Early Tendon Transfer Research Articles

Outcomes after arthroscopically assisted lower trapezius transfer with Achilles tendon allograft

Lower trapezius tendon transfer is 1 option to improve pain and function with massive irreparable rotator cuff tears. Magnetic resonance imaging (MRI) evaluation of tendon healing with the procedure has not yet been reported. The purpose of this study was to evaluate early tendon transfer healing using postoperative MRI scans and to assess early clinical outcomes in patients after arthroscopically assisted lower trapezius tendon transfer (AALTT) for massive irreparable rotator cuff tears. This was a single institution retrospective review of consecutive patients with massive irreparable rotator cuff tears who underwent AALTT with a single surgeon from January 2017 to July 2020 with a minimum 6-month follow-up. Patient information including age, sex, follow-up, prior surgical history, and type of work (sedentary or labor-intensive) was recorded. Preoperative and postoperative range of motion, external rotation strength, presence of a lag sign, and pain visual analog scale data were extracted from medical records. Patient-reported outcomes were extracted from patient charts. Six-month postoperative MRIs were reviewed for tendon transfer healing at both the greater tuberosity and the trapezius-allograft interface. A total of 19 patients met inclusion criteria with average age 56.7 (range, 29-72years). Of these patients, 17 (89.5%) were male. The average follow-up was 14.6 (range, 6-45) months. Fifteen (78.9%) patients had unsuccessful previous rotator cuff repair. Six-month MRI demonstrated complete healing of the transferred tendon in 17 of 19 patients (89.5%). There were significant improvements in postoperative pain visual analog scale (5.9±2 vs. 1.8±2), ASES score (44.6±18 vs. 71.2±24), and Patient Reported Outcomes Measurement Information System Physical (46.3±6 vs. 51.3±11) and in external rotation motion (10.5±17° vs. 40.5±13°) and strength (2.8/5±1 vs. 4.7/5±0.5) at final follow-up. All patients with a preoperative external rotation lag sign had reversal of their lag sign at final follow-up (15/15). Of 17 work-eligible patients, 13 (76.4%) were able to return to work. In this series, AALTT showed a high rate of healing of the transferred tendon on MRI by 6months postoperatively. The current findings of a high rate of early tendon transfer healing are consistent with the good early and mid-term outcomes that have been observed in AALTT and provide support for surgeon and patient expectations, postoperative rehabilitation, and return to work following AALTT for massive posterior superior rotator cuff tears.

Ballistic peripheral nerve injuries: basic concepts, controversies, and proposal for a management strategy.

Ballistic injuries to peripheral nerves are devastating injuries frequently encountered in modern conflicts and civilian trauma centers. Such injuries often produce lifelong morbidity, mainly in the form of function loss and chronic pain. However, their surgical management still poses significant challenges concerning indication, timing, and type of repair, particularly when they are part of high-energy multi-tissue injuries. To help trauma surgeons, this article first presents basic ballistic concepts explaining different types of missile nerve lesions, described using the Sunderland classification, as well as their usual associated injuries. Current controversies regarding their surgical management are then described, including nerve exploration timing and neurolysis's relevance as a treatment option. Finally, based on anecdotal evidence and a literature review, a standardized management strategy for ballistic nerve injuries is proposed. This article emphasizes the importance of early nerve exploration and provides a detailed method for making a diagnosis in both acute and sub-acute periods. Direct suturing with joint flexion is strongly recommended for sciatic nerve defects and any nerve defect of limited size. Conversely, large defects require conventional nerve grafting, and proximal injuries may require nerve transfers, especially at the brachial plexus level. Additionally, combined or early secondary tendon transfers are helpful in certain injuries. Finally, ideal timing for nerve repair is proposed, based on the defect length, associated injuries, and risk of infection, which correlate intimately to the projectile velocity.

Immediate Tendon Transfer with Nerve Repair in Low Combined Ulnar and Median Nerve Injury.

