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Weber MB, Wu KY, Spinner RJ, Bishop AT, Shin AY. Triceps-to-Biceps Tendon Transfer for Restoration of Elbow Flexion in Brachial Plexus Injury. J Hand Surg Am 2023:S0363-5023(23)00353-2. [PMID: 37542495 DOI: 10.1016/j.jhsa.2023.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 06/12/2023] [Accepted: 06/28/2023] [Indexed: 08/07/2023]
Abstract
PURPOSE Restoring elbow flexion is a reconstructive priority in patients with brachial plexus injuries. This study aimed to evaluate the results and assess factors contributing to outcomes of triceps-to-biceps tendon transfer in patients presenting with delayed or chronic upper brachial plexus injury. METHODS Patients with traumatic brachial plexus injuries undergoing triceps-to-biceps tendon transfer at a single institution's multidisciplinary brachial plexus center between 2001 and 2021 were retrospectively reviewed. The entire triceps tendon was transferred around the lateral aspect of the arm, secured to the radius with a tenodesis button, and reinforced with a side-to-side tendon transfer to the biceps tendon. Primary outcomes include the modified British Medical Research Council (mBMRC) elbow flexion strength and active elbow range of motion. RESULTS Twelve patients (eight men and four women; mean age, 45.2 years) were included. The mean follow-up was 10.4 (range, 5-34) months. Nine patients achieved mBMRC ≥3. Five patients achieved mBMRC 4. Average active elbow flexion was 119°, with average extension deficit of 11°. There were three patients with unsatisfactory results, achieving mBMRC 2 elbow flexion. CONCLUSIONS Triceps-to-biceps tendon transfer is an excellent tendon transfer option for restoring elbow flexion in certain patients with an adequately functioning triceps muscle, who present with a delayed or chronic brachial plexus injury. Although most patients achieved mBMRC ≥3 elbow flexion, there was an expected permanent loss of elbow active extension with a residual elbow flexion contracture. LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Morgan B Weber
- Division of Hand Surgery, Department of Orthopaedic Surgery, Mayo Clinic. Rochester, MN
| | - Kitty Y Wu
- Division of Hand Surgery, Department of Orthopaedic Surgery, Mayo Clinic. Rochester, MN
| | | | - Allen T Bishop
- Division of Hand Surgery, Department of Orthopaedic Surgery, Mayo Clinic. Rochester, MN
| | - Alexander Y Shin
- Division of Hand Surgery, Department of Orthopaedic Surgery, Mayo Clinic. Rochester, MN.
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Current Concepts in Elbow Extension Reconstruction for the Tetraplegic Patient. J Am Acad Orthop Surg 2023; 31:221-228. [PMID: 36745692 DOI: 10.5435/jaaos-d-22-00348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/13/2022] [Indexed: 02/08/2023] Open
Abstract
Individuals with C5 or C6 spinal cord injury (SCI) have paralysis of the triceps brachii, and the subsequent loss of elbow extension makes it impossible to reliably use their hands above shoulder level because of the inability to hold the elbow extended against gravity. For persons with cervical SCI, elbow extension can be restored with both tendon and nerve transfers. Elbow extension is necessary for dressing, eating, wheelchair locomotion, pressure relief maneuvers, independent transfers, and reaching objects above shoulder level. Deltoid-to-triceps and biceps-to-triceps tendon transfers have established efficacy and a longer history of use. Transfer of motor branches from the axillary nerve to triceps motor branches is new with no current published prospective studies but shows early promise. This review aims to highlight the amazing potential these procedures can have on the independence and quality of life for people with quadriplegia. Despite the immense benefit possible, fewer than 14% of eligible people with cervical SCI in the United States receive upper limb reconstructive surgery. Surgical timing is critical. A broader understanding and raised awareness of reconstructive options for elbow extension in people with quadriplegia will increase recognition of eligible patients and speed referral time to the appropriate practitioner.
