TENDON TRANSFER

Dr. Chinmoyee Panigrahy

INTRODUCTION

▪ A tendon transfer is the operative relocation of a (donor) muscle,

along with its neurovascular structures, to a different (recipient)
anatomical site in order to achieve or augment a lost function.

▪ The procedure involves detaching the tendon insertion, mobilizing

the muscle and reattaching the distal tendon into a recipient tendon
or bone insertion site.
▪ Tendon transfers have application in a variety of disorders, including
paralysis associated with lower motor neuron injury (peripheral
nerve, poliomyelitis or brachial plexopathies); paralysis or spasticity
associated with upper motor neuron injury (spinal cord injury,
cerebral palsy, traumatic brain injury, cerebrovascular accident) and
limb dysfunction following primary muscle or tendon damage
(ischemic injury, rupture, irreparable laceration)
▪ Tendon or muscle transfers restore balance to a hand crippled by loss
of muscle function.

▪ They involve the same basic concept as all reconstructive surgery.

▪ Nothing is created; rather, remaining functional parts, or those that

can be made functional, are redistributed into the best possible
working combination.
▪ Tendon or muscle transfers redistribute power to compensate for
power losses due to muscle or tendon destruction or muscle
paralysis.

▪ They involve detaching the tendon distally, mobilizing the muscle—

tendon unit without damage to its neurovascular pedicle and
rerouting it to a new distal attachment onto bone or tendon.
BASIC PRINCIPLES
BIOMECHANICAL PRINCIPLES by Bunnel’s

▪ Maintain meticulous hemostasis using a tourniquet

▪ Use atraumatic operative technique

▪ Provide fat grafts to enhance gliding Preserve pulleys to maximize

function

▪ Avoid midline palmar incisions to prevent scar contracture

▪ Use free tendon grafts (donors: palmaris longus, flexor digitorum superficialis or toe
extensors) as needed

▪ Use gentle progressive splinting to overcome contractures

▪ Construct pedicle grafts to place new tendons into soft, pliable beds in scarred areas

▪ Consider use of early, but not excessive, motion

▪ Transfers for thumb opposition can be performed using FCU donor, pisiform as pulley
▪ One tendon transfer can optimally perform only one junction (two
opposing insertions of the same tendon could not succeed)

▪ Principles of primary nerve repair should be understood and

encouraged epineural repair technique use of silk sutures noted
better results with more distal repair Appreciate sensibility and its
importance to hand function
SUMMARY OF STARR’S PRINCIPLES OF TENDON
TRANSFERS

▪ Donor muscles used should have an action similar to the one they are replacing

▪ If only a part of the muscle/tendon is to be transferred, it must have the same

action as the muscle it is to replace

▪ One muscle can best provide only one function; if a muscle is expected to perform
more than one task, it will only move the joint which has the tightest attachment

▪ The line of pull should be as straight as possible; the muscle will work efficiently
only if the line between its origin and its new insertion is straight
▪ The donor muscle should have adequate excursion; excursion that is equal to or
greater than that of the injured muscle The donor muscle should have adequate
capability of force generation; force generation similar to that of the injured muscle

▪ The transferred tendon should be placed under tension

▪ The tenodesis action of the wrist should be preserved

▪ Pre-existing deformity due to soft tissue contracture should be corrected prior to

tendon transfer
▪ Tendons can be transferred down the sheath of the muscle they are
to replace

▪ Tendons can be transferred through fatty subcutaneous tissue

▪ Attachment of the donor tendon can be into tendon, bone or

periosteum; care must be taken to provide attachment of adequate
strength Immobilization should follow tendon transfer for 3 weeks
EARLY PRINCIPLES OF TENDON TRANSFERS
ESTABLISHED BY JONES AND HUNT

▪ Joints must be mobile Muscles to the tendons must have sufficient

strength to carry out motion ,minimum of grade 3 is required.