Background:Combined median-ulnar nerve injury at the level of distal forearm (below the musculotendinous junction) causes a detrimental effect on hand functions, which have a great impact on patients’ hands as well as a financial burden. Many previous authors advocated early or immediate tendon transfer in solitary median or ulnar nerve injuries.Methods:This study included 20 patients with combined distal ulnar-median nerve injury, who were divided into 2 groups. Group I (control) included 10 patients who underwent primary (group fascicular) repair of both nerves only. Group II (study) included 10 patients underwent primary (group fascicular) repair with immediate tendon transfer simultaneously: opponenplasty using extensor indicies and adductoplasty extensor carpi radialis brevis with appropriate splinting, postoperative rehabilitation, and biofeedback facilities.Results:Twenty patients (age: 18–38 years) were affected. The response of median and ulnar nerves showed invariable results in both groups, whilst the hand grip, hand pinch, and opposition showed marked improvements in group II. Moreover, inter-phalangeal and metacarpophalangeal joints of thumb showed no deformities in group II in comparison with high level of deformities in group I, owing to early regain of thumb movements.Conclusions:Immediate (during neurorrhaphy) tendon transfer may offer additional merits over nerve repair only for distal combined ulnar and median injury, as it offers scarless field, no adhesion, and no joint edema, leading to very early return to normal hand functions with a consequent decrease of thumb deformities, better hand grip, and key pinch.

Functional evaluation of early tendon transfer for thumb opposition in median nerve palsy

BackgroundThere is paucity of literature on early tendon transfer in surgical rehabilitation of hands with median nerve injuries. Since the single most important functional deficit in median nerve palsy is the loss of thumb opposition, we evaluated the results of early tendon transfer in restoration of thumb opposition. MethodsThis prospective study involved 10 cases of isolated median nerve paralysis (axonotmesis or neurotmesis) that underwent early tendon transfer for restoration of thumb opposition. A pre- and post-operative evaluation in terms of power and precision grip strength and range of opposition of thumb was done. Median nerve exploration was performed in 4 cases and was supplemented by a tendon transfer for thumb opposition. The extensor indicis proprius (EIP) opponensplasty was performed in nine out of ten cases. In one case where the patient had scarring over the EIP tendon, palmaris longus (PL) opponensplasty was performed. ResultsThe median age at injury was 29 years (range; 8 years–57 years). Minimum period of follow-up was 6 months. Six patients who underwent EIP transfer had excellent opposition while 3 had good opposition. The patient, in whom PL opponensplasty was done, had an excellent opposition. The median time for return to work was 2.75 months.There was significant improvement in the power grip and all three types of precision grip at 6 months follow-up. The percentage deficit in the affected hand compared to the normal hand was significantly reduced. There was no case of tendon pull out in our study, nor did any of our patients have an extensor lag following EIP transfer. ConclusionEarly tendon transfer has a unique role in the management of median nerve palsy hand and we suggest this procedure should be considered in both high and low lesions.

Functional evaluation of early tendon transfer for foot drop.

Early tendon transfer has shown good outcomes in peripheral nerve injuries of upper limb. However, there is lack of knowledge on early tendon transfer for peripheral nerve palsy in lower limb. This study has been designed to study the functional outcomes of early tendon transfer in the lower limb, particularly for foot drop. We enrolled 30 cases of foot drop due to traumatic sciatic/common peroneal nerve (CPN) palsy between September 2012 and March 2016. We performed nerve exploration with repair and early tendon transfer in all patients. All patients were followed up for a minimum period of 24 months. Functional evaluation was carried out using Stanmore assessment questionnaire. At the end of 24 months postoperatively, the Stanmore assessment questionnaire score showed a significant improvement from a mean preoperative score of 17.5 to mean postoperative score of 86.2. All patients were free of ankle-foot orthosis (AFO). All patients were subjectively satisfied. Time to return to original job was 5.2 months on an average. Ankle dorsiflexion of the operated limb was comparable to the normal limb in cases where there was nerve recovery. Planovalgus foot, a known complication of this procedure, was noted in 24 patients. However, it was not disabling to any patient. Early tendon transfer in CPN palsy/sciatic nerve palsy has a definite place in the management of the injured patient. The transfer, if appropriately carried out, acts as a helper, an internal splint, a substitute, or perhaps all of the three at varying times in the rehabilitative phase of the patient. Dorsiflexor clearance in swing phase of locomotion was quickly restored in all patients, obviating the need for AFO.

