motor branch to the gracilis from the obturator nerve always lies proximal to the dominant pedicle. The vascular pedicle and motor branch are dissected and mobilized to provide maximum length.

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The gracilis tendon is released as distally as possible. A retractor or a nger is placed below the muscle origin to protect the surrounding structures. Using cautery, the muscle origin is released from the pubis. The muscle is mobilized, leaving the pedicle intact, and is allowed to perfuse for 15 to 20 minutes (Fig. 1B).

Obturator n. branch Profunda femoris a. & v.

Suture markers Gracilis

Vascular pedicle to gracilis m.

B
Figure 1. A, Measurement of the resting length of the gracilis. B, Harvested gracilis muscle.

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Revascularization When the muscle has been perfused and the vasospasm has resolved, the pedicle is ligated, maintaining maximum pedicle length. The muscle is transferred to the recipient site. Provisional staples or sutures are used to secure the muscle to the surrounding tissues. The gracilis origin is sutured to the intended recipient site origin. The muscle belly is stretched to its resting length, and the position of the vascular repair is assessed. The position of the vascular anastomosis is determined with the muscle stretched to its resting length and at its maximally shortened length. There should be no traction on the pedicle during either lengthening or shortening of the muscle belly. At the time of wound closure, the pedicle must be carefully evaluated and positioned so that there is no redundancy of the pedicle that would allow it to be kinked. The skin aps should be carefully positioned so as not to compress the pedicle. If the skin closure is too tight, and the pedicle is at risk of compression, it is better to change plans for wound closure and consider a skin graft or other closure options. The arterial repair is performed rst either as an end-to-end or an end-to-side anastomosis, dependent on the recipient vessel. For an end-to-end repair, the authors prefer to use a 10-0 nylon suture on a 75 m needle. For an end-to-side repair, a 9-0 nylon suture is used on a 100 m needle. The venous repair is performed endto-end. A concomitant vein is used for the recipient vein. The repair is performed with 10-0 nylon suture on a 75 m needle.

Reinnervation Nerve repair should be carried out as close as possible to the gracilis muscle belly. An epineurial repair is done with 10-0 nylon on a 75 m needle. Manktelow and colleagues have recommended a fascicular repair with 11-0 nylon suture. This repair may be useful in reconstructing two independently controlled neuromuscular units; however, the maneuver requires two appropriately sized suitable motor fascicles at the recipient site. At times, nerve grafting may be required to reach the recipient nerves. The sural nerve is the most common donor for grafting.

Muscle Position and Tension When the vascular and neural anastomoses have been completed, the gracilis muscle origin is denitively secured. Adjustments are made to the provisional xation to minimize compression or traction on the pedicle and to best recreate the anatomic axis of pull of the muscle function that is to be restored. The origin is secured with a horizontal mattress stitch using nonabsorbable braided 2-0 suture.

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The transferred muscle is stretched to its resting length such that the previously placed marker sutures are at 5-cm intervals (Fig. 2A). The distal tendon repair is performed with the extremity in extension when restoring exion and in exion when restoring extension. When possible, the distal repair is completed as a Pulvertaft weave using a braided 3-0 nonabsorbable suture (Fig. 2B). In the deltoid reconstruction, the distal repair is often near the musculotendinous junction of the gracilis, and the repair may be done directly to bone.

Radial a. (end-to-side) venae comitantes Ant. interosseous n. 5 cm Pull Medial epicondyle Gracilis m.

Flexor tendons

Neurovascular bundle

Flexor pollicis longus tendon

Flexor tendons

B
Figure 2. A, Restoration of resting length at the transplant site. B, Transplanted muscle with new origin and insertion.

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Soft-Tissue Coverage The transplanted muscle requires a healthy soft-tissue environment so that it can glide freely in its transposed position. Harvesting a fasciocutaneous skin paddle with the gracilis provides smooth gliding coverage for the proximal half of the muscle. The distal tendinous portion of the gracilis cannot be covered with the skin paddle or a skin graft. For reconstruction of the shoulder girdle and arm, the distal gracilis is usually easily covered by local tissue. In the forearm, there is more commonly soft-tissue deciency, which may require additional procedures, such as preoperative soft-tissue expansion or a random fasciocutaneous ap.

