Tendon Transfer

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Introduction

Tendon transfer surgery is a procedure in which a functioning muscle-tendon unit is redirected to improve a lost function in another area. Tendon transfers are selected and performed to maximally improve the function in the area addressed, with minimal compromise at the donor site. The procedure is used to improve mobility of limb segments, stability of joints, or balance between muscle groups in patients who have suffered injuries or neuro-muscular disorders. Tendon transfers have become an essential tool in the field of limb reconstruction and usually is an adjunct to bone and joint reconstruction procedures

Indications and Contraindications

Tendon Transfer Indications

Indications for tendon transfers are very wide and are commonly employed in nerve or muscle injuries, paralysis, congenital deficiencies, and degenerative diseases:

Nerve or muscle injuries: After a motor nerve damage or muscle or tendon irreparable injury, when muscle or tendon function cannot be restored by other means, a tendon transfer can help restore lost function.
Paralysis: In an incomplete paralysis due to spinal cord injuries or neurological disorders some muscles’ function may be preserved – these functioning units may be redirected to provide a better functional movement.
Congenital deficiencies: Abnormal or absent muscle function leads to muscle imbalance, which must be improved through tendon transfers.
Degenerative Diseases: Conditions such as muscular dystrophy, where muscle strength progressively declines, transfers may temporarily improve function or decelerate deformities caused by muscle imbalance.

Contraindications

While tendon transfers offer remarkable benefits, not all conditions can benefit from this procedure. Contraindications include:

Poor General Health: Where general surgical and anaesthetic risks outweigh the benefits of the intervention, or can be a cause of serious postoperative complications.
Unrealistic Expectations: Patients with unrealistic expectations about the outcomes will need meticulous counselling.
Severe Muscle dysfunction: Weakness, or atrophy of the potential donor muscle will limit the success of the procedure. Occasionally, tendon transfer can be performed to stabilize a joint, without providing an active motor function.

Benefits and Risks

Benefits

Restoration of Function: Tendon transfers can significantly improve joint function and stability, particularly in cases where a native muscle has been weak or paralysed.
Improved Mobility: The procedure can enhance joint mobility and active range of motion, improving daily activities and function.
Muscle balance: Increased the stability of joints.
Pain Reduction: Alleviated pain and discomfort through improved alignment, and stability of the joint and function. Correction of Deformities: This can be used to correct flexible deformities of the joints and restore their more natural appearance and function.

Risks

Infection and delayed wound healing: As with any surgery, there is a risk of infection or wound dehiscence. Incomplete Healing or Loss of Donor Function: A transferred tendon loses its strength partially. It can fully lose its function in case it fails to heal to its new insertion site.
Nerve Damage to adjacent nerves can occur during tendon harvest.
Stiffness: Stiffness and reduced range of motion may develop after tendon transfer or prolonged immobilisation.
Scarring: Procedure often requires multiple incisions – extensive scarring is common, and can sometimes affect the appearance and/or function.

Surgical Approach

The surgical approach to tendon transfers involves careful planning, skilful execution and a very scrupulous rehabilitation plan. A multidisciplinary team, including orthopaedic surgeons, neurophysiologists, physical and occupational therapists, and occasionally plastic surgeons collaborates to ensure the best possible outcomes for the patient.

Tendon transfer surgeries are highly specialised and technically demanding. Our team has extensive training and experience in performing these procedures successfully.

Pre-Surgery Information

The following is what can be expected prior to a tendon transfer procedure

Preparing for tendon transfer surgery involves a thorough assessment of the patient’s medical history, physical condition, and expectations. It is important to inform us of any medical conditions and medications. The functional deficiencies are assessed and additional diagnostic imaging or neuromuscular tests might be also needed. Potential donor muscles are examined, this is followed by discussions with the surgical team about the procedure plan, potential risks, and anticipated outcomes. It is important for the patient to understand, that a completely normal function is never achievable with tendon transfer. Also, a functional improvement in one area is gained at the expense of partial functional loss at the donor site.

Skin preparation: The night before and on the morning of the operation, you will be asked to wash the leg with a sponge provided at the pre-admission clinic. If there is any suspicion of an iodine allergy, a Betadine Skin test might be used.
Bowel Prep: Glycerin suppositories will be provided at the pre-admission clinic, and you will need to administer them the evening prior to the surgery. An instruction leaflet will be given to guide them.
Patient education: During a physiotherapy assessment, a qualified physical therapist will provide you with personalised instructions on gait training, the use of crutches, and pre- and postoperative exercises. You will be fitted with crutches to take home and practise before the surgery.

On the day of the Surgery

Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
A hospital gown will be given, and the operation site will be shaved and cleaned.
Betadine skin prep will be applied to the area above the operation site and wrapped.
All x-rays are to be sent with the patient to the theatre

Surgical Procedure

Anaesthesia: General anaesthesia or regional anaesthesia (spinal or epidural) is used to ensure a pain-free procedure.
Surgery: A carefully placed incision allows access to the donor’s tendons, according to the pre-surgical plan. The tendon is released and rerouted to the new location. Another incision is made at the recipient site, where the harvested tendon will be either sutured to another tendon at the new location to reinforce it or will be anchored directly to the bone, allowing for a new function.
Closure: After the tendon has been anchored, the incisions are closed using sutures. Dressing and a cast are applied.

Post-Surgery Information

Following tendon transfer surgery, patients can expect:

Hospital Stay: Simple procedures require a day stay, after complex surgeries you will be admitted to the hospital for a few days for monitoring and initial rehabilitation.
Pain Management: Pain medications will be administered to keep you comfortable. You may also need muscle relaxants to protect the new tendon transfer from rupture, in cases of inadvertent muscle contractures or spasms.

Immobilisation: Immobilisation typically lasts up to 6 weeks, depending on the surgery type and other associated procedures performed at the time of tendon transfer.
Weight-Bearing: Weight-bearing restrictions are usually necessary, to protect the transferred tendon from the rupture.

Follow-Up

Regular follow-up appointments with the team will help monitor your progress and address any concerns:

1 week postop: for wound check,
2 weeks postop: for sutures removal,
6 weeks postop: for assessment of functional progress.

After that, 3 months postop, 6 months postop, 1 year postop and further annual follow-up will be required.

Physical Therapy

A tailored rehabilitation program will help regain strength, flexibility, and mobility of the joint around which the tendon transfer was performed.

Recovery from tendon transfer surgery can take between 6 weeks to a year, and commitment to rehabilitation as well as follow-up appointments is essential for optimal outcomes. Always consult with your healthcare provider for personalized guidance and recommendations.

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 3000