A system for assessing the results of tibialis posterior tendon transfers in the treatment of foot drop secondary to nerve palsy is proposed. There are seven sections to this scoring system: pain, need for orthosis, ability to wear normal shoes, activity level, muscle power of ankle dorsiflexion, degree of active ankle dorsiflexion, and foot posture. The total score is 100. The results are classified as excellent for scores between 85 and 100, good between 70 and 84, fair between 55 and 69, and poor for scores below 55. The results of 18 patients (mean followup, 64.6 months) who had a tibialis posterior tendon transfer were assessed using this method. Four patients (22.2%) had an excellent result, seven (38.8%) had a good result, two (11.1%) had a fair result, and five (27.7%) had a poor result. The average score was 67.2, suggesting an overall fair result for this operation. In nine patients, there was correlation between the outcome when assessed with this method and with patient rating. In two patients, the outcomes were better when assessed with this method than with patient rating, whereas the reverse was true in seven other patients. Thus, this system may provide a more objective and critical evaluation of tibialis posterior transfers for foot drop.
Radial nerve palsy following traumatic humeral diaphyseal fractures occurs uncommonly. Most recover with good outcome. However the cases with poor outcome or recovery will have tendon transfers to regain the lost functions. Various tendon transfer methods and choices are available in literatures citing acceptable to good results. We report a case of radial nerve transection secondary to a closed traumatic diaphyseal fracture of the humerus which did not improve despite the repair. As many conventional technique produce asynergistic muscle action with secondary post-transfer deformity, thus we had resorted to tendon transfer procedure using an unconventional donor and recipient tendons yielding good results. This new combination of tendon transfers was invented involves better dynamic correlation of synergistic muscles action and produces good outcome and hand function.
Traumatic brachial plexus injuries rarely recover spontaneously and if the window period for neurotisation has elapsed, the only option for restoration of function lies in a salvage procedure. Many such salvage procedures have been described in the literature with variable functional results. We report the case of a 16-year-old boy who presented after unsuccessful treatment for a complete brachial plexus injury; we performed a pectoralis major tendon transfer to attain elbow flexion. Postoperatively, the elbow was splinted with flexion at 100°. After 4 weeks of immobilization the splint was removed and the patient could actively flex his elbow from 30° to 100°.
We have all heard the old aphorism, "Necessity is the mother of invention." While the provenance of the proverb is uncertain, its truth is not in doubt. This is true for the development of hand surgery in Malaysia. As part of the management for leprosy, patients with high ulnar nerve palsies were managed by the pioneers of hand surgery in Malaysia. They did tendon transfers to improve the quality of life of these patients. Since then, hand surgery in Malaysia have grown leaps and bounds. From a small humble beginning in the suburb of Sungai Buloh to organizing the 10th Congress of Asian Pacific Federation of Societies for Surgery of the Hand, hand surgery in Malaysia will only get better with time.
Cervical spinal cord injury (SCI) often causes debilitating loss of function of the upper limb. Upper extremity reconstruction surgery can restore some of the upper limb function in tetraplegic patients with SCI. The procedures are typically muscle-tendon unit transfer surgeries, which redistribute the remaining functional muscles to restore active elbow extension, key grip, and finger grasping. In addition to the tendon transfer surgeries, nerve transfers have emerged recently and are showing promising results. However, despite more than half of the tetraplegic patients can benefit from upper limb surgery, only a few of them receive the procedures. This missed opportunity may be due to the lack of communication between SCI specialists and hand surgeons, or the lack of awareness of such options among the specialists and patients. In this review, we provide a basic overview of upper limb reconstruction in tetraplegic patients with target audience of SCI specialists for their better understanding of the basic concept of surgery and information for patient consultation before referring to hand surgeons.
Tendon transfers for radial nerve palsy is a common operation with good results. We did a retrospective study on twenty patients with radial nerve palsy who underwent tendon transfer surgery and recovered between January 2008 and December 2012. Outcomes measured were motor power of wrist extension, finger extension, grip strength and DASH scores. There was significant improvement of motor power of wrist and finger extension between the preoperative period and three months post-operatively, between the pre operative period and six months post operatively and between three and six months postoperatively (p = 0.0005). Grip strength improved significantly as well between preoperative, three and six months postoperatively (p = 0.0005). DASH scores reflecting patient satisfaction at six months postoperatively showed only mild or moderate difficulty of function.
Tendon transfer for radial nerve palsy is a common procedure done under general anesthesia. We describe a surgical technique of triple tendon transfer with wide awake local anesthesia no tourniquet (WALANT). We transfer flexor carpi radialis to extensor digitorum communis, palmaris longus to extensor pollicis longus, and pronator teres to extensor carpi radialis brevis. This is commonly known as the Brand transfer. Our anesthetic or WALANT solution consists of up to 200 mL of 1:400,000 epinephrine, 0.25% lidocaine buffered with sodium bicarbonate. This technique overcomes the problem of judging the appropriate amount of transfer tension by observing awake patients actively extend their fingers, thumb, and wrist during the surgery and making adjustments before we close the wound. In our experience, there is no need of brain retraining because a patient is able to immediately use the flexor muscles to perform extension movements. WALANT is a safe and viable option for radial nerve tendon transfers.
Twelve patients with drop-foot secondary to sciatic or common peroneal nerve palsy treated with transfer of the tibialis posterior tendon were followed-up for a mean of 90 (24-300) months. In 10 patients the results were 'excellent' or 'good'. In 11 patients grade 4 or 5 power of dorsiflexion was achieved, although the torque, as measured with a Cybex II dynamometer, and generated by the transferred tendon, was only about 30% of the normal side. Seven patients were able to dorsiflex their foot to the neutral position and beyond. The results appeared to be better in men under 30 years of age with common peroneal palsies. A painful flatfoot acquired in adulthood does not appear to be a significant long-term complication despite the loss of a functioning tibialis posterior tendon.
One hundred and forty-one patients with non-traumatic paraplegia were reviewed. The common causative factors and the problems arising were evaluated. Management of the clinical problems were described. The need for prevention and early treatment has been stressed.