1. Department of Hand & Reconstructive Microsurgery TENDON TRANSFERS FOR THE HAND National Congress of Indonesian Surgery for Surgery of the Hand (HIPITA) 2 nd Flap dissection course and workshop Surabaya, March 31-April 2, 2005 Aymeric Lim Department of Hand & Reconstructive Microsurgery, National University Hospital

2. Department of Hand & Reconstructive Microsurgery Definitions In a tendon transfer a tendon is transected and reinserted into a bone or another tendon. Tendon graft Free muscle transfer

3. Department of Hand & Reconstructive Microsurgery Indications –Paralysed muscle: –Peripheral nerve injuries –Quadriplegia –Brachial plexus injuries –Peripheral nerve compression –Muscle loss: –Rheumatoid arthritis –Congenital deformities –Severe trauma –Restoration of muscle balance: –Cerebral palsy –Stroke

4. Department of Hand & Reconstructive Microsurgery Programme Principles –Biomechanical –Surgical Tendon transfers in peripheral nerve injuries –Radial nerve

5. Department of Hand & Reconstructive Microsurgery Length- tension curve

6. Department of Hand & Reconstructive Microsurgery Muscle length- tension relationship The force developed by a muscle during contraction varies with its starting length.

7. Department of Hand & Reconstructive Microsurgery Whole muscle architecture Two basic parameters: –Strength (maximum muscle force)  Cross sectional area (PCSA) –Amplitude (Max muscle excursion)  Fibre length

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9. Upper limb muscles

10. Department of Hand & Reconstructive Microsurgery Surgical principles Tissue equilibrium (Steindler) –No soft tissue induration –No reaction in the wounds –Joints supple –Scars soft

11. Department of Hand & Reconstructive Microsurgery Choice of muscle Expendable Working Synergistic Straight line of pull One tendon one function

12. Department of Hand & Reconstructive Microsurgery Transferred muscles Loss of power by one grade Adhesions

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14. Synergy Synergistic muscles contract simultaneously to achieve the desired effect Finger flexors with wrist extensors Finger extensors with wrist flexors Considered important consideration by some surgeons (Littler)

15. Department of Hand & Reconstructive Microsurgery Planning a tendon transfer What works What is available What is needed Matching Staging

16. Department of Hand & Reconstructive Microsurgery Timing Bevin (Hand 1976): 12 radial nerve repairs compared with 13 tendon transfers. Tendon transfer group returned to work in 8 weeks. Nerve repair group returned to work at 8 months.

17. Department of Hand & Reconstructive Microsurgery High radial nerve palsy

18. Department of Hand & Reconstructive Microsurgery High radial nerve palsy What works: All median and ulnar innervated muscles What is available: All except FDP, FPL Needed: Wrist extension Finger extension Thumb extension

19. Department of Hand & Reconstructive Microsurgery DonorInsertionFunctionReference PT FCR FCU ECRL & ECRB EPL, EPB,APL, EDC EDC Wrist ext. Thumb ext, abd. Index. Finger ext. Jones, 1921 PT FDS(mid) FCU ECRB EPL EDC Wrist ext. Thumb ext, abd. Finger ext. Goldner, 1974 PT PL FCR ECRB EPL EDC Wrist ext. Thumb ext. Finger ext. Brand, 1975 PT FCR FDS (ring) FDS (middle) ECRL and ECRB APL & EPB EPL and EIP EDC Wrist ext. Thumb abd. Thumb & index ext. Finger ext. Boyes 1970 PT PL FDS (little) FDS (ring) ECRB APL EPL EDC Wrist ext. Thumb abd. Thumb ext. Finger ext. Beasley 1970 PT FCU ECRL EPL (rerouted) EDC Wrist ext. Thumb ext. Finger ext. Riordan 1964

20. Department of Hand & Reconstructive Microsurgery High radial nerve palsy- The standard transfer Incisions for Tubiana Transfer

21. Department of Hand & Reconstructive Microsurgery PT to ECRB Transfer

22. Department of Hand & Reconstructive Microsurgery FCU to EDC Transfer

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26. Immobilisation 3-4 weeks.

27. Department of Hand & Reconstructive Microsurgery Thank you

28. Department of Hand & Reconstructive Microsurgery The three most common variants FunctionTubianaSmithBoyes Finger extension FCUFCRFDS IV Thumb extension PL FDS III PL to APL Wrist extension PT

29. Department of Hand & Reconstructive Microsurgery Median nerve palsy

30. Department of Hand & Reconstructive Microsurgery Principles Replace lost nerve function: –Motor and sensory. Low median nerve palsy: –Sensation in the radial 3 fingers. –Thumb opposition. High median nerve palsy: –Sensation in the radial 3 fingers. –Thumb opposition. –Flexion in the radial 3 fingers. –Flexion in the thumb.

31. Department of Hand & Reconstructive Microsurgery Sensation Late nerve repair. Littler heterodigital neurovascular island flap from ring or little finger to thumb.

32. Department of Hand & Reconstructive Microsurgery Thumb opposition The action of bringing the pulp of the thumb into contact with the pulp of one of the other fingers. Opposition cones: –199, greater cone, Bunnell. –200, lesser cone.