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Liew SK, Shim BJ, Gong HS. Upper Limb Reconstruction in Tetraplegic Patients: A Primer for Spinal Cord Injury Specialists. Korean J Neurotrauma 2020; 16:126-137. [PMID: 33163420 PMCID: PMC7607018 DOI: 10.13004/kjnt.2020.16.e48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/11/2020] [Accepted: 09/23/2020] [Indexed: 11/15/2022] Open
Abstract
Cervical spinal cord injury (SCI) often causes debilitating loss of function of the upper limb. Upper extremity reconstruction surgery can restore some of the upper limb function in tetraplegic patients with SCI. The procedures are typically muscle-tendon unit transfer surgeries, which redistribute the remaining functional muscles to restore active elbow extension, key grip, and finger grasping. In addition to the tendon transfer surgeries, nerve transfers have emerged recently and are showing promising results. However, despite more than half of the tetraplegic patients can benefit from upper limb surgery, only a few of them receive the procedures. This missed opportunity may be due to the lack of communication between SCI specialists and hand surgeons, or the lack of awareness of such options among the specialists and patients. In this review, we provide a basic overview of upper limb reconstruction in tetraplegic patients with target audience of SCI specialists for their better understanding of the basic concept of surgery and information for patient consultation before referring to hand surgeons.
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Affiliation(s)
- Siew Khei Liew
- Department of Orthopedic Surgery, Hand and Reconstructive Microsurgery Division, Faculty of Medicine and Health Sciences, University Putra Malaysia, Selangor, Malaysia
| | - Bum Jin Shim
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul, Korea
| | - Hyun Sik Gong
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul, Korea
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McPherson A, Matthew R, Estrada M, Bajcsy R, Tomizuka M. Design of a Passive, Variable Stiffness Exoskeleton for Triceps Deficiency Mitigation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:4921-4925. [PMID: 33019092 DOI: 10.1109/embc44109.2020.9175350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Individuals with neurological impairment, particularly those with cervical level spinal cord injuries (SCI), often have difficulty with daily tasks due to triceps weakness or total loss of function. More demanding tasks, such as sit-skiing, may be rendered impossible due to their extreme strength demands. Design of exoskeletons that address this issue by providing supplemental strength in arm extension is an active field of research but commercial devices are not yet available for use. Most current designs employ electric motors that necessitate the addition of bulky power sources and extraneous wiring, rendering the devices impractical in daily life. The possibility of powering an upper extremity exoskeleton passively has been explored, but to date, none have delivered sufficient function or strength to provide useful assistance for sit-skiing. We seek to rectify this with the design of a passively actuated exoskeletal arm brace capable of operating in two, adjustable-strength modes: one for low level gravity compensation to aid in active range of motion, and the other for more stringent weight bearing activities. The mechanism developed through this paper allows for an affordable, lightweight, modular device that can be adjusted and customized for the needs of each individual patient.
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Combined nerve and tendon transfer to restore elbow extension in tetraplegic patients: surgical technique and case report. Spinal Cord Ser Cases 2020; 6:31. [PMID: 32355201 DOI: 10.1038/s41394-020-0281-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/10/2020] [Accepted: 04/13/2020] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION In individuals with tetraplegia, elbow extension is critical for overhead activities, weight shifting, independent transfers, and to perform self-care tasks such as eating. At present, restoration of elbow extension in tetraplegic patients can be performed using either tendon or nerve transfers. Each procedure presents several advantages and limitations that must be discussed with the potential surgical candidate, based on remaining muscular functions and functional goals. CASE PRESENTATION We propose a novel combined technique of both tendon and nerve transfer to restore active elbow extension by transferring the posterior deltoid tendon to the triceps tendon and the branch of teres minor nerve to the long head of the triceps nerve. Techniques were performed from the same shoulder posterior surgical approach. DISCUSSION This surgical technique can add the benefits of each tendon and nerve transfer, leading to a reduction of failure rates, with more predictable outcomes.
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Bryden A, Kilgore KL, Nemunaitis GA. Advanced Assessment of the Upper Limb in Tetraplegia: A Three-Tiered Approach to Characterizing Paralysis. Top Spinal Cord Inj Rehabil 2018; 24:206-216. [PMID: 29997424 DOI: 10.1310/sci2403-206] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: More than half of all individuals who sustain a spinal cord injury (SCI) experience some degree of impairment in the upper limb. Functional use of the arm and hand is of paramount importance to these individuals. Fortunately, the number of clinical trials and advanced interventions targeting upper limb function are increasing, generating optimism for improved recovery and restoration after SCI. New interventions for restoring function and improving recovery require more detailed examination of the motor capacities of the upper limb. Objectives: The purpose of this article is to introduce a three-tiered approach to evaluating motor function, with specific attention to the characteristics of weak and fully paralyzed muscles during acute rehabilitation. The three tiers include (1) evaluation of voluntary strength via manual muscle testing, (2) evaluation of lower motor neuron integrity in upper motor neuron-paralyzed muscles using surface electrical stimulation, and (3) evaluation of latent motor responses in paralyzed muscles that exhibit a strong response to electrical stimulation, using surface electromyographic recording electrodes. These characteristics contribute important information that can be utilized to mitigate potential secondary conditions such as contractures and identify effective interventions such as activity-based interventions or reconstructive procedures. Our goal is to encourage frontline clinicians - occupational and physical therapists who are experts in muscle assessment - to consider a more in-depth analysis of paralysis after SCI. Conclusion: Given the rapid advancements in SCI research and clinical interventions, it is critical that methods of evaluation and classification evolve. The success or failure of these interventions may depend on the specific characteristics identified in our three-tiered assessment. Without this assessment, the physiological starting point for each individual is unknown, adding significant variability in the outcomes of these interventions.
