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Multiple Reconstructions

The following studies report results from multiple procedures to reconstruct the upper limb.

Table 23 Multiple Reconstruction post-SCI

Author Year

Country

Research Design

Score

Total Sample Size

MethodsOutcome
Dunn et al., 2014

New Zealand

Cohort

N=19

Population: Mean Age: 53 yr; Gender: males=18, females=1; Level of Injury: C5=3, C6=9, C7=7.

Intervention: Patients who had received tendon transfers between 1982-1991 were followed up as part of a longitudinal study. Surgical procedures included brachioradialis (BR) to flexor pollicis longus (FPL; n=27, 31%), extensor carpi radialis longus (ECRL) to flexor digitorum profundus (FDP; n=20, 23%), elbow extension (n=18, 21%), BR to FDP (n=7, 8%), FPL tenodesis (n=6, 7%), pronator teres (PT) to FPL (n=4, 5%), and FDP tenodesis (n=4, 5%). Assessments were conducted 11yr after previous follow-up.

Outcome Measures: Lamb & Chan questionnaire (LCQ), Key pinch strength, Grip strength, Type of wheelchair used.

1.     Only patients who had undergone a left-side tenodesis reported a significant improvement in key pinch strength (p=0.04) from the previous follow-up (2001) to current follow-up (2012).

2.     No significant differences were reported between patients who had undergone active transfer or tenodesis at current follow-up.

3.     The active transfer patients declined by 8% (left side) and 5% (right side), but left and right side tenodesis grip strength increased by 70% and 32%, respectively (both p<0.05) from previous follow-up to current follow-up.

4.     Although the majority of the items on the LCQ were unchanged from the previous follow-up to current follow-up, three items were found to have worsened with 10 patients reporting a decline in their ability to propel their wheelchair up and down a slope, and the ability to propel their wheelchair on a level surface.

5.     Further, 7 patients reported a decline in the ability to raise themselves from their seat on the LCQ.

Friden et al., 2012bSweden

Case Control

N=12

Population: Treatment group (n=6): Mean age: 32.2±4.9 yr; Gender: males=4, females=2.

Control group (n=6): Mean age: 31.2±5.0 yr; Gender: males=4, females=2.

Intervention: Individuals in the treatment group had a brachioradialis (BR) to Flexor pollicis longus (FPL) transfer dorsal to radius through the interosseous membrane whereas the control group received traditional palmar BR to FPL.

Outcome Measures: Lateral key pinch, Pronation range of motion (ROM).

1.     Post-operative active pronation was significantly greater in the dorsal transfer group in comparison to the palmar group (149±6° and 75±3°, respectively).

2.     Pinch strength was similar between both groups (1.28±0.16 kg and 1.20±0.21 kg), respectively.

3.     It is feasible to reconstruct lateral key pinch and forearm pronation simultaneously using only the BR muscle.

Friden et al., 2012a

Sweden

Pre-post

N=15

Population: Age range: 19-70 yr; Type of SCI: traumatic=12, non-traumatic=3; Level of injury: tetraplegia=15, paraplegia=0; Mean time since injury: 54.2±42.8 mo; International classification of patients’ upper extremities: OCu4-OCu8.

Intervention: All patients had their extensor digiti minimi (EDM) tendon transferred to the abductor pollicis brevis (APB) through the interosseous membrane, in addition to ≥3.2 procedures to restore key pinch.

Outcome Measures: Maximum distance between the thumb and index finger tips during active or passive opening of the hand, Maximum angle of palmar abduction, grip and key pinch strength, Active finger range of motion (ROM).

1.       Active thumb-index opening increased significantly from 2.5 (SEM 1.0) cm before surgery to 9.0 (SEM 0.8) cm after surgery.

2.      Nine patients without previous active opening of the first web space recovered a mean thumb-index opening of 9.1 (SEM 1.7) cm; this distance increased 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.

4.     14/15 patients were able to direct and coordinate key pinch and perform tasks using restored APB function including five patients whose EDM strength was rated as grade 3 before the transfer.

Gregersen et al., 2015

Denmark

Post Test

N=40

Population: Median Age: 48 yr; Gender: males=33, females=7; Level of Injury: C4=7, C5=14, C6=12, C7=6, C8=1; Severity of Injury: AIS A=25, AIS B=9, AIS C=3, AIS D=3.

