DALHOUSIE

PLASTIC

Tendon Transfers

Doug Humphreys
Division of Plastic Surgery
Dalhousie University
Halifax, Nova Scotia

Tendon Transfers
Definition
The Detachment Of A Functioning MuscleTendon Unit From Its Insertion And
Reattachment To Another Tendon Or Bone To
Replace The Function Of A Paralyzed Muscle
Or Injured Tendon

Tendon Transfers

Indications
1)

2)

3)

Restore Function To A Muscle Paralyzed As A

Result Of Injury Of The Peripheral Nerves,
Brachial Plexus Or Spinal Cord
To Restore Function After Closed Tendon
Ruptures Or Open Injuries To The Tendons
Or Muscles
Restore Balance To A Hand Deformed From
Neurological Conditions

Tendon Transfers

General Principles
1)
2)
3)
4)
5)
6)
7)
8)

Straight Line Of Pull

Expendable Donor
Adequate Strength
Correction Of Contracture
One Tendon One Function
Amplitude Of Motion
Synergism
Tissue Equilibrium

Tendon Transfers
1)

Correction Of Contracture

Keep All Joints Supple

Soft Tissue Contracture Easier To Prevent Than

Correct

Stiff Joints Will Not Move!!

Tendon Transfers
2)

Adequate Strength

Donor Strength Must Be

Adequate To Perform
New Function In Its
Altered Position

Work Of Muscle Related

To Muscle Volume

Transferred Muscles Lose

One Grade Of Strength

Tendon Transfers
3)

Amplitude Of Motion

Wrist Flexors And Extensors

Finger Extensors And EPL

33mm
50mm

Finger Flexors

70mm

Tendon Transfers
3)

Amplitude Of Motion

Augmentation Of Effective Amplitude

a)
b)

Convert From Monarticular To Multiarticular

Utilize Tenodesis
Dissection Of Surrounding Fascial Attachments

Tendon Transfers
4)

Straight Line Of Pull

5)

Most Efficient Transfer

One Tendon One Function

Single Tendon Cannot Perform Two Opposite

Functions Simultaneously
May Insert Into More Than One Tendon

FCU EDC

Tendon Transfers
6)

Synergism

7)

Expendable Donor

8)

Easier To Retrain
Use Of Muscle Must Not Result In Unacceptable
Functional Loss

Tissue Equilibrium

No Transfer Should Be Done Unless Tissues In

Optimal Condition

Scars Soft, No Induration

Tendon Transfers
Surgical Principles
Carefully Planned Incisions
Tendons Should Not Lie Beneath Scars

Careful Mobilization Of Muscles

Prevent Neurovascular Pedicle Damage

Subcutaneous Tunneling Of Transfers

No Small Fascial Windows

Radial Nerve Palsy

Tendon Transfers
Radial Nerve Palsy

Functional Deficits
Wrist Extension
Finger Extension
Extension And Radial Abduction Of The
Thumb

Tendon Transfers
Radial Nerve Palsy

Timing Of Tendon Transfers

Controversial
Early
Internal Splint At Time Of Nerve Repair

Conventional
Performed After Reinnervation Of Paralyzed Muscles
Fails To Occur By 3 Months After Expected

Late

Tendon Transfers
Radial Nerve Palsy

Early Transfer
Pronator Teres to ECRB
Temporary Substitute Until Reinnervation
Suboptimal Reinnervation Acts To Augment
Function

Tendon Transfers
Radial Nerve Palsy

Historical Perspective
Evolved During The Two World Wars
Classic Jones Transfer (1916)
PT ECRL and ECRB
FCU EDC III-V
FCR EIP, EDC II, and EPL

Tendon Transfers
Radial Nerve Palsy

FCU Transfer

Tendon Transfers
Radial Nerve Palsy
Incision 1:
FCU And PL Transected Proximally
FCU Freed Up Proximally

Incision 2:
Deep Fascia Overlying FCU Incised And Muscle Freed
Proximally
Limit Neurovascular Pedicle

Incision 3:
Insertion Of PT Freed With Strip Of Periosteum
EPL Tendon Identified

Tendon Transfers
Radial Nerve Palsy

Setting The Proper Tension

Err On Suturing Extensor Tendons Tightly
PT ECRB
Wrist 45 Extension
Tendon Sutured With Maximal Tension

