Upper Limb

Biceps to Triceps

Loss of elbow extension after spinal cord injury can significantly affect upper limb function and independence in daily activities. Reconstructive tendon transfer procedures can help restore this movement by redirecting functioning muscles. A biceps to triceps transfer is one surgical option used to create elbow extension in individuals who retain active supinator and brachialis muscles to compensate for the transferred biceps. This procedure can help improve functional arm use for tasks such as reaching, transfers, and mobility.

A biceps to triceps transfer can be used to create elbow extension in patients who have active supinator and brachialis muscles to provide for the lost functions of the transferred biceps (Kuz et al. 1999).

Table 22. Reconstructive Surgery: Elbow Extension (Biceps to Triceps)

Author Year Country Research Design Score Total Sample Size	Methods	Outcome
Mulcahey et al., 2003 USA RCT PEDro=6 N=9	Population: Gender: males=7, females=2; Level of injury: tetraplegic; ICSHT: 0-4; Tendon transfer for elbow extension: deltoids n=8, biceps n=8. Intervention: Surgery. Outcome Measures: Muscle strength, Flexion torque, Modified University of Minnesota Tendon Transfer Functional Improvement Questionnaire, Canadian Occupational Performance Measure (COPM), Activities of Daily Living (ADL).	1. After surgery, elbow extension muscle strength was improved in bicep and deltoid groups (p<0.001). 2. No significant increase in elbow extension muscle strength was found following surgery. 3. Seven of eight bicep-to-triceps procedures had clinical improvements in antigravity muscle strength, in comparison with one of eight deltoid transfers completed. 4. No significant difference between the groups was found for elbow flexion torque (47% reduction in torque after two yr versus baseline). 5. Following surgery, 48/63 elbow extension ADL did not improve in subjects and there was no alteration in the remaining 15/63. 6. Performance and satisfaction with personal goals improved post-surgery as well.
Medina et al., 2017 Spain Pre-Post N=4	Population: Mean age=28.2 yr; Gender: males=4; Time since injury: 2.2 yr; Level of injury: C6, tetraplegia=4; Severity of injury: AISA A=2, B=2. Intervention: Tetraplegic patients underwent biceps-to-triceps transfer surgery according to Zancolli’s modified technique. Outcome measures were evaluated before surgery and 12 months after surgery, following standard rehabilitation. Outcome Measures: Elbow extension; Muscle strength assessment scale (MRC); Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.	1. All patients that underwent the surgery achieved full and active elbow extension against gravity 12 months after surgery (M4 on MRC scale, substantial functional improvement of activities above their heads, and independence of transfers. 2. No significant difference in DASH score was observed pre (73.2±7.8) and postoperatively (30.8±13.4) (p>0.05).
Kozin et al., 2010 USA Case Series N_Initial=45; N_Final=40	Population: Mean age: 17.3 yr; Level of injury: C5=10, C6=29, C7=1. Intervention: Surgery for a biceps to triceps tendon transfer (36 left, 32 right). Outcome Measures: Manual muscle testing, Canadian Occupational Performance Measure (COPM).	1. Manual muscle testing for elbow extension revealed a statistically significant increase in preoperative to postoperative muscle strength (p<0.001). 2. 42/68 arms able to extend completely against gravity (manual muscle testing 3/5 or greater). 3. 9/68 arms had mild extension lag against gravity (manual muscle testing of 3/5). 4. 75% (51/68) arms were able to function overhead. 5. 17/68 arms were less than 3/5 (lack of strength attributed to a post-operative complication). 6. Improvement in one goal on the COPM was observed by each patient. 7. COPM total mean score statistically increased from 2.6 to 5.6 and from 1.8 to 5.7 for performance (p<0.001) and satisfaction (p<0.001), respectively.
Kuz et al., 1999 USA Case Series N=3	Population: Level of injury: tetraplegia. Intervention: Surgery. Outcome Measures: Self-reported satisfaction and need for adaptive aids.	1. No statistical results reported. 2. Subjects indicated they were satisfied with the surgery. 3. Activities that required precision hand placement had improved. 4. Elimination of the need for some adaptive aids was possible post-surgery.

Author Year

Country

Research Design

Score

Total Sample Size

Methods

Outcome

Mulcahey et al., 2003

USA

RCT

PEDro=6

N=9

Population: Gender: males=7, females=2; Level of injury: tetraplegic; ICSHT: 0-4; Tendon transfer for elbow extension: deltoids n=8, biceps n=8.

Intervention: Surgery.

Outcome Measures: Muscle strength, Flexion torque, Modified University of Minnesota Tendon Transfer Functional Improvement Questionnaire, Canadian Occupational Performance Measure (COPM), Activities of Daily Living (ADL).

1. After surgery, elbow extension muscle strength was improved in bicep and deltoid groups (p<0.001).

2. No significant increase in elbow extension muscle strength was found following surgery.

3. Seven of eight bicep-to-triceps procedures had clinical improvements in antigravity muscle strength, in comparison with one of eight deltoid transfers completed.

4. No significant difference between the groups was found for elbow flexion torque (47% reduction in torque after two yr versus baseline).

5. Following surgery, 48/63 elbow extension ADL did not improve in subjects and there was no alteration in the remaining 15/63.

6. Performance and satisfaction with personal goals improved post-surgery as well.

Medina et al., 2017

Spain

Pre-Post

N=4

Population: Mean age=28.2 yr; Gender: males=4; Time since injury: 2.2 yr; Level of injury: C6, tetraplegia=4; Severity of injury: AISA A=2, B=2.

Intervention: Tetraplegic patients underwent biceps-to-triceps transfer surgery according to Zancolli’s modified technique. Outcome measures were evaluated before surgery and 12 months after surgery, following standard rehabilitation.

Outcome Measures: Elbow extension; Muscle strength assessment scale (MRC); Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

1. All patients that underwent the surgery achieved full and active elbow extension against gravity 12 months after surgery (M4 on MRC scale, substantial functional improvement of activities above their heads, and independence of transfers.

2. No significant difference in DASH score was observed pre (73.2±7.8) and postoperatively (30.8±13.4) (p>0.05).

Kozin et al., 2010

USA

Case Series

N_Initial=45; N_Final=40

Population: Mean age: 17.3 yr; Level of injury: C5=10, C6=29, C7=1.

Intervention: Surgery for a biceps to triceps tendon transfer (36 left, 32 right).

Outcome Measures: Manual muscle testing, Canadian Occupational Performance Measure (COPM).

1. Manual muscle testing for elbow extension revealed a statistically significant increase in preoperative to postoperative muscle strength (p<0.001).

2. 42/68 arms able to extend completely against gravity (manual muscle testing 3/5 or greater).

3. 9/68 arms had mild extension lag against gravity (manual muscle testing of 3/5).

4. 75% (51/68) arms were able to function overhead.

5. 17/68 arms were less than 3/5 (lack of strength attributed to a post-operative complication).

6. Improvement in one goal on the COPM was observed by each patient.

7. COPM total mean score statistically increased from 2.6 to 5.6 and from 1.8 to 5.7 for performance (p<0.001) and satisfaction (p<0.001), respectively.

Kuz et al., 1999

USA

Case Series

N=3

Population: Level of injury: tetraplegia.

Intervention: Surgery.

Outcome Measures: Self-reported satisfaction and need for adaptive aids.

1. No statistical results reported.

2. Subjects indicated they were satisfied with the surgery.

3. Activities that required precision hand placement had improved.

4. Elimination of the need for some adaptive aids was possible post-surgery.

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