Intervention: Patients completed a questionnaire on general satisfaction, independence, activities of daily living (ADL), appearance, reliability of the surgery, postoperative therapy, and life impact since undergoing upper extremity surgery post-SCI. Patients were also asked to write a list of activities that they performed better/worse and if they needed fewer aids post-surgery. A total of 102 surgical procedures had been performed including pinch/thumb stabilization (n=46), elbow extension posterior deltoid to triceps (n=20), hand grasp/finger flexion (n=14), wrist extension (n=7), Zancolli (n=7), freehand (n=3), and miscellaneous (n=5). Assessments were conducted at post-treatment.

Outcome Measures: Custom satisfaction survey.

 

1.     The mean percentage for positive responses (strongly agree/agree) was 76% for general satisfaction and 84% for life impact.

2.     Appearance of the patients’ hand(s) was scored relatively lower with only 28% reporting an improvement in appearance post-surgery and 49% were unsatisfied.

3.     Positive responses were reported in 73% of patients for improvements in ADL with 85% reporting that ADL had become easier and 58% reporting that activities could be performed faster after surgery.

4.     Patients who had received surgery between the yr 1991-2008 reported greater levels of general satisfaction and ADL than patients who had received surgery between the yr 1973-1990 (both p<0.001).

5.     When comparing patients who had elbow extension or pinch/thumb surgery as the only procedure, patients who had received elbow extension surgery reported significantly greater levels of satisfaction regarding ADL (p=0.027) and independence (p<0.001).

6.     Patients reported that eat and drinking, grasping and coordination, dressing/undressing, stretching, and using tools were easier after surgery.

Friden et al., 2014

Sweden

Case Series

N=11

 

Population: Mean Age: 49 yr; Gender: males=4, females=7; Injury etiology: Thrombosis=3, Spinal haemorrhage=2, Tumour=2, Syringomyelia=1, Guillain-Barre Syndrome=1, Unspecified=2.

Intervention: Data was collected and analysed from patient records who had completed evaluations prior to and after tendon transfer surgery. Surgical procedures included active key pinch by brachioradialis-to-flexor pollicis longus (FPL) transfer (n=10), distal thumb tenodesis (n=10), extensor carpi radialis longus-to-flexor digitorum profundus 2-4 transfer (n=8), intrinsic balancing using either House or Zancolli plasty (n=6), activation of thumb abduction by extensor digiti minimi-to-abductor pollicis brevis transfer in (n=3), carpometacarpal joint of thumb, arthrodesis (n=3), posterior deltoid-to-triceps transfer (n=1), passive key pinch by FPL tenodesis to the radius (n=1). Assessments were conducted at pre-treatment and at 12 mo post treatment.

Outcome Measures: Key pinch strength, Grip strength, Maximal distance between the thumb and index finger, Anti-gravity elbow extension.

1.     Key pinch strength had improved significantly with means increasing from 0kg at pre-treatment to 1.6kg at 12m post treatment (p<0.05).

2.     Grip strength had improved significantly with means increasing from 0kg at pre-treatment to 3.2kg at 12m post treatment (p<0.05).

 

3.     Maximal distance between the thumb and index finger had improved significantly with means increasing from 2.1cm at pre-treatment to 6.4cm at 12m post treatment (p<0.05).

4.     Anti-gravity elbow extension was restored in one patient.

Rothwell et al., 2003

New Zealand

Case Series

NInitial=29; NFinal=24

Population: Mean age: 42.9 yr; Mean time since injury: 20.5 yr; Mean time since surgery: 15.1 yr; Handedness: right=22, left=24; Level of Injury: 01: 6 hands; 02: t3 hands; 03: 5 hands; 0Cu2: 2 hands; 0Cu3: 6 hands; 0Cu4: 17 hands; 0Cu5: 8 hands; 0Cu6: 1 hand; tetraplegia.

Intervention: Surgery.

Outcome Measures: Lamb and Chan questionnaire with additional 10 Burwood questions, Swanson sphygmomanometer (SGM) (hook grip), Preston Pinch Meter (key pinch), Quadriplegic index of Function (QIF), Digital Analyzer (DA) (key and grip pinch).

