Tendon Transfers

Brocha Z. Stern, MOT, OTR/L, CHT

Curtis National Hand CenterBaltimore, MD

October 6-8, 2017

Objectives

• Describe general goals, principles, and mechanical considerations of tendon transfers

• Explain general preoperative and postoperative rehabilitative guidelines for tendon transfers

• Apply anatomical and surgical considerations to the rehabilitation of specific tendon transfers, with emphasis on median, ulnar, and radial nerve palsies

Fundamentals

(Brand, 2011; Brand, Beach, & Thompson, 1981; Brand & Hollister, 1985; Jones, 2013; Livermore & Tueting, 2016; Peljovich, Ratner, & Marino, 2010; Ratner & Kozin, 2011;

Sammer & Chung, 2009a, 2009b; Wilbur & Hammert, 2016)

Overview

• Restore balance that has been lost or compromised through disease or injury

• Indications

• Substitute for weak or paralyzed muscle

• Replace damaged tendon or muscle

• Correct muscle imbalance caused by CNS lesion

• Potential diagnoses

• Peripheral nerve injuries, cerebral palsy, spinal cord injury, thumb hypoplasia, rheumatoid arthritis

(http://www.ehealthstar.com/wp-content/uploads/2013/08/Froment-Sign.jpg)

Mechanism• “Altering the insertion or origin of a nearby, redundant,

strong, and voluntarily controlled muscle” (Pelojovich, Ratner, & Marino, 2010, p. 1365)

• Muscle is redirected by changing the insertion site of its tendinous portion

• Tendon-tendon coaptation

• Blood and nerve supply unaffected

**Differentiate from free muscle transfer or nerve transfer

(Baumeister, 2015; http://emedicine.medscape.com/article/1286712-treatment#d11)

Principles

• Donor properties• Must be expendable

• Adequate power to motor the recipient tendon

• Similar tendon excursion as the recipient

• Function synergistic with the recipient

• Normal PROM

• Tissue equilibrium

• Straight line of pull

• Single function per transfer

Strength & Work

• Strength• Ability to generate tension• Proportionate to cross-sectional area• Does not change with transfer

• Functional change in strength (~1 muscle grade)due to factors such as drag

• Work• Force x distance• Proportionate to muscle mass

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Potential Excursion (Amplitude)

• The distance a muscle can contract if

• Freed from all its connective tissue attachments

• Stimulated from its fully stretched position

• Proportionate to muscle fiber length

• Dependent on number of sarcomeres in muscle fiber

(Wilhelmi, 2017; http://emedicine.medscape.com/

article/1245758-overview#a4)

Required Excursion

• The distance a muscle needs to contract to move the joint(s) through full range of motion

• Typically less than potential excursion• i.e. ECRB – 6 cm of potential excursion but only

~3.5 cm of required excursion

Wrist extensors and flexors 33 mm

Finger extensors 50 mm

Finger flexors 70 mm

Available Excursion

• The distance a muscle can contract as permitted by the surrounding connective tissue

• Varies from person to person• Dependent on recent use of joints and tendons

• Assessed intra-operatively after cutting tendon at its insertion

• Measured by stimulating after placement at full stretch

• Maintained with transfer only if minimal change in position and minimal scarring

Leverage

• Ability of a force to cause rotation on a lever

• Moment arm • Perpendicular distance between axis of rotation and

tendon as it crosses the joint

• Force Torque

• Torque = Force x moment arm

• Mechanical advantage• Moment arm of force / Moment arm of load• “Price of increased power is reduced range” (Brand, 2011)

Drag

• “Internal resistance in the form of friction and the need to stretch passive soft tissues” (Brand, 2011)

• Friction• Resisting force that occurs whenever two objects move

against each other

• Soft tissue• A transferred tendon becomes attached to its new area

by soft tissue• Living tissue has the ability to remodel or to grow in

response to mechanical force

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Synergy

• Facilitates post-operative retraining

• Increases excursion

(http://www.eatonhand.com/complic/figures/tenodesis2.htm)

Neuroplasticity

(Schultz, 2006, CC 3.0; https://commons.wikimedia.org/wiki/File:DTI-sagittal-fibers.jpg)

New Considerations

• Wide-awake surgery• “Tendon transfer is actually best indicated for such

wide-awake surgery” (Tang, 2015, p. 280)

• Improved ability to obtain optimal tension of transfer

Rehabilitation: General Guidelines

(Duff & Humpl, 2011; Schwartz, 2014)

(B. Stern)(B. Stern)

Preoperative Considerations

• Evaluation• Assess capabilities and impairments• Identify potential donor muscles• Establish goals

