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Hand Surgery and Rehabilitation 35 (2016) 6880
Recent advance
Abstract
Tendon transfers are carried out to restore functional deficits by rerouting the remaining intact muscles. Transfers are highly attractive in the
context of hand surgery because of the possibility of restoring the patients ability to grip. In palsy cases, tendon transfers are only used when a
neurological procedure is contraindicated or has failed. The strategy used to restore function follows a common set of principles, no matter the
nature of the deficit. The first step is to clearly distinguish between deficient muscles and muscles that could be transferred. Next, the type of palsy
will dictate the scope of the program and the complexity of the gripping movements that can be restored. Based on this reasoning, a surgical
strategy that matches the means (transferable muscles) with the objectives (functions to restore) will be established and clearly explained to the
patient. Every paralyzed hand can be described using three parameters. 1) Deficient segments: wrist, thumb and long fingers; 2) mechanical
performance of muscles groups being revived: high energywrist extension and finger flexion that require strong transfers with long excursion; low
energywrist flexion and finger extension movements that are less demanding mechanically, because they can be accomplished through gravity
alone in some cases; 3) condition of the two primary motors in the hand: extrinsics (flexors and extensors) and intrinsics (facilitator). No matter the
type of palsy, the transfer surgery follows the same technical principles: exposure, release, fixation, tensioning and rehabilitation. By performing an
in-depth analysis of each case and by following strict technical principles, tendon transfer surgery leads to reproducible results; this allows the
surgeon to establish clear objectives for the patient preoperatively.
# 2016 SFCM. Published by Elsevier Masson SAS. All rights reserved.
Keywords: Tendon transfer; Hand; Palsy; Principles
Rsum
Les transferts tendineux permettent de restaurer une fonction dficitaire en dtournant des muscles rests intacts. la main, ils sont dautant
plus intressants quils ont pour but de restituer la prhension. En cas de paralysies, les transferts tendineux ne vivent que des checs ou contreindications dun geste vise neurologique. Quelle que soit la nature du dficit, la stratgie de restauration fonctionnelle est tablie suivant les
mmes principes. Dans un premier temps, la distinction prcise entre muscles dficitaires et potentiellement transfrables constitue la base de la
rflexion. Ensuite, le type de paralysie dictera lambition du programme et la complexit des prises pouvant tre restitues. lissue de cette
rflexion, une stratgie chirurgicale en adquation entre les moyens (muscles transfrables) et les objectifs (fonctions restaurer) sera tablie et
clairement explicite au patient. Chaque main paralyse peut tre schmatise selon 3 paramtres : 1) les segments dficitaires : poignet, pouce et
doigts longs ; 2) les performances mcaniques de groupes ou systmes musculaires ranimer : a) haute nergie : extension du poignet/flexion des
doigts, ncessitant des transferts forts avec une course importante ; b) basse nergie : flexion du poignet/extension des doigts mcaniquement moins
exigeants pouvant parfois tre activs par la seule pesanteur ; 3) le statut des deux grands systmes moteurs de la main, extrinsque (flchisseurs/
extenseurs), et intrinsque facilitateur. Quel que soit le type de paralysie, cette chirurgie de transfert suit les mmes principes techniques,
dexposition, de libration, de fixation, de rglage de la tension et de rducation. partir dune analyse prcise de chaque cas et en suivant des
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principes techniques stricts, la chirurgie de transfert conduit des rsultats reproductibles, permettant dtablir avec le patient des objectifs
propratoires clairs.
# 2016 SFCM. Publi par Elsevier Masson SAS. Tous droits rservs.
Mots cls : Transfert tendineux ; Main ; Paralysie ; Principes
1. Introduction
Tendon transfers are carried out to restore functional deficits
by using the remaining intact muscles. This is one of the most
interesting fields within hand surgery because it aims to restore
the hands primary functionthe ability to grip.
For a long time [1,2], surgeons have been fascinated by
tendon transfers, with multiple techniques having been
developed to address various types of palsy. In contrast to
primary procedures aimed at neurological function, tendon
transfers provide more reproducible results, but require a more
detailed clinical analysis of the deficit to establish an a la
carte strategy to restore function.
Articles on this topic are as plentiful as the surgical
techniques, making it difficult and tedious to describe each in
detail. The objective of this review is to provide a framework as to
how to construct a tendon transfer strategy appropriate for each
type of case through a systematic analysis of each type of palsy.
Fig. 1. Basic muscle biomechanics. The muscles mechanical outputs are its
excursion and its force-generating ability. Excursion is a function of the length
of the muscle fibers and the pennation angle (a). Force is a function of the
muscles volume (V) and its length (). The cross-sectional area (CSA) is equal
to V/. The physiologic CSA (PCSA) takes into account the pennation angle
(a): PCSA = V.cos a / l.
Motor territories
Radial
Median
Ulnar
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Fig. 2. Representation of the mechanical properties of hand muscles as a function of their excursion and force according to Brand [6].
Fig. 3. Results of the summation of tendon excursions due to the wrist tenodesis
effect when restoring the finger flexors. ECRL: extensor carpi radialis longus;
FDP: flexor digitorum profundus. Tenodesis effect 30 mm = 50 to 60 mm.
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Fig. 5. Diagram of the various motor systems of the hand muscles. There are two types of extrinsic systems (high energy and low energy) based on their excursion and
contractile force and an intrinsic (facilitator) system. EDC: extensor digitorum communis; EIP: extensor indicis proprius; FCR: flexor carpi radialis; FCU: flexor carpi
ulnaris; FDS: flexor digitorum superficialis; FDP: flexor digitorum profundus.
