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We describe a method to restore active palmar abduction of the thumb and report its functional impact in tetraplegia. At 54.2 (SD 42.8) months after cervical spinal cord injury (12 traumatic, 3 nontraumatic), the extensor digiti minimi (EDM) tendon was transferred to the abductor pollicis brevis (APB) through the interosseous membrane in 15 tetraplegic patients (age range 19-70 years) in addition to a mean 3.2 procedures to restore key pinch. According to International Classification, the operated upper extremities were in the OCu4 to OCu8 (1 patient X) group. The maximum distance between thumb and index finger tips during active or passive opening of the hand, maximum angle of palmar abduction, grip and key pinch strength, and active finger range of motion were measured. All patients were re-examined after 38.4 (SD 22.7) months. The active thumb-index opening increased significantly from 2.5 (SEM 1.0) cm before to 9.0 (SEM 0.8) cm after surgery. Nine patients without previous active opening of the first web space recovered a mean thumb-index opening of 9.1 (SEM 1.7) cm, whereas this distance increased by an average of 2.9 (SEM 0.8) cm in six patients who had active thumb index distance of 6.3 (SEM 1.6) cm before surgery. All but one patient were able to direct and coordinate key pinch and perform tasks using the restored APB function, including five patients whose EDM strength was rated as grade 3 before transfer. This EDM-to-APB transfer meets the theoretical requirements of architecture matching between donor and recipient muscles, the principles of tendon transfer, and our surgical expectations. We strongly recommend that an active EDM is transferred to the APB to restore opening of the hand and help in key pinch control in patients with tetraplegia.

Our aim was to evaluate the functional outcome of reconstruction of elbow extension in tetraplegia using a new technique for improving the attachment sites of posterior deltoid-to-triceps transfer in conjunction with an active rehabilitation programme. Ten tetraplegic patients (15 arms) had modified deltoid-to-triceps transfer using a tibialis anterior tendon graft. The operation included large overlaps between the tendon attachments, and additional security by anchoring the distal stump of the tendon graft to the olecranon. During the first 3 weeks of immobilisation, isometric contractions were made and during the following 4 weeks the flexion angle of the elbow was increased by 15 degrees a week; weights were also used to reinforce muscle strength. The mean follow up was 10 months (range 5-19). The elbow extension strength after posterior deltoid-to-triceps transfer was measured in horizontal and vertical planes. After rehabilitation the active range of motion and strength of elbow extension had improved substantially. The mean active elbow extension range of motion was 132 degrees (range 120 degrees -145 degrees ) and the elbow could be extended actively in all planes. Elbow extension strength was restored to well above the counteraction of the weight of the arm. Mean (SEM) elbow extension was significantly greater in the horizontal shoulder plane compared with the vertical plane (10.4 (1.0) compared with 6.5 (1.2) Nm, p < 0.001) and strength increased roughly linearly as the degree of flexion of the elbow increased. The most dramatic increase was in the range between 120 degrees and 135 degrees of flexion, regardless of the plane of action of the shoulder. We have shown good functional results and a shorter rehabilitation period using a rigorous suturing technique that allows for active strength and mobility training without additional adverse effects.

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