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Variability in Surgical Technique for Brachioradialis Tendon Transfer

Evidence and Implications

¹ The Bone and Joint Center, VA Palo Alto Health Care System, 3801 Miranda Avenue (153), Palo Alto, CA 94304. E-mail address: murray{at}rrdmail.stanford.edu
² Robert A. Chase Hand and Upper Limb Center, Department of Surgery, Stanford University and Veterans Administration Medical Center, 770 Welch Road, #400, Stanford, CA 94304-5775
³ Department of Hand Surgery, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden
⁴ Departments of Orthopaedics and Bioengineering, University of California and Veterans Administration Medical Centers, 9500 Gilman Drive, La Jolla, CA 92093-9151

Investigation performed at VA Palo Alto Health Care System, Palo Alto, California, and Sahlgrenska University Hospital, Göteborg University, Göteborg, Sweden

In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from the Rehabilitation Research and Development Service of the Department of Veterans Affairs (Palo Alto B2785R and San Diego A2626R) and the National Institutes of Health (RO1 HD046774 and RO1 HD048501). None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Methods: The surgical technique used for the brachioradialis tendon transfer was assessed in two ways. First, the surgical attachment length of the brachioradialis was quantified, after transfer to the flexor pollicis longus, with use of intraoperative laser diffraction to measure muscle sarcomere length in eleven individuals (twelve limbs) with tetraplegia. Second, ten surgeons who regularly performed this procedure were surveyed regarding their tensioning preferences. Using a biomechanical model of the upper extremity, we investigated theoretically the effect of different surgical approaches on the active muscle-force-generating capacity of the transferred brachioradialis in functionally relevant elbow, wrist, and hand postures.

Results: The average sarcomere length (and standard deviation) of the transferred brachioradialis was 3.5 ± 0.3 µm. That length was significantly correlated to the in situ sarcomere length (r² = 0.53, p < 0.05). Surgical tensioning preferences varied considerably; however, six of the ten surgeons positioned the patient's elbow between full extension (0° of elbow flexion) and 50° of flexion when selecting the attachment length, and six of the ten stated that their goal was to tension the transfer slightly tighter than its resting tension. The computer simulations suggested that a "tighter" brachioradialis transfer would produce its peak active force in an elbow position that is more flexed than the elbow position in which a "looser" transfer would produce its peak active force.

Conclusions: This study provides evidence that experienced surgeons perform this tendon transfer differently from one another. Biomechanical simulations suggested that these differences could result in substantial variability in the active force that the transferred brachioradialis can produce in functionally relevant postures.

Clinical Relevance: The surgical attachment length and the position of the patient's limb at the time of tendon transfer are both controllable and measurable parameters. Understanding the relationship between surgical technique and postoperative muscle function may provide surgeons with more control of clinical outcomes.

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