▪ Muscles and tendons must traverse a straight course from origin to

insertion

▪ Transferred tendons should be attached under slight tension

BASIC RULES OF TENDON TRANSFERS
ESTABLISHED BY MAYER

▪ Maintain asepsis with minimal hemorrhage and minimal trauma

▪ Restore normal relationship between tendon and sheath Transfer the

tendon through tissue adapted to tendon gliding

▪ Reproduce normal insertion of the original tendon into bone or

cartilage

▪ Establish normal tension Have an effective line of traction

▪ Steindler refined and reinforced the principles of Bunnell and Starr, and
discussed their use in specific clinical situations.

▪ He provided classic discussion of tendon transfers in 1939 and emphasized that

soft tissue contractures required correction prior to tendon transfer.

▪ The muscle selected for replacement should have a similar or related action.

▪ Steindler acknowledged that muscle re-education was often necessary.

▪ The transferred muscle must have adequate power.

▪ Steindler emphasized straight-line pull of the transferred muscle if

possible, or the use of a pulley for mechanical advantage.

▪ The transferred tendon should be placed with some tension.

▪ Steindler also stressed the necessity of preserving the gliding

apparatus of the tendon.
BIOMECHANICS AND APPLIED ANATOMY

▪ Pertinent to tendon transfers are the features of muscle

architecture, the length–tension relationships of muscle contraction
and the concepts of moment arm and torque.

▪ These concepts can assist in the selection of donor muscles, routes

of transfer and the relationship and importance of proper tension
setting to muscle function.
 MUSCLE ARCHITECTURE

▪ Features of muscle architecture include the physiological cross-sectional area, the fiber
bundle length, muscle length, muscle mass and pennation angle (angle of muscle fibers
from the line representing the longitudinal vector of its tendon).

▪ Muscles throughout the upper extremity are unique in their respective anatomy and
architecture, which result in each muscle’s individual distinctive ability to produce
force, specific velocity of contraction and an amount of excursion.

▪ In general, it is optimal to select a donor muscle with architectural properties similar to

those of the one that it is to replace (i.e. similar force generation, similar excursion).
▪ Muscle force generation :Muscles are ▪ Certain muscles with a large
unique in having contractile elements
physiological crosssectional area,
and the ability to generate force. The
such as the flexor carpi ulnaris or
force that a muscle can generate is
proportional to the physiological palmaris, are designed more for
cross-sectional area of the muscle. force generation than those with
The greater is the muscle cross- a smaller cross-sectional area,
sectional area, the greater is the
such as the flexor carpi ulnaris
potential force generation.
▪ Muscle excursion and velocity of
▪ Muscles with similar
contraction :
architectural features and
▪ The excursion of a muscle and velocity
similar functional capabilities
of contraction are proportionate to
the muscle’s fiber length. Muscles thus can be grouped together
with high fiber length are designed
more for longer excursion and higher
velocity of contraction.
▪ Blix curve (sarcomere length–tension ▪ Maximal tension is produced in the mid-
relationship) and tension of muscles sarcomere length due tomaximal actin and

myosin cross-bridging interaction and these

▪ Although the physiological cross-sectional
aspects of muscle tension have implications
area of a muscle will give static
for tendon transfer
characteristics of the muscle’s general
ability to generate force, the tension and ▪ A muscle that is transferred and attached too

the force of contraction that an individual loosely or one that is too tight will not be able

muscle can generate will vary as the to generate the maximal tension achievable

sarcomere length of the muscle changes. in the mid-sarcomere length.

▪ During transfer, a tendon is usually placed under partial tension,
generally based on the

▪ In surgery, in order to achieve maximal torque in a tendon transfer, the

moment arm can be maximized by strategic operative placement of
the muscle or tendon across the joint.

