Principles Principles of of tendon

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Institut Institut de la Main de la Main

Principles Principles of of tendon

tendon transfers transfers

Caroline LECLERCQ Caroline LECLERCQ Institut de la Main Institut de la Main Paris, France Paris, France

Principles Principles

Indications Indications Prerequisites Prerequisites Technique Technique Strategy Strategy of of repair repair Alternatives Alternatives

Traumatic

Traumatic nerve nerve injury injury

-- Nerve Nerve trunktrunk

-- Brachial plexus Brachial plexus -- Spinal Spinal cordcord (tetraplegia) (tetraplegia)

→ unrepaired→

unrepaired, , unrepairable unrepairable

→ repaired→

repaired but but failed failed

Indications Indications

1 - Nerve 1 - Nerve lesion lesion

- -Posttraumatic Posttraumatic rupture rupture

distal radial fracture (EPL) distal radial fracture (EPL)

Indications Indications

2-Muscle or tendon 2-Muscle or tendon lesion lesion

Indications Indications

2-Muscle or tendon 2-Muscle or tendon lesion lesion - -Muscle Muscle defect defect

complexcomplex armarm//forearmforearm trauma trauma

Indications Indications

2-Muscle or tendon 2-Muscle or tendon lesion lesion -Posttraumatic - Posttraumatic ischemia ischemia

Volkman

Volkman’’s contractures contracture

(2)

Indications Indications

2-Muscle or tendon 2-Muscle or tendon lesion lesion -

-Rheumatologic Rheumatologic disease disease

tendon rupture

Indications Indications

3 -

3 - Central lesion Central lesion -

-Neurologic Neurologic disease disease - -Cerebral Cerebral palsy palsy - -Head Head injury injury - -Stroke Stroke… …

Indications Indications

4 -

4 - Neuro-muscular Neuro-muscular disease disease

- -Charcot-Marie-Tooth Charcot-Marie-Tooth - -Myopathy Myopathy… …

-

-Arthrogryposis Arthrogryposis -

-Thumb Thumb hypoplasia hypoplasia… …

ADM Transfer

Indications Indications

5 5 – – Congenital malformations Congenital malformations

Prerequisites Prerequisites

1.1. Local Local --skin skin coveragecoverage skin skin flapflap

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Institut Institut de la Main

de la Main InstitutInstitut

de la Main de la Main

Prerequisites Prerequisites

1.

1. LocalLocal -

- skin skin coveragecoverage -

- supplesupple joints joints arthrolysisarthrolysis

Prerequisites Prerequisites

1.

1. LocalLocal -

- skin skin coveragecoverage - - supplesupple joints joints -

- stable joints stable joints

stabilizationstabilization

Prerequisites Prerequisites

1.

1. LocalLocal -

- skin skin coveragecoverage -- supplesupple joints joints -

- stable joints stable joints

-- discriminative sensation (relative) discriminative sensation (relative)

Prerequisites Prerequisites

2.

2. GeneralGeneral - Patient

- Patient’’s s cooperationcooperation

IQ (relative)IQ (relative)

behaviourbehaviour problemsproblems

realisticrealistic expectations expectations motivation motivation - Age - Age elderlyelderly

veryvery youngyoung ? ?

Prerequisites Prerequisites

3.

3. PostoperativePostoperative regimenregimen -

- PhysiotherapyPhysiotherapy

dailydaily basis basis

trainedtrained physiotherapistphysiotherapist -

- MedicalMedical andand familial familial environmentenvironment

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Timing of

Timing of surgery surgery

Timing of

Timing of surgery surgery

varies

varies according according to to pathology pathology

Posttraumatic

Posttraumatic nerve nerve injury injury

no

no clinicalclinical / EMG progression / EMG progression -

- UnrepairableUnrepairable

: :

Brachial plexus : 6-9 Brachial plexus : 6-9 monthsmonths Tetraplegia Tetraplegia : 9-12 : 9-12 monthsmonths -

- RepairedRepaired but but failedfailed:: 1

1 yearyear post post repairrepair

Timing of

Timing of surgery surgery

varies

varies according according to to pathology pathology

Neurologic Neurologic disease disease

Non progressive Non progressive

Technique Technique

Technical

Technical principles principles

Choice Choice of of motor motor Direction of Direction of transfer transfer Tension of Tension of transfer transfer Distal insertion Distal insertion