1.     Elbow Extension: bilateral surgery 9/11 subjects; Hook Grip; 17 right hands (av. Grip 46.2 mm Hg in 1991; improved slightly, not statistical significant (p=0.30)) Left hand: 15 hands: significant increase (p<0.001), av. 28.7 mmHg to 53.2 mmHg; no statistical significance between right and left hook grip as measured by SGM and DA in 2001 (p=0.93 and p=0.97).

2.     Key Pinch: av. key pinch 20 right thumbs in 1991 25.8 N and decreased in time to av. 13.9 N (significant decrease p<0.001); average pinch strength 18 left thumbs decreased from 17.7-8.8 N (significant decrease p<0.001). Average pinch strength measured by DA, increase in key pinch when compared to 1991, significant for both right (p=0.01) and left (p=0.01) thumbs.

3.     Active Transfer versus Tenodeses: hook grip: active transfers 2x strength of tenodeses in 1991 (p=0.05) and 2001 (p=0.03). Pinch grip: similar to 1991 data (p<0.001), 2001 data does not follow trend. 2001 DA data did not reach significance (p=0.06).

4.     Longitudinal Comparison: hook grip strength 25 hands with active transfers significant increase 42.1-60.2 mm Hg (p<0.001) and pinch grip increase from 24.0-38.4 N in 31 thumbs that had active transfers using 2001 DA data (p=0.03). Hook strength obtained from a tenodesis in seven hands did not weaken over time (p=0.05) but pinch strength in 7 thumbs significantly increased (p<0.001) using 2001 DA data.

5.     Questionnaire results; Lamb and Chan activity measure: showed perceived improvement of functional activities significantly lower in 2001 (p<0.001). QIF scores of current functional independence was significantly better (p=0.004).

6.     Additional Burwood questionnaire showed levels of satisfaction, perceived expectation, gratification and opportunity enhancement were maintained over time (p=0.281).

Welraeds et al., 2003

Belgium

Case Series

N=25

Population: Mean age: 37 yr; Level of injury: C5-C8; Time since injury: 7-356 mo.

Intervention: Upper limb surgery.

Outcome measures: Functional testing.

1.     No statistical analysis provided-gestural ability improved in more than 80% of the patients and functional gain was important in more than half.

2.     43 procedures; Atypical procedures (2) good: 2; Moberg procedures (18) good: 17; poor: 1; Deltoid/triceps (12) good: 7; fair 3; poor 2; Additional procedures (11) good: 7; fair: 3; poor: 1.

Freehafer 1998

USA

Case Series

N=285

Population: Level of injury: C5-C8.

Intervention: Surgical reconstruction.

Outcome Measures: Self-reported improvement.

1.     Oponens transfers were done 180 times; transfers for finger flexion-161 times; posterior deltoid transfers-59 times; transfers for wrist extension-17 times.

2.     13 out of 285 stated that they were no better, and no patient said they were worse.

Mohammed et al., 1992

New Zealand

Case Series

N=57

Population: Mean age: 27 yr; Gender: males=51, females=6; Level of Injury: 00:4; 01: 6; 02: 4; 03: 6; 0X: 3; Cu3: 6; Cu 4: 24; Cu 5: 10; Cu 6: 3; Cu X: 3; tetraplegia.

Intervention: Surgery.

Outcome Measures: Activities of Daily Living (ADL), Preston Pinch Meter, Hook-grip strength, Elbow extension.

1.     Subjective Assessment: obtained for 86% of the patients, av. Follow up of 37 mo (range 5-86 mo); 70% reported good or excellent results; 22% fair; 8% poor.

2.     Simultaneous surgery for key-grip and hook grip strength: 96% good or excellent results.

3.     Objective Results: over 70% of patients, av. follow up of 32 mo; Key Pinch 52/68 cases (76%); av. strength was 2.1 kg. Hook grip measured in 42/58 cases (72%), thumb included av. strength was 42 mmHg; thumb excluded 29 mmHg.

4.     Elbow extension measured in 71% of patients, obtained grade 3 or 4 strength.

Ejeskar & Dahllof 1988 Sweden

Case Series

N=43

Population: Age: 26-70 yr; Gender: males=36, females=7; Level of Injury: 0:1 9 pts; 0:2 2 pts; 0Cu:1 4 pts; 0Cu:2 13 pts; 0Cu:3 9 pts; 0Cu:4 5 pts; 0Cu:6 1 pt. Re-examined 1-14 yr after the last operation.