Reliability and validity of the Brachial Plexus Outcome Measure in children with obstetric brachial plexus palsy

Study DesignClinical measurement and cross-sectional study. IntroductionNumerous scales have been developed to examine activities of daily living and function in children with brachial plexus palsy. The Brachial Plexus Outcome Measure (BPOM) scale was developed in 2012 by Emily S. Ho and contains 14 items that measure activity and self-evaluation. Purpose of the StudyThe aim of the study was to cross-culturally translate the BPOM scale into Turkish and test its measurement properties in children with brachial plexus palsy. MethodsThe scale was translated into Turkish using standard cross-cultural translation procedures. Forty-eight children with obstetric brachial plexus palsy (OBPP) were included in psychometric evaluations. Internal structure consistency and test-retest reliability were measured for reliability analyses. For each item on the scale, Cronbach alpha coefficient and item-total score correlations for all subscales were calculated. The scale was administered at baseline and 1 week later by 2 different physiotherapists to evaluate test-retest reliability. Concurrent construct validity was assessed using Pearson correlations between the OBPP and the Mallet classification system. ResultsEighteen (37.5%) girls and 30 (62%) boys, in total 48 children, whose mean age was 8.7 ± 2.4 (minimum-maximum = 5-14) years were included in the study; 9 (18.9%) have a history of both early microsurgery and tendon transfers and 39 (81.3%) have a history of only tendon transfer. Cronbach alpha ranged from 0.89 to 0.96, and for the whole scale, it was calculated as 0.938. DiscussionTest-retest reliability was high. Moderate correlations were observed between the measures. ConclusionThe Turkish BPOM scale is a valid and reliable measurement for assessing function in children with OBPP in the Turkish population.

Early tendon transfer after wide resection of an undifferentiated sarcoma of the forearm in a neonate: A case report

A 1-month-old female baby was diagnosed with an undifferentiated sarcoma of her forearm after incisional biopsy. She received five cycles of chemotherapy before a wide resection of her extensor muscles including the radial nerve was undertaken, resulting in a complete drop of wrist and fingers. At this stage, primary tendon transfer of the brachioradialis to extensor carpi radial brevis muscle was performed, which proved to be not sufficient. Five months after resection of the tumour, restoration of the extensor function was achieved by flexor tendon transfers to provide wrist, finger and thumb extension. After 2 years, the patient did not show any signs of recurrence and she has a good wrist, finger and thumb extension and flexion. The diagnosis of an undifferentiated sarcoma is one per exclusion. Treatment includes chemotherapy and complete resection of the tumour with a wide margin. We discuss the diagnosis of undifferentiated sarcoma as well as early restoration of hand function in neonates.

Paralytic congenital talipes equinovarus of unknown origin: A new entity. Multicenter study of 42 cases

Paralysis of the lateral and/or anterior leg muscles can lead to relapse of treated talipes equinovarus. The muscle function impairment is due to isolated permanent paralysis, and early palliative tendon transfer may prevent recurrence of the deformity. Forty-two cases of congenital talipes equinovarus that recurred after conservative therapy were reviewed after a mean follow-up of 10years. In 39cases, second-line surgery was performed (posteromedial release, n=33; and muscle transfer, n=26). Outcomes were evaluated clinically. Separating the cases into two groups, based on whether muscle transfer was performed, showed a statistically significant difference: muscle transfer intended to restore eversion and/or dorsal flexion of the foot was associated with significantly better functional outcomes. In addition to providing etiological insights, the identification of paralysis in patients with talipes equinovarus can influence treatment decisions, depending on the nature of the muscle deficiencies, with the goal of preventing recurrences. Early muscle transfer to restore eversion and/or dorsal flexion of the foot may provide the best functional outcomes by minimizing the need for soft-tissue release. IV, retrospective multicentre study.