Technical

Technical principles principles

Choice Choice of of motor motor

MRC MRC scalescale Grade 0

Grade 0 : no response: no response

Grade 1

Grade 1 : palpable contraction: palpable contraction

Grade 2

Grade 2 : active movement with gravity: active movement with gravity

Grade 3

Grade 3 : movement against gravity: movement against gravity

Grade 4

Grade 4 : movement against resistance: movement against resistance

Grade 5 Grade 5 : normal: normal

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Technical

Technical principles principles

Choice Choice of of motor motor

-

- BMRC 4 BMRC 4 andand + + Full

Full movementmovement againstagainst resistanceresistance No muscle fatigue

No muscle fatigue

SomeSome muscles are muscles are difficultdifficult to to assessassess

Testing of Brachioradialis

Technique Technique

Choice Choice of of motor motor

-

- BMRC 4 andBMRC 4 and + + -

- Similar Similar lengthlength

AvoidAvoid graftsgrafts

ex: ECRL to ex: ECRL to fingersfingers: : graftgraft

Technique Technique

Choice Choice of of motor motor

-

- BMRC 4 BMRC 4 andand + + -

- SimilarSimilar lengthlength -

- No No potentialpotential deficitdeficit at at donordonor site site

Donor : FCR

Donor Donor : FPB : FPB -MPj-MPj arthrodesisarthrodesis -or distal re-

-or distal re-attachmentattachment

Technique Technique

Choice Choice of of motor motor

-

- BMRC 4 BMRC 4 andand + + -

- SimilarSimilar lengthlength -

- No No potentialpotential deficitdeficit at at donordonor site site -

- AgonistAgonist of of thethe movementmovement to to bebe restoredrestored

ex: fingerex: finger flexor to flexor to wristwrist extensorextensor

Technique Technique

Choice Choice of of motor motor

-

- Similar excursion Similar excursion

WristWrist tendons: 33mm tendons: 33mm

FingerFinger extensorsextensors: 50mm: 50mm

FingerFinger flexorsflexors: 70 mm: 70 mm

example

example : BR(25) to FDP(70) = no : BR(25) to FDP(70) = no

Smith, 1987

(6)

Technique Technique

Choice Choice of of motor motor

-- SimilarSimilar excursion excursion -

- SimilarSimilar power power

Power

Power ≈≈ muscle cross-sectional area muscle cross-sectional area

*Physiologic Cross Section (PCS)

= muscle volume / mean fiber length= muscle volume / mean fiber length

*Tension fraction

*Tension fraction = PCS / sum of PCS = PCS / sum of PCS

Tension fraction Tension fraction

Ex : BR to FPL

PL to wrist extensors InstitutInstitut

de la Main de la Main

Tension fraction Tension fraction

Ex : BR to FPL PL to wrist extensors

Technique Technique

Direction of Direction of transfer transfer

-- Direct route (straight line of pull)Direct route (straight line of pull) Proximal dissection of muscle body Proximal dissection of muscle body

WideWide subcutaneoussubcutaneous tunnel tunnel

ThroughThrough interosseousinterosseous membrane ? membrane ?

Technique Technique

Direction of Direction of transfer transfer

-- AvoidAvoid pulleyspulleys But

But theythey are are sometimessometimes necessarynecessary

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Technique Technique

Tension of Tension of transfer transfer

One of

One of thethe criticalcritical factorsfactors

Tension-length

Tension-length curvecurve ( (BlixBlix curvecurve):):

as one as one increasesincreases passive stretch passive stretch contractile forces

contractile forces decreasedecrease

Institut Institut de la Main de la Main 300

300 250 250 200 200 150 150 100 100 50 50

Muscle Length (mm) Muscle Length (mm)

Muscle ForceMuscle Force

Posterior Deltoid-to-Triceps Tendon Transfer Posterior Deltoid-to-Triceps Tendon Transfer

