Fundamentals. Objectives. Tendon Transfers. Overview. Principles. Mechanism. Brocha Z. Stern, MOT, OTR/L, CHT

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1 Objectives Tendon Transfers Brocha Z. Stern, MOT, OTR/L, CHT Curtis National Hand Center Baltimore, MD October 6-8, 2017 Describe general goals, principles, and mechanical considerations of tendon transfers Explain general preoperative and postoperative rehabilitative guidelines for tendon transfers Apply anatomical and surgical considerations to the rehabilitation of specific tendon transfers, with emphasis on median, ulnar, and radial nerve palsies Overview Fundamentals (Brand, 2011; Brand, Beach, & Thompson, 1981; Brand & Hollister, 1985; Jones, 2013; Livermore & Tueting, 2016; Peljovich, Ratner, & Marino, 2010; Ratner & Kozin, 2011; Sammer & Chung, 2009a, 2009b; Wilbur & Hammert, 2016) Restore balance that has been lost or compromised through disease or injury Indications ( Substitute for weak or paralyzed muscle Replace damaged tendon or muscle Correct muscle imbalance caused by CNS lesion Potential diagnoses Peripheral nerve injuries, cerebral palsy, spinal cord injury, thumb hypoplasia, rheumatoid arthritis Mechanism Altering the insertion or origin of a nearby, redundant, strong, and voluntarily controlled muscle (Pelojovich, Ratner, & Marino, 2010, p. 1365) Muscle is redirected by changing the insertion site of its tendinous portion Tendon-tendon coaptation Blood and nerve supply unaffected **Differentiate from free muscle transfer or nerve transfer (Baumeister, 2015; article/ treatment#d11) Principles Donor properties Must be expendable Adequate power to motor the recipient tendon Similar tendon excursion as the recipient Function synergistic with the recipient Normal PROM Tissue equilibrium Straight line of pull Single function per transfer

2 Strength & Work Strength Ability to generate tension Proportionate to cross-sectional area Does not change with transfer Functional change in strength (~1 muscle grade) due to factors such as drag Work Force x distance Proportionate to muscle mass ( Cellular_Physiology/Cell_junctions_and_Tissues) Potential Excursion (Amplitude) The distance a muscle can contract if Freed from all its connective tissue attachments Stimulated from its fully stretched position Proportionate to muscle fiber length Dependent on number of sarcomeres in muscle fiber (Wilhelmi, 2017; article/ overview#a4) Required Excursion The distance a muscle needs to contract to move the joint(s) through full range of motion Typically less than potential excursion i.e. ECRB 6 cm of potential excursion but only ~3.5 cm of required excursion Wrist extensors and flexors 33 mm Finger extensors 50 mm Finger flexors 70 mm Available Excursion The distance a muscle can contract as permitted by the surrounding connective tissue Varies from person to person Dependent on recent use of joints and tendons Assessed intra-operatively after cutting tendon at its insertion Measured by stimulating after placement at full stretch Maintained with transfer only if minimal change in position and minimal scarring Leverage Ability of a force to cause rotation on a lever Moment arm Perpendicular distance between axis of rotation and tendon as it crosses the joint Force Torque Torque = Force x moment arm Mechanical advantage Moment arm of force / Moment arm of load Price of increased power is reduced range (Brand, 2011) Drag Internal resistance in the form of friction and the need to stretch passive soft tissues (Brand, 2011) Friction Resisting force that occurs whenever two objects move against each other Soft tissue A transferred tendon becomes attached to its new area by soft tissue Living tissue has the ability to remodel or to grow in response to mechanical force ( spaces.com/friction)

3 Synergy Neuroplasticity ( Facilitates post-operative retraining Increases excursion (Schultz, 2006, CC 3.0; New Considerations Wide-awake surgery Tendon transfer is actually best indicated for such wide-awake surgery (Tang, 2015, p. 280) Improved ability to obtain optimal tension of transfer Rehabilitation: General Guidelines (Duff & Humpl, 2011; Schwartz, 2014) Preoperative Considerations Preoperative Evaluation Evaluation Assess capabilities and impairments Identify potential donor muscles Establish goals Intervention Increase joint and soft tissue mobility Isolate and strengthen donor muscles Orthosis fabrication Patient education History Physical Exam AROM and PROM Note joint contractures Sensibility Manual muscle testing, grip/pinch Observe muscle substitution or motor signs Motor learning aptitude Functional tests

4 Preoperative Orthoses Temporarily restore balance via external support Prevent or correct joint contractures or adaptive shortening i.e. Web spacer, PIP extension serial casts Prevent overstretching or maladaptive compensatory patterns i.e. Dynamic digital/thumb extension orthosis, Anti-claw orthosis Increase function i.e. Short opponens orthosis, Dynamic digital/thumb extension orthosis, Anti-claw orthosis Preoperative Orthoses MEDIAN NERVE Web spacer Short opponens (ASHT test prep book, p. 351) Colditz design ULNAR NERVE Anti-claw orthosis Theratube design (Staines, 2015) Preoperative Treatment Joint and soft tissue mobilization for ROM Muscle training and strengthening Isolate donor muscle Provide feedback via biofeedback and/or NMES Patient education Realistic expectations Timeframes of recovery Anticipated rehabilitation demands Communication with Surgeon Specific muscle-tendon units affected Anatomical route of the transferred tendon Pulleys and retinaculum Site of coaptation Quality of soft tissue and strength of suture Appearance of wound bed and potential for scarring Source of tendon grafts if used ( Immobilization/Early Phase Protect transfer Post-op cast generally for 3-4 weeks Immobilize in protective position to minimize tension on juncture Control edema Protect areas of diminished or absent sensation Prevent stiffness of uninvolved joints Mobilization/Intermediate Phase Protect transfer between exercises with orthoses Initiate activation of transfer Avoid overstretching Isolated joint ROM prior to composite Dynamic orthosis with stop blocks for limited tendon gliding No PROM against transferred tendon Monitor early motion to avoid muscle substitution i.e. Wrist flexion to extend digits; thumb flexion/adduction instead of opposition Short, frequent exercise sessions

5 Mobilization/Intermediate Phase Biofeedback and/or electrical stimulation (at sub-tetany contraction) Mobilize surrounding soft tissue to increase available excursion Scar management Sensory reeducation Introduce functional activities Resistive/Late Phase Add resistance to transfer Initiate when can activate transfer without assistance Motion against gravity Strengthen gradually Continue to avoid muscle substitution patterns Restore passive motion Gentle passive stretches, monitoring effect on transfer Focus on hand function Blocked vs. random task practice Feedback Transfer Activation Facilitation Transfer Activation Facilitation Preoperative preparation Place and holds Start exercises in gravity eliminated plane Light tasks that result in unconscious activation i.e. Opponensplasty touch thumb to the SF tip Perform the original motion of the donor muscle i.e. RF FDS FPL Tapping/vibration over muscle belly Biofeedback/NMES to encourage correct action Visual cues as adjunct Mirror visual feedback (Grangeon et al., 2010) Training orthoses i.e. Lumbrical bar as assist following intrinsic transfer Perform movements bilaterally New Considerations Early mobilization Systematic review Within 1 week of surgery Safe (no incidence of ruptures or pull-outs) Improved hand function in short-term, reduced costs, and decreased treatment time compared to immobilization Inconclusive findings for long-term outcomes (Sultana, MacDermid, Grewal, & Rath, 2013) Common Tendon Transfers: Anatomy, Surgery, & Rehabilitation Median, Ulnar, & Radial N. Injuries (Chadderdon & Gaston, 2016; Cheah, Etcheson, & Yao, 2016; Cook, Gaston, & Lourie, 2016; Diaz-Garcia & Chung, 2016; Duff & Humpl, 2011; Giuffre, Bishop, Spinner, & Shin, 2015; Isaacs & Ugwu-Oju, 2016; Ratner & Kozin, 2011; Sammer & Chung, 2009a, 2009b; Schwartz, 2014)

6 Median Nerve (Haymaker & Woodhall, 1953) HIGH LOW Median Nerve Muscle loss PT, PQ* FCR FDS IF/MF/RF/SF, FDP IF/MF* FPL* Lumbricals IF/MF APB, OP, superficial FPB Functional deficit Weak/absent forearm pronation Weak wrist flexion / radial deviation PIP/DIP flexion absent IF/MF, weak RF/SF Loss of thumb IP flexion MP flexion/ip extension deficit of IF/MF Loss of opposition, palmar abduction (deficits in functional prehension) * Restore thumb opposition * Restore thumb IP joint flexion * Restore digital flexion * = AIN innervation Median Nerve Opponensplasty Median Nerve Opponensplasty Camitz(PL APB) Allows excellent palmar abduction but limited pronation Used with long-standing CTS Superficialis (RF FDS APB) Uses pulley at pisiform to pull thumb into pronation/opposition Huber (ADM APB) Other potential donors EIP, EDQ, ECU (Sammer - gery/plastic/80.html) Post-op immobilization Thumb in palmar abduction, forearm-based unless intrinsic donor, wrist in slight flexion Mobilization at 3-4 weeks Active use of transfer Thumb flexion, extension, opposition, circumduction Avoid preoperative pattern of adduction/supination No simultaneous wrist and thumb extension 6-8 weeks D/c orthosis Functional and strengthening activities (pinch) Median Nerve Other Ulnar Nerve Fewer motors to choose from for high-level ECRL IF/MF FDP FDP of RF/SF IF/MF FDP BR FPL Often need concurrent nerve transfers for sensation (Young, Fattah, & Felming, 2008) (Haymaker & Woodhall, 1953)

7 Ulnar Nerve HIGH LOW Muscle loss FCU FDP RF/SF AP and 1st DI FPB deep head Lumbricals RF/SF Interossei Functional deficit Weak wrist flexion / UD Loss of power grip Loss of key pinch (Froment s/jeanne s sign) Impaired thumb stability during pinch Clawing of RF/SF (Duchenne s) Wartenberg s sign, flattened palmar arch (Masse sign) * Correct clawing for functional grasp: Restore intrinsic function via MCP joint flexion (and IP joint extension if negative Bouvier test) * Restore pinch: Restore thumb adduction (and IF abduction prn) * Restore RF/SF DIP flexion Ulnar Nerve Intrinsic Plus Brand: ECRB with PL free graft to intrinsics via lateral bands Modified Stiles-Bunnell: FDS of RF/MF inserted into lateral band or P1 Zancolli Lasso: FDS passed through pulley and sutured back to itself Other donors: EDQ, EIP, ECRL, BR (Sammer - Ulnar Nerve Intrinsic Plus Post-op immobilization Forearm-based with MPs in flexion and IPs in extension Mobilization Avoid muscle substitution Avoid fisting in first few weeks to limit stress on transfer Avoid passive IP flexion/extension Avoid full extension of MP (particularly in first 3 weeks) Increase MP extension gradually and expect a lag Use lumbrical bar as orthosis assist at 4-6 weeks during light functional activities Protect from heavy use for up to 3 months post-surgery Ulnar Nerve Other Adductorplasty Restore thumb adduction and lateral pinch Most transfers provide improved stability and improved pinch strength of 25-50% Boyes: BR extended with free graft Smith-Hastings: ECRB AP/1 st metacarpal Gross composite flexion ECRB FDP IF/MF FDP RF/SF FDP (Sammer - ery/plastic/80.html) Radial Nerve HIGH LOW Radial Nerve Muscle loss Functional deficit Brachioradialis Weak elbow flexion ECRL/ ECRB* Weak wrist extension / radial deviation Supinator Weak supination (test in extension to eliminate biceps) ECU Weak wrist extension / ulnar deviation EDC, EIP, EDQ Lost digital extension EPL, EPB, APL Lost thumb extension / radial abduction *Variable, may be innervated by PIN and may be lost in low-level (Haymaker & Woodhall, 1953) * Restore wrist extension * Restore MCP extension * Restore thumb extension

8 Radial Nerve PT ECRB/L to restore wrist extension FCU, FCR, or FDS EDC to restore finger extension PL or FDS EPL to restore thumb extension (Sammer - gery/plastic/80.html) Radial Nerve Postoperative Post-op immobilization Long-arm orthosis 90 elbow flexion, forearm pronation, wrist extension, MP extension, IPs free, thumb radial abduction Protective orthosis is continued for a total of ~8 weeks May be able to switch to wrist cock-up at 6 weeks Mobilization starts at 3-4 weeks Gentle isolated AROM of each joint is performed Avoid composite wrist/digital flexion until ~8 weeks Resistance initiated ~8 weeks Thumb Tendon Ruptures Other Tendon Transfers (Ashworth & Kozin, 2011; Bednar, 2016) EIP EPL Rheumatoid arthritis Distal radius fracture FDS MF/RF FPL Mannerfelt lesion Volar plating s/p distal radius fracture (Baumeister, 2015; rticle/ treatment#d10) Elbow Shoulder Restore elbow flexion Latissimus dorsi biceps Pectoralis major biceps Triceps biceps Steindler flexorplasty (flexorpronator mass) Restore elbow extension Posterior deltoid triceps Biceps triceps ( s/38/steindler%e2%80%99s+flexorplasty.jpg ) Restore shoulder external rotation L Episcopo: teres major posterior cuff Modified L Episcopo: teres major and latissimus dorsi posterior cuff (Shi, Cahill, Ek, Tompson, Higgins, & Warner, 2015)

9 A Word (or Two) on Nerve Transfers Sensory and/or motor Potential advantages over tendon transfers Restore sensation and motor Restore function to multiple muscles Preserve muscle balance Avoid dissection to muscle bed, preserving excursion Limitation More time-sensitive cannot be done after motor end plate degeneration (12-18 months) References Ashworth, S., & Kozin, S. H. (2011). Brachial plexus palsy reconstruction: Tendon transfers, osteotomies, capsular release, and arthrodesis. In In T. M. Skirven, A. L. Osterman, J. M. Fedorczyk, & P. C. Amadio (Eds.), Rehabilitation of the hand and upper extremity (6th ed., pp ). Philadelphia, PA: Elsevier. Bednar, M. S., (2016). Tendon transfers for tetraplegia. Hand Clinics, 32, doi: /j.hcl Brand, P. W. (2011). Mechanics of tendon transfers. In T. M. Skirven, A. L. Osterman, J. M. Fedorczyk, & P. C. Amadio (Eds.), Rehabilitation of the hand and upper extremity (6th ed., supplemental chapter available online.). Philadelphia, PA: Elsevier. Brand, P. W., & Hollister, A. (1985). Clinical mechanics of the hand (2nd ed.). St Louis: Mosby. Brand P. W., Beach, R. B., & Thompson, D. E. (1981). Relative tension and potential excursion of muscles in the forearm and hand. Journal of Hand Surgery, 6A, Chadderton, R. C., & Gaston, R. G. (2016). Low median nerve transfers (opponensplasty). Hand Clinics, 32, doi: /j.hcl Cheah, A. E., Etcheson, J., & Yao, J. (2016). Radial nerve tendon transfers. Hand Clinics, 32, doi: /j.hcl Cook, S., Gaston, R. G., & Lourie, G. M. (2016). Ulnar nerve tendon transfers for pinch. Hand Clinics, 32, doi: /j.hcl Diaz-Garcia, R. J., & Chung, K. C. (2016). A comprehensive guide on restoring grasp using tendon transfer procedures for ulnar nerve palsy. Hand Clinics, 32, doi: /j.hcl Duff, S. V., & Humpl, D. (2011). Therapist s management of tendon transfers. In T. M. Skirven, A. L. Osterman, J. M. Fedorczyk, & P. C. Amadio (Eds.), Rehabilitation of the hand and upper extremity (6th ed., pp ). Philadelphia, PA: Elsevier. Grangeon, M., Guillot, A., Sancho, P. O., Picot, M., Revol, P., Rode, G., & Collet, C. (2010). Rehabilitation of the elbow extension with motor imagery in a patient with quadriplegia after tendon transfer. Archives of Physical Medicine and Rehabilitation, 91, doi: /j.apmr Isaacs, J., & Ugwu-Oju, O. (2016). High median nerve injuries. Hand Clinics, 32, doi: /j.hcl Jones, N. F. (2013). Tendon transfers in the upper extremity. In P. C. Neligan (Ed.), Plastic surgery (3rd ed., pp e3). London: Elsevier. Livermore, A., & Tueting, J. L. (2016). Biomechanics of tendon transfers. Hand Clinics, 32, doi: /j.hcl Meals, C. G., & Meals, R. A. (2013). Tendon versus nerve transfers in elbow, wrist and hand reconstruction: A literature review. Hand Clinics, 29, doi: /j.hcl Peljovich, A., Ratner, J. A., & Marino, M. (2010). Update of the physiology and biomechanics of tendon transfer surgery. Journal of Hand Surgery, 35A, doi: /j.jhsa Ratner, J. A., & Kozin, S. H. (2011). Tendon transfers for upper extremity peripheral nerve injuries. In T. M. Skirven, A. L. Osterman, J. M. Fedorczyk, & P. C. Amadio (Eds.), Rehabilitation of the hand and upper extremity (6th ed., pp ). Philadelphia, PA: Elsevier. Sammer, D. M., & Chung, K. C. (2009). Tendon transfers part I: Principles of transfer and transfers for radial nerve palsy. Plastic Surgery and Reconstruction, 123, 169e-177e. doi: /prs.0b013e3181a20526 Sammer, D. M., & Chung, K. C. (2009). Tendon transfers part II: Transfers for ulnar nerve palsy and median nerve palsy. Plastic Surgery and Reconstruction, 124, 212e-221e. doi: /prs.0b013e3181b037c7 Schwartz, D. A. (2014). Tendon transfers. In Cooper, C. (Ed)., Fundamentals of hand therapy (2nd ed., pp ). St. Louis, MO: Elsevier. Sultana, S. S., MacDermid, J. C., Grewal, R., & Rath, S. (2013). The effectiveness of early mobilization after tendon transfers in the hand: A systematic review. Journal of Hand Therapy, 26, doi: /j.jht Tang, J. B. (2015). Wide awake flexor tendon repair, tenolysis, and tendon transfer. Clinics in Orthopedic Surgery, 7, doi: /cios Wilbur, D., & Hammert, W. C. (2016). Principles of tendon transfers. Hand Clinics, 32, doi: /j.hcl References Images American Society of Hand Therapists. (2014). Test Prep for the CHT Exam (3rd ed.). Mt. Laurel, NJ: Author. Baumeister, S. (2015). Hand tendon transfers. Retrieved from Medscape, Haymaker, W. & Woodhall, B. (1953). Peripheral nerve injuries (2 nd revised ed.). Philadelphia, PA: Saunders. Sammer, D. M. (n. d.). Principles of tendon transfers. Retrieved from Shi, L. L., Cahill, K. E., Ek, E. T., Tompson, J. D., Higgins, L. D., & Warner, J. J. P. (2015). Latissimus dorsi and teres major transfer with reverse shoulder arthroplasty restores active motion and reduces pain for posterosuperior cuff dysfunction. Clinical Orthopaedics and Related Research, 473, doi: /s Staines, K. G. (2015). Low-profile theratube splint for radial nerve palsy. ASHT Times, 22, Wilhelmi, B. J. (2017). Tendon transfers. Retrieved from Medscape, Young, P., Fattah, A., & Fleming, A. S. (2008). Ulnar nerve palsy after carpal tunnel decompression: Case report and review of the literature. Indian Journal of Plastic Surgery, 41, doi: / When designated, images are courtesy of Primal Pictures

10 Contact Info Brocha Z. Stern, MOT, OTR/L, CHT PhD Candidate, New York University, NY, NY Kessler Rehabilitation Center, NJ