Tendon transfer is a surgical procedure used to restore function to a limb or joint that has been impaired by nerve damage, injury, or deformity. The basic principle involves rerouting a healthy tendon to a new location, where it can compensate for the loss of function in a damaged or nonfunctional muscle. By transferring a tendon to a different site, surgeons aim to harness the strength and movement of one muscle to improve the performance of another, effectively restoring some of the lost or compromised function.
Principles of Tendon Transfer:
Restoration of Function: The primary goal is to restore lost function, such as improving strength, motion, and stability. The tendon being transferred should be capable of performing a similar function to the one being replaced.
Optimal Tendon Selection: The tendon chosen for transfer should have enough strength and range of motion to take over the desired function. It should also be positioned in a way that minimizes tension on the muscle during normal activity.
Minimal Donor Site Morbidity: Ideally, the donor tendon should be selected in a way that its transfer will not significantly impair the donor site’s original function.
Biomechanical Matching: The mechanical properties of the donor tendon should match those of the recipient tendon, including tension, length, and function.
Post-Operative Rehabilitation: The success of tendon transfer depends on proper rehabilitation, including strengthening and range-of-motion exercises to help the new tendon integrate effectively into its new function.
Indications
Peripheral Nerve Injuries:
Brachial Plexus Injury: For example, after a traumatic injury to the brachial plexus, tendon transfer may be used to restore hand function, such as restoring thumb opposition or improving grip strength.
Muscle or Tendon Dysfunction:
Rotator Cuff Tears: When irreparable tears occur in the rotator cuff, a tendon transfer can be performed to restore shoulder stability.
Hand Paralysis: In conditions like radial nerve palsy or ulnar nerve palsy, tendon transfers can improve hand function and prevent deformities.
Cerebral Palsy:
Moving a tendon from one muscle to another remains an effective procedure for patients with cerebral palsy if they have spasticity alongside muscle imbalances or need surgical treatment to fix equinus foot deformities.
Trauma or Amputation: A tendon transfer procedure becomes essential to restore function through the affected body parts after experiencing tendon or muscle damage from traumatic injuries in hand or foot areas.
Congenital Deformities: Some conditions like clubfoot together with specific muscular dystrophy types result in muscle dysfunction while tendon transfers help improve both body positioning and functional abilities of affected areas.
Tendon Ruptures: Tendon transfers become an appropriate treatment when severe tendon ruptures cannot be repaired after failing to undergo any restorative procedures.
Contraindications
Poor Skin Coverage or Soft Tissue Health: The surgical outcome is unfavourable when patients have insufficient skin coverage or poor health of soft tissue.
Severe Joint Deformities: The procedure produces poor results when joint deforming structures exist at a severe level or potentially deteriorate the condition further.
Active Infection: Any active infection near the tendon or joint would be a contraindication as it could interfere with healing or cause complications.
Non-Functional Donor Tendon: If the donor tendon does not have sufficient strength or function, it may not be able to compensate for the loss of the original tendon function.
Loss of Joint Mobility: If the joint has lost too much range of motion or function, tendon transfer may not restore adequate movement.
Neurovascular Compromise: The healing process and recovery period could be negatively affected due to substantial nerve or blood vessel damage near the tendon transfer site.
Unrealistic Functional Expectations: The patient’s unrealistic belief that a tendon transfer can fully restore all function that was lost when the procedure does not provide this capability makes the transfer not suitable.
Outcomes
Periprocedural care
Equipment’s Surgical Tools
Tendon Suture Systems
Orthopedic Guides and Jigs
Bone Anchors and Screws
Post-Surgery Splints/Orthoses
Rehabilitation Equipment Patient preparation
Preoperative Assessment Medical History: Review past surgeries, comorbidities, and medications. Physical Examination: Assess deformity, muscle strength, joint mobility, and sensation. Patient Education: Explain the procedure, risks, benefits, and recovery expectations. Preoperative Optimization: Manage comorbidities and improve physical conditioning. Surgical Planning: Select the appropriate tendon and procedure based on functional goals.