Intraoperative and Postoperative Management During the surgical procedure, the anesthesiologist should closely monitor the patients core temperature, systolic blood pressure, and urinary output. The patient should not be paralyzed for the procedure, especially when trying to separate the fascicles of the nerve to the gracilis to restore independent function to the thumb and ngers. Urinary output should be between 80 and 100 mL/hour. Systolic blood pressure should not be maintained with vasopressors. Before the microsurgical anastomosis, the patient may be kept hypotensive. After the vascular anastomosis, the systolic blood pressure should be maintained between 120 and 130 mm Hg. Postoperatively, the patient is monitored in an intensive care unit, ideally by nursing staff familiar with free-tissue transfers. The room temperature should be maintained between 75 and 80 F. The patient should be kept without enteral intake but well hydrated. Urinary output should be between 80 and 100 mL/hour for the rst 24 hours. The ap should be monitored for temperature and capillary rell. Doppler signal is not always audible through the skin ap. In the rst 24 hours, any rmness of the skin paddle or purplish petechiae around the edges are signs of venous obstruction, and the patient should immediately be taken to the operating room for reexploration. These signs, even in the presence of a normal temperature and capillary rell, are sufcient to warrant emergent surgery. If the surgical anastomosis is patent, the dominant perforators to the skin paddle should be examined. If outow from the skin paddle is compromised, the skin paddle should be removed, and the muscle should be skin grafted. If thrombosis occurs, revascularization of the muscle can be achieved, even with 3 hours of ischemia time. Nevertheless, more than 2 hours of ischemia time in a functional muscle transfer can cause irreparable damage to the muscle function. If ischemia time exceeds 2 hours, the transposed muscle should be removed and replaced with a new functional graft. Postoperative immobilization is continued for 4 weeks. Uninvolved joints are kept supple through active and passive range of motion. At 4 weeks, a therapy program of passive stretching of the transferred muscle is initiated. When spontaneous muscle contraction occurs, the patient is encouraged and directed in active range of motion and gradual resistive exercises. The authors believe that after spontaneous muscle contraction occurs, there is a role for muscle stimulation in muscle reeducation.

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FUNCTIONAL RECONSTRUCTION Functional reconstruction of the anterior deltoid (Fig. 3), biceps (Fig. 4A C), triceps (Fig. 5), forearm exors (Fig. 6A E), and forearm extensors (Fig. 7, Fig. 8A E) is outlined in Table 1. (Text continued on page 179)

Axillary n.

Gracilis

Deltoid insertion Thoracodorsal a. & venae comitantes

Figure 3. Anterior deltoid reconstruction.

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Branch of accessory n.

Gracilis

Thoracoacromial a. & v.

C
Figure 4. A, Biceps reconstruction. B and C, This 32-year-old patient sustained a right-side brachial plexus injury from a motorcycle accident 3 years before presentation. He underwent brachial plexus exploration and repair 4 months after his initial injury. He had good recovery of hand function, partial recovery of deltoid and latissimus function, and no recovery of his musculocutaneous nerve function. He underwent a functional free gracilis muscle transfer with arterial anastomosis to the thoracoacromial artery and vein, and neural anastomosis to a trapezial branch of the accessory nerve. At 3 years, he recovered 120 of elbow exion with M-4 strength.

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Post. margin of acromion

Gracilis m.

Thoracodorsal a. & venae comitantes Triceps branch of radial n.

Latissimus dorsi Triceps tendon

Figure 5. Triceps reconstruction.

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Figure 6. A 6-year-old patient underwent resection of a rhabdomyosarcoma of the forearm. The tumor involved the exor-pronator muscle mass of the proximal forearm. Following excision of the exor muscles, with the exception of the exor pollicis longus, a functional free gracilis was transferred to provide soft-tissue coverage of the proximal forearm and to restore exor function to the ngers. A, MR image of the rhabdomyosarcoma. B, Resection of the tumor and exor-pronator group. C, Transplanted gracilis with skin paddle. Neural anastomosis was performed to the motor branch of the exor digitorum supercialis. Arterial repair was performed end-to-side to the ulnar artery and venous repair was an end-to-end repair to the concomitant vein. Illustration continued on opposite page

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Figure 6 (Continued). D and E, Functional outcome 2 years from initial surgery.

