Tendon Transfers Genesis

Principles and Practice • Birth palsy

Leonid I. Katolik, M.D. • Cerebral palsy

The Philadelphia Hand Center, P.C.
• Polio

• World war

Goal Principles Simplified

• Principles of tendon transfer
– Focus on radial nerve transfers
• To rob from Peter and
• Specific transfers for: to give to Paul
– Radial Nerve
– Median Nerve
– Ulnar nerve • Peter remains none
• Not Included the wiser
– Combined injuries
– Excessive mental masturbation

Principles Principles
• Straight line of pull • Expendable Donor
• Transfer Synergy – Exploiting redundancy
– Finger flexion with Wrist extension
– Finger extension with Wrist flexion • One tendon – One function
– Independent cortical control may bail you out
• Timing -- “Tissue Equilibrium”
– Scars soft
– Wounds mature
– Induration gone
– Joints supple
 Principles Principles
• Timing • Match work capacity
– Early v. Late  not that controvertial – PT 1.2  ECRB 0.9
– Internal splint
– Improves power following nerve regeneration – FCR 0.8  EDC 1.7
– Minimizes period of dysfunction when nerve – FCU 2.0  EDC 1.7 better match?
regeneration expected to be poor
• Age – PL 0.1  EPL 0.1
• Gap > 4cm – FDS 4.8  EPL 0.1
• Crush

Principles Evaluation
• Match amplitude of tendon excursion • At least two meetings pre op
– Wrist flexion and Wrist extension require – Answer questions
33mm of excursion
– Finger extension and Thumb extension – Chance to re-examine
require 30mm of excursion – Meet with therapy pre op
– Finger flexion requires 70 mm of excursion
• Check sensation

• Increase amplitude by tenodesis effect • EMG not routinely useful

• Increase amplitude by dissection of donor • What’s in – What’s out

Radial Nerve Transfer

• My favorite
• Predictable outcomes
Radial Nerve Transfers – Easy to relearn
• High v. Low
– More work v. less work
– But not much
• Three main varieties
 Radial Nerve Transfer Radial Nerve Transfer
• “FCR transfer” • “FCU transfer”
– FCR  EDS – FCU  EDC
– PT  ECRB – PT  ECRB
– PL  rerouted EPL – PL  rerouted EPL
– Straighter line of pull
– More powerful, however…
• Tenodesis more than makes up for it
– Excessive radial deviation

Radial Nerve Transfer Radial Nerve Transfer

• FCR and FCU transfers rely on intact PL • “Superficialis transfer”
• If PL not there… – PT to ECRB
– FDS III to EDC
– FDS IV to EPL
– FDS IV to EPL and EIP
– FCR to APL and EPB
– Violates “one tendon – one function”
– Maybe too powerful
• Work capacity FDS 4.8
• Work capacity EPL 0.1

Technique Technique
• OK to optimize incisions • OK to optimize incisions

• Take PT with periosteum

 Technique Technique
• OK to optimize incisions • OK to optimize incisions

• Take PT with periosteum • Take FCR with periosteum

• Set tension of EDC first • Set tension of EDC first

• Reroute EPL

Setting Tension
• By “feel”
– Nothing beats experience
Median Nerve Transfers
• Pulvertaft weave

• Too tight better than

too loose

Median Nerve Transfers Median Nerve Transfers

• Not so much my favorite • Principles remain the same
– Loss of sensation very disabling
– Attempts to restore sensation illustrate – Good soft tissue
triumph of technology over reason
– Full passive ROM
• Must be clear why you are operating and
what you hope to gain – Good sensation
 Median Nerve Transfers Median Nerve Transfers
• Principles remain the same • Reconstruction determined by
– Straight line of pull – Quality of sensation
– Good synergy – Contralateral hand function
– Good amplitude match – Patient motivation
• Tension of APB + Opp = 3.0 – Ability to adapt to sensory loss
• FDS IV (3.0) PL (1.2) • Cortical plasticity
• ADM (4.0) EIP (5.5)
– Must reach MCP

