Tendon trasnfer

procedure and its managemnet prior and after surgery

1. Tendon Transfer and pt management - Y SAI SUDHA SAMAJA

2. outline Tendon ,tendon transfer and graft. Principle of tendon transfer. Indication for tendon transfer. Tendon transfer for different condition with Pt management.

3. Tendon -it’s the continuity of the muscle to have its actions at the site especially at hand foot and digits.covered by thin synovial sheet that provides smooth gliding of tendon.

4. Tendon transfer –its an operation in which insertion of the tendon of a functioning muscle is moved to a new site so muscle henceforth has different actions. Transfer operation is planned in such way that loss of the transferred muscles original function does not cause problems. Tendon graft- if there isn't enough healthy tendon to reconnect. tendon graft using a piece of tendon from another part of the body. Is used for restoring function.

5. Principle of tendon transfer Donor tendon Should be expandable. Minimum muscle power of 4 or 5. Preferably a synergist muscle. Amplitude of excursion to match that of the recipient muscle. Recipient site Rom of jt on which the transferred muscle is expected to work should be good. No scarring at the bed of the transferred tendon.

6. Technical consideration Transferred tendon should take a straight route. It should be placed in subcutaneous space. Fixation must be under adequate tension. Patient consideration Age min of 5 yrs . The disease should be non progressive. Any infection to bone or jt to be controlled. Good range of passive movt available at jt .

7. Indication Muscle paralysis –restore or improve active control of jt by utilizing a healthy muscle to act in place of paralyzed muscle. Muscle imbalance-to restore the balance between opposite groups of muscles in case of one is weaker than other. Rupture of tendon (suture is not possible). Some congenital abnormalities. To remove the deforming force. Condition like polio, cerebral palsy , rheumatic arthritis have following deformity.

8. 1.Cerebral palsy – movt and posture disorder caused by non progressive lesion of immature brain cells. Tendon transfer surgery To correct deformity , balance muscle power and stabilize uncontrolled jt Few deformities of Upper limb flexion deformities of wrist and fingers Thumb in palm deformity Pronation contracture of forearm Lower limb Knee flexion contracture Patella alta Claw toes and Talipes equinovarus.

9. 2.Poliomyelitis-viral infection of ant horn cells resulting to permanent or temporary paralysis. Tendon transfer surgery to replace function of paralysis muscle , remove deforming force improve stability , Few deformities of Upper limb Elbow flexion paralysis Wrist paralysis Lower limb Gluteal medial paralysis Quadriceps paralysis First metatarsal drop Talipus valgus - paralysis of tibialis anterior muscle Talipus varus - paralysis of peroneal muscle Talipus calcaneous – paralysis of gastrocnemius muscle.

10. 3.Multiple congenital contracture( arthtogryposis multiplex congentia ) Congenital condition which is non progressive in which 2 upper limb and 6 lower limb deformities are encounterd Elbow wrist-flexed attitudes Shoulder –medial rotation Hip- extension,abduction and external rotation Knee- flexion contracture and fixed ext Foot- planovalgus and equionovarus .

11. 4.Leprosy-chronic infectious disease effects the peripheral nerves. Few deformities that can be corrected by surgery of tendon transfer are Upper limb Ulnar Claw hand –ulnar nerve injury at elbow Total claw hand –ulnar nerve injury at elbow and median nerve injury at wrist Triple nerve palsy ulnar nerve injury at elbow, median nerve injury at wrist, radial nerve injury at radial groove Lower limb Foot drop –lateral popliteal nerve injury Contracture of tendo calcaneus.

12. Other indication can be The prognosis of the neurogenic recovery is poor after nerve repair. Muscle have been destroyed. Nerve graft have been required to restore nerve continuity and serve nerve injury

13. Nerve injury and classification

14. Pre operative goals for tendon transfer Achieving and maintain full passive and active range as possible . Maintain max strength of the donor muscle and antagonist muscle. Maintaining the soft tissue with no tightness , scar and adhesions. Complete evaluation of sensory and fuctional assessment. Educating patient.

15. Post operative goals for tendon transfer Regaining jt mobility. Training of tendon to glide in new course. Activation of new muscle to achieve some function,which requires development of new neural pathways. Children are usually manages with static protocols or longer protective phase.

16. General pt management Protective phase -after surgery lasts for 3-4 weeks. -protective splinting, edema control and mobilize uninvolved jt. Mobilization phase -after adequate healing of tendon for its activation (after 3-5weeks). -immobilize soft tissue. -mobilize the tendon transfer. -day time dynamic splint night time static splint. -mobilize uninvolved jt to avoid jt stifness .

17. Intermediate phase -post operatively 5-8 weeks. -gradually increases the passive range of motion, limited functional movements are permitted . Resistive phase Begins at 8-12 weeks. Tendon jn are strong enough to withstand increasing resistance so increasing the endurance and strength of transferred muscles. Work related tasks are begun.

18. Ulnar nerve injury Spinal root – C8-T1(medial cord of brachial plexus ) Supplies flexor carpi ularis and medial half of flexor digitorum profundus in the forearm. In hand through superficial branch supplies palamis brevis and digital branches to the volarside of the little finger and medial half of the ring finger.The deep branch supplies hypothenar, the dorsal and palmar introseei , two medial lumbricals and the adductor pollicis muscle of hand. Causes of injury Axilla – crutch pressure , aneurysm of weak axillary vessels Arm - # shaft of humerus , penetration gun shot injury

19. 3.Elbow -# of lateral epicondyle, compression by he accessory muscle, cubitus valgus deformity. 4.Forearm - both bone # ,gun shot wounds. 5.Wrist - # hook of the hamate , compression of ganglion , wrist injury. 6.Hand – blunt injury , penetrationg injury. The above ulnar nerve injuries will lead to claw hand deformity , true type or ulnar claw hand Deformity with hyperextension of MCP JT and flexion of IP JT of the fingers. Pinch and grasp is decreased. Roll up manevor lost.

20. Tendon transfer for ulnar nerve Neighbouring healthy tendon is brought to replace the action of the lost intrincic . Tendon chosen is passed through the lumbrical canal and attached to the dorsal digital expansion which brings action of the lost intrinsic.

21. Pt management for ulnar nerve palsy Splint position –wrist at 45 degree ext , MCP jt at 70 degreeflexion jt full ext , thumb free Week 1-2 – check the splint and cast positioning, tension within to be checked , active and passive rom ex within splint. cryotherapy for swelling, pain control modalities ( ultrasound,ift ), Scar tissue mobilization. Week 3-4 –active rom ex without splint , avoid composite extension, Hand and forearm to be maintained in splined position for month.

22. Week 5-6- no splint during ex wrsit ext , mcp flexion and ip ext. At end gentle wrist flexion is started with mild resistance. Week 6-12- resistive ex, gripping ex ( light initially to the power grip).

23. Radial nerve injury Spinal root- C5-T1 (posterior cord of brachial plexus). Supplies all the 3 heads of triceps, anconeus , brachialis, brachioradialis, extensor carpi radialis longus brevis and supinator muscle. Causes of injury Axilla – crutch palsy , aneurysm of weak axillary vessels Arm - # of proximal humerus , shoulder dislocation Elbow -# of radius, monteggia #, posterior dislocation of elbow Forearm- bothbone #, penetrating gunshot wounds 5. In spiral groove – shaft #, Saturday night palsy , syringe palsy

24. 6.Bw spiral groove and lateral epicondyle- # shaft humerus , supracondylar #, lateral epicondyle #, cubitus valgus. High lesion- wrsit drop, thumb drop, finger drop, unable to extend elbow Sensation along the posterior surface of arm and forearm is lost. Low lesion –wrist thumb and finger extension lost. Loss of sensation over the first dorsal web space.

25. Tendon transfer for radial nerve Active treatment – neighbouring tendons are intact and if all the criteria for transfer of tendon are met then following transfers will happen For wrist flexors- Flexor carpi radialis for the flexion Pronation- pronator quadratus for pronation Finger flexion- flexor digitorum superficialis is chosen. High lesion Elbow ext transfer of latissimus dorsi or pectoralis major to the triceps muscle can be done. Pt needs active ext to use crutches, gravity alone will help in passive ext of elbow.