▪ There is, however, a price to pay for the increase in torque; there can be
a loss of joint motion.
CLINICAL ASPECTS OF
TENDON TRANSFER
CONSIDERATIONS PRIOR TO TENDON
TRANSFER

▪ Timing of tendon transfers ▪ This situation may be observed in the

recovery periods of an axonotmesis injury,
▪ The patient should have a static
repaired peripheral nerve, incomplete
condition that will not improve
spinal cord injury or primary muscle injury.
spontaneously i.e.,
▪ In these injuries, appropriate time from
▪ If a patient’s neurological or muscle injury is allowed for recovery while the
function is still recovering, tendon patient is maintained in a comprehensive
transfers should be delayed until hand therapy program.
there is a plateau in improvement.
▪ Hand therapy is used to minimize edema, maintain motion and remaining strength, correct or improve
contractures and assist with re-education and muscle substitution during these recovery periods.

▪ When the recovery and functional deficit are observed to be stable and when no additional
improvement is expected or felt achievable through hand therapy or by operative means, then tendon

transfers can be performed.

▪ If not previously performed, alternative operative methods to improve function are investigated prior
to tendon transfers. These include nerve decompression, nerve repair and repair of tendon or muscle

lacerations or rupture.
▪ Management of soft tissue ▪ When tendon imbalance occurs
contractures : Soft tissue
from spasticity, correction of the
contractures must be corrected prior
deformity may be more optimally
to tendon transfer. A transfer cannot
and predictably achieved using
overcome the joint stiffness of a fixed
tendon lengthening, recession or
contracture. Joint stiffness and
contractures may only worsen during arthrodesis. These procedures may
any postoperative immobilization be preferable to transfers to correct
following tendon transfers. a deformity if spasticity is severe.
▪ Condition of the soft tissue bed :
▪ Infections must be cleared,
▪ A satisfactory soft tissue bed with tissue
open wounds healed,
equilibrium must be present along the
route of the planned transfer. inflammation and edema

▪ If the bed of the planned transfer is stabilized and satisfactory soft

severely damaged from scarring or chronic
tissue provided.
wounds, soft tissue reconstruction is
indicated prior to tendon transfer.
▪ Tendons can be transferred in the anatomic intervals between muscles,
through windows placed in the interosseous membranes or through
subcutaneous fat, or placed in the sheath from the original tendon.

▪ Transferred tendons should not be placed directly under the skin or skin
grafts, or along rough or bleeding bone surfaces, as these can lead to
adhesions.
▪ Selection of tendon for transfer

▪ Selection of the particular tendon(s) for transfer is based on the deficit

remaining and the donor muscles available.

▪ In creating a treatment plan, it is useful to develop a list of the specific

muscles or functions needed, and a list of expendable muscles available
for transfer.
▪ Expendable muscles, whose function can be substituted by remaining muscles so
that donor morbidity is minimized, usually include the palmaris longus, pronator
teres, brachioradialis, supinator, flexor digitorum to the ring or long finger (in the
presence of intact flexor digitorum profundus), extensor indicis proprius, flexor
carpi radialis (in the presence of intact flexor carpi ulnaris), flexor carpi ulnaris (in the
presence of intact flexor carpi radialis), extensor carpi radialis brevis (in the
presence of intact extensor carpi radialis longus or extensor carpi ulnaris), extensor
carpi radialis longus (in the presence of intact extensor carpi radialis longus),
supinator and adductor digiti minimi
▪ The donor muscle must be of adequate strength, preferably not
injured or reinnervated.

▪ In certain conditions, with limited available donor muscles, a weak

muscle (grade 4/5) can be considered for transfer; however, a limited
outcome may result.
▪ When several donor muscles are available for transfer, additional factors are
considered.

▪ These include the condition of soft tissue that a transfer must cross, route and
direction of the transfers, donor site morbidity, architecture of the donor muscle
and function desired, synergism of the tendon transfer, experience and
preference of the surgeon and consensus or preferences of an informed patient.

