Transferencias Paralisis Radial

Tendon Transfers

Doug Humphreys

Division of Plastic Surgery

Dalhousie University

Halifax, Nova Scotia

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Tendon Transfers

• Definition– The Detachment Of A Functioning Muscle-

Tendon Unit From Its Insertion And Reattachment To Another Tendon Or Bone To Replace The Function Of A Paralyzed Muscle Or Injured Tendon

Tendon Transfers

• Indications 1) Restore Function To A Muscle Paralyzed As

A Result Of Injury Of The Peripheral Nerves, Brachial Plexus Or Spinal Cord

2) To Restore Function After Closed Tendon Ruptures Or Open Injuries To The Tendons Or Muscles

3) Restore Balance To A Hand Deformed From Neurological Conditions

Tendon Transfers

• General Principles1) Straight Line Of Pull

2) Expendable Donor

3) Adequate Strength

4) Correction Of Contracture

5) One Tendon – One Function

6) Amplitude Of Motion

7) Synergism

8) Tissue Equilibrium

Tendon Transfers

1) Correction Of Contracture– Keep All Joints Supple

• Soft Tissue Contracture Easier To Prevent Than Correct

Stiff Joints Will Not Move!!

Tendon Transfers

2) Adequate Strength– Donor Strength Must Be

Adequate To Perform New Function In Its Altered Position• Work Of Muscle Related

To Muscle Volume

– Transferred Muscles Lose One Grade Of Strength

Tendon Transfers

3) Amplitude Of Motion– Wrist Flexors And Extensors

• 33mm

– Finger Extensors And EPL• 50mm

– Finger Flexors• 70mm

Tendon Transfers

3) Amplitude Of Motion– Augmentation Of Effective Amplitude

a) Convert From Monarticular To Multiarticular – Utilize Tenodesis

b) Dissection Of Surrounding Fascial Attachments

Tendon Transfers

4) Straight Line Of Pull– Most Efficient Transfer

5) One Tendon – One Function– Single Tendon Cannot Perform Two Opposite

Functions Simultaneously– May Insert Into More Than One Tendon

• FCU EDC

Tendon Transfers

6) Synergism– Easier To Retrain

7) Expendable Donor– Use Of Muscle Must Not Result In Unacceptable

Functional Loss

8) Tissue Equilibrium– No Transfer Should Be Done Unless Tissues In

Optimal Condition• Scars Soft, No Induration

Tendon Transfers

• Surgical Principles– Carefully Planned Incisions

• Tendons Should Not Lie Beneath Scars

– Careful Mobilization Of Muscles• Prevent Neurovascular Pedicle Damage

– Subcutaneous Tunneling Of Transfers• No Small Fascial Windows

Radial Nerve Palsy

Tendon TransfersRadial Nerve Palsy

• Functional Deficits– Wrist Extension– Finger Extension– Extension And Radial Abduction Of The

Thumb


• Timing Of Tendon Transfers– Controversial

• Early – Internal Splint At Time Of Nerve Repair

• Conventional– Performed After Reinnervation Of Paralyzed Muscles

Fails To Occur By 3 Months After Expected

• Late


• Early Transfer– Pronator Teres to ECRB– Temporary Substitute Until Reinnervation– Suboptimal Reinnervation – Acts To Augment

Function

• Historical Perspective– Evolved During The Two World Wars– Classic Jones Transfer (1916)

• PT ECRL and ECRB

• FCU EDC III-V

• FCR EIP, EDC II, and EPL



FCU Transfer

• Incision 1:– FCU And PL Transected Proximally– FCU Freed Up Proximally

• Incision 2:– Deep Fascia Overlying FCU Incised And Muscle Freed

Proximally– Limit – Neurovascular Pedicle

• Incision 3:– Insertion Of PT Freed With Strip Of Periosteum– EPL Tendon Identified