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Affiliation(s)
- Anne Bryden
- Case Western Reserve University, Cleveland, Ohio
| | - Kevin L Kilgore
- Case Western Reserve University, Cleveland, Ohio.,MetroHealth Medical Center, Cleveland, Ohio.,Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio
| | - Gregory A Nemunaitis
- Case Western Reserve University, Cleveland, Ohio.,MetroHealth Medical Center, Cleveland, Ohio
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Abstract
Individuals with tetraplegia face many obstacles with activities of daily living. Although approximately 65% to 75% of individuals with tetraplegia would benefit from upper extremity surgery that could make many of their activities of daily living more spontaneous, only 14% of patients who are surgical candidates undergo tendon transfer procedures. A good surgical candidate has an injury at one of the cervical spine levels and an International Classification for Surgery of the Hand in Tetraplegia group of 1 or better, has functional goals, and is committed to the postoperative rehabilitation process. Surgery primarily consists of tendon transfers, tenodesis, and arthrodesis to restore elbow extension and hand pinch, grasp, and release. Nerve transfers and functional electrical stimulation are also options for treatment.
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Bertelli JA, Soldado F, Ghizoni MF, Rodríguez-Baeza A. Transfer of the musculocutaneous nerve branch to the brachialis muscle to the triceps for elbow extension: anatomical study and report of five cases. J Hand Surg Eur Vol 2017; 42:710-714. [PMID: 28490272 DOI: 10.1177/1753193417694585] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED We report the study of the anatomical feasibility of transferring the nerve to the brachialis muscle to the upper medial head motor branch that innervate the triceps, and outcomes of such transfers in restoring elbow extension in five patients with posterior cord lesion of the brachial plexus. The length of the branches to the brachialis muscle measured 7.6 cm and the triceps upper medial head motor branch was 5 cm in 10 adult cadavers. Five male patients were treated with this transfer 5 months after the injury (range 4 to 6 months) after posterior cord injury of the brachial plexus with a mean follow-up of 31 months (range 28 to 36 months). Elbow extension scored M4 in all cases. No complications occurred. These preliminary results suggest that transferring the nerve to the brachialis muscle is an effective technique for the reconstruction of elbow extension after posterior cord brachial plexus injuries. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- J A Bertelli
- 1 Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Santa Catarina, Brazil.,2 Center of Biological and Health Sciences, University of the South of Santa Catarina (Unisul), Tubarão, Brazil
| | - F Soldado
- 3 Pediatric Hand Surgery and Microsurgery Unit, Universitat de Barcelona, Barcelona, Spain
| | - M F Ghizoni
- 2 Center of Biological and Health Sciences, University of the South of Santa Catarina (Unisul), Tubarão, Brazil
| | - A Rodríguez-Baeza
- 4 Human Anatomy Unit, Universitat Autònoma de Barcelona, Barcelona, Spain
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Johanson ME, Jaramillo JP, Dairaghi CA, Murray WM, Hentz VR. Multicenter Survey of the Effects of Rehabilitation Practices on Pinch Force Strength After Tendon Transfer to Restore Pinch in Tetraplegia. Arch Phys Med Rehabil 2017; 97:S105-16. [PMID: 27233585 DOI: 10.1016/j.apmr.2016.01.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 01/13/2016] [Accepted: 01/14/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To identify key components of conventional therapy after brachioradialis (BR) to flexor pollicis longus (FPL) transfer, a common procedure to restore pinch strength, and evaluate whether any of the key components of therapy were associated with pinch strength outcomes. DESIGN Rehabilitation protocols were surveyed in 7 spinal cord injury (SCI) centers after BR to FPL tendon transfer. Key components of therapy, including duration of immobilization, participation, and date of initiating therapy activities (mobilization, strengthening, muscle reeducation, functional activities, and home exercise), were recorded by the patient's therapist. Pinch outcomes were recorded with identical equipment at 1-year follow-up. SETTING Seven SCI rehabilitation centers where the BR to FPL surgery is performed on a routine basis. PARTICIPANTS Thirty-eight arms from individuals with C5-7 level SCI injury who underwent BR to FPL transfer surgery (N=34). INTERVENTION Conventional therapy according to established protocol in each center. MAIN OUTCOME MEASURES The frequency of specific activities and their time of initiation (relative to surgery) were expressed as means and 95% confidence intervals. Outcome measures included pinch strength and the Canadian Occupational Performance Measure (COPM). Spearman rank-order correlations determined significant relations between pinch strength and components of therapy. RESULTS There was similarity in the key components of therapy and in the progression of activities. Early cast removal was associated with pinch force (Spearman ρ=-.40, P=.0269). Pinch force was associated with improved COPM performance (Spearman ρ=.48, P=.0048) and satisfaction (Spearman ρ=.45, P=.0083) scores. CONCLUSIONS Initiating therapy early after surgery is beneficial after BR to FPL surgery. Postoperative therapy protocols have the potential to significantly influence the outcome of tendon transfers after tetraplegia.
