Integrated nerve and tendon transfer approach to restore functional balance of the hand in tetraplegia

The primary goal for many individuals with tetraplegia is restoration of hand and arm function. Recent advancements in surgical techniques for upper extremity reconstruction have significantly progressed motor control and postural stability to restore functional balance of the hand and upper limb. The integration of nerve and tendon transfers has enabled improvements in essential activities of daily living.Key considerations:It is crucial to ensure that surgical interventions are tailored to the unique functional needs and wishes of each patient, related to self-care, mobility, vocational aspirations and social engagement. Comprehensive evaluation of preoperative hand use for specific tasks is an essential component of surgical planning. Also, patients should be thoroughly informed about both preoperative and postoperative rehabilitation protocols, critical to optimizing functional outcomes. Preoperative preparation may involve strengthening existing key functions, enhancing donor muscle strength, preserving or improving passive joint range of motion, utilizing surface electrical stimulation where indicated and addressing spasticity when necessary. Postoperative rehabilitation should focus on structured, supervised motor retraining to facilitate effective restoration of motor balance and functionality.Reconstructive options:There are pros and cons for nerve vs. tendon transfers, although these can be combined for optimal results, to reconstruct either different functions or the same function. Tendon transfers can be used secondarily; in the same way, reanimated muscles through nerve transfer can also be transferred at a later stage. Strong consideration should be given to a nerve transfer reconstruction when surgery is performed early. Secondary surgery may be required to further adjust the hand position to optimize balance and maximize function if it is suboptimal after primary surgery.