▪ Optimally, the donor muscle must be healthy, synergistic and similar in

architecture, and have an adequate soft tissue bed along the route of transfer.
▪ Direction of transfer

▪ The direction of the selected tendon for transfer should optimally

have as straight a line of action as possible.

▪ The direction of its path should parallel that of the muscle fibers of
the damaged or paralyzed muscle that it is replacing.
▪ If a transfer must change direction along its course to reach its new
insertion, it should have adequate room for excursion and traverse a
smooth, stable pulley.

▪ If the transfer passes through a narrow space or interosseous

membrane, adequate soft tissue release is needed to minimize
friction and the possibility of adhesions.
▪ One muscle–one function concept:
▪ It is best to select a muscle to provide
one specific function.
▪ If a transferred muscle is inserted into
two points or across two separate
joints, it will tend to move the joint
which has the greatest tendon tension.
▪ If a muscle is passed across several joints,
its relative motion across each joint may
be influenced by multiple factors, such as
the moment arm and direction of pull
across each joint.
▪ If a single donor tendon is inserted into
two tendons with different functions, the
donor function is dissipated, and the
overall function will usually be diminished.
▪ Muscle architecture as applied to tendon selection

▪ important selection criteria are provided for matching a donor

muscle to the one it is replacing, based on these architectural
features and associated functional capabilities.
▪ Muscle synergism :

▪ Synergistic muscles are those that contract simultaneously to achieve a desired

movement.

▪ A classic example is that of the digital flexors and wrist extensors. The wrist often
extends simultaneously during digital flexion of a power grip.

▪ Synergism is considered desirable in the selection of a donor muscle, and may

facilitate retraining and promote faster re-education during the rehabilitative
process.
▪ However, that transfer of some non-synergistic muscle may still
functionally retrain and provide good function.

▪ A classic example of this is the extensor indicis proprius transfer for

thumb opposition. The digital extensor easily retrains to provide thumb
palmar abduction.

▪ If other factors are equal, selection of a donor muscle that is synergistic

is probably advantageous.
▪ Donor site morbidity :

▪ Donor site morbidity is an additional consideration in the selection of a tendon

for transfer.

▪ Most of the established tendons for harvest have muscles that can substitute for
some of their function, however, some remaining donor site weakness does exist.

▪ The specific needs of patients can assist in determining which associated

weakness would be best tolerated.
▪ Besides residual weakness, several muscles have specific aspects of donor
morbidity unique to that muscle.

▪ In harvesting the flexor digitorum superficialis (FDS) to the ring or long finger,
the digit may develop an extension deformity at the proximal interphalangeal
joint due to loss of joint flexion; this can further develop into a swan-neck
deformity.

▪ Donor site morbidity associated with harvest of the brachioradialis includes a

loss of about 20% elbow flexor strength.
▪ Gentle handling of tissues : Meticulous technique and gentle handling of
tissues is utilized to minimize soft tissue scarring and tendon adhesions, to
maximize tendon gliding.

▪ Setting length and tension of the transferred tendon : a transferred tendon

must not be placed in too little or too much tension (i.e. too short or too long
a sarcomere length), as this will lead to suboptimal actin/myosin interactions,
and result in a fall in the ability of the muscle to generate force or maximal
excursion.
Methods of tendon attachment

▪ Several methods exist as to attachment of the donor tendon to its new site.

▪ If the tendon is to be transferred into an existing tendon stump, a traditional

tendon weave such as the Pulvertaft technique can be performed.

▪ If the tendons’ ends are of unequal size, end-to-end suture can be performed by
preparing the larger tendon into a ‘fish mouth’ and placing the smaller tendon
into the fish mouth and securing using a Kessler suture technique.
Postoperative concerns

▪ In most types of tendon surgery, early passive motion in a protected range is desirable.

▪ In tendon transfers, controversy remains as to the management protocols in the weeks

following the transfers.

▪ Some recommend immobilization for 3–4 weeks while others advocate early passive
motion.