33. Department of Hand & Reconstructive Microsurgery Opposition Anteposition or abduction: –Tm joint mainly. Flexion: –All three joints. Pronation: –Tm jont.

34. Department of Hand & Reconstructive Microsurgery Hands of man and monkeys

35. Department of Hand & Reconstructive Microsurgery Feet of man and monkeys

36. Department of Hand & Reconstructive Microsurgery Mechanism of opposition The thumb is opposed when its pulp is parallel to the pulp of the middle finger: –1 pronation –2 flexion –3 abduction

37. Department of Hand & Reconstructive Microsurgery Choice of trajectory of transferred muscle 1 when abduction is needed. 2 and 3 when deficit is in pronation and flexion.

38. Department of Hand & Reconstructive Microsurgery EIP transfer (Burkhalter) Simple and efficient. EIP harvested and hood repaired. Multiple vector changing incisions. EIP weaved into APB insertion.

39. Department of Hand & Reconstructive Microsurgery FDS IV (Royle) Originally, the distal edge was used as the pulley. 15 different trajectories proposed. Merle uses pisiform. Short transverse incision for harvesting. Insertion onto EPL and APB. Tension: thumb in complete abduction with wrist flexed 30 degrees.

40. Department of Hand & Reconstructive Microsurgery Clinical result, FDS IV

41. Department of Hand & Reconstructive Microsurgery Palmaris longus transfer (Camitz) Simple with minimal donor site morbidity. Can be combined with carpal tunnel release. Fascial extension necessary. Angle of insertion is primarily for abduction

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43. Abductor digiti minimi (Huber) Difficult, the neurovascular pedicle must be dissected up till the Guyon canal. It forms the centre of rotation.

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45. High median nerve paralysis Reanimation of thumb and index pinch: ECRL to FDP index.

46. Department of Hand & Reconstructive Microsurgery Brachioradialis to FPL.

47. Department of Hand & Reconstructive Microsurgery Ulnar nerve paralysis

48. Department of Hand & Reconstructive Microsurgery Loss Pinch MCPJ flexion leading to claw hand Loss of finger abduction and adduction Flattening of the arch FDP flexion of ring and little fingers. Loss of FCU Sensation on ulnar border of hand.

49. Department of Hand & Reconstructive Microsurgery Restoration of pinch Littler technique using FDS IV. Angle of pull parallel to adductor pollicis fibers.

50. Department of Hand & Reconstructive Microsurgery Restoration of pinch Smith’s technique ECRL can be used: –Synergistic –Needs a graft Better for high palsies so as to preserve FDS tendons.

51. Department of Hand & Reconstructive Microsurgery Restoration of pinch Index abduction should be reconstructed to counter the increased thumb pinch. EPB biomechanically more logical than EIP(Bruner).

52. Department of Hand & Reconstructive Microsurgery Restoration of ring and little finger flexion FDP III to FDP IV V FDS III to FDP IV V

53. Department of Hand & Reconstructive Microsurgery Correction of claw deformity Results from interosseous paralysis. 3 common techniques: –Zancolli capsulodesis –Zancolli lasso transfer –Brand transfer

54. Department of Hand & Reconstructive Microsurgery Bouvier manoeuvre To verify reducible claw. Passively reduce MCPJ hyperextension. If the fingers extend completely, tenodeses are sufficient to reduce the claw.

55. Department of Hand & Reconstructive Microsurgery Zancolli capsulodesis For moderate deformities. A1 pulley cut. U flap in volar plate sutured proximally to flex MCPJ 30 degrees.

56. Department of Hand & Reconstructive Microsurgery Zancolli lasso procedure FDS III divided into 3 slips and transferred to A1 pulley-MCPJ complex.

57. Department of Hand & Reconstructive Microsurgery Brand technique ECRL extended with a graft and sutured to A1 pulleys aiming for 30 degrees of MCPJ flexion.

58. Department of Hand & Reconstructive Microsurgery If Bouvier’s manoeuvre is positive, the tendon slips should be passed to the intermetacarpal ligament and sutured to the lateral bands.

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60. Finger adduction ( Wartenberg sign) Transfer of half of EDC IV to interosseous expansion.

61. Department of Hand & Reconstructive Microsurgery Combined paralyses Deficit of muscle units. Additional units can be freed by arthrodesing certain joints.

62. Department of Hand & Reconstructive Microsurgery Ulnar and median nerves ECRB to FDP BR to FPL EIP to thumb for opposition ECU to A1 pulleys for claw correction MP thumb fusion

63. Department of Hand & Reconstructive Microsurgery Radial and ulnar nerves Better prognosis because hand sensation is preserved palmarly. PT to ECRL. PL to EPL. FDS III to EDC. FDP IV V to III. Zancolli capsulodesis

64. Department of Hand & Reconstructive Microsurgery Median and Radial nerves The most difficult to treat. Classically: Wrist fusion. FCU to EDC and EPL. Thumb IPJ fusion. Huber transfer.

65. Department of Hand & Reconstructive Microsurgery Fusion, FDP LF to FPL, split FCU to EPL and EDC

66. Department of Hand & Reconstructive Microsurgery Thank you

67. Department of Hand & Reconstructive Microsurgery