Low Median Nerve Transfers Low Median Nerve Transfers

• Low median nerve palsy • Current indications
– Distal to AIN takeoff – Traumatic injury to motor branch
– Loss of APB, opponens, and FPB
– Neuromuscular disorders
• HOWEVER • Charcot-Marie-Tooth
– Many patients can retain thumb abduction and
• Spinal muscular atrophy
opposition from ulnar muscles
• Syringomyelia
• THEREFORE
– While the indication for opponensplasty is lack of
opposition, the indication for SURGERY is loss of
function due to the loss of opposition

Low Median Nerve Transfers Low Median Nerve Transfers

• 4 Standard Opponensplasties • 4 Standard Opponensplasties
– FDS – FDS
• Excellent tension match • Excellent tension match
– EIP
• Excellent tension
• Excellent line of pull
 Low Median Nerve Transfers Low Median Nerve Transfers
• 4 Standard Opponensplasties • 4 Standard Opponensplasties
– FDS – FDS
• Excellent tension match • Excellent tension match
– EIP – EIP
• Excellent tension • Excellent tension
• Excellent line of pull • Excellent line of pull
– ADM – ADM
• Cosmetic also • Cosmetic also
– PL
• “Easy”

High Median Nerve Transfers High Median Nerve Transfers

• Injury above AIN takeoff • BR to FPL

• Need to restore
– Flexion of thump
– Flexion of index finger

• ECRL to FDP IF/MF

• Lack of sensibility tempers enthusiasm

Ulnar Nerve Transfers

• Goals are straightforward
– Stop clawing
– Increase grip
Ulnar Nerve Transfers – Increase pinch

• Distinguish
– High
– Low
– Very low

Neuromuscular disorders spare sensation

 Level of Injury Ulnar Nerve Transfers
• High • Goals: FIX THE CLAW
– Motor to extrinsics
– Motor to intrinsics – Static transfers
– Sensation dorsal and palmar • Capsulodesis
No strength in transferable muscles
• Low •
• Easy
– Motor to intrinsics • Poor durability
– Sensation to hand
• Very Low
– Spares hypothenar

Ulnar Nerve Transfers Ulnar Nerve Transfers

• Goals: FIX THE CLAW • Goals: FIX THE CLAW

– Static transfers – Static transfers

• Capsulodesis • Tenodesis
• No strength in transferable muscles • U-shaped graft
• Easy – 2 tails each end
– Extensor retinaculum
• Poor durability
– Start dorsal, go palmar, end dorsal
• Looks good on paper
• Impossible to tension

Ulnar Nerve Transfers Ulnar Nerve Transfers

• Goals: FIX THE CLAW • Goals: FIX THE CLAW

– Dynamic transfers – Dynamic transfers

• MANY kinds • FDS motor
• Principle the same
– Palmar motor
– Flex MCP
– Couple to PIP extension
 Ulnar Nerve Transfers Ulnar Nerve Transfers
• Goals: FIX THE CLAW • Goals: FIX THE CLAW

– Dynamic transfers – Dynamic transfers

• FDS motor • FDS motor
• Zancolli Lasso • Zancolli Lasso
• ECRL transfer with graft

Ulnar Nerve Transfers Ulnar Nerve Transfers

• Goals: INCREASE PINCH • Goals: INCREASE GRIP
– Restore thumb adduction – Side to side transfer
– Easy
FDS ECRB

Summary Summary
• Radial nerve transfers • Keep the principles in mind
– Like magic
• Median nerve transfer • Your colleagues will make this shine
– Little indication
– Keep it simple - opposition
• Make sure to thank them daily!
• Ulnar nerve transfers
– Fix claw
– Improve pinch
THANKS!
 Post Op Care Post Op Care
• 0-4 Weeks Post-Op • 4 Weeks Post-Op
• Short arm splint • Removable short arm extension splint
– Personal preference – Remover for Finger/thumb ROM exercises
– Wrist 45º extension – Synergistic movements
– MP joints 10-15º flexion – ? dynamic extension splint
– IP joints Free – Static protective splint for crowds/sleeping for
– Thumb max Abd & Ext 4-6 weeks