26. Low lesion- 2 types Type 1 For wrist ext - pronator teres transfer. For finger extenson - flexor carpi ulnaris is split into 4 slips and transferred dorsally into 4 fingers. Thumb ext and abd - palmaris longus transfer. Type 2 – wrist ext spares Finger ext - flexor carpi ulnaris transfers 4 slips. Thumb ext -palmaris longus transfer. Thumb abduction- pronator teres transfer.

27. 0mers technique- splitting of FCU into 5 slips and transferring to all 5 fingers instead of 4. Boye’s technique- use of FDS instead of FCU to bring ext of 4 fingers.

28. PT MANAGEMENT FOR RADIAL NERVE PALSY Splint position – elbow a 90 degree, fore arm 30-90 degree pronated, wrist 30-45 degree ext , mcp jt 10-15 degree flexion. pip jt free or 20-45 degree.Splint extends still proximal pip, thumb is max ext and abd . Week 1-2 – check the splint and cast positioning, tension within to be checked , active and passive rom ex within splint and uninvolved jt , scar management , edema management. cryotherapy for swelling, pain control modalities ( ultrasound,ift ).

29. Week 3-4 –splint or fabricate splint may or may not include elbow acc to condition rom ex, scar management (scar tissue mobilization). Week 5-6- muscle re-education by ex stimulation. Week 7- dynamic flexion splinting if extensor tightness is present, rom ex. Week 8- protective day time dynamic splinting , resistive ex passive wrist flexion to gain max pronator teres strength. Week 9-12- strengthening and resuming unrestricted activities.

30. Median nerve injury Spinal root-  originates from the lateral and medial cords of the brachial plexus, and has contributions from ventral  roots  of C5-C7 (lateral cord) and C8 and T1 (medial cord). The  median nerve  is the only  nerve  that passes through the carpal tunnel. Injury at Elbow- flexors and pronators are paralysed . Wrist-Loss of skin sensation over thumb index finger and middle finger and opposition and flexion of thumb is lost thenar muscle paralysis.

31. Tendon transfer for median nerve palsy

32. Pt management for median nerve palsy Splint position- wrist neutral, thumb held in opposition And ext , ip in ext , fingers free to move. Week 0-2- edema and scar management , checking for splinting, check the tension of tendon, cryotherapy for swelling, pain control modalities ( ultrasound,ift ), scar tissue mobilization. Week3-4- active rom ex of thumb in splint and other uninvoved jt.

33. Week5-8- light gasp and prehension tasks , resistive ex along with passive and active rom ex ,night time static splint. Week8-12 - PRE(imp to not to fatigue the transfer ) and resume unrestricted activities.

34. Foot drop Scatic nerve Spinal root – L4-5, S1-3 Supplies the hams and adductor muscle. Through superficial branch it supplies peroneus longus and brevis muscle Deep branch supplies ant compartment of leg causes of injury 1.At spine- spina bifida, tumors ,prolapse disk 2.Hip – dislocation, acetabulum # 3.Gluteal region- deep IM injection 4.At thigh- # femur shaft

35. 5.knee-dislocation,# lateral condyle tibia, lateral meniscal cyst and tumor , direct injury. Following the injury it could be complete ( sciatic nerve and popliteal nerve injury ) or incomplete (superficial and deep peroneal nerve). High lesion complete foot drop. Low lesion Type 1- pt cannot dorsiflex and invert the foot Sensation over dorsal web lost. Type 2- cannot evert Sensation lost over outer leg and foot.

36. Pt management for footdrop Splinting- ankle in neutral. Week 1-2- splinting,edema and scar management, elevated position of limb, cryotherapy for swelling, pain control modalities ( ultrasound,ift ),ex for uninvoled jt. Week 3-6 – rom ex (passive and active),soft tissue mobilization and scar tissue mobilization. Daytime dynamic splitting and night time static splinting. Week 6-12- strenghthening ex, resistive ex, gait training, proprioceptive and balance ex.

37. Complication after surgery Scarring of tendon to surrounding structure. Difficulty in activating transfer. Transfer to loose or tight (wait 6 weeks before passive rom ex and removing splint). Rupture of tendon repair. Overstretching of transferred tendon.

38. Reference Essentials of orthopaedics – john Ebenezer. Essentials orthopaedics and applied physiotherapy – jayath joshi . Essential orthopaedics- maheswari and mahskar . Slideshare.net THANK YOU