Tendon Transfer for Radial Nerve Palsy
Step 1-Preoperative Preparation:
Conduct detailed evaluation for radial nerve damage severity and extent of muscle paralysis in combination with functional requirements.
Patient Education: Inform the patient about the surgery, potential outcomes, and rehabilitation process.
Anesthesia: The surgical procedure is performed with general anesthesia, but specific cases may require regional anesthesia.
Step 2-Incision: Use a marker to indicate the donor tendon position that comes from the flexor muscles and the recipient site located at the extensor mechanism of the wrist or fingers.
A surgical incision is performed over the forearm section to reach the tendon transfer sites.
Step 3-Harvesting the Donor Tendon: The three most preferred donor tendons for this procedure are the flexor carpi radialis (FCR), flexor digitorum superficialis (FDS) followed by palmaris longus when present.
Proper visualization of the donor tendon requires thorough exposure which maintains crucial blood supply elements and relevant surrounding tissues.
The tendon is then released from its original insertion.
Step 4-Tendon Transfer: A surgical tunnel route is made just under the skin to move the tendon from its original position to the targeted area which commonly lies on the forearm or along the wrist. The surgeon must pass the tendon through the tunnel after which they suture it onto the recipient muscle or bone structure to achieve appropriate tension and alignment.
Step 5-Reconstructing the Extensor Mechanism: The tendon is typically inserted it into the extensor mechanism by placing the tendon either directly into the tendon itself or by bone anchorage.
The surgical purpose focuses on regaining extension abilities of both wrists and fingers to restore hand functionality.
Step 6-Closure: The Skin undergoes closure with sutures after checking that tendon placement and tension are accurate.
A sterile dressing serves to protect the operated surgical area.
Step 7-Postoperative Care:
Splinting: A splint is often used to maintain the corrected wrist or finger position and to protect the tendon while healing.
Pain Management: Pain control is provided with medications.
Physical Therapy: Rehabilitation is essential to regain muscle strength, flexibility, and functional use of the hand.
Follow-up and Rehabilitation
Regular Follow-ups: Monitoring the progress of tendon healing and functionality.
Rehabilitation: Gradual strengthening exercises are introduced, and the patient is guided through exercises to improve motor function and prevent stiffness.
Tendon Transfer for Ulnar Nerve Palsy
Step 1: Preoperative Evaluation
Assessment: Evaluate the extent of the ulnar nerve injury (complete vs. partial palsy) and determine which muscles are affected.
Examine: Test muscle strength, sensory function, and deformities (e.g., claw hand) to determine the optimal transfer.
Radiological imaging may be used to assess bone structure and rule out other injuries.
Step 2: Marking and Anesthesia
Positioning: The patient is placed in a supine position, with the arm supported to expose the operative site.
Anesthesia: General or regional anesthesia is administered, depending on the extent of the surgery.
Marking: The surgeon marks the area for tendon transfer, identifying the donor muscle (usually from the wrist or forearm) and the recipient site (typically for finger or thumb function).
Step 3: Incision
A surgical incision is made along the forearm or wrist, depending on the location of the tendon transfer.
Another incision may be made on the hand or fingers to access the recipient muscles.
Step 4: Harvesting the Tendon
The donor tendon (often from the flexor carpi radialis, flexor digitorum superficialis, or other muscles) is identified and carefully isolated.
The tendon is then freed from surrounding tissues and prepared for transfer.
Step 5: Tendon Transfer
The harvested tendon is routed through a tunnel or over the bones to the recipient area, usually the finger or thumb.
The tendon is reattached or sutured to the target muscle or joint. This may involve adjusting the tendon length or tension to achieve the desired function.
Step 6: Fixation and Closure
The tendon is secured in place using sutures, anchors, or other fixation devices to ensure proper positioning and tension.
The incisions are closed with sutures, and the area is dressed appropriately.