• Intervention• Increase joint and soft tissue mobility• Isolate and strengthen donor muscles• Orthosis fabrication• Patient education

(B. Stern)

Preoperative Evaluation

• History

• Physical Exam• AROM and PROM

• Note joint contractures

• Sensibility

• Manual muscle testing, grip/pinch• Observe muscle substitution or motor signs

• Motor learning aptitude

• Functional tests

(B. Stern)

Preoperative Orthoses

• Temporarily restore balance via external support • Prevent or correct joint contractures or adaptive

shortening• i.e. Web spacer, PIP extension serial casts

• Prevent overstretching or maladaptive compensatory patterns

• i.e. Dynamic digital/thumb extension orthosis, Anti-claw orthosis

• Increase function• i.e. Short opponens orthosis, Dynamic digital/thumb

extension orthosis, Anti-claw orthosis

Short opponens

(B. Stern)

Preoperative Orthoses

Colditz design

Anti-claw orthosis

(B. Stern)

Web spacer

(ASHT test prep book, p. 351)

(Staines, 2015)

Theratube design

MEDIAN NERVE ULNAR NERVE

(http://www.medi-stim.com/stims/hvpg/300pv.html)

Preoperative Treatment

• Joint and soft tissue mobilization for ROM

• Muscle training and strengthening• Isolate donor muscle• Provide feedback via biofeedback and/or NMES

• Patient education• Realistic expectations• Timeframes of recovery• Anticipated rehabilitation demands

Communication with Surgeon

• Specific muscle-tendon units affected

• Anatomical route of the transferred tendon• Pulleys and retinaculum

• Site of coaptation

• Quality of soft tissue and strength of suture

• Appearance of wound bed and potential for scarring

• Source of tendon grafts if used

• Protect transfer• Post-op cast generally for 3-4 weeks

• Immobilize in protective position to minimize tension on juncture

• Control edema

• Protect areas of diminished or absent sensation

• Prevent stiffness of uninvolved joints

Immobilization/Early Phase

• Protect transfer between exercises with orthoses

• Initiate activation of transfer• Avoid overstretching

• Isolated joint ROM prior to composite

• Dynamic orthosis with stop blocks for limited tendon gliding

• No PROM against transferred tendon

• Monitor early motion to avoid muscle substitution• i.e. Wrist flexion to extend digits; thumb flexion/adduction

instead of opposition

• Short, frequent exercise sessions

Mobilization/Intermediate Phase

• Biofeedback and/or electrical stimulation (at sub-tetany contraction)

• Mobilize surrounding soft tissue to increase available excursion

• Scar management

• Sensory reeducation

• Introduce functional activities

Mobilization/Intermediate Phase• Add resistance to transfer

• Initiate when can activate transfer without assistance• Motion against gravity• Strengthen gradually• Continue to avoid muscle substitution patterns

• Restore passive motion• Gentle passive stretches, monitoring effect on transfer

• Focus on hand function• Blocked vs. random task practice• Feedback

Resistive/Late Phase

• Preoperative preparation

• Place and holds

• Start exercises in gravity eliminated plane

• Light tasks that result in unconscious activation• i.e. Opponensplasty – touch thumb to the SF tip

• Perform the original motion of the donor muscle• i.e. RF FDS FPL

Transfer Activation – Facilitation

(B. Stern)

Transfer Activation – Facilitation

• Tapping/vibration over muscle belly

• Biofeedback/NMES to encourage correct action

• Visual cues as adjunct

• Mirror visual feedback (Grangeon et al., 2010)

• Training orthoses • i.e. Lumbrical bar as assist following

intrinsic transfer

• Perform movements bilaterally

(B. Stern)

New Considerations

• Early mobilization • Systematic review• Within 1 week of surgery• Safe (no incidence of ruptures or pull-outs)• Improved hand function in short-term, reduced costs,

and decreased treatment time compared to immobilization

• Inconclusive findings for long-term outcomes(Sultana, MacDermid, Grewal, & Rath, 2013)

Common Tendon Transfers: Anatomy, Surgery, &

RehabilitationMedian, Ulnar, & Radial N. Injuries

(Chadderdon & Gaston, 2016; Cheah, Etcheson, & Yao, 2016; Cook, Gaston, & Lourie, 2016; Diaz-Garcia & Chung, 2016; Duff & Humpl, 2011; Giuffre, Bishop,

Spinner, & Shin, 2015; Isaacs & Ugwu-Oju, 2016; Ratner & Kozin, 2011; Sammer & Chung, 2009a, 2009b; Schwartz, 2014)

(Haymaker & Woodhall, 1953)