• Setting The Proper Tension– Err On Suturing Extensor Tendons Tightly– PT ECRB

• Wrist 45° Extension

• Tendon Sutured With Maximal Tension

– FCU EDC • Wrist and MP Joints In Neutral

• Adjust EDC Tension Individually

• +/- EDM


• Setting The Proper Tension– PL EPL

• Wrist In Neutral• Maximal Tension On EPL And PL

• Test Passive ROM– Wrist In Extension

• Passively Flex Fingers Into Palm

– Wrist In Flexion• MP Joints In Full Extension• Should Not Hyperextend


• Postoperative Management– Splint For 4 Weeks

• Wrist 15-30° Pronation• Forearm 45° Extension• MP Joints Slight Flexion (10-15°)• Thumb – Maximal Extension And Abduction• PIP Joints – Left Free

– 4 To 6 Weeks• Removable Splint• Planned Exercise Program – With Therapist


• Potential Problems– Excessive Radial Deviation

– From Removing FCU– Further Aggravated If PT Inserted Into ECRL– Problem With PIN Palsy

• Solutions– FCU Transfer Contraindicated With PIN Palsy– Reinsert ECRL Into 4th Metacarpal

– Bowstringing Of EPL• Solution

– Hook EPL Around Insertion Of APL


• Potential Problems– Absence Of Palmaris Longus

• Solutions– Include Thumb Extrinsics In FCU EDC Transfer

» Violates One Tendon – One Function Principle

– Use Brachioradialis

» Possible Only With PIN Palsy

» Requires Extensive Freeing Up

» More Difficult To Reeducate

– Use FDS III Or IV


FCR Transfer(Starr, Brand, Tsuge)


• FCR EDC

• PT ECRB, When Required– Performed As Before

• PL EPL – Performed As Before– If Absent

• EPL Joined With EDC To FCR Transfer


• Incision – Between FCR And PL

• FCR Freed To Middle Of Forearm

• FCR Passed Around Radial Border– Subcutaneous Tunnel

• Two Best Tendons Sutured To FCR– Other Two Sutured To Neighbors

Sutured With Wrist & MP’s In Neutral


Superficialis Transfer(Boyes)


• PT ECRB

• FDS III EDC III,IV,V

• FDS IV EIP & EPL

• FRC APL & EPB


• PT Tendon Exposed– Volar – Radial Incision

• Sublimis Tendons Exposed– Transverse Incision Palm– Divided Proximal To Chiasm

Pass Tendons Through Interosseous Membrane Or Around Radial And Ulnar Borders


• Potential Problems– Protect Anterior And Posterior Interosseous

Arteries• One Opening On Either Side Of The Artery

– Avoid Kinking The Median Nerve• FDS III Routed To The Radial Side Of Profundus

– Between FDP And FPL

• FDS IV Routed To The Ulnar Side Of Profundus


• Transfer– FDS III

• EDC (Long, Ring and Little)

– FDS IV • EIP and EPL

Advantages– Independent Motion Of Thumb And Index

– Palmaris Absent

• Indian J Orthop. 2011 Nov-Dec; 45(6): 558–562.

• Outcome of tendon transfer for radial nerve paralysis: Comparison of three methods

• Alia Ayatollahi Moussavi, Alireza Saied, and Ali Karbalaeikhani1

• 41 pacientes / 3 Grupos• FCU Extensión dedos

– PL EPL (Abducción y extensión D1)

• FCR Extensión dedos– PL EPL (Abducción y extensión D1)

• FDS 3º Extensión dedos– FDS 4º EPL

• En todos si se necesitaba restaurar extension muñeca: PT ECRB

• Si no tenian PL, eran excluidos

• Postop– Valva ABP con muñeca y dedos en extensión

por 4 semanas– Luego 3 meses nocturna– Fisioterapia desde el 1º mes

• Grupo 1– 18 Pacientes



• Resultados

• Sin diferencias:– ROM muñeca, D1, dedos

– DASH: 35 / 38 / 30

• 95% Se volveria a operar• Extension simultanea de muñeca-dedos

– Solo 4 del grupo 3

• Contractura en flexion – 3 pacientes del grupo 3

• Pronosupinacion conservada en todos

• Varios presentaron disminución flexion muñeca– Ninguno lo reporto

• Todos lograron buen grip– No fue medido por falta de instrumentos

• Sin desviaciones radiales

Transferencias Paralisis Radial

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