Step 7: Postoperative Care
Splinting: The hand may be splinted to immobilize the joint and protect the tendon transfer during the healing process.
Pain Management: Pain control is provided through medications and anti-inflammatory drugs.
Rehabilitation: Physical therapy starts soon after the surgery to improve tendon strength, flexibility, and restore function.
Step 8: Follow-up
Regular follow-up visits are necessary to monitor healing, function, and any complications such as tendon rupture or scarring.
Gradual progression of rehabilitation exercises is introduced to restore hand function.
Tendon transfer for median nerve palsy
Step 1-Preoperative Assessment
History & Physical Examination: Confirm the diagnosis of median nerve palsy as well as documentation of muscle strength and hand functions.
Imaging & Testing: Electromyography (EMG) can be performed to check nerve activity and muscle function.
Patient Education: Discuss expected outcomes, risks, and a plan for rehabilitation.
Step 2-Anesthesia
The procedure is generally administered under general anesthesia, although this might be done under regional anesthesia for specific requirements.
Step 3- Incision & Exposure:
An incision is made over the wrist, forearm, or upper arm, depending on the muscle to be transferred.
The paralyzed muscles are identified along with the donor muscles which will offer a functional tendon for transfer.
Common donor muscles for median nerve palsy include flexor carpi ulnaris for flexion of the fingers or the flexor digitorum superficialis for finger flexion.
Step 4-Tendon Harvesting
The tendon of the donor muscle is isolated and prepared for transfer. For example, the tendon of flexor carpi ulnaris may be harvested to reinnervate the paralyzed finger flexors.
Step 5-Tendon Transfer
This is done by detaching the tendon of the donor muscle, then routing it through a new path to replace the function of the paralyzed muscle. It is used for the most common case of median nerve palsy: to restore finger flexion and thumb opposition.
The tendon is passed, either through a subcutaneous tunnel or around a pulley system, to position it near the target muscle or joint.
The tendon is then reattached to the desired position, such as the flexor digitorum profundus (for flexion of the fingers) or opponens pollicis (for thumb opposition).
Step 6-Reconstruction of the Tendon-to-Tendon Attachment
The tendon of the donor muscle is sutured securely to the recipient tendon or bone.
If the tendon needs to be re-routed to the finger or thumb, it is anchored appropriately, ensuring that the transferred tendon is positioned to assist the required motion.
Step 7-Closing the Incision
The incision is closed with sutures, and sterile dressing is applied. Step 8-Postoperative Care
Splinting: The hand is typically immobilized in a splint for a period to allow the tendon to heal in its new position.
Pain Management: Pain relief medications are administered.
Rehabilitation: Physical therapy begins shortly after the procedure to regain range of motion and strength. Stretching, strengthening, and functional exercises are key components of rehabilitation.
Follow-up
The patient will have regular follow-up appointments to monitor healing, tendon function, and the progress of rehabilitation.
Complications
Failure of Tendon Graft: The transferred tendon may not integrate properly and will fail, making the joint non-functioning or weak.
Muscle Imbalance: Failing to transfer may lead to an imbalance in the muscles, thus leading to abnormal movements and discomfort at the joint.
Overuse of Other Tendons: The muscle or tendon that takes on a new function might become overused, leading to strain or damage over time.
Infection: As with any surgery, tendon transfer carries the risk of infection, especially since the procedure often involves moving tissue and inserting screws or anchors.
Scar Tissue Formation: Scar tissue can form around the transferred tendon, leading to stiffness, reduced range of motion, or pain.
Nerve Injury: There is a risk of nerve damage during tendon transfer surgery, which could lead to loss of sensation or motor function.
Failure of Rehabilitation: A poorly executed rehabilitation program, or lack of appropriate post-surgical care, can lead to failure of the transfer.
Joint Dysfunction: If the tendon transfer does not adequately mimic the original muscle action, it may not restore the proper function of the joint, potentially leading to pain or limited motion.
