Upper Limb Table 17 Reconstructive Surgery Multiple Reconstructions

Author Year
PEDro Score
Research Design
Total Sample Size



Friden et al. 2012a

Population: Age range: 19-70 yr; Type of SCI: traumatic=12, non-traumatic=3; Level of injury: tetraplegia=15, paraplegia=0; Mean time since SCI: 54.2±42.8 mo; International classification of patients’ upper extremities: OCu4-OCu8 (with one patient who was exceptional).
Treatment: 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, and active finger range of motion.
  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
  3. 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.

Friden et al. 2012b
Case Control

Population: Treatment group (n=6): Mean age: 32.2±4.9 yr (25-56); Gender: males=4, females=2; Control group (n=6): Mean age: 31.2±5.0 yr (19-52); Gender: males=4, females=2.
Treatment: 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 and pronation range of motion.
  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.

Rothwell et al.
New Zealand
Case Series
NInitial=29; NFinal=24

Population: Mean age=42.9 yr; Time since injury=20.5 yr; Time since surgery=15.1 yr; Handedness: right=22, left=24; Level of Injury: 01: 6 hands; 02: 3 hands; 03: 5 hands; 0Cu2: 2 hands; 0Cu3: 6 hands; 0Cu4: 17 hands; 0Cu5: 8 hands; 0Cu6: 1 hand; tetraplegia.
Treatment: Surgery.
Outcome Measures: Lamb and Chan questionnaire with additional 10 Burwood questions; Swanson sphygmomanometer (hook grip); Preston Pinch Meter (key pinch); Quadriplegic index of Function (QIF); Digital Analyzer (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 to 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 Vs. 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 to 60.2 mm Hg (p=<0.001) and pinch grip increase from 24.0 to 38.4 N in 31 thumbs that had active transfers using 2001 DA data (p=0.03). Hook strength obtained from a tenodesis in 7 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). Additional Burwood questionnaire showed levels of satisfaction, perceived expectation, gratification and opportunity enhancement were maintained over time (p=0.281).

Welraeds et al.
Case Series

Population: Mean age=37yr; Level of injury: C5-C8; Time since injury=7-356 months.
Treatment: 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
Case Series

Population: Level of injury: C5-C8.
Treatment: Surgical reconstruction.
Outcome Measures: Not specified.
  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.
New Zealand
Case Series

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.
Treatment: Surgery.
Outcome Measures: Subject assessment of ADL by questionnaire; Objective assessment of key pinch (Preston Pinch Meter); Hook-grip strength (modified Sphygmomanometer); Elbow extension: MRC grading system.
  1. Subjective Assessment: obtained for 86% of the patients, av. Follow up of 37 months (range 5-86 months); 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 months; 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

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.
Treatment: Surgery.
Outcome Measures: Questionnaire of 55 ADL tasks; opinion of the effect of surgery to perform these ADL tasks; elbow extension (evaluation of extension deficit or holding a sand bag in hand); key grip pinch (Preston Pinch Guage); finger flexion (Martin Vigorimeter).
  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. 4 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.
Case Series

Population: Mean age=15-61 yr; Level of injury: tetraplegia; Time since injury=1-17 yr.
Treatment: Surgical reconstruction.
Outcome Measures: Comparison of the post-surgical with the pre surgical condition.
  1. One hundred forty two 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
Case Series

Population: Mean age=29 yr; Gender: males=38, females=3; Level of injury: tetraplegia; Severity of injury: complete; Follow up time=6 months – 25 yr.
Treatment: Surgery.
Outcome Measures: Elbow strength; Hand function (assessment checklist developed); ADL (developed checklist).
  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
Case Series
NInitial=30; NFinal=23

Population: Level of injury OCu 1,2,3.
Treatment: Reconstruction of key grip and active elbow extension.
Outcome Measures: Interview and/or questionnaire (self-care, communication, mobility), objective measurements – pre + post op strength, ROM wrist + elbow extension, strength of key pinch, range of passive wrist flexion + functional testing
  1. No statistically significant findings reported
  2. Subjective client reports.

Note: ADL=Activities of Daily Living; ROM=Range of Motion; BR=Brachioradialis; ECLR=Extensor Carpi Radialis Longus