Median Nerve Median Nerve

* = AIN innervation

Muscle loss Functional deficit

HIGHLEVEL

PT, PQ* Weak/absent forearm pronationFCR Weak wrist flexion / radial deviationFDS IF/MF/RF/SF, FDP IF/MF*

PIP/DIP flexion – absent IF/MF, weak RF/SF

FPL* Loss of thumb IP flexion

LOW LEVEL

Lumbricals IF/MF MP flexion/IP extension deficit of IF/MF

APB, OP, superficial FPB

Loss of opposition, palmar abduction (deficits in functional prehension)

* Restore thumb opposition

* Restore thumb IP joint flexion

* Restore digital flexion

Median Nerve – Opponensplasty

• Camitz (PL APB)‐ Allows excellent palmar

abduction but limited pronation‐ Used with long-standing CTS

• Superficialis (RF FDS APB)‐ Uses pulley at pisiform to pull

thumb into pronation/opposition

• Huber (ADM APB)

• Other potential donors‐ EIP, EDQ, ECU

(Sammer -http://doctorlib.info/sur

gery/plastic/80.html)

Median Nerve – Opponensplasty• Post-op immobilization

• Thumb in palmar abduction, forearm-based unless intrinsic donor, wrist in slight flexion

• Mobilization at 3-4 weeks• Active use of transfer• Thumb flexion, extension, opposition, circumduction• Avoid preoperative pattern of adduction/supination• No simultaneous wrist and thumb extension

• 6-8 weeks• D/c orthosis• Functional and strengthening activities (pinch)

Median Nerve – Other

• Fewer motors to choose from for high-level

• ECRL IF/MF FDP• FDP of RF/SF IF/MF FDP• BR FPL

• Often need concurrent nerve transfers for sensation

Ulnar Nerve

(Haymaker & Woodhall, 1953)(Young, Fattah, & Felming, 2008)

Ulnar NerveMuscle loss Functional deficit

HIGH LEVEL

FCU Weak wrist flexion / UD

FDP RF/SF Loss of power grip

LOW LEVEL

AP and 1st DILoss of key pinch (Froment’s/Jeanne’s sign)

FPB deep headImpaired thumb stability during pinch

Lumbricals RF/SF Clawing of RF/SF (Duchenne’s)

InterosseiWartenberg’s sign, flattened palmar arch (Masse sign)

* Correct clawing for functional grasp: Restore intrinsic function via MCP joint flexion (and IP joint extension if negative Bouvier test)

* Restore pinch: Restore thumb adduction (and IF abduction prn)

* Restore RF/SF DIP flexion

Ulnar Nerve – Intrinsic Plus

• Brand: ECRB with PL free graft to intrinsics via lateral bands

• Modified Stiles-Bunnell: FDS of RF/MF inserted into lateral band or P1

• Zancolli Lasso: FDS passed through pulley and sutured back to itself

• Other donors: EDQ, EIP, ECRL, BR

(Sammer - http://doctorlib.info/surgery/plastic/80.html)

Ulnar Nerve – Intrinsic Plus• Post-op immobilization

• Forearm-based with MPs in flexion and IPs in extension

• Mobilization• Avoid muscle substitution• Avoid fisting in first few weeks to limit stress on transfer• Avoid passive IP flexion/extension• Avoid full extension of MP (particularly in first 3 weeks)

• Increase MP extension gradually and expect a lag

• Use lumbrical bar as orthosis assist at 4-6 weeks during light functional activities

• Protect from heavy use for up to 3 months post-surgery

Ulnar Nerve – Other

• Adductorplasty• Restore thumb adduction and lateral pinch

• Most transfers provide improved stability and improved pinch strength of 25-50%

• Boyes: BR extended with free graft

• Smith-Hastings: ECRB AP/1st metacarpal

• Gross composite flexion• ECRB FDP

• IF/MF FDP RF/SF FDP

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Radial Nerve

(Haymaker & Woodhall, 1953)

Radial Nerve

* Restore wrist extension

* Restore MCP extension

* Restore thumb extension

Muscle loss Functional deficitHIGH LEVEL

Brachioradialis Weak elbow flexionECRL/ ECRB* Weak wrist extension / radial deviation

LOWLEVEL

SupinatorWeak supination (test in extension to eliminate biceps)

ECU Weak wrist extension / ulnar deviationEDC, EIP, EDQ Lost digital extension

EPL, EPB, APL Lost thumb extension / radial abduction

*Variable, may be innervated by PIN and may be lost in low-level

Radial NervePT ECRB/L to restore wrist extension

FCU, FCR, or FDS EDC to restore finger extension

PL or FDS EPL to restore thumb extension

(Sammer -http://doctorlib.info/sur

gery/plastic/80.html)

