Rebalancing the Spastic Wrist by Transposition of Antagonistic Muscle-Tendon Complex

Combined Wrist Extensor Tenodesis and Tendon Transfers for Severe Spastic Flexed Wrist Deformity: Surgical Technique and Case Series

Spastic wrist flexion deformities both limit the functional use of the hand for grasp and pinch producing a stigmatizing appearance. Tendon transfers and total wrist arthrodesis are treatment options for this condition depending on the patient's characteristics, the latter the most commonly used in patients with severe wrist flexion deformities. Tendon transfers alone in this scenario have the tendency for recurrent deformity due to tenorrhaphy failure or soft tissue creep and resultant loss of tension. Total wrist arthrodesis is a more invasive procedure, which can have hardware or fusion problems and that is irreversible. We propose a novel technique that incorporates a distally based wrist extensor tendon slip and suture tape tenodesis to the distal radius. The rationale of this technique is to act as a protective, internal splint to prevent recurrent deformity after primary or revision tendon transfer for moderate to severe spastic flexed wrist deformities, avoiding the need to perform a total wrist arthrodesis.

Wrist extensor pathomechanics: implications for tendon and nerve transfer

Central and peripheral nervous system lesions may disrupt the intricate balance of the prime movers of the wrist. In spasticity, hyperactive wrist flexors create a flexion moment and, if untreated, can lead to flexion contractures. In patients with C6 spinal cord injury and tetraplegia, the posterior interosseus nerve is typically affected by a complex pattern of upper and/or lower motoneuron lesions causing radial deviation of the wrist due to loss of ulnar deviation actuators. In this report, we illustrate severe pathomechanics that may occur even with relatively modest changes in wrist balance. These results illustrate how thorough understanding of muscle-tendon-joint interaction aids in designing tendon and nerve reconstructive surgeries to normalize wrist positions and balance in neuromuscular conditions.

Wrist arthrodesis and soft tissue rebalancing in the spastic hand

The aim of the present study was to investigate the outcomes of wrist arthrodesis with simultaneous soft tissue rebalancing of the digits in the spastic wrist. In 43 wrists (40 patients) the surgical goals, patient selection, procedures and outcomes were assessed. Preoperatively, mean passive extension was to 44° below neutral and only two patients had volitional control. Postoperatively, 33 and 10 cases reported excellent and good outcomes, respectively. A mean Goal Attainment Score of 62.4 indicated better than expected outcomes. In total, 37 hands required simultaneous finger rebalancing: 24 underwent tendon transfers and 13 surgical releases. A total of 12 thumbs required tendon transfers, three soft tissue releases and five metacarpophalangeal joint stabilization. Ten patients experienced complications, most commonly wound problems and implant failure, predominantly observed in patients with severe wrist and elbow contractures. In conclusion, wrist arthrodesis with simultaneous soft tissue rebalancing of the digits offers a viable approach in patients with severe spasticity. Cautious patient selection and consideration of potential complications are crucial for good outcomes.Level of evidence: IV.