Tendon Transfer Should Be Used More Often in Tetraplegia

Tendon transfer can significantly improve hand and elbow function in quadriplegic patients, but the procedure is greatly underused, according to a new study.

A review of studies by hand surgeon Professor Michael Bednar, MD, of Loyola Medicine (Maywood, IL, USA) found that an estimated 65-75% of patients with cervical spinal cord injuries could benefit from upper extremity tendon transfer surgery, but only 14% of patients actually complete the procedure. Tendon transfer surgically redirects functional muscles to do the work of muscles that are paralyzed. Depending on the extent of the spinal cord injury, tendon transfers can enable a patient to grasp objects, pinch, open the hand, and straighten the elbow.

The procedure takes advantage of the fact that in many cases, more than one muscle performs the same function, and that the tendon of one of the spare muscles can be relocated to a new position and function. For example, the surgeon may detach one of the working elbow muscles (the brachioradialis) and reattach it to a nonworking muscle that flexes the thumb (the flexor pollicis longus). The number of functioning muscles a patient has will determine what tendon transfers the surgeon will perform.

Patients who stand to benefit most from tendon transfers have spinal cord injuries in the C5-C8 cervical nerves in the lower neck, and should be free of chronic medical conditions such as infections, pressure sores, medical instability, or spasticity. The procedure typically involves two surgeries on each arm, performed three months apart. The arms are done one at a time, and during rehabilitation, the patients are taught how to use the transferred muscles. The review was published in the August 2016 issue of Hand Clinics.

“A good surgical candidate has functional goals, is motivated, understands benefits and limitations of surgery, demonstrates emotional and psychological stability/adjustment to disability, and is committed to the post-operative rehabilitation process,” concluded Dr. Bednar. “Tendon transfers also do not restore full function. But while pinch strength and grasp strength after rehabilitation are not as high as in a normal hand, they are high enough to perform most activities of daily living.”

A previous study that queried quadriplegics as to which function they would most like restored, 75 % said hand function, followed in order by bowel and bladder use (13%), walking (8%) and sexual performance (3%). Patients with defined goals, who actively participate in therapy and understand expected outcomes, appear to have the highest satisfaction following tendon transfer procedures.

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