Tendon Transfer Surgery for People With Tetraplegia: An Overview


      After cervical spinal cord injury, the loss of upper limb function is common. This affects an individual's ability to perform activities of daily living and participate in previous life roles. There are surgical procedures that can restore some of the upper limb function lost after cervical spinal cord injury. Tendon transfer surgery has been performed in the tetraplegic population since the early 1970s. The goals of surgery are to provide a person with tetraplegia with active elbow extension, wrist extension (if absent), and sufficient pinch and/or grip strength to perform activities of daily living without the need for adaptive equipment or orthoses. These procedures are suitable for a specific group, usually with spinal cord impairment of C4-8, with explicit components of motor and sensory loss. Comprehensive team assessments of current functioning, environment, and personal circumstances are important to ensure success of any procedure. Rehabilitation after tendon transfer surgery involves immobilization for tendon healing followed by specific, targeted therapy based on motor learning and goal-orientated training. Outcomes of tendon transfer surgery are not limited to the improvements in an individual's strength, function, and performance of activities but have much greater life affects, especially with regard to well-being, employment, and participation. This article will provide an overview of the aims of surgery, preoperative assessment, common procedures, postoperative rehabilitation strategies, and outcomes based on clinical experience and international published literature.


      List of abbreviations:

      ADL (activities of daily living), ICF (International Classification of Functioning, Disability and Health), ISNCSCI (International Standards for Neurological Classification of Spinal Cord Injury), SCI (spinal cord injury)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hanson R.W.
        • Franklin M.R.
        Sexual loss in relation to other functional losses for spinal cord injured males.
        Arch Phys Med Rehabil. 1976; 57: