Symposium on Tendon Transfers in the Upper Extremity

Fundamental Principles of Tendon

Transfer

Raymond M. Curtis, M.D.*

The principle underlying transfer of a tendon of an intact muscle to

compensate for loss of function of one or more paralytic muscles was
first applied by Nicoladoni'" in a case involving the lower leg, one of the
oldest of orthopedic operations. His work undoubtedly stimulated fur-
ther investigation, among which the work of Lange," who in 1911
reported his experience with more than 1000 tendon transfers in the
arm and leg, Biesalski,' Mayer,J2-J4 Jones,7 SteindlerJ" and Bunnell"
is notable. .
There are six fundamental considerations in undertaking a tendon
transfer: tissue equilibrium, movability of joints, the power, amplitude,
al?d direction of the muscle transfer, and the integrity of surgical tech-
mque.

TISSUE EQUILIBRIUM

The concept of tissue equilibrium, introduced by Steindler,"" em-

phasizes that one cannot expect a tendon to glide through edematous
and scarred tissue, nor can one expect the transfer to move joints that
are stiffened by fibrosis and disease. The edematous and fibrosed ex-
tremity must be returned to as near normal as possible by physiotherapy,
occupational therapy, special splinting techniques, and active exercise.
Figure 1 illustrates, for example, a hand crushed in an accident. One
look at this stiffened edematous hand, one palpation of the induration
present, should demonstrate that only after months of therapy will this
hand be ready for reconstructive surgery.
"'Associate Professor of Plastic Surgery and Associate Professor of Orthopedic Surgery,
Johns Hopkins University School of Medicine. Consultant in Hand Surgery, Chil-
dren's Hospital and Union Memorial Hospital, Baltimore, Maryland. Surgical Con-
sultant to the Surgcon Gcneral of the Army.

Orlho!JI,die Clinics of ,'Vorlh Amcrua-« Vol. 5, No.2, April 1974 231

232 RAYMOND M. CURTIS

Figure I. This hand is not suitable for tendon transfers because of poor tissue
equilibrium and stiffness of the metacarpophalangeal joints.

Figure 2. Plaster splinting should be repeated daily. gradually stretching the meta-
carpophalangeal joints into flexion.
FUNDAMENTAL PRINCIPLES OF TENDON TRANSFER 233

Figure 3. The pedicle flap provides good subcutaneous tissue through which
tendon transfers call be passed.

Splinting of various types can be used. For example, we use a

molded plaster splint technique to mobilize the stiffened metacarpo-
phalangeal joints (Fig. 2).
The provision of a good skin cover is also of importance, for con-
tracted or scarred skin may necessitate pedicle grafting in order to
provide gliding tissue for the transfer and to correct contracture (Fig. 3).

MOVABLE JOINTS

The wrist joint, if in acute flexion, can be placed in a position of

function by capsulotomy of the radiocarpal and intercarpal joints with
tendon lengthening of the wrist flexors. If necessary, proximal row car-
pectomy may also be useful in certain instances. In any event, movability
of the wrist should be preserved if at all possible.
The metacarpophalangeal and interphalangeal joints may require
release by capsulotomy. If necessary, a joint prothesis may be used when
the bony architecture of the joint has been destroyed.
Tenotomy of contracted interosseous tendons or tendolysis of
adherent flexor or extensor tendons may have to be performed prior to
the transfer in order to achieve joints that can be moved by the transfer.
In the case of the thumb, tenotomy or excision of a contracted short ad-
ductor and first interosseous muscle with rotation flap or pedicle graft
coverage of the web may be useful prior to tendon transfers for opposi-
tion (Fig. 4).
234 RA YMOND M. CURTIS

Figure 4. A. Preoperative view of thumb web contracture. B. Excision of scar tissue

and fibrotic muscle. C, Application of pedicle flap for proper skin cover.
FUNDAMENTAL PRINCIPLES OF TENDON TRANSFER 235
Action del!ends on 4 foctors:

CD Muscle Power
@Amplitude

® Angle of Approach of Tendon Figure 5. Action of muscle-tendon

I ANGLE INCREASE = GREATER MOTION I unit.

@ Site of Implantation of Tendon

CLOSER INSERTION = GREATER MOTION
TO AXIS OF MOTION

Peripheral nerve repair should precede tendon transfer, for a re-

turn of sensibility to the hand will make function, power grasp, and
precision handling possible.

POWER OF THE MUSCLE TRANSFER

There must be adequate power in the donor muscle. When one

transfers a muscle, its power cannot be increased because this is a fixed
value determined by the cross sectional area of the muscle. Its leverage
may be altered. but its absolute power remains the same (Fig-s. :> to 7).
Steindler'" and Recklinghausen'? accept the value of 3.65 kg. times
the physiologic cross sectional area of the muscle as the absolute power
of the muscle. Steindler'" states that the power of a muscle is that force
that will draw out the muscle from its maximally contracted state to its

W= Fxd
F (force) = absolute muscle power 3.65 x cm2
of physiologic cross section

d (distance) = amplitude or displacement

Figure 6. Working capacity of mus-

cleo

distance~~c-~_ --~_
236 RAY MON D M. CUR TIS

Pronator
teres

@ Flexor
carpi
radialis
@
Brachio· Palmaris
radialis longus

@ @ brevis

@
Flexor Extensor
carpi carpi
ulnaris ulnaris

CD @

Abductor Abductor
Flexor Extensor pollicis
pollicis digitorum digitorum longus
longus profundus communis

@ @

Figu re 7. Wor king capa city of muscle in Mkg

.
FUNDAMENTAL PRINCIPLES OF TENDON TRANSFER 237
Table 1. Amplitude ofExeursion

Wrist tendons 33 rnm.

Flexor profundus 70 mm.
Flexor su perficialis 64 mm.
Extensor digitorum communis 50 mm.
Flexor pollicis longus 52 mm.
Extensor pollicis longus 58 mm.
Extensor pollicis brevis 28 mm.
Abductor pollicis longus 28 mm.

natural length; this equals 3.65 kg. times the cross sectional area. Het-
ringer" estimated this to be 4 kg. per square centimeter (Fig. 6).

AMPLITUDE OF TRANSFER

The amplitude of motion of the muscle-tendon unit to be trans-

ferred must be adequate to provide the desired motion. Table I lists the
normal amplitudes for most of the muscles of the hand and forearm." 4.8
Normal amplitude can be limited by the tissue through which the ten-
don passes. Rarely is the normal amplitude of a muscle-tendon unit
maintained completely when a transfer is carried out.
Boyes" has pointed out how this amplitude can be increased in some
muscles by liberating them from their surrounding fascial attachments.
The amplitude of the brachioradialis, for example, can be doubled
by a release of the fascial attachments and its broad tendinous attach-

Extensor digitorum communis

238 RAYMOND M. CURTIS

-----9

Figure ~J. Insertion of tendon. showing related motion.

ment to the radius. The amplitude of a muscle-tendon unit can also be

changed by making a monoarticular muscle into a multiarticular muscle.
For example. a wrist flexor when transferred to the finger flexors
becomes a multiarticular muscle. This corresponds to the concept of
"dynamic tenodesis" of Lipscomb et al.!" according to which the wrist
flexor is sutured with such accurate tension into the flexor profundus
tendon of the fingers that the 33 mm. excursion of this wrist flexor ef-
fects a full 70 mm. of excursion of the finger flexors partly by a tenodesis
effect and partIy as a result of the amplitude of the contracting muscle.
The angle of approach of a tendon can also alter the motion. The
nearer to the axis of motion the tendon is inserted. the more motion is
obtained (Fig. 9).20

Choosing the Motor Muscle

In choosing the motor muscle, one should make a chart and list on
one side the needs. On the other side the muscles available should be
listed. Then after careful testing and grading of the strength of each
muscle. the proper transfers are selected. considering their power and
amplitude and whether the one selected will cause any loss of function.
Movements in the hand are patterned in the brain as motions, not as
specific muscle actions," As Steindler-" describes it. there is no motion in
the hand into which a transferred muscle enters that is not already famil-
iar. Others. however, feel that it is important when possible to use a
synergistic muscle in the transfer.!': IX For example, when the fingers
FUNDAMENTAL PRINCIPLES OF TENDON TRANSFER 239
are tightly flexed, the wrist extensors tighten and thus a wrist extensor
would act well as a finger flexor. Also, when the fingers extend, the wrist
flexors tighten; hence, a wrist flexor would act well as a finger extensor
(Fig. 10).

DIRECTION OF TRANSFER

Maximal efficiency and strength are achieved when the transferred

tendon is made to take a straight course from the muscle origin to the
new point of tendon insertion. Whenever a pulley must be used, one
must have additional power available in the transfer to overcome the
friction of the pulley.

INTEGRITY OF SURGICAL TECHNIQUE

A muscle-tendon unit cannot as a rule serve recipients of differing

excursions. For example, a transfer sutured to the long and short exten-
sors of the thumb will pull effectively only through the amplitude of the
lesser of the two. By contrast, the pronator teres transferred to the ex-
tensor carpi radialis longus and brevis continues to act as a pronator of
the forearm because of the direction of its pull.

Figure 10. Extent of the sensory and motor cortex devoted to the hand.
240 RAYMOND M. CURTIS

MISCELLANEOUS CONSIDERATIONS

1. Atraumatic technique is important. The tendon, its sheath, and

its gliding mechanism must not be traumatized. Drying of the field and
the tendons should be prevented. The tendon should never be grasped
with an instrument.
2. When possible, anastomoses should be placed in an adequate tis-
sue bed.
3. Normal tendon sheaths should be used when possible.
4. Incisions must be planned carefully in order to mimimize wound
trauma.
5. The tendon tension is critical for the transplant. In 1916 Mayer'"
demonstrated that he could produce degeneration in the gastrocnemius
muscle of the dog if the transplant was placed under too much tension.
Within six weeks the muscle was half its normal size and fibers were
replaced by fat. The rule, says Mayer," in reality is most simple: Suture
the tendon under normal tension.
Local anesthesia or intravenous regional anesthesia allows the
transfer to be woven into the tendon it is to power. One can then re-
lease the tourniquet and actually check by active motion to be cer-
tain that the tension is correct.
Tetanic stimulation of muscle belly can also be used to check and
then adjust correct tension." One must learn to avoid too much or too
little tension.
6. A knowledge of the anatomy of the individual tendons and
muscles is vital in order to avoid damage to the blood and nerve supplies.
7. The transferred tendon either should be anastomosed end to end
to the one it is to provide motor power for, or it can be interwoven, as,
for example, the flexor carpi ulnaris interwoven into the common exten-
sors of the fingers. I feel that one can interweave if it is done atraumatic-
ally. This is the reason one method might be superior to another. In
either case, one must avoid the tendon "T" effect, for this defeats the
purpose of a straight line pull.
8. The transfer should be carried out at the optimal time. Age does
not seem to be a contraindication. For example, rehabilitation in op-
ponens transfers has been effected successfully in children under three
years of age. In poliomyelitis 75 per cent of the muscle strength returns
in six months, and thus transfers usually can be carried out safely one
year later.

ARTHRODESIS

Arthrodesis of the wrist can be a useful procedure but should be

used only when a fixed deformity or pain exists and when there is no
FUNDAMENTAL PRINCIPLES OF TENDON TRANSFER 241
need for a movable wrist to accomplish the functional end result. Fusion
of the wrist in many paralytic patients robs them of a tenodesis effect and
may make transferring from wheelchair to bed impossible.

TENODESIS

Tenodesis is a useful procedure when only a few motor muscles are

available; for example, in some cervical cord and brachial plexis injuries.
By tenodesing the finger flexors and thumb flexor, a single wrist exten-
sor can be made to close the fingers."

CAPSULODESIS

Capsulodesis is a useful procedure in preventing hyperextension at

metacarpophalangeal or interphalangeal joints and may be used in con-
junction with active tendon transfer, as, for example, at the metacarpo-
phalangeal joint to prevent clawing of fingers."

REFERENCES

I. Biesalski, K.. and Mayer, L.: Die physiologische Sehnenuerpllanzung. Berlin, Julius
Springer, I!J16.
2. Boyes, J. H.: Bunnell's Surgery of the Hand. J. B. Lippincott Co., Philadelphia, 1970.
3. Boyes, .I. H.: Selection of donor muscle for tendon transfer. Bull Hosp. Joint Dis.,
23:1,1962.
4. Bunnell, S.: Tendon transfers in the hand and forearm. Instructional Course Lecture,
American Academy of Orthopedic Surgeons. St. Louis, The C. V. Mosby Co., 1949,
Vol. 6, p. 106.
5. Curtis, R. M.: In Flynn, J. E. (Editor): Hand Surgery. Baltimore, The Williams & Wilk-
ins Co., 1966.
6. Hettinger. 1'.: III Thurlwell, M. H. (Editor): Physiology of Strength. Springfield. Illi-
nois. Charles C Thomas. 1961, p. 12.
7. Jones, R.: Notes on Military Orthopaedics. London, Cassell & Co., 1917.
8. Kaplan, E. B.: Functional and Surgical Anatomy of the Hanel. Ed. 2. Philadelphia,.J.
B. Lippincott Co .. 1965.
9. Lange. F.: Die Sehnenverpllanzung. III Ergebn. d. Chir. u. Orthop. Berlin, Julins
Springer. 1911 Bd. 2s. 1-31.
10. Lipscomb, 1'. R., Elkins. E. C., and Henderson, E. D.: Tendon transfers to restore
function of the hands in tetraplegia especially after fracture dislocation of the sixth
cervical vertebra on the seventh. J. Bone Joint Surg.. </OA: 1071. 1!)58.
II. Littler, J. W.: Tendon transfers and arthrodesis in combined median and ulnar nerve
paralysis. J. Bone Joint Surg., 31 A:225, 1949.
242 RAYMOND M. CURTIS

12. Mayer. L.: The physiological method of tendon transplantation. I. Historical: anatomy
and physiology of tendons. Surg. Gynec. Obstet., 22: 182-197, 1916.
13. Mayer. L.: The physiological method of tendon transplantation. II. Operative tech-
nique. Surg. Gynec. Obstet., 22:2!l8-306. 1916.
14. Mayer, L.: The physiological method of tendon transplantation. Ill. Experimental
and clinical experiences. Surg. Gynec Obstet., 22:472-481. 1916.
15. Mayer, L.: The physiological method of tendon transplants reviewed after forty years.
Instrumental Course Lectures, American Academy of Orthopedic Surgeons. St.
Louis, The C. V. Mosby Co., Vol. 13, p. 116.
16. Nicoladoni, C.: Nachtrag zum Pes calcaneus and zur. Transplantation del' Peroneal-
sehnen. Arch. Klin. Chir., 27:660-666, 1882.
17. Recklinghausen: Gliedermechanik and Lahmungsprothesen. Berlin, .J. Springer,
1920.
18. Riordan, D. C.: Surgery of the paralytic hand, Instructional Course Lectures, Ameri-
can Academy of Orthopedic Surgeons. St. Louis, The C. V. Mosby Co.• 1959,
Vol. 16.
19. Riordan. D. C.: Tendon transplantation in median and ulnar nerve paralysis. .J. Bone
Joint Surg., 35A:312, 1953.
20. Stcindler, A.: Kinesiology of the Human Body. Springfield. Illinois, Charles C Thomas,
1955. p. 47.
21. Steindler, A.: Orthopedic Operations: Indications. Technique and End Results.
Springfield, Illinois, Charles C Thomas, 1940.
22. Williams. S. B.: New dynamic concepts in grafting of flexor tendons. Piast. Reconstr.
Surg.• 36:377. 1965.
23. Zancolli, E. A.: Claw-hand caused by paralysis of the intrinsic muscles; a single
procedure for its correction. J. Bone Joint Surg., 39A: 1076, 1957.

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