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Lateral epicondyle Radial a. & venae comitantes (end-to-end or end-to-side) Post. interosseous n.

Gracilis m.

Ulna

Figure 7. Forearm extensor reconstruction.

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Figure 8. This 26-year-old patient sustained severe left upper extremity injury following a motorcycle accident. He had undergone seven previous surgeries for an open fracture of the radius and ulna. He had loss of extensor function caused by initial injury and a poor softtissue envelope. A groin ap was originally used to cover the distal third of the forearm. Two years following his original injury, he underwent open reduction and internal xation of the radial and ulnar nonunions. Simultaneously, a functional free gracilis was performed to provide proximal soft-tissue coverage and to restore wrist and nger extension. A, Nonunion after eradication of infection. B, Soft-tissue envelope before groin ap. C, Absent wrist extension. Illustration continued on following page

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Figure 8 (Continued). D, Radiographs 2 years after free gracilis muscle transfer with interval hardware removal. E, Functional wrist extension 2 years following free gracilis transfer.

FUNCTIONAL FREE GRACILIS TRANSFER FOR UPPER EXTREMITY RECONSTRUCTION Table 1. UPPER EXTREMITY MUSCLE FUNCTION RESTORED WITH FUNCTIONAL FREE GRACILIS Muscle Anterior deltoid Origin Distal third of clavicle and acromion Insertion Residual of tendinous insertion on the lateral arm or directly to the humerus Distal biceps tendon, if present, or to the radial tuberosity through bone tunnel Tensioning Gracilis stretched to its resting length with the shoulder extended Shoulder and elbow in extension Recipient Vessels Thoracodorsal artery and concomitant veins, or thoracoacromial trunk and concomitant veins, or tributaries of the cephalic vein Thoracodorsal artery and concomitant veins, thoracoacromial trunk and concomitant vein or tributaries of the cephalic vein Thoracodorsal artery and concomitant veins, posterior circumex humeral, or profunda brachii and concomitant veins Radial or ulnar artery as end-to-side or end-toend anastomosis and concomitant veins End-to-end or end-toside to the radial artery, or ulnar artery using a vein graft, or radial recurrent artery Venous repair to venae comitantes of the radial artery

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Recipient Nerve Axillary nerve, or anterior branches of the spinal accessory nerve, nerve to pectoralis minor (requires nerve graft) Motor bers of the musculocutaneous nerve, intercostal nerves, or anterior branches of the spinal accessory nerve Triceps branches of the radial nerve, intercostal nerves, branch to teres minor from the axillary nerve Anterior interosseous nerve or branches from the median nerve to the supercialis or profundus muscles Posterior interosseous nerve; if not present, then a single branch of the median nerve to one of the supercialis muscles, with nerve grafting as necessary

Biceps

Triceps

Distal portion of the clavicle and acromion or coracoid process and clavipectoral fascia, depending on the length of the gracilis muscle Posterior aspect of the acromion

Triceps tendon or directly to the olecranon

Shoulder and elbow exion

Forearm exors

Medial epicondyle of the humerus

Flexor digitorum profundus tendons at level of the wrist*

Elbow, wrist, and ngers in maximum extension

Forearm extensors

Lateral epicondyle of the humerus

Extensor digitorum communis and extensor pollicis longus tendons at the level of the wrist

Wrist and ngers positioned in maximum exion

*If independent thumb and nger exion is to be reconstructed, the gracilis muscle needs to be longitudinally split and separated into its autonomously controlled fascicles. Distally, one tendon is repaired to the exor digitorum profundus, and the other repaired to the exor pollicis longus. Two separate motor nerve branches should be used.

COMPLICATIONS Potential complications affecting graft viability include venous or arterial thrombosis, hematoma, and isolated failure of the skin paddle. Any of these complications should be addressed with an emergent return to the operating room. As discussed previously, ischemia time greater than 2 hours results in poor functional outcome.7 The transplanted muscle under this circumstance should be removed and replaced with another transplanted gracilis muscle. This option should be listed in the informed surgical consent. Late complications include poor nerve regeneration, adhesions, and tendon rupture. Adhesions and tendon ruptures can be corrected surgically, whereas poor nerve regeneration cannot. If the procedure was performed properly and no nerve graft was required, some recovery of muscle function should be seen at 3 months.13 If no recovery is seen by 1 year after transplantation, no useful functional recovery can be anticipated.