Lieber Lieber & & FridenFriden 2003 2003

Institut Institut de la Main de la Main 300

300 250 250 200 200 150 150 100 100 50 50

Muscle Length (mm) Muscle Length (mm)

Muscle ForceMuscle Force

Posterior Deltoid-to-Triceps Tendon Transfer Posterior Deltoid-to-Triceps Tendon Transfer

Lieber Lieber & & FridenFriden 2003 2003

Ideal tension

Technique Technique

Tension of Tension of transfer transfer

-

- No objective per-opNo objective per-op measurementmeasurement -

- Temporary suture: Temporary suture: physiologicalphysiological tension tension (

(evaluatedevaluated withwith thethe tenodesistenodesis effecteffect)) -

- Slightly Slightly superiorsuperior to to physiologicalphysiological tension tension

personalpersonal experienceexperience

Technique Technique

Distal insertion Distal insertion -

- To tendon To tendon

ResistantResistant but non but non adherentadherent andand non-ischemicnon-ischemic → →weavingweaving PulvertaftPulvertaft

→f →fine ine nonabsorbablenonabsorbable sutures sutures

-

- To To bone bone

BoneBone anchoranchor

Strategy

Strategy of of repair repair

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Strategy

Strategy of of repair repair

1- One

1- One transfer transfer for one for one function function

Example Example

radial radial palsy palsy

One One transfertransfer for for wristwrist extension extension One

One transfertransfer for for fingerfinger extension extension One One transfertransfer for for thumbthumb extension extension

Example Example

thumb

thumb abduction abduction

Insérer film Insérer film

Strategy

Strategy of of repair repair

2-

2- Several Several options options according according to to the the patient

patient’ ’s s needs needs

ex: Radial ex: Radial palsypalsy -

- HeavyHeavy manualmanual workerworker: : leaveleave FCU in place FCU in place -

- OtherwiseOtherwise : use FCU for : use FCU for transfertransfer

Strategy

Strategy of of repair repair

3-

3- Depends Depends of of extent extent of of paralysis paralysis

Normally

Normally 39 muscles to 39 muscles to activateactivate thethe hand hand andand wristwrist

→S

→Simple paralyses (1 nerve

imple paralyses (1 nerve trunk trunk) )

Repair Repair all all functions functions

Strategy

Strategy of of repair repair

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Strategy

Strategy of of repair repair

3- Depends 3- Depends of of extent extent of of paralysis paralysis

Normally

Normally 39 muscles to 39 muscles to activateactivate thethe hand hand andand wristwrist

→

→Complex

Complex paralyses paralyses

Example

Example tetraplegia: 1 muscle tetraplegia: 1 muscle availableavailable Restore

Restore thethe mostmost important important functionfunction + + additionaladditional

proceduresprocedures

Strategy

Strategy of of repair repair

4-

4- The The tenodesis tenodesis effect effect

Automatic

Automatic movementmovement of one joint of one joint activated

activated by by anotheranother joint joint

Strategy

Strategy of of repair repair

Wrist

Wrist flexion ( flexion (throughthrough gravitygravity)) = = automaticautomatic fingerfinger extension extension Wrist

Wrist extension extension = = automaticautomatic pinchpinch = =potentializepotentialize fingerfinger flexion flexion

Think

Think twicetwice beforebefore fusingfusing thethe wristwrist

Strategy

Strategy of of repair repair

5-

5- Additional Additional procedures procedures

Joint fusions (

Joint fusions (thumbthumb)) Tenodeses Tenodeses

Alternatives Alternatives

Tenodesis Tenodesis Arthrodesis Arthrodesis Nerve

Nerve transfer transfer, , neurotization neurotization Free muscle

Free muscle transfer transfer

Tenodesis Tenodesis

Passive (Zancolli)

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Tenodesis Tenodesis

Active (Zancolli)

Tenodesis Tenodesis

Gilbert

Alternatives Alternatives

Arthrodesis Arthrodesis

Alternatives Alternatives

Nerve

Nerve transfertransfer, , neurotizationneurotization

Ex:

Ex: transfertransfer of AIN to of AIN to motor

motor branchbranch of of ulnarulnar nerve nerve

Alternatives Alternatives

Free muscle Free muscle transfertransfer

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