Functional restoration after early tendon transfer in high radial nerve paralysis

We assessed the effect of an early transfer of pronator teres to extensor carpi radialis brevis on hand function in patients with high radial nerve paralysis. Power grip and precision grip were measured preoperatively and postoperatively using a dynamometer. Fifteen patients were operated on, of which ten could be assessed at the end of 6 months. At 6 months after surgery, there was a median increase of 48% in power grip, 162% in tip pinch, 90% in key pinch and 98% in palmar pinch. Decreased palmar flexion was seen in four patients. Fraying of the periosteal extension and rupture of sutures at the junction site were each seen in one patient, leading to unsatisfactory results. Early tendon transfer quickly restored efficient grip while awaiting reinnervation of wrist extensors, avoiding the need for prolonged external splintage.

Elbow flexion restoration by muscular transfers combined with biceps neurotisation in brachial plexus palsy

Findings: The average amount of derotation at operation was 43”. The preoperative Mallet score was improved from 10.2 to 15.0 postoperatively. Average external rotation of -24.3” and average abduction of 93.1” were improved to +24” and 117.6” respectively. Discussion: The development of bony deformities can be prevented by releasing contractures combined with early tendon transfers. If internal rotation contracture and an associated bony deformity has occurred in the shoulder, derotation osteotomy may be a suitable option. The osteotomy done proximal to the deltoid insertion overcomes the internal rotation contracture and also the relatively strong anterior fibres of the deltoid increases abduction. conclusion: HumeraI derotation osteotomy is the treatment of choice in patients with internal rotation contractures of the shoulder and associated bony deformities, following birth palsy.

MANAGEMENT PRINCIPLES TO TREAT NERVE LOSS AFTER VIOLENT TRAUMA TO THE UPPER EXTREMITY

This article discusses nerve loss treatment options. The role of cable graft versus early tendon transfers are delineated. Vascularized grafts and the timing of nerve grafting also are discussed.

The functional results of ulnar nerve repair: Defining the indications for tendon transfer

The subjective, objective and functional outcome following repair of isolated ulnar nerve injuries was assessed in 50 patients, 1 to 7 years after repair. We tried to identify those patients who may benefit from early tendon transfer. This study confirmed a satisfactory functional result in sedentary workers, but not in manual labourers. Intrinsic muscle power, grip strength, key pinch and sensation continued to improve following repair of high injuries for at least 2 years, and of low injuries for at least 3 years. Early tendon transfers are only recommended in manual workers who complain of poor grip or key pinch.

Foot and Ankle Manifestations of Charcot-Marie-Tooth Disease

The term Charcot-Marie-Tooth disease represents a spectrum of neurological dysfunction more recently described as hereditary motor-sensory neuropathies. An abnormality of myelination is thought to be responsible for the clinical manifestations. While histological findings have been well described, the exact biochemical basis for this disorder remains unknown. Over one half of patients with Charcot-Marie-Tooth disease manifest foot and ankle problems, including pain, weakness, deformity, and, rarely, paresthesias. Characteristic patterns of neuromuscular weakness have been identified. Bilateral pes cavovarus is the most common pathologic foot deformity seen. The specific components include hindfoot varus, anterior or forefoot cavus, and, often clawtoes. The etiology of this abnormal foot posture usually results from tibialis posterior overpowering peroneus brevis coupled with peroneus longus overpowering tibialis anterior. Multiple treatment options have been described. Rationale for specific tendon transfers, soft tissue release, osteotomies, and arthrodesis is discussed. Results of surgical intervention are difficult to interpret and compare because of the wide spectrum of both neurological dysfunction and described operative procedures. In the presence of flexible deformity, early soft tissue release and tendon transfers may help prevent or delay more extensive bony procedures. The clinical results of triple arthrodesis in the Charcot-Marie-Tooth disease patient appear to deteriorate with time. Genetic transmission, progression of the neurological dysfunction, flexibility of the deformity, distribution of muscular weakness, and anticipated foot demands vary a great deal within this patient population. Treatment decisions, therefore, must be individualized and based upon a clear history, careful examination, and well-defined patient goals.