▪ These protocols are best individualized, based on the specific transfer, the condition of
the soft tissues and the reliability of the patient.
▪ If secure fixation of a healthy tendon can be accomplished using grasping suture
techniques, early passive motion (with active patient assistance) through a
protected range can be considered. Assistance with a hand therapist is required.

▪ If soft tissues are suboptimal, such as in inflammatory disorders, and/or the

patient’s reliability is questionable, immobilization may be desirable for 3–4
weeks.

▪ This will lead to stiffness, and the need for additional hand therapy should be
expected.
TEACHERS STUDENTS

FUN THING WE STILL WILL CONTINUE

CONTRAINDICATIONS TO TENDON TRANSFER

▪ Joint contractures or skin contractures that would limit transfers

▪ Non availability of suitable muscles

▪ Progressive neuropathy

▪ Radiation therapy in last one year

▪ Complicated medical conditions : circulatory inadequacy, muscle

spasm
PHYSIOTHERAPY REHABILITATION

▪ Careful preoperative evaluation and treatment increase the prospects for a

successful result.

▪ The postoperative care of the tendon transfer is a team effort by the surgeon,
therapist, and patient; each must have a clear understanding of the goals and
precautions of each stage of treatment.

▪ Restrictions are initially placed upon the patient's mobility to allow healing;
these are then reduced as he activates the transfer and then begins to
incorporate the new motion into daily activity.
▪ Resistance is added gradually to the patient's tolerance, and care is
taken throughout the rehabilitation process not to overwork the muscle
in its new function.

▪ Tendon transfer is never completely restorative, but often makes a

striking difference in the patient's functional abilities.

▪ The outcome can be very gratifying for the patient and for those who
collaborate in his treatment.
TREATMENT GOAL: PREOPERATIVE

▪ Educate patient about the procedure, need of rehab, splinting

requirements and prerequisite expectations.

▪ Achieving and maintaing full PROM and AROM if possible

▪ Achieving maximum strength of the donor muscle

▪ Maintaining supple joints and tissue by minimising scar, edema and
adhesion by use of tapes, bandaging etc.

▪ Complete comprehensive evaluation including, functional assessment,

sensory evaluation, ROM and strength and photographs for
postoperative comparisons.

▪ Establish good rapport and communication with the surgeon discuss time
of surgery and rehab and the establish the primary and secondary goals.
POSTOPERATIVE GOALS

▪ Protect transferred tendon

▪ Maintain ROM of uninvolved and involved joints

▪ Protect from postoperative edema and adhesion formation and pain

▪ Control scar tissue and decrease adhesion to decrease the drag for
the transferred tendon

▪ Progress patient to functional use of hand.

For 1st week

▪ Edema and pain management

▪ Maintain ROM of uninvolved joint

▪ PROM of involved joint in patient’s tolerance

▪ Splinting ( as per the transfer, cock up splint for radial nerve palsy )

▪ Proper wound care of the donor site to prevent from infections and
adhesion formation
2nd through 3rd week

▪ Continue previous treatment

▪ Start active assisted movements of the involved joints

▪ Place and hold
▪ Isometric holds

▪ Splinting continued and removed for exercise

3rd through 6th week

▪ Continue above protocol

▪ Night splinting continued and intermittent day splinting if extensor lag is present or if
joints tend to collapse

▪ Grip strengthening and strengthening at the individual joint including the proximal and
distal joints are gradually started

▪ One joint at time should be taken with les degree of simultaneous motion at all the joints
should be considered i.e. within patients limit

▪ Muscle re-education using electrical stimulator

6th through 8th week

▪ Functional training begun

▪ Splinting may be discontinued or weaned off in next 4 weeks

▪ Patient must be reevaluated functionally and made aware about the

prognosis

▪ Resistance training is started aggressively.

▪ Full activity is resumed in twelve weeks

THANK YOU