»
Home » Procedure » Tendon Transfer Principles and Mechanics
Tendon Transfer Principles and Mechanics
Updated :
April 2, 2025
Tendon transfer is a surgical procedure used to restore function to a limb or joint that has been impaired by nerve damage, injury, or deformity. The basic principle involves rerouting a healthy tendon to a new location, where it can compensate for the loss of function in a damaged or nonfunctional muscle. By transferring a tendon to a different site, surgeons aim to harness the strength and movement of one muscle to improve the performance of another, effectively restoring some of the lost or compromised function.
Principles of Tendon Transfer:
Restoration of Function: The primary goal is to restore lost function, such as improving strength, motion, and stability. The tendon being transferred should be capable of performing a similar function to the one being replaced.
Optimal Tendon Selection: The tendon chosen for transfer should have enough strength and range of motion to take over the desired function. It should also be positioned in a way that minimizes tension on the muscle during normal activity.
Minimal Donor Site Morbidity: Ideally, the donor tendon should be selected in a way that its transfer will not significantly impair the donor site’s original function.
Biomechanical Matching: The mechanical properties of the donor tendon should match those of the recipient tendon, including tension, length, and function.
Post-Operative Rehabilitation: The success of tendon transfer depends on proper rehabilitation, including strengthening and range-of-motion exercises to help the new tendon integrate effectively into its new function.
Peripheral Nerve Injuries:
Brachial Plexus Injury: For example, after a traumatic injury to the brachial plexus, tendon transfer may be used to restore hand function, such as restoring thumb opposition or improving grip strength.
Muscle or Tendon Dysfunction:
Rotator Cuff Tears: When irreparable tears occur in the rotator cuff, a tendon transfer can be performed to restore shoulder stability.
Hand Paralysis: In conditions like radial nerve palsy or ulnar nerve palsy, tendon transfers can improve hand function and prevent deformities.
Cerebral Palsy:
Moving a tendon from one muscle to another remains an effective procedure for patients with cerebral palsy if they have spasticity alongside muscle imbalances or need surgical treatment to fix equinus foot deformities.
Trauma or Amputation: A tendon transfer procedure becomes essential to restore function through the affected body parts after experiencing tendon or muscle damage from traumatic injuries in hand or foot areas.
Congenital Deformities: Some conditions like clubfoot together with specific muscular dystrophy types result in muscle dysfunction while tendon transfers help improve both body positioning and functional abilities of affected areas.
Tendon Ruptures: Tendon transfers become an appropriate treatment when severe tendon ruptures cannot be repaired after failing to undergo any restorative procedures.
Poor Skin Coverage or Soft Tissue Health: The surgical outcome is unfavourable when patients have insufficient skin coverage or poor health of soft tissue.
Severe Joint Deformities: The procedure produces poor results when joint deforming structures exist at a severe level or potentially deteriorate the condition further.
Active Infection: Any active infection near the tendon or joint would be a contraindication as it could interfere with healing or cause complications.
Non-Functional Donor Tendon: If the donor tendon does not have sufficient strength or function, it may not be able to compensate for the loss of the original tendon function.
Loss of Joint Mobility: If the joint has lost too much range of motion or function, tendon transfer may not restore adequate movement.
Neurovascular Compromise: The healing process and recovery period could be negatively affected due to substantial nerve or blood vessel damage near the tendon transfer site.
Unrealistic Functional Expectations: The patient’s unrealistic belief that a tendon transfer can fully restore all function that was lost when the procedure does not provide this capability makes the transfer not suitable.
Equipment’s Surgical Tools
Tendon Suture Systems
Orthopedic Guides and Jigs
Bone Anchors and Screws
Post-Surgery Splints/Orthoses
Rehabilitation Equipment Patient preparation
Preoperative Assessment Medical History: Review past surgeries, comorbidities, and medications. Physical Examination: Assess deformity, muscle strength, joint mobility, and sensation. Patient Education: Explain the procedure, risks, benefits, and recovery expectations. Preoperative Optimization: Manage comorbidities and improve physical conditioning. Surgical Planning: Select the appropriate tendon and procedure based on functional goals.
Step 1-Preoperative Preparation:
Conduct detailed evaluation for radial nerve damage severity and extent of muscle paralysis in combination with functional requirements.
Patient Education: Inform the patient about the surgery, potential outcomes, and rehabilitation process.
Anesthesia: The surgical procedure is performed with general anesthesia, but specific cases may require regional anesthesia.
Step 2-Incision: Use a marker to indicate the donor tendon position that comes from the flexor muscles and the recipient site located at the extensor mechanism of the wrist or fingers.
A surgical incision is performed over the forearm section to reach the tendon transfer sites.
Step 3-Harvesting the Donor Tendon: The three most preferred donor tendons for this procedure are the flexor carpi radialis (FCR), flexor digitorum superficialis (FDS) followed by palmaris longus when present.
Proper visualization of the donor tendon requires thorough exposure which maintains crucial blood supply elements and relevant surrounding tissues.
The tendon is then released from its original insertion.
Step 4-Tendon Transfer: A surgical tunnel route is made just under the skin to move the tendon from its original position to the targeted area which commonly lies on the forearm or along the wrist. The surgeon must pass the tendon through the tunnel after which they suture it onto the recipient muscle or bone structure to achieve appropriate tension and alignment.
Step 5-Reconstructing the Extensor Mechanism: The tendon is typically inserted it into the extensor mechanism by placing the tendon either directly into the tendon itself or by bone anchorage.
The surgical purpose focuses on regaining extension abilities of both wrists and fingers to restore hand functionality.
Step 6-Closure: The Skin undergoes closure with sutures after checking that tendon placement and tension are accurate.
A sterile dressing serves to protect the operated surgical area.
Step 7-Postoperative Care:
Splinting: A splint is often used to maintain the corrected wrist or finger position and to protect the tendon while healing.
Pain Management: Pain control is provided with medications.
Physical Therapy: Rehabilitation is essential to regain muscle strength, flexibility, and functional use of the hand.
Follow-up and Rehabilitation
Regular Follow-ups: Monitoring the progress of tendon healing and functionality.
Rehabilitation: Gradual strengthening exercises are introduced, and the patient is guided through exercises to improve motor function and prevent stiffness.
Step 1: Preoperative Evaluation
Assessment: Evaluate the extent of the ulnar nerve injury (complete vs. partial palsy) and determine which muscles are affected.
Examine: Test muscle strength, sensory function, and deformities (e.g., claw hand) to determine the optimal transfer.
Radiological imaging may be used to assess bone structure and rule out other injuries.
Step 2: Marking and Anesthesia
Positioning: The patient is placed in a supine position, with the arm supported to expose the operative site.
Anesthesia: General or regional anesthesia is administered, depending on the extent of the surgery.
Marking: The surgeon marks the area for tendon transfer, identifying the donor muscle (usually from the wrist or forearm) and the recipient site (typically for finger or thumb function).
Step 3: Incision
A surgical incision is made along the forearm or wrist, depending on the location of the tendon transfer.
Another incision may be made on the hand or fingers to access the recipient muscles.
Step 4: Harvesting the Tendon
The donor tendon (often from the flexor carpi radialis, flexor digitorum superficialis, or other muscles) is identified and carefully isolated.
The tendon is then freed from surrounding tissues and prepared for transfer.
Step 5: Tendon Transfer
The harvested tendon is routed through a tunnel or over the bones to the recipient area, usually the finger or thumb.
The tendon is reattached or sutured to the target muscle or joint. This may involve adjusting the tendon length or tension to achieve the desired function.
Step 6: Fixation and Closure
The tendon is secured in place using sutures, anchors, or other fixation devices to ensure proper positioning and tension.
The incisions are closed with sutures, and the area is dressed appropriately.
Step 7: Postoperative Care
Splinting: The hand may be splinted to immobilize the joint and protect the tendon transfer during the healing process.
Pain Management: Pain control is provided through medications and anti-inflammatory drugs.
Rehabilitation: Physical therapy starts soon after the surgery to improve tendon strength, flexibility, and restore function.
Step 8: Follow-up
Regular follow-up visits are necessary to monitor healing, function, and any complications such as tendon rupture or scarring.
Gradual progression of rehabilitation exercises is introduced to restore hand function.
Step 1-Preoperative Assessment
History & Physical Examination: Confirm the diagnosis of median nerve palsy as well as documentation of muscle strength and hand functions.
Imaging & Testing: Electromyography (EMG) can be performed to check nerve activity and muscle function.
Patient Education: Discuss expected outcomes, risks, and a plan for rehabilitation.
Step 2-Anesthesia
The procedure is generally administered under general anesthesia, although this might be done under regional anesthesia for specific requirements.
Step 3- Incision & Exposure:
An incision is made over the wrist, forearm, or upper arm, depending on the muscle to be transferred.
The paralyzed muscles are identified along with the donor muscles which will offer a functional tendon for transfer.
Common donor muscles for median nerve palsy include flexor carpi ulnaris for flexion of the fingers or the flexor digitorum superficialis for finger flexion.
Step 4-Tendon Harvesting
The tendon of the donor muscle is isolated and prepared for transfer. For example, the tendon of flexor carpi ulnaris may be harvested to reinnervate the paralyzed finger flexors.
Step 5-Tendon Transfer
This is done by detaching the tendon of the donor muscle, then routing it through a new path to replace the function of the paralyzed muscle. It is used for the most common case of median nerve palsy: to restore finger flexion and thumb opposition.
The tendon is passed, either through a subcutaneous tunnel or around a pulley system, to position it near the target muscle or joint.
The tendon is then reattached to the desired position, such as the flexor digitorum profundus (for flexion of the fingers) or opponens pollicis (for thumb opposition).
Step 6-Reconstruction of the Tendon-to-Tendon Attachment
The tendon of the donor muscle is sutured securely to the recipient tendon or bone.
If the tendon needs to be re-routed to the finger or thumb, it is anchored appropriately, ensuring that the transferred tendon is positioned to assist the required motion.
Step 7-Closing the Incision
The incision is closed with sutures, and sterile dressing is applied. Step 8-Postoperative Care
Splinting: The hand is typically immobilized in a splint for a period to allow the tendon to heal in its new position.
Pain Management: Pain relief medications are administered.
Rehabilitation: Physical therapy begins shortly after the procedure to regain range of motion and strength. Stretching, strengthening, and functional exercises are key components of rehabilitation.
Follow-up
The patient will have regular follow-up appointments to monitor healing, tendon function, and the progress of rehabilitation.
Complications
Failure of Tendon Graft: The transferred tendon may not integrate properly and will fail, making the joint non-functioning or weak.
Muscle Imbalance: Failing to transfer may lead to an imbalance in the muscles, thus leading to abnormal movements and discomfort at the joint.
Overuse of Other Tendons: The muscle or tendon that takes on a new function might become overused, leading to strain or damage over time.
Infection: As with any surgery, tendon transfer carries the risk of infection, especially since the procedure often involves moving tissue and inserting screws or anchors.
Scar Tissue Formation: Scar tissue can form around the transferred tendon, leading to stiffness, reduced range of motion, or pain.
Nerve Injury: There is a risk of nerve damage during tendon transfer surgery, which could lead to loss of sensation or motor function.
Failure of Rehabilitation: A poorly executed rehabilitation program, or lack of appropriate post-surgical care, can lead to failure of the transfer.
Joint Dysfunction: If the tendon transfer does not adequately mimic the original muscle action, it may not restore the proper function of the joint, potentially leading to pain or limited motion.
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