Radial Nerve – Postoperative• Post-op immobilization

• Long-arm orthosis• 90° elbow flexion, forearm pronation, 30-45° wrist extension,

MP extension, IPs free, thumb radial abduction

• Protective orthosis is continued for a total of ~8 weeks• May be able to switch to wrist cock-up at 6 weeks

• Mobilization starts at 3-4 weeks• Gentle isolated AROM of each joint is performed

• Avoid composite wrist/digital flexion until ~8 weeks

• Resistance initiated ~8 weeks

Other Tendon Transfers

(Ashworth & Kozin, 2011; Bednar, 2016)

Thumb Tendon Ruptures

• EIP EPL• Rheumatoid arthritis• Distal radius fracture

• FDS MF/RF FPL• Mannerfelt lesion • Volar plating s/p distal

radius fracture(Baumeister, 2015;

http://emedicine.medscape.com/article/1286712-treatment#d10)

Elbow

• Restore elbow flexion• Latissimus dorsi biceps• Pectoralis major biceps• Triceps biceps• Steindler flexorplasty (flexor-

pronator mass)

• Restore elbow extension• Posterior deltoid triceps• Biceps triceps

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Shoulder

• Restore shoulder external rotation

• L’Episcopo: teresmajor posterior cuff

• Modified L’Episcopo: teres major and latissimus dorsiposterior cuff

(Shi, Cahill, Ek, Tompson, Higgins, & Warner, 2015)

A Word (or Two) on Nerve Transfers

• Sensory and/or motor

• Potential advantages over tendon transfers• Restore sensation and motor• Restore function to multiple muscles• Preserve muscle balance• Avoid dissection to muscle bed, preserving excursion

• Limitation• More time-sensitive – cannot be done after motor end

plate degeneration (12-18 months)

References• Ashworth, S., & Kozin, S. H. (2011). Brachial plexus palsy reconstruction: Tendon

transfers, osteotomies, capsular release, and arthrodesis. In In T. M. Skirven, A. L. Osterman, J. M. Fedorczyk, & P. C. Amadio (Eds.), Rehabilitation of the hand and upper extremity (6th ed., pp. 792-812). Philadelphia, PA: Elsevier.

• Bednar, M. S., (2016). Tendon transfers for tetraplegia. Hand Clinics, 32, 389-396. doi:10.1016/j.hcl.2016.03.013

• Brand, P. W. (2011). Mechanics of tendon transfers. In T. M. Skirven, A. L. Osterman, J. M. Fedorczyk, & P. C. Amadio (Eds.), Rehabilitation of the hand and upper extremity (6th ed., supplemental chapter available online.). Philadelphia, PA: Elsevier.

• Brand, P. W., & Hollister, A. (1985). Clinical mechanics of the hand (2nd ed.). St Louis: Mosby.

• Brand P. W., Beach, R. B., & Thompson, D. E. (1981). Relative tension and potential excursion of muscles in the forearm and hand. Journal of Hand Surgery, 6A, 209-219.

• Chadderton, R. C., & Gaston, R. G. (2016). Low median nerve transfers (opponensplasty). Hand Clinics, 32, 349-359. doi:10.1016/j.hcl.2016.03.005

• Cheah, A. E., Etcheson, J., & Yao, J. (2016). Radial nerve tendon transfers. Hand Clinics, 32, 232-338. doi:10.1016/j.hcl.2016.03.003

• Cook, S., Gaston, R. G., & Lourie, G. M. (2016). Ulnar nerve tendon transfers for pinch. Hand Clinics, 32, 369-376. doi:10.1016/j.hcl.2016.03.007

• Diaz-Garcia, R. J., & Chung, K. C. (2016). A comprehensive guide on restoring grasp using tendon transfer procedures for ulnar nerve palsy. Hand Clinics, 32, 361-368. doi:10.1016/j.hcl.2016.03.006

• Duff, S. V., & Humpl, D. (2011). Therapist’s management of tendon transfers. In T. M. Skirven, A. L. Osterman, J. M. Fedorczyk, & P. C. Amadio (Eds.), Rehabilitation of the hand and upper extremity (6th ed., pp. 781-791). Philadelphia, PA: Elsevier.

