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Tendon Transfer Surgery
Tendon transfer surgery
is a type of hand surgery that is performed in order to improve lost
hand function. A functioning tendon is shifted from its original attachment
to a new one to restore the action that has been lost.
Many different conditions
can be treated by tendon transfer surgery. Tendon transfer surgery is
necessary when a certain muscle function is lost because of a nerve injury.
If a nerve is injured and cannot be repaired, then the nerve no longer
sends signals to certain muscles. Those muscles are paralyzed and their
muscle function is lost. Tendon transfer surgery can be used to attempt
to replace that function. Common nerve injuries that are treated with
tendon transfer surgery are spinal cord, radial nerve, ulnar nerve, or
median nerve injury.
Tendon transfer surgery may also be necessary when a muscle has ruptured
or been lacerated and cannot be repaired. Common muscle or tendon injuries
that are treated with tendon transfer surgery are tendon ruptures due
to rheumatoid arthritis or fractures. Also, tendon lacerations that cannot
be repaired after injury may be treated with tendon transfer surgery.
Tendon transfer surgery may also be needed if a muscle function has
been lost due to a disorder of the nervous system. In this situation,
the nervous system disease or injury prevents normal nerve signals from
being sent to a muscle, and imbalance in hand function occurs. The muscle
imbalance or muscle loss due to nervous system disease may be treated
with tendon transfers. Common nervous system disorders treated with tendon
transfer surgery are cerebral palsy, stroke, traumatic brain injuries,
and spinal muscle atrophy.
Finally, there are some conditions in which babies are born without
certain muscle functions. In these situations, the missing muscle functions
can sometimes be treated with tendon transfer surgery. Common conditions
treated this way include hypoplastic thumbs and birth brachial plexopathy.
Below the elbow,
there are over forty muscles. Each different muscle has a different function.
For example, there are 9 muscles that move the thumb. Each muscle has
a starting point (origin), and tapers down from its muscle belly into
a tendon that then attaches onto bone (insertion) in a specific place;
when the muscle fires (contracts), it causes a certain motion (action).
During tendon transfer surgery, the origin of the muscle is left in
place; the nerve supply and blood supply to the muscle is left in place.
The tendon insertion onto bone is detached and re-sewn into a different
place. It can be sewn into a different bone, or it can be sewn into a
different tendon. After its insertion has been moved, when the muscle
fires, it will produce a different action, depending on where it has
been inserted.
You
can discuss other treatment choices with your hand surgeon. Other options
may include repairing the nerve that has been injured, or repairing the
tendon or muscle that has been injured. In some cases, tendon grafts
can be used, in which a portion of intact tendon is removed, without
its muscle, and used to bridge a gap in an injured tendon. In other cases,
tendon lengthening or bone fusions may be necessary as part of reconstructing
hand function.
All surgery
has some risk, although those risks may be small. All surgeries produce
a surgical scar. Surgical incisions may develop infection. All surgeries
require the use of anesthesia, and will require a complete history and
physical examination by your primary care physician to determine if you
have medical risks associated with anesthesia. Evaluation by the anesthesiologist
will help outline your risks and options.
When a tendon is transferred and sewn into another position, the tendon
transfer will need a period of time to heal, usually about one to two
months. A splint or cast may be used, followed by therapy to teach you
the new tendon function. Finally, exercises will be needed to strengthen
the muscle after your hand surgeon feels the tendon transfer has sufficiently
healed. You will need to follow post-operative instructions. Movement
too early can lead to rupture of the tendon transfer. Movement too late
can lead to excessive scarring of the tendon with resultant stiffness.
Discussion of your individual case with your hand surgeon will help you
further understand the risks and benefits associated with tendon transfer
surgery.
After a fracture
of the wrist, the fragments of bone associated with the fracture may
erode the tendon that straightens the tip of the thumb. In this situation,
the thumb tip would not be able to move upward (extend). The muscle that
extends the tip of the thumb is the extensor pollicus longus (EPL) (see
Figure 1). In this example, the EPL tendon typically cannot be directly
repaired because it is too frayed. There are two muscles that extend
the index finger. Just like the body has two kidneys, so that one can
be spared if necessary, the body also has two tendons that extend the
index finger. One tendon is left intact on the index finger so that it
won’t lose extension, and the “extra” tendon
can be transferred over to the thumb to replace the lost function. The
tendon insertion of the “extra” index finger extensor tendon
(Extensor indicus proprius—EIP) is detached. The EIP tendon is
then re-directed and sewn into the thumb bone or thumb tendon (EPL).
After this type of surgery, a splint or cast is used for one month, after
which supervised therapy may be started to re-learn how to use the transferred
tendon to extend the thumb. Gentle movement with a protective splint
may be used for an additional month. If adequate progress is made, the
therapy may be advanced one month later to re-learn activities and to
strengthen the muscle, with restoration of the ability to extend the
thumb.
Example of Tendon Transfer surgery.
© 2007 American Society for Surgery of the Hand
Developed by the ASSH Public Education Committee
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