Tendon transfer surgery : Author’s experience

Tendon Transfer Surgery in Quadriplegia

Quadriplegia is a devastating condition which results not only in chest down paralysis but also impaired hands functions. Quite often it happens to young, energetic and active individuals. Major causes of it are accidents and shallow water diving. With impaired hands functions and chest down paralysis, one becomes dependent on other people for majority of their daily activities. Rehabilitation helps to get independence to some extent. With no cure around, Tendon transfer surgery is the only option to improve hand functionality. The field of hand surgery had started developing after world War II when people with quadriplegia would live longer life with arrival of antibiotics.

Tendon transfer surgery is a technique in which tendon of a healthy muscle is detached and transferred to a paralyzed muscle resulting in new movement. Transferring only a portion of healthy muscle may also results in a new useful movement.

What is the function of a tendon?

Anatomically, function of a tendon is to attach muscle to bone. The lower the level of quadriplegia the more the donor muscles are available to be transferred and the more chances of improved hand function.

Author’s experience of tendon transfer :

I myself a c5, c6 quadriplegic 15 years post spinal cord injury. My triceps muscles were paralyzed therefore I had no active elbow extension. I can extend my wrists but no wrist flexion or fingers movements are present.

I have so far underwent two tendon transfer surgeries. First one for elbow extension and second one for key/ thumb pinch.

The first surgery I underwent was five years ago for elbow extension. It was done by plastic surgeon Dr Shahid at CMH Rawalpindi.

First surgical procedure:

• A portion of my posterior deltoid muscle was transferred to tricep muscle.
• A tendon  from thigh area was used as an interposition graft.
• After surgery, the whole arm from shoulder to fingers was kept in hard bandage with elbow around 10 degrees, to prevent elbow flexion and over stretching of interposition graft.
• After six weeks the bandage was removed and occupational therapy was started at Armed Forces Institute of Rehabilitation Medicine to gain maximum results out of the process.

Results of the surgery:

At first I could not flex the elbow above 15 degrees. But then gradually with specialized occupational therapy my transferred muscles got stronger along with full elbow flexion. Now my transferred deltoid is working as a tricep facilitating elbow extension. The surgery helps me extending  my arms above head, pushing elevator buttons, pulling blanket off my face and assists in transfers between wheelchair and bed.

The second surgery performed was for key pinch grip restoration at Hands and Upper Limb Surgery center CMH Lahore by Classified hand surgeon Dr Khalid Masood in summer.

Second surgical procedure:

• A small portion of brachioradialis muscle was transferred to Flexor Policis Longus muscle
•  tenodesis of FPL and APL was done
• CMC joint fusion of thumb was done to prevent undesired movement of thumb.
• Lasso procedure was done on index and middle finger to keep them in a bit flex position for providing base to thumb for key pinch grip.
• Bandage was applied for six weeks to prevent thumb and fingers movements and overstretching of transferred tendons .
• I then performed occupational therapy for few weeks.

Results of the surgery:

Results of the tendon transfer surgery were amazing. I can move my thumb in two ways:

• First one is through wrist movements. When I move my wrist upward or extend it, my thumb move inward. The more I extend my wrist the more powerful the thumb keypinch grip gets. Downward movement or flexion of wrist releases keypinch grip.
• Another way of moving my thumb is through brachioradialis muscle. This way of movement came and got stronger a few weeks later than the first way. In this way I can make a strong key pinch grip by merely concentrating on brachioradialis and without moving wrist.

This surgery helped me in becoming little more independent and I can pick items like cloth, mobile phone, book etc. Some changes that I would have liked in this surgery is transfer of ECRL to FDP or just tenodesis of FDP for fingers grasp. But my Dr though it may weaken my wrist extension. My Dr is planning another phase of surgery for solving the issue and restoring fingers movements for forming grasp.

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