Preparing for Surgery

The final decision to undergo surgical reconstruction of upper extremity function is made after thorough considerations of pros and cons. Persons living with tetraplegia hesitate to become more dependent even though it is temporary. Therefore it is essential to reduce the extent of postoperative dependency as much as possible. Restrictions no doubt exist after surgery to protect the newly reconstructed functions but nevertheless much can be done to prevent tissue swelling by using muscle pump and to retain a generally good physical shape. Most patients have struggled quite a lot to reach a “normal” level of physical and psychological status and maintaining this accomplishment as far as possible is critical also during the surgical rehabilitation. Preparations prior to surgery must include detailed information and discussion about restrictions and what consequences these limitations will have for the individual in daily life. The ability to transfer both to the wheelchair and in the wheelchair, intimate self-care and the ability to work are common matters brought up before surgery. Specific transfer training and different parts of ADL training with new techniques and aids are necessary in order to maintain independence. Ability to maintain pressure relief might be limited and needs to be addressed. Analysis and, if necessary, modification of sitting position in the wheelchair is another important aspect of preparation to prevent pressure sore.

Elbow Extension

The ability to bend and straighten the elbow is crucial for the person's mobility, so this is often the first surgery to be performed. In most cases, a portion of the deltoid muscle in the shoulder is used to provide elbow extension. The back (posterior) portion of the deltoid is brought down toward the elbow. Because the deltoid portion is not long enough to reach the attachment point in the lower arm, a tendon graft is taken from a lower leg muscle (tibialis anterior) to provide the necessary length. In some cases, the biceps muscle in the upper arm is used instead of the deltoid muscle. After the surgery, the arm is immobilized in a straight position for up to four weeks. When the cast is removed, a hinged brace is used to allow a gradual stretching and strengthening of the muscles. Initially, the brace is worn night and day, but as the individual gains the ability to fully extend the arm, the brace is worn only at night. Tendon transfer to achieve elbow extension is done on one arm at a time because the arm is totally immobilized during rehabilitation. This means that the person becomes even more dependent on others for the simple activities of daily living. However, the results are impressive.

It can eliminate the need for many adaptive devices and enable the person with tetraplegia to propel a wheelchair, to move independently from bed to chair, to shift weight within a chair or bed and to reach up and outwards.

Key Pinch
Restoring key pinch enables the individual to grip items between the thumb and the hand. This greatly enhances the ability of the patient with tetraplegia to accomplish activities of daily living, such as writing or feeding themselves. In this surgery, one of the forearm muscles (brachioradialis) is grafted to the tendon that flexes the thumb and another muscle that stretches the wrist is moved to flex the fingers. The surgeon may also stiffen the basal thumb joint so that when the wrist is extended, the grip forms automatically.

Finger Flexion
In persons with strong wrist extension, one of the wrist extensors may be grafted to the finger flexors. This enables the individual to actively (under voluntary control) flex the fingers. Training of this new function starts immediately after surgery (the day after). As for the key pinch, the active training is guided and supervised by a physiotherapist.

Grip Function
These two surgeries significantly improve hand and arm function in many patients, providing them with much greater independence.

Flexion-Extension Reconstruction Combined
Although the postoperative rehabilitation is more demanding, the one-stage reconstruction of hand function in tetraplegia proves a successful operation with predictable results. With nearly 5 years of experience with this type of reconstruction, we strongly believe that this combined operation that covers the basic needs of hand control has not only saved one extra operation for the patient but also greatly reduced the total time of rehabilitation. The outcome is generally better than the operations made in two steps (separate flexor and extensor reconstructions). The boxes above demonstrate the 7 different procedures comprised in this reconstruction. Thumb flexion and finger flexion functions are restored by active transfers. Remaining procedures are tendon tensionings (tenodeses) that are controlled by joint motions, for example wrist flexion. The basis of the thumb is fused to secure both a good contact against index finger when flexing the thumb and sufficient opening when wrist if flexed by gravity or by active motion. Picture to the left shows how patient operates computer mouse 4 weeks after the combined one-stage operation.