FCU EDC
Wrist and MP Joints In Neutral
Adjust EDC Tension Individually
+/- EDM

Tendon Transfers
Radial Nerve Palsy

Setting The Proper Tension

PL EPL
Wrist In Neutral
Maximal Tension On EPL And PL

Test Passive ROM

Wrist In Extension
Passively Flex Fingers Into Palm

Wrist In Flexion
MP Joints In Full Extension
Should Not Hyperextend

Tendon Transfers
Radial Nerve Palsy

Postoperative Management
Splint For 4 Weeks

Wrist 15-30 Pronation

Forearm 45 Extension
MP Joints Slight Flexion (10-15)
Thumb Maximal Extension And Abduction
PIP Joints Left Free

4 To 6 Weeks
Removable Splint
Planned Exercise Program With Therapist

Tendon Transfers
Radial Nerve Palsy

Potential Problems
Excessive Radial Deviation
From Removing FCU
Further Aggravated If PT Inserted Into ECRL
Problem With PIN Palsy

Solutions
FCU Transfer Contraindicated With PIN Palsy
Reinsert ECRL Into 4th Metacarpal

Bowstringing Of EPL
Solution
Hook EPL Around Insertion Of APL

Tendon Transfers
Radial Nerve Palsy

Potential Problems
Absence Of Palmaris Longus
Solutions
Include Thumb Extrinsics In FCU EDC Transfer
Violates One Tendon One Function Principle
Use Brachioradialis
Possible Only With PIN Palsy
Requires Extensive Freeing Up
More Difficult To Reeducate
Use FDS III Or IV

Tendon Transfers
Radial Nerve Palsy

FCR Transfer
(Starr, Brand, Tsuge)

Tendon Transfers
Radial Nerve Palsy

FCR EDC
PT ECRB, When Required
Performed As Before

PL EPL
Performed As Before
If Absent
EPL Joined With EDC To FCR Transfer

Tendon Transfers
Radial Nerve Palsy

Incision Between FCR And PL

FCR Freed To Middle Of Forearm
FCR Passed Around Radial Border
Subcutaneous Tunnel

Two Best Tendons Sutured To FCR

Other Two Sutured To Neighbors

Sutured With Wrist & MPs In Neutral

Tendon Transfers
Radial Nerve Palsy

Superficialis Transfer
(Boyes)

Tendon Transfers
Radial Nerve Palsy

PT ECRB
FDS III EDC III,IV,V
FDS IV EIP & EPL
FRC APL & EPB

Tendon Transfers
Radial Nerve Palsy

PT Tendon Exposed
Volar Radial Incision

Sublimis Tendons Exposed

Transverse Incision Palm
Divided Proximal To Chiasm
Pass Tendons Through Interosseous Membrane Or
Around Radial And Ulnar Borders

Tendon Transfers
Radial Nerve Palsy

Potential Problems
Protect Anterior And Posterior Interosseous
Arteries
One Opening On Either Side Of The Artery

Avoid Kinking The Median Nerve

FDS III Routed To The Radial Side Of Profundus
Between FDP And FPL

FDS IV Routed To The Ulnar Side Of Profundus

Tendon Transfers
Radial Nerve Palsy
Transfer
FDS III
EDC (Long, Ring and Little)

FDS IV
EIP and EPL

Advantages
Independent Motion Of Thumb And Index
Palmaris Absent

 Indian J Orthop. 2011 Nov-Dec; 45(6):

558562.
Outcome of tendon transfer for radial
nerve paralysis: Comparison of three
methods
Alia Ayatollahi Moussavi, Alireza Saied,
and Ali Karbalaeikhani1

 41 pacientes / 3 Grupos
FCU Extensin dedos
PL EPL (Abduccin y extensin D1)

FCR Extensin dedos

PL EPL (Abduccin y extensin D1)

FDS 3 Extensin dedos

FDS 4 EPL

En todos si se necesitaba restaurar extension

mueca: PT ECRB
Si no tenian PL, eran excluidos

 Postop
Valva ABP con mueca y dedos en extensin
por 4 semanas
Luego 3 meses nocturna
Fisioterapia desde el 1 mes

 Grupo 1
18 Pacientes

Grupo 2
10 Pacientes

Grupo 3
13 Pacientes

 Resultados

 Resultados

 Sin diferencias:
ROM mueca, D1, dedos
DASH: 35 / 38 / 30

95% Se volveria a operar

Extension simultanea de mueca-dedos
Solo 4 del grupo 3

Contractura en flexion
3 pacientes del grupo 3

Pronosupinacion conservada en todos

 Varios presentaron disminucin flexion mueca

Ninguno lo reporto

Todos lograron buen grip

No fue medido por falta de instrumentos

Sin desviaciones radiales