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Affiliation(s)
| | | | | | | | - Vincent R Hentz
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Department of Surgery, Stanford University, Palo Alto, CA
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Dunn JA, Sinnott KA, Rothwell AG, Mohammed KD, Simcock JW. Tendon Transfer Surgery for People With Tetraplegia: An Overview. Arch Phys Med Rehabil 2016; 97:S75-80. [DOI: 10.1016/j.apmr.2016.01.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 01/08/2016] [Accepted: 01/11/2016] [Indexed: 10/21/2022]
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Upper Extremity Assessment in Tetraplegia: The Importance of Differentiating Between Upper and Lower Motor Neuron Paralysis. Arch Phys Med Rehabil 2016; 97:S97-S104. [DOI: 10.1016/j.apmr.2015.11.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 10/06/2015] [Accepted: 11/02/2015] [Indexed: 12/25/2022]
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Kerver ALA, Carati L, Eilers PHC, Langezaal AC, Kleinrensink GJ, Walbeehm ET. An anatomical study of the ECRL and ECRB: feasibility of developing a preoperative test for evaluating the strength of the individual wrist extensors. J Plast Reconstr Aesthet Surg 2013; 66:543-50. [PMID: 23369737 DOI: 10.1016/j.bjps.2012.12.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 11/16/2012] [Accepted: 12/14/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tendon transfers are essential for reconstruction of hand function in tetraplegic patients. To transfer the extensor carpi radialis longus (ECRL), the extensor carpi radialis brevis (ECRB) has to be sufficiently strong. However, there is currently no reliable clinical test to individually analyse both muscles. In order to develop a reliable preoperative clinical test, the anatomy of the muscle (innervation) areas of ECRB, ECRL and brachio-radialis (BR) was examined. METHODS In 20 arms, the ECRB, ECRL and BR were dissected and localised. Subsequently, muscle-innervation points were mapped and categorised. A novel method, computer-assisted surgical anatomy mapping (CASAM), was used to visualise muscle areas and innervation points in a computed arm with average dimensions. RESULTS For both ECRL and ECRB a 100% area could be identified, a specific area in the computed average arm in which the muscle was present for all 20 arms. For the ECRL, this area was situated at 16% of the distance between the lateral epicondyle and the deltoid muscle insertion. The ECRB 100% area was 5 times bigger than that of the ECRL and was located at 40% of the distance between the lateral epicondyle and the radial styloid process. The ECRL and BR showed one to three innervation points, the ECRB one to four. In 47% of the cases, there was a combined nerve branch innervating both the ECRL and the ECRB. CONCLUSIONS It is feasible to develop a preoperative test; the 100% areas can be used for needle electromyography (EMG) or local anaesthetic muscle injections.
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Affiliation(s)
- A L A Kerver
- Department of Anatomy and Neuroscience, Erasmus MC, Rotterdam, The Netherlands.
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Fridén J, Gohritz A. Novel Concepts Integrated in Neuromuscular Assessments for Surgical Restoration of Arm and Hand Function in Tetraplegia. Phys Med Rehabil Clin N Am 2012; 23:33-50, ix-x. [DOI: 10.1016/j.pmr.2011.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Bibliography Current World Literature. CURRENT ORTHOPAEDIC PRACTICE 2012. [DOI: 10.1097/bco.0b013e3182434f58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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