Shortened rehabilitation period using a modified surgical technique for reconstruction of lost elbow extension in tetraplegia

Abstract

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.

Voluntary activation of biceps-to-triceps and deltoid-to-triceps transfers in quadriplegia

“…The average maximum moment we recorded in the biceps transfer arms (8.80 N-m) in the horizontal plane exceeds the combined average of deltoid transfer arms previously reported in the horizontal plane (5.3 N-m) [ 9 , 10 , 12 , 14 , 15 ]. Thus, although the arms with deltoid transfer we tested were weaker in elbow extension relative to other cross-sectional studies that measured isometric moments [ 10 , 12 , 14 ], on average, we expect the biceps transfer to enable greater elbow extension strength relative to the deltoid transfer when patients are candidates for either procedure.…”

“…The average maximum moment we recorded in the biceps transfer arms (8.80 N-m) in the horizontal plane exceeds the combined average of deltoid transfer arms previously reported in the horizontal plane (5.3 N-m) [ 9 , 10 , 12 , 14 , 15 ]. Thus, although the arms with deltoid transfer we tested were weaker in elbow extension relative to other cross-sectional studies that measured isometric moments [ 10 , 12 , 14 ], on average, we expect the biceps transfer to enable greater elbow extension strength relative to the deltoid transfer when patients are candidates for either procedure. The average maximum elbow moment we measured in the deltoid transfer arms (2.74 ± 0.22 N-m) was similar to the average of arms tested by Memberg et al [ 15 ] (1.2 ± 2 N-m) and Kirsch et al [ 9 ] (2.7 ± 3.5 N-m), but weaker relative to arms tested by Lieber et al [ 10 ] (5.89 ± 0.24 N-m), Rabischong et al [ 12 ] (6.6 ± 3.9 N-m), and Turcsanyi and Friden [ 14 ] (10.4 ± 1.0 N-m).…”

“…However, when elbow extension strength has been assessed objectively via measurement of the isometric moment during maximum voluntary effort, cross-sectional studies report a wide range of moments generated after deltoid transfer, which are on average greater relative to the biceps transfer. Specifically, the only study to measure moments after biceps transfer reported the average maximum moment to be 3.7 N-m [ 13 ], which is less than moments reported after deltoid transfer (combined average is 5.3 N-m) [ 9 , 10 , 12 , 14 , 15 ]. The source of the contrasting results of the single prospective study relative to the cross-sectional studies is unclear; differences in experimental design, including the study cohorts (e.g., Revol et al assessed individuals with biceps transfers who were not candidates for deltoid transfer) and assessment procedures may be contributing factors [ 11 , 13 ].…”

Launching a new national tetraplegia upper extremity surgery service

“…Reconstructive surgery of the upper extremities using tendon transfer and joint stabilizations or, more recently, nerve transfer, has become an accepted part of rehabilitation of patients with cervical spinal cord injury (2,3). Numerous case series have demonstrated that key functions, such as elbow extension and handgrip can be restored reliably in individuals affected by traumatic or non-traumatic tetraplegia (4)(5)(6)(7)(8)(9)(10)(11). Consequently, the mobility, spontaneity and independence of tetraplegic individuals can be markedly and persistently increased (12)(13)(14).…”

Activity Gains After Reconstructions of Elbow Extension in Patients With Tetraplegia

“…[5][6][7][8] The most common outcome measure used to assess elbow extension is the Medical Research Council (MRC) score, which grades muscle strength from 0 to 5. In a review of 14 studies reporting outcomes of triceps reconstruction including a total of 190 limbs, average postoperative elbow extension strength was an MRC score of 3.3.…”