Fig. 6. Finger flexion and extension in patients with palsy of the intrinsics: note the uneven curling of the fingers with the PIP and DIP joints flexing first, incomplete
PI extension and MCP hyperextension.
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Fig. 8. Method used to determine the progress of axonal regrowth during nerve
recovery to help establish a prognosis. The brachioradialis (BR) is the first
muscle to be re-innervated.
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5.3. Trajectory
The trajectory of a transferred muscletendon unit greatly
determines its action. A straighter trajectory results in the
transferred muscle having greater activity, and more importantly,
less energy lost to friction. The trajectory of a transferred tendon
is also a means to alter its action. A good example is transferring
the EIP around the ulna to counter deficiency in the thenar
muscles. The action of the transferred muscletendon unit will
vary greatly depending on the location of the simple pulley
relative to the pisiform: when it is proximal to the pisiform, the
transfer has a larger abduction component; when it is distal to the
pisiform, the adduction component will be greater.
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Fig. 11. Systematized representation of the various nerve trunk palsies affecting the hand to identify the functions that need to be restored and the muscles
that can be transferred. This can help the surgeon establish a tendon transfer
strategy for each type of palsy. High radial nerve palsy.
Table 2
Proposition of strategy while facing a high radial nerve palsy.
Nerves
Transferable muscles
Strategy
High radial
Wrist extension
RP +++
FCU
FDS III
FCR +++
FCU+++
FDS IV +++
PL ++
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Fig. 14. Result of transferring the extensor indicis proprius around the ulna
based on its trajectory relative to the pisiform.
Table 3
Proposition of strategy while facing a low radial nerve palsy.
Nerves
Transferable muscles
Strategy
Low radial
FCR +++
FCU+++
FDS IV +++
PL ++
Table 4
Proposition of strategy while facing a low median nerve palsy.
Nerves
Transferable muscles
Strategy
Low median
Thumb positioning
EIP +++ PL ++
FCU
FDS IV
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flexors: flexor pollicis longus (FPL), the FDP and FDS of digit
II, and the FDS of digits III to V (Fig. 15, Table 5).
Thumb opposition will be restored using the previously
described techniques. Lateral anastomosis of the FDP for digits
IIIV to that of digit II will restore index flexion; the BR can be
transferred to the FPL to restore thumb flexion. All of these
transfers are carried out during the same surgery session.
Cases of anterior interosseous nerve palsy with associated
FDP-II and FPL palsy will be treated using the same strategy.
6.5. Low ulnar palsy
High ulnar palsy mainly affects the intrinsic muscles of the
hand (Fig. 16, Table 6). Thumb adduction is affected the most,
along with a pronation deficit of the thumb column that
prevents pulp-to-pulp contact. Correction of this deformity
rests on transferring the EIP around the ulna, but this time
passing it distally relative to the pisiform to enhance its
adduction and pronation functions.
Table 5
Proposition of strategy while facing a high median nerve palsy.
Nerves
Transferable muscles
Strategy
High median
Thumb positioning:
Thumb flexion: FPL
EIP +++
BR +++
ECRL
FDP IV V
ECRL
IIIII
Anastomosis FDP
IVV
onto FDPII
III
Table 6
Proposition of strategy while facing a low ulnar nerve palsy.
Nerves
Transferable muscles
Strategy
Low ulnar
EIP +++
PL +
FCU
FDS IV
FDS
ECRL + graft
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Transferable muscles
Strategy
High ulnar
EIP +++
PL +
FCU
FDS IV
FDS
ECRL + graft
III IV V
FDP II
ECRL
III
++
Table 8
Proposition of strategy while facing a low median-ulnar nerve palsy.
Nerves
Transferable muscles
Strategy
Low
MedianUlnar
Thumb positioning
EIP +++
PL +
FCU
FDS IV
FDS
ECRL + graft
Stabilization of MP in digits II to V
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Table 9
Proposition of strategy while facing a high median-ulnar nerve palsy.
Nerves
Transferable muscles
Strategy
High MedianUlnar
Thumb positioning
EIP +++
Stabilization of MP in digits II to V
FDS
ECRL + graft
III IV V
ECRL
7. Conclusion
High median and ulnar nerve palsy cases are the most severe
nerve trunk deficit; they also correspond to the clinical picture
described for low-level tetraplegia [13,23,24] (Fig. 19, Table 9).
As in cases of low palsy, these patients have completely
deficient intrinsic muscles and more importantly, the extrinsic
flexor muscles.
Two surgical sessions are often needed: the first to restore
the extrinsic system and the second to perform an intrinsic
procedure to position the thumb column and stabilize the MCP
joints, as described above.
When it comes to restoring the extrinsic functions, any of the
muscles innervated by the radial nerve can be transferred. In
general, the ECRL is transferred on the FDP tendons after
synchronization, and the BR transferred on the FPL to restore
the indexthumb pinch. Synchronization of tendons receiving a
transfer consists of suturing them together so that the transfer
acts the same way on the various muscles being revived. This
also makes it possible to set a different tension on each ray
(physiological digital cascade). For the flexors, a suture will be
placed around the four tendons beforehand, distal to the transfer
fixation area.
Disclosure of interest
The author declares that he has no competing interest.
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