Role of Early Tendon Transfers in Radial Nerve Palsy

SummarySixteen cases of wrist drop were managed by tendon transfers using Boyes Technique for early rehabilitation. The procedure was found useful both in remedial and irremedial radial nerve lesions. In the former they act as internal splints during the period of recovery. Results in high as well as in low radial nerve lesion were equally good. Patients were able to return to their original work, 6 to 8 weeks after surgery.

The long-term results of the surgical management of paralytic pes cavus by soft tissue release and tendon transfer.

Twenty-six patients with paralytic pes cavus were managed by early soft tissue correction and tendon transfer. Eighteen had spina bifida, 6 had peroneal muscular atrophy and two had cerebral palsy. The most frequent operations were flexor hallucis longus tenodesis, Girdlestone's flexor to extensor tendon transfer and plantar release. The indications for these procedures are discussed and the results presented, with particular reference to static and dynamic foot pressure studies performed at review. Follow-up averaged 5.2 years. Toe correction was found to be successful in most cases but plantar release failed in 55% of feet, with many progressing to fusion. Many failed feet had presented at an earlier age and it was felt that the initial procedures had delayed the need for bony correction thus minimising growth disturbance.

Early tendon transfers in the rehabilitation of median, radial, and ulnar palsies

Early tendon transfers car restore a balanced simplification of motor performance and provide an essential component for re-education of sensation. Recommended transfers include the extensor indicis proprius to restore thumb opposition in low median palsy, the pronator teres to restore wrist extension in radial palsy, and the multi-tailed single flexor digitorum superficialis to restore thumb-index pinch and prevent ring-little finger clawing in low ulnar palsy.

Rehabilitation of Peripheral Nerve Injuries

Rehabilitation of the patient with a peripheral nerve injury requires knowledge, understanding, and cooperation between the patient, the physician, and the therapist. Careful documentation of the patient's status prior to beginning rehabilitation and periodic follow-up assessments are of utmost importance. We have presented a detailed scheme for initial and follow-up evaluation. Prevention of unnecessary stiffness, swelling, and contractures is emphasized. Education of the patient to prevent the individual from doing further damage to the anesthetic area is important. Proper splinting techniques, from the postoperative splint and cast to splints that prevent deformities as well as overcome established contractures and improve function, will aid in the patient's recovery. Desensitization is an important aspect of sensory recovery, and sensory reeducation will aid in recovery of sensibility. Early tendon transfers are found to be particularly advantageous for high radial and median nerve palsies to gain functional recovery earlier and to allow the patient to become brace-free sooner.

Early tendon transfer for radial nerve transection

A retrospective comparison of twelve patients with radial nerve transection treated by nerve repair, and thirteen similar patients treated by tendon transfer only, showed an average time to recovery of 7.5 months after nerve repair, and eight weeks after transfer. In view of this, a policy of early tendon transfer instead of radial nerve suture is advised. Results are reported in nine patients who had tendon transfers at an average of thirteen days after nerve injury.

Early tendon transfer in upper extremity peripheral nerve injury.

*Chief, Orthopedic Service, Department of the Army, Fitzsimons Army Medical Center, Denver, Colorado 80240