• Grangeon, M., Guillot, A. , Sancho, P. O., Picot, M., Revol, P., Rode, G., & Collet, C. (2010). Rehabilitation of the elbow extension with motor imagery in a patient with quadriplegia after tendon transfer. Archives of Physical Medicine and Rehabilitation, 91, 1143-1146. doi:10.1016/j.apmr.2010.04.011

• Isaacs, J., & Ugwu-Oju, O. (2016). High median nerve injuries. Hand Clinics, 32, 339-348. doi:10.1016/j.hcl.2016.03.004

• Jones, N. F. (2013). Tendon transfers in the upper extremity. In P. C. Neligan(Ed.), Plastic surgery (3rd ed., pp. 745-776.e3). London: Elsevier.

• Livermore, A., & Tueting, J. L. (2016). Biomechanics of tendon transfers. Hand Clinics, 32, 291-302. doi:10.1016/j.hcl.2016.03.011

• Meals, C. G., & Meals, R. A. (2013). Tendon versus nerve transfers in elbow, wrist and hand reconstruction: A literature review. Hand Clinics, 29, 393-400. doi:10.1016/j.hcl.2013.04.010

• Peljovich, A., Ratner, J. A., & Marino, M. (2010). Update of the physiology and biomechanics of tendon transfer surgery. Journal of Hand Surgery, 35A, 1365-1369. doi:10.1016/j.jhsa.2010.05.014

• Ratner, J. A., & Kozin, S. H. (2011). Tendon transfers for upper extremity peripheral nerve injuries. In T. M. Skirven, A. L. Osterman, J. M. Fedorczyk, & P. C. Amadio (Eds.), Rehabilitation of the hand and upper extremity (6th ed., pp. 771-780). Philadelphia, PA: Elsevier.

• Sammer, D. M., & Chung, K. C. (2009). Tendon transfers part I: Principles of transfer and transfers for radial nerve palsy. Plastic Surgery and Reconstruction, 123, 169e-177e. doi:10.1097/PRS.0b013e3181a20526

• Sammer, D. M., & Chung, K. C. (2009). Tendon transfers part II: Transfers for ulnar nerve palsy and median nerve palsy. Plastic Surgery and Reconstruction, 124, 212e-221e. doi:10.1097/PRS.0b013e3181b037c7

• Schwartz, D. A. (2014). Tendon transfers. In Cooper, C. (Ed)., Fundamentals of hand therapy (2nd ed., pp. 438-456). St. Louis, MO: Elsevier.

• Sultana, S. S., MacDermid, J. C., Grewal, R., & Rath, S. (2013). The effectiveness of early mobilization after tendon transfers in the hand: A systematic review. Journal of Hand Therapy, 26, 1-20. doi:10.1016/j.jht.2012.06.006

• Tang, J. B. (2015). Wide awake flexor tendon repair, tenolysis, and tendon transfer. Clinics in Orthopedic Surgery, 7, 275-281. doi:10.4055/cios.2015.7.3.275

• Wilbur, D., & Hammert, W. C. (2016). Principles of tendon transfers. Hand Clinics, 32, 283-289. doi:10.1016/j.hcl.2016.03.001

References – Images • American Society of Hand Therapists. (2014). Test Prep for the CHT Exam (3rd ed.). Mt.

Laurel, NJ: Author.• Baumeister, S. (2015). Hand tendon transfers. Retrieved from Medscape,

http://emedicine.medscape.com/article/1286712-overview#showall• Haymaker, W. & Woodhall, B. (1953). Peripheral nerve injuries (2nd revised ed.).

Philadelphia, PA: Saunders.• Sammer, D. M. (n. d.). Principles of tendon transfers. Retrieved from

http://doctorlib.info/surgery/plastic/80.html• Shi, L. L., Cahill, K. E., Ek, E. T., Tompson, J. D., Higgins, L. D., & Warner, J. J. P.

(2015). Latissimus dorsi and teres major transfer with reverse shoulder arthroplasty restores active motion and reduces pain for posterosuperior cuff dysfunction. Clinical Orthopaedics and Related Research, 473, 3212-3217. doi:10.1007/s11999-015-4433-4

• Staines, K . G. (2015). Low-profile theratube splint for radial nerve palsy. ASHT Times, 22, 34-37.

• Wilhelmi, B. J. (2017). Tendon transfers. Retrieved from Medscape, http://emedicine.medscape.com/article/1245758-overview

• Young, P., Fattah, A., & Fleming, A. S. (2008). Ulnar nerve palsy after carpal tunnel decompression: Case report and review of the literature. Indian Journal of Plastic Surgery, 41, 73-75. doi:10.4103/0970-0358.41117

• When designated, images are courtesy of Primal Pictures

Contact Info

Brocha Z. Stern, MOT, OTR/L, CHT

PhD Candidate, New York University, NY, NY

Kessler Rehabilitation Center, NJ

bzstern1@gmail.com