Intervention: Surgery.

Outcome Measures: Activities of Daily Living (ADL), Elbow extension, Key grip pinch, Finger flexion.

1.     Elbow Extension: 30 elbows in 23 patients; (23/30 with free tendon graft;7/30 Castro-Sierra and Lopez-Pita method); 5/23 with free tendon graft 1/23 full ext.; 8/23 lack ext. against gravity of max. 60; 10/23 lack even more ext.; 6/7 ext. deficit greater than 60.

2.     Key Grip: 50 hands/40 patients; Strength 0-3.5 kg (av. 0.7 kg); 15 cases had minimum of 1.0 kg.

3.     Finger Flexion: 14 hand/13 patients (ECRL to profundi II-V); grip 0-0.27 kP (av. 0.13 kP); 5/14 minimum strength 1.0 kg.

4.     Four patients reported no improvement (1 severe spasticity, 2 BR muscle transferred to wrist; 1 operation on weaker hand); 4/43 could not state how much they had improved, 35/43 average improved capacity to perform 23/55 ADL tasks; 3/43 patients a functional deterioration.

Freehafer et al., 1984

USA

Case Series

N=68

Population: Age: 15-61 yr; Level of injury: tetraplegia; Time since injury: 1-17 yr.

Intervention: Surgical reconstruction.

Outcome Measures: Comparison of the post-surgical with the pre-surgical condition.

1.     142 transfers were performed on 68 subjects.

2.     No upper limbs were made worse.

3.     Four remained unimproved, all others that had tendon transfers improved.

Lamb & Chan 1983

UK

Case Series

N=41

Population: Mean age: 29 yr; Gender: males=38, females=3; Level of injury: tetraplegia; Severity of injury: complete.

Intervention: Surgery.

Outcome Measures: Elbow strength, Hand function (assessment checklist developed), Activities of daily living (ADL).

1.     Elbow Function: 10/16 elbows (10 patients): full extension; 2/16 elbows 20-degree flexion contracture; 4/16 15 degrees of extension lag. All 10 patients considered the procedure beneficial.

2.     Hand Function: 48 hands (assessed only 27 patients). 5 rated as excellent; 28 rated good; 11 rated as fair; 4 graded as poor. No patient had any impairment of hand function after operation.

3.     ADL: 29 patients assessed. No one considered their functional capability deteriorated after operation. Most significant improvement in basic activities such as washing, eating and using the toilet, hold glasses and cups, wash limbs and brush hair, turn on taps, improve bladder compression, insertion of suppositories, change from complete reliance on other for self-care, more mobile, 7 able to drive a car. Improvement in UL function facilitated development of personal interests.

Hentz et al., 1983

USA

Case Series

NInitial=30; NFinal=23

Population: Level of injury: OCu 1,2,3.

Intervention: Reconstruction of key grip and active elbow extension.

Outcome Measures: Interview and/or questionnaire (self-care, communication, mobility), Objective measurements – pre + post op strength, Range of motion (ROM) of wrist + elbow extension, Strength of key pinch, Range of passive wrist flexion + functional testing.

1.     No statistically significant findings reported.

2.     Subjective client reports.

Summary Table: Multiple Reconstructions

Discussion

In reviewing the identified studies as a whole, the operative interventions on the tetraplegic hand and upper limb bring definite gains in pinch force, cylindrical grasp, and the ability to reach above shoulder height that result in an improvement in ADL function and quality of life for the individual with tetraplegia. Despite the low level of evidence (grade 4) the subjective acceptance among patients who have had reconstructive surgery is high. One of the reported downsides of surgery is the high complication rate (infection, torn attachments) and the extended period of time post-surgery for rehabilitation and increased need for personal care (Meiners et al. 2002).

Many SCI centres do not offer or have access to reconstructive surgery or neuroprothesis interventions. It is also debated whether the overall cost of surgery or use of neuroprostheses is more beneficial to the client, as the client has to relearn new movement strategies in order to perform activities of daily living (ADL) (van Tuijl et al. 2002).

Conclusion

There is level 4 evidence (see Table 9-18) that support the use of reconstructive surgery for the tetraplegic upper limb for the improvement of ADL and quality of life.

Reconstructive surgery appears to improve pinch, grip and elbow extension functions that improve both ADL performance and quality of life in tetraplegia.