TENDON TRANSFERS AND UPPER LIMB DISORDERS Aws Khanfar, MBBS, MRCSI, MFSEM, CHSOrth, FEBOT

What is a tendon transfer? The tendon of a functioning muscle is detached from its insertion and reattached to another tendon or bone to replace the function of a paralysed muscle or injured tendon. The transferred tendon remains attached to its parent muscle with an intact neurovascular pedicle.

What is a tendon transfer? “Using the power of a functioning muscle unit to activate a non functioning nerve/muscle/tendon unit”. Tendon transfers work to correct: instability imbalance lack of co-ordination restore function by redistributing remaining muscular forces

Indications Paralysed muscle Injured (ruptured or avulsed) tendon or muscle Balancing deformed hand e.g. cerebral palsy or rheumatoid arthritis Some congenital abnormalities

General principles - Only justified in restoring functional motion of the hand, -. Patient factors Age Functional disabilities with poor non operative prognosis Ability to understand nature and limitations of surgery, including aesthetic goals Motivated to co-operate with post operative physiotherapy

General principles -. Recipient site Tissue bed into which transfer is placed should be soft and supple Good soft tissue coverage Stable underlying skeleton Full passive range of motion of joints to be powered Area to be powered must be sensate

General principles Amplitude of the donor muscle ( TENDON EXCURSION) -. Donor muscle factors Amplitude of the donor muscle ( TENDON EXCURSION)

General principles Power of the donor muscle Any transferred muscle loses at least one grade of strength, so only Grade 5 muscles are satisfactory

General principles One tendon, One function Effectiveness reduced in transfer designed to produce multiple functions Synergistic muscle groups are generally easier to retrain Fist group – wrist extensors, finger flexors, digital adductors, thumb flexors, forearm pronators, intrinsics Open hand group – wrist flexors, finger extensors, digital abductors, forearm supinators Use of synergistic muscles tends to help retain joint balance

General principles Line of transfer Should approximate pull of original tendon if possible Acute angles should be avoided Expendability Transfer must not cause loss of an essential function

General Post Operative Management Rehabilitation is equally important in tendon transfer success as surgical execution Rehabilitation / physiotherapy is essential in Regaining joint mobility lost during splinting Training tendon to glide in new course Teaching patients to activate a new muscle to achieve a certain function, which requires development of new neural pathways The more that a patient notices a disability, the greater the motivation, so the easier the retraining Children are usually managed with static protocols or longer protective phase

Basic Principles of Post Operative Rehabilitation 1. Pro tective phase Begins at surgery and lasts 3 – 5 weeks Objectives:- Protective splinting Oedema control Mobilise uninvolved joints

Mobilise tendon transfer 2. Mobilisation phase Begins when tendon healing is adequate for activation (usually 3 – 5 weeks post op) Objectives Mobilise tendon transfer Continue mobilisation of uninvolved joints to prevent joint stiffness from disuse Reinforce preoperative teaching and patient education Continue oedema control and protective splinting

Basic Principles of Post Operative Rehabilitation 3. Intermediate phase Begins 5 – 8 weeks post operatively Gradually increases hand activity and passive range of motion exercises Limited functional movements permitted 4. Resistive phase Beginning at 8 – 12 weeks Tendon junctions are strong enough to withstand increasing resistance Therapeutic objective is to increase endurance and strength of transferred muscles Work related simulated tasks are begun to patient tolerance

Radial Nerve Palsy Wrist extension is critical for stability, which is essential for grip and assisting the function of many tendons crossing the wrist

Tendon Transfers Well defined and highly effective, aiming to replace Wrist extension Finger extension Thumb extension and abduction Standard

Radial Nerve Palsy Non-Operative Treatment Splintage Maintenance of full passive ROM in all joints of the wrist/hands and prevent contractures

Radial Nerve Palsy Early transfers (“Internal Splintage”) greatest functional loss is grip strength

PT to ECRB

FCU to EDC

PL to EPL

Common Upper limb disorders Symptoms: Muscle/tendon problems : Pain , Swelling ,Weakness Nerve related : Tingling/altered sensation , Weakness

Tendon problems: Dequervain’s History: New, repetitive activity Pain over thumb side of the wrist Pain on making a fist, grasping or holding objects

Examination Swelling Thickening Tenderness Freinklestein test

Treatment Activity modification NSAID Splintage – thumb widely abducted Steroid Injection

. Surgical Release

Tennis/Golfers elbow Incidence General population: 0.6% Tennis players: 9% Age: 35 and 50 years, with an equal distribution between males and females Associated Rotator cuff problems: 20-40%

Etiology Multiple microtraumatic events Disruption of the internal structure of the tendon and degeneration of the cells and matrix

Presentation Pain : outer aspect (Tennis elbow )of elbow/ inner aspect (Golfers) Increases with activity and Lifting objects Sometimes pain at rest Palapation : Tenderness Special test Resisted wrist extension , Elbow flexion , Elbow Extension

Non- Operative Treatment options Topical NSAIDs Oral NSAIDs Orthotic devices Physiotherapy

Operative treatment Surgery to repair the tendon

CTS Incidence: 1-3 cases per 1000 persons per year Prevalence: 50 cases per 1000 persons aged in their 30s and 50s Women are affected 2-3 times more often

Association of CTS in computer workers

Symptoms Pins and needles Pain The pain may travel up the forearm. Numbness of finger Dryness of the skin Weakness of muscles

AnatomyContents: Nine flexor tendons Tendons Median Nerve

Examination Dry pulps Wasting of Thenar muscles Tinels

 Investigations Nerve conduction test

Treatment Night splints Surgical release

Shoulder Impingement syndrome Pain in shoulder Increases with activity Clicking sensation in shoulder Pain with overhead activities/ reaching for seat belt, wearing cloths

Treatment Pain medication Activity modification Physio ,To improve scapular position , Strengthen a specific group of muscles Injection into shoulder Surgery