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SUMMARY The authors rst choice for reconstruction about the shoulder girdle and elbow is a functional rotational latissimus dorsi muscle ap. This procedure has been well described for reconstruction of the deltoid, biceps, and triceps. In the forearm, many different types of tendon transfer have been successfully used, and this operation should be the primary reconstructive procedure. When these options are not available owing to brachial plexus injury, soft-tissue loss from extensive trauma or tumor resection, or the need for reconstruction of multiple functional decits, microneurovascular free gracilis transfer is an excellent tool for restoration of lost function. References
1. Chuang D: Functioning free-muscle transplantation for the upper extremity. Hand Clin 13: 279 289, 1997 2. Chung D, Carver N, Wei F: Results of functioning free muscle transplantation for elbow exion. J Hand Surg 21A:1071 1077, 1996 3. Doi K, et al: Double muscle transfer for upper extremity reconstruction following complete avulsion of the brachial plexus. Hand Clin 15: 757 767, 1999 4. Doi K, et al: Limb-sparing surgery with reinnervated free-muscle transfer following radical excision of soft-tissue sarcoma in the extremity. Plast Reconstr Surg 104:1679 1687, 1999 5. Doi K, et al: Reinnervated free muscle transplantation for extremity reconstruction. Plast Reconstr Surg 91:872 883, 1993 6. Harii K, Ohmori K, Tori S: Free gracilis muscle transplantation with microneurovascular anastomoses for treatment of facial paralysis. Plast Reconstr Surg 57:133 143, 1976 7. Kuzon W, McKee N, Fish J: The effect of intraoperative ischemia on the recovery of contractile function after free muscle transfer. J Hand Surg 13A:263, 1988 Manktelow R: Functioning microsurgical muscle transfer. Hand Clin 4:289 296, 1988 Manktelow R: Muscle transplantation by fascicular territory. Plast Reconstr Surg 73:751 755, 1984 Manktelow R, McKee N: Free muscle transplantation to provide active nger exion. J Hand Surg 3A:416 426, 1978 Manktelow R, Zucker R: The principles of functioning muscle transplantation: Applications to the upper arm. Ann Plast Surg 22:275282, 1989 OBrien B, et al: Free microneurovascular muscle transfer in limbs to provide motor power. Ann Plast Surg 9:381 391, 1982 Stevanovic M, Seaber A, Urbaniak J: Canine experimental free muscle transplantation. Microsurgery 7:105 113, 1986 Tamai S, et al: Free muscle transplants in dogs with microsurgical neurovascular anastomoses. Plast Reconstr Surg 46:219 225, 1970 Address reprint requests to Milan Stevanovic, MD Hand and Microsurgery Department of Orthopedics University of Southern California Los Angeles County Medical Center GNH Room 3900 2025 Zonal Avenue Los Angeles, CA 90033 e-mail: stevanov@hsc.usc.edu

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Atlas of the Hand Clinics


Copyright 2006 Saunders, An Imprint of Elsevier

Volume 7, Issue 1 (March 2002)


Issue Contents: (Pages ix-180) ix-ix Preface Kozin SH 1-17 Tendon transfers for thumb opposition Shin AY 19-39 Tendon transfers for intrinsic function in ulnar nerve palsy Kalainov DM 41-52 Tendon transfer for radial nerve palsy Rettig ME 53-66 Tendon transfers for elbow flexion Kozin SH 67-77 Tendon transfers for lateral pinch Weiss AA 79-95 Tendon transfers for restoration of active grasp Peljovich AE 97-108 Elbow extension tendon transfer Van Heest AE 109-117 Tendon transfers during index finger pollicization Lourie GM 119-131 Tendon transfers for thumb-in-palm deformity Carlson MG 133-151 Tendon transfer for wrist flexion deformity in cerebral palsy Wright TW

1 2 3 4 5 6 7 8 9 10 11

12 13

153-162 Superficialis to profundus tendon transfer Palma DA 163-180 Functional free gracilis transfer for upper extremity reconstruction Stevanovic M