Tendon Transfer Surgery Page
"When a muscle is paralysed, it is sometimes possible to duplicate its function by using a muscle that is not paralysed. This is done by detaching one end of the non-paralysed muscle’s tendon from its insertion to the bone and re-attaching it to the tendon of the paralysed muscle. For example, it is common for tetraplegics with spinal cord lesions at C4 or C5 to be able to flex their elbow but not straighten it. In such a case it is possible to use part of the non-paralysed deltoid muscle that extends the arm at the shoulder to provide elbow extension. Similarly, tetraplegics with spinal cord lesions of C6 or C7 who have poor hand function but have active muscles controlling their wrist and elbow can have their grip improved.
Surprisingly, it is not hard to adjust to the new use of the muscles. Physiotherapy and Occupational therapy is given to help the candidate achieve the full potential from the tendon transfer. The operations take between one and four hours and require hospitalisation for one week."
These are the very lines taken from the Salisbury District Hospital website that inspired me to investigate further the possibilities that this surgery might give me. On this page I have detailed my case history regarding the Tendon Transfer Surgery (TTS) and what I feel the benefits are. Please remember that these are my views and experiences, yours might be very different.
Initial Pre-operative Investigations
Obviously, before any major surgical procedure it is best practice by all parties to investigate the potential benefits and problems to the patient. Once through the minefield that is getting all the proper requests and referrals, and of course the usual lost letters and such I was offered an initial consultation at the National Spinal Injuries Centre (NSIC) at Stoke Mandeville, who I was told were just ramping up to include this type of surgery.
At this first consultation meeting, I met the team who were going to be doing the operation and rehabilitation. These included;
* Tony Heywood - Reconstructive Plastic Surgeon
* Greg O'Toole - Senior Houseman (and part time digital photographer)
* Diane Taal - Head Occupational Therapist
* Michelle Clarke - Occupational Therapist
* Ruth Peachment - Peripatetic Nurse
At this meeting I had several test to find out my general abilities, ranging from my ability to push, through to things like opening a lock or taking money from a wallet or purse. Each task was timed and videoed so that I will have a measure of how well I have improve after the surgery. Thankfully for me it was deemed that TTS would be of benefit, and so I was placed on the waiting list. At this meeting we all agreed that it would useful to me to start with the right arm as this is naturally my weaker side. I was admitted to St. Patrick's Ward on the 26th February, and my operation took place on the 28th.
What Surgery Did I Have
The surgery that Mr. Heywood and the team felt was most beneficial for me was both on the upper and lower parts of the arm. The diagram to the right shows very clearly the muscle groups of the arm. Please refer back to this when I start talking about which muscles have been moved.
The surgery that Mr. Heywood undertook has traditionally been completed as two separate operations, but it is now the view of those surgeons carrying out this type of procedure that where possible, it is of benefit to do them as one. The major benefit for me was less time in hospital. I am pleased to say that Mr. Hobby from Salisbury District Hospital agreed to come and oversee the operation, as he has been carrying out his procedure for quite some time.
For clarity though, I will break the procedure back down into its two major elements.
Upper Arm
Reason for surgery - As a tetraplegic of my level, I do not have a functioning Triceps muscle. If there is any flicker of movement within the muscle, then it is was of no practical use prior to surgery.
The procedure on my arm was to take the posterior (rear) section of the Deltoid muscle and via an implant, attach it to where the tendons join the Triceps to the elbow joint. This allows me to flex and use my Triceps by using the original movement I had with the posterior Deltoid function. As with all things it is a balancing act as to what you gain over the lose of the original movement. In my case I feel that I have gained greater control of movement for only a small reduction in the power and range of movement within my shoulder.
If you would like to view pictures taken during the actual operation on my arm, then please follow the link below. WARNING as with all pictures of operations they are very graphic and bloody, please don't view them if you are squeamish!
Lower Arm
Reason for surgery - Again, with my level of injury, I don't have any real function within my hand. I do have wrist extension, but it is weak. This wrist extension does allow me a very weak form of hand grip called tenodisis. Tenodisis is where on extending the hand backwards, the fingers will pull gently together as the tendons within the hand shorten. This so called 'Tetra trick grip' on my right side has always been weak, and being naturally left handed, I was skeptical as to the out come of this part of the surgery.
The procedure on my hand was to increase my ability of the wrist extension, while taking a small portion of my Brachioradialis muscle and attaching it to my thumb. The idea for this is that when the forearm is flexed, then the thumb pulls firmly against the fingers giving a basic pinch/key grip. So far this side of the surgery has been only 60% successful in my opinion. As my right hand has always bent at the second knuckles of the fingers, this means that my thumb does not yet make contact with the index finger to create the grip. The thumb itself has been a total success though, and so some remedial work on the hand may improve my current situation.
With regard to the next lot of surgery on my left hand side, this will be a better proposition, as my hand naturally forms a better position for pinch/key grip. The entire operation took just over five hours.
Post Operative Recovery
I was in hospital for six weeks after my surgery, and was not allowed to put any pressure through my arm for a further six weeks. At the top of this page in the abstract it states that hospitalisation of one week is the normal time at Salisbury, but the whole team and I felt that as the first candidate through this surgery in several years at NSIC (a few pilot candidates had been operated on previously, but not with this current team), that it would be better to take a more conservative outlook. This also gave the clinical team the ability to see how a candidate like myself progressed during rehabilitation.
Immediately after my operation, my arm was fully immobilised in a plaster splint over the wound dressings. This is to hold the elbow straight allowing the tendons to heal. After ten days this plaster splint was removed and with an adjustable brace that allows some flexion of the elbow. This brace had its range of movement increased each week until at six weeks post operation it was at 90 degrees. During this six week period the Occupational Therapy team, in conjunction with the Physiotherapy Team, I was given gradually increasing movement tasks to do. This was to slowly allow my arm to regain the movement and flexibility.
At six weeks I was allowed home. At home, I had a further six weeks of rehabilitation physiotherapy at a local unit. It is now mid September and I am still feeling a slight gain in movement and flexibility in my right arm, and although as I have already stated things didn't go completely to plan, I'm extremely pleased with the results so far. I would also like to say a huge thank you to all those involved in getting me to this point. Especial thanks must go to Mr. John Hobby and Mr. Tony Heywood for their skill during my surgery.