Our experience of upper-limb transfers in cases of tetraplegia

Clinical and radiographic evaluation of surgical reconstruction of finger flexion in tetraplegia

PURPOSE

To define the order and frequency of elongation in tendon junctions in extensor carpi radialis longus (ECRL) to flexor digitorum profundus tendon transfer and its correlation to grip strength and lack of finger flexion.

METHODS

Forty-seven tetraplegic patients had surgery involving the reconstruction of finger flexion with the transfer of the ECRL in a total of 62 arms. During surgery metal markers were placed on both sides of the tendon-to-tendon attachment site. After surgery the distance between the markers was measured on radiographs. Any increase in the distance between the markers was judged as elongation. The grip strength and mean pulp-to-palm distance were evaluated a minimum of 6 months after surgery. Three arms had a second surgery because of insufficient functional results.

RESULTS

The average final elongation was 9 +/- 10 mm (mean +/- SD). The mean grip strength was 16 +/- 12 kPa (range, 0-50). The lack of flexion (mean value of pulp-to-distal palmar crease of 3 ulnar digits) was 0.8 +/- 1.2 cm on average. Elongation up to 15 to 20 mm still was compatible with good grasp.

CONCLUSIONS

The tendon junction after a transfer of the ECRL to the finger flexors can be overloaded. Elongation therefore must be considered as one among several possible causes of an unsatisfactory result after this type of tendon transfer but elongation less than 15 mm usually is compatible with excellent function.

[Functional surgery of upper limb in tetraplegics since 50 years]

OBJECTIVE

Development of upper limb functional surgery in tetraplegics in the last 50 years.

METHODS

The literature review relating to the years 1950-2002 was carried out with 3 data bases: Medline, Pascal, Embase. This review also involved a thorough study of non-indexed references.

RESULTS

A large number of surgical procedures are described. Two priorities are stressed by the authors: safety of these procedures and duration of postoperative immobilization.

CONCLUSION

This review of literature shows that the prospects for restoring upper limb function in tetraplegics are greater than ever, offering a larger number of patients the possibility to increase their independence in daily life. Functional surgery remains, nevertheless, demanding in terms of length of immobilization and presupposes requiring a multidisciplinary approach requiring rehabilitation teams to be up to date with surgical procedures.

Principles of conservative management for a non-orthotic tenodesis grip in tetraplegics

The effectiveness of a tenodesis grip is determined by the passive properties of the hand. An effective tenodesis grip can be achieved by encouraging a decrease in the resting length (i.e., adaptive shortening) of the flexor digitorum profundus and the flexor digitorum superficialis so that the fingers flex when the wrist is extended. Also, adaptive shortening of the flexor pollicis longus needs to be encouraged so that the thumb approximates the flexed fingers when the wrist is extended. The length of the adductor pollicis will in part dictate where along the radial side of the index finger the thumb will contact. Development of an effective tenodesis grip also requires that excessive metacarpophalangeal and interphalangeal joint stiffness of the fingers be prevented and that the interphalangeal joint of the thumb become stiff in extension. Careful management of the tetraplegic hand can ensure the development of the musculoskeletal changes necessary for an effective tenodesis grip.

Single-stage reconstruction of key pinch and extension of the elbow in tetraplegic patients

The results in ten arms of nine patients who had post-traumatic tetraplegia at the fifth or sixth cervical level were reviewed after combined transfer of the brachioradialis to the flexor pollicis longus and of the posterior part of the deltoid to the triceps tendon to restore key pinch and extension of the elbow. The average age of the patients was twenty-nine years, the average time from the injury to the operation was five years, and the average duration of follow-up was thirty-one months. Key pinch improved from essentially none preoperatively to an average of 2.0 pounds (0.9 kilogram) postoperatively: an average of 3.0 pounds (1.4 kilograms) for the patients who had tetraplegia at the sixth cervical level and an average of 0.9 pound (0.4 kilogram) for those who had tetraplegia at the fifth cervical level. Key pinch was favorably influenced by extension of the wrist, while the position of the elbow had no effect. Maximum active extension of the elbow against gravity was within 20 degrees of full extension in eight of the ten arms. There was an improvement in the performance of activities of daily living, including wheelchair use, and most of the patients discontinued use of special equipment for the upper extremity. The results of this study, when compared with those of each procedure performed separately, suggest that a combination of the operations improves function of the upper extremity and shortens the duration of dependence postoperatively.

Tendon transfers in patients with cervical spinal cord injury

Between 1983 and 1988, 32 patients with cervical spinal cord injuries underwent 124 upper limb tendon transfers during 85 procedures. Of the numerous surgical procedures that have been recommended for treatment of this condition, my experience indicates that the most successful are posterior deltoid-to-triceps transfer, restoration of finger flexion, and restoration of thumb opposition. Longitudinal incisions prove to be quite cosmetic.

Long-term follow-up of the Moberg key grip procedure

The long-term results of the key grip procedure (tenodesis of the flexor pollicis longus tendon to the radius, release of the A1 pulley, and percutaneous pin fixation of the interphalangeal joint of the thumb) were evaluated in 10 tetraplegic patients. Seven patients also had tenodesis of the extensor pollicis longus and brevis tendons to prevent flexion at the metacarpophalangeal (MP) joint. Patients were examined an average of 7.4 years after surgery. Progressive flexion of the MP joint gradually occurred, indicating failure of the extensor tenodesis. Excessive bowstringing of the flexor pollicis longus tendon across the MP joint occurred in nine patients. Because of failure of the extensor tenodesis and bowstringing of the flexor tendon, the patients had to progressively extend the wrist further to pinch small objects. Functional testing demonstrated improved hand use in eight patients. Lateral pinch strength was related to wrist extension torque.

Postoperative results of opponensplasty and flexor tendon transfer in patients with spinal cord injuries

Key pinch, palmar pinch, and grasp strength were evaluated after opponensplasty and flexor tendon transfer in 24 patients who had suffered cervical spinal cord injuries during a 17-year period. The patients had 57 tendon transfers: 35 opponensplasties and 22 flexor tendon transfers. The average follow-up was 4.2 years. The brachioradialis and pronator teres were the most frequently used motors for the opponensplasty and flexor tendon transfer. Key pinch strength averaged 1.47 kg (range of 0.13 to 4.70 kg). Grasp strength averaged 2.81 kg (range of trace to 10.0 kg). Palmar pinch was obtained in 45% of the extremities; the overall result was 1.04 kg (range of 0.20 to 3.00 kg). In general, patients with higher functional classifications achieved better results. We believe that intraoperative length-tension studies were an important factor in improving the results. The choice of muscle for opponensplasty or flexor transfer when two different adequate motors were available did not seem to affect the outcome of key pinch or grasp. We believe that tendon transfers are beneficial and should be considered in all patients with spinal cord injuries regardless of age at injury if at least 1 year has elapsed since injury and the patients are neurologically stable and have participated in a rehabilitation program.

Brachioradialis to flexor pollicis longus tendon transfer for active lateral pinch in the tetraplegic

Seventeen hands in 15 patients with posttraumatic tetraplegia had transfers of the brachioradialis tendon to the flexor pollicis longus in an attempt to create an active lateral pinch. In addition, interphalangeal joint fixation with a Moberg screw was performed in 16 thumbs and tenodesis of the extensor pollicis longus and brevis tendons to the metacarpal was performed in 11 patients. Average patient age was 32 years, time from onset of tetraplegia to operation was 5.3 years, and postoperative follow-up was 2.3 years. Functional improvement was noted in 15 hands and 80% of the patients could name at least four activities of daily living that were now possible or made more efficient as a result of surgery. With the elbow flexed to 90 degrees, the average lateral pinch was 3.9 pounds with the wrist extended 30 degrees, 4 pounds with the wrist in the neutral position, and 2.3 pounds with the wrist flexed 30 degrees. There was a direct correlation between pinch strength and the amount of residual triceps and wrist extensor strength.

Some thoughts on the current state of treatment of the upper limb in traumatic tetraplegia

Traumatic tetraplegia often affects healthy young men. The medullary lesion is located at C6 in 75% of cases. The author on the basis of 20 years of experience believes it possible to improve independence and life quality by surgical procedures such as tendon transfers, which are the most often used, for restoring two important functions: active elbow extension and active hand grip. The restoration of elbow extension is accomplished by Moberg's procedure of transferring the posterior tendon of the deltoid onto the triceps. The results are very satisfactory. To restore hand grip the author makes use of the first radial tendon transferred onto the deep common flexor, and for the thumb, the long supinator onte the long flexor of the thumb. Definite functional improvement was found in 33 of 45 cases.