Biceps to Triceps Transfer in Tetraplegic Patients

Abstract

Background: Management and indications for surgery in the tetraplegic patient are highly complex because of the substantial functional deficits that they present and their effect on their daily activity. Our purpose was to evaluate the functional outcome in tetraplegic patients who underwent biceps-to-triceps transfer surgery according to Zancolli's modified technique. Methods: This is a retrospective study of 6 biceps-to-triceps transfers using Zancolli's modified technique in 4 patients. Mean follow-up was 45 months. We evaluated each patient's DASH (Disabilities of the Arm, Shoulder and Hand) score before surgery and 12 months later. Results: In the 6 arms that underwent surgery, full and active elbow extension against gravity at 12 months after surgery was achieved. The mean DASH score was 73.2 preoperatively and 20.8 twelve months postoperatively. One complication occurred. One patient reported loss of elbow flexion preventing thigh lift for transfers. This was resolved with a program of rehabilitation and specific muscle strengthening Conclusions: Zancolli's modified technique is simple and effective, with few complications, whereby we can provide more autonomy for the tetraplegic patient.

Current Concepts in Elbow Extension Reconstruction for the Tetraplegic Patient

“…In 1954, Friedenberg detailed the first successful use of biceps transfer to restore full elbow extension. 8 Previously, in 1951, Mayer described a biceps-to-triceps technique; however, his patient “lacked the final 30° of extension.” 6,8 Both Mayer and Friedenberg used the lateral routing method to transfer the biceps tendon to the triceps insertion. Lateral routing has been largely abandoned because of complications from compression of the radial nerve.…”

“…Improvement plateaus 1 year after the injury. 6 There is no debate in the literature that functional supinator and brachialis muscles are prerequisites to biceps-to-triceps transfer; however, differing opinions exist regarding elbow flexion contractures preoperatively. In tetraplegic patients with paralyzed triceps brachii, there is unopposed elbow flexion, which can lead to notable flexion contractures over time.…”

“…10 Both Medina et al and Revol et al weave the biceps tendon into the distal triceps tendon without using bone tunnels in the olecranon. 6,11 Kuz et al 8 tension the transfer to permit 90° of passive elbow flexion. All other techniques tension the transfer, while the elbow is maintained in full extension.…”

“…All other techniques tension the transfer, while the elbow is maintained in full extension. 6,7,10,11…”

“…5 In patients with tetraplegic SCI, the goal of surgery is to provide them with independence and "rebuild a thumb-index pinch usable in a wide range of possible working space." 6 Active elbow extension is critical for success. Patients with C5 or C6 SCI have paralysis of the triceps brachii.…”