Download PRINCIPLES OF TENDON TRANSFERS

TENDON TRANSFERS FOR
THE HAND
National Congress of Indonesian Surgery for Surgery of the Hand (HIPITA)
2nd Flap dissection course and workshop
Surabaya, March 31-April 2, 2005
Aymeric Lim
Department of Hand & Reconstructive Microsurgery,
National University Hospital
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
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
Department of Hand & Reconstructive Microsurgery
Programme
• Principles
– Biomechanical
– Surgical
• Tendon transfers in peripheral nerve
injuries
– Radial nerve
Department of Hand & Reconstructive Microsurgery
Length- tension curve
Department of Hand & Reconstructive Microsurgery
Muscle length- tension
relationship
• The force developed by a muscle during
contraction varies with its starting length.
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
Department of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive Microsurgery
Upper limb muscles
Department of Hand & Reconstructive Microsurgery
Surgical principles
• Tissue equilibrium (Steindler)
– No soft tissue induration
– No reaction in the wounds
– Joints supple
– Scars soft
Department of Hand & Reconstructive Microsurgery
Choice of muscle
•
•
•
•
•
Expendable
Working
Synergistic
Straight line of pull
One tendon one function
Department of Hand & Reconstructive Microsurgery
Transferred muscles
• Loss of power by one
grade
• Adhesions
Department of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive Microsurgery
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)
Department of Hand & Reconstructive Microsurgery
Planning a tendon transfer
• What works
• What is available
• What is needed
• Matching
• Staging
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.
Department of Hand & Reconstructive Microsurgery
High radial nerve palsy
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
Department of Hand & Reconstructive Microsurgery
Donor
Insertion
Function
Reference
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
PT
FCU
ECRL
EPL (rerouted)
EDC
Wrist ext.
Thumb ext.
Finger ext.
Riordan 1964
Department of Hand & Reconstructive Microsurgery
High radial nerve palsy- The
standard
transfer
Incisions for Tubiana Transfer
Department of Hand & Reconstructive Microsurgery
PT to ECRB Transfer
Department of Hand & Reconstructive Microsurgery
FCU to EDC Transfer
Department of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive Microsurgery
Immobilisation
• 3-4 weeks.
Department of Hand & Reconstructive Microsurgery
Thank you
Department of Hand & Reconstructive Microsurgery
The three most common
variants
Function
Tubiana
Smith
Boyes
Finger
extension
FCU
FCR
FDS IV
Thumb
extension
PL
PL
Wrist
extension
PT
PT
FDS III
PL to APL
PT
Department of Hand & Reconstructive Microsurgery
Median nerve palsy
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.
Department of Hand & Reconstructive Microsurgery
Sensation
• Late nerve repair.
• Littler heterodigital neurovascular island
flap from ring or little finger to thumb.
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.
Department of Hand & Reconstructive Microsurgery
Opposition
• Anteposition or
abduction:
– Tm joint mainly.
• Flexion:
– All three joints.
• Pronation:
– Tm jont.
Department of Hand & Reconstructive Microsurgery
Hands of man and monkeys
Department of Hand & Reconstructive Microsurgery
Feet of man and monkeys
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
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.
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.
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.
Department of Hand & Reconstructive Microsurgery
Clinical result, FDS IV
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
Department of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive Microsurgery
Abductor digiti minimi (Huber)
• Difficult, the
neurovascular pedicle
must be dissected up
till the Guyon canal.
• It forms the centre of
rotation.
Department of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive Microsurgery
High median nerve paralysis
• Reanimation of thumb
and index pinch:
• ECRL to FDP index.
Department of Hand & Reconstructive Microsurgery
Brachioradialis to FPL.
Department of Hand & Reconstructive Microsurgery
Ulnar nerve paralysis
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.
Department of Hand & Reconstructive Microsurgery
Restoration of pinch
• Littler technique using
FDS IV.
• Angle of pull parallel
to adductor pollicis
fibers.
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.
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).
Department of Hand & Reconstructive Microsurgery
Restoration of ring and little finger
flexion
• FDP III to FDP IV V
• FDS III to FDP IV V
Department of Hand & Reconstructive Microsurgery
Correction of claw deformity
• Results from interosseous paralysis.
• 3 common techniques:
– Zancolli capsulodesis
– Zancolli lasso transfer
– Brand transfer
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.
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.
Department of Hand & Reconstructive Microsurgery
Zancolli lasso procedure
• FDS III divided into 3
slips and transferred
to A1 pulley-MCPJ
complex.
Department of Hand & Reconstructive Microsurgery
Brand technique
• ECRL extended with
a graft and sutured to
A1 pulleys aiming for
30 degrees of MCPJ
flexion.
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.
Department of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive Microsurgery
Finger adduction ( Wartenberg
sign)
• Transfer of half of
EDC IV to
interosseous
expansion.
Department of Hand & Reconstructive Microsurgery
Combined paralyses
• Deficit of muscle units.
• Additional units can be freed by
arthrodesing certain joints.
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
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
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.
Department of Hand & Reconstructive Microsurgery
Fusion, FDP LF to FPL, split
FCU to EPL and EDC
Department of Hand & Reconstructive Microsurgery
Thank you
Department of Hand & Reconstructive Microsurgery
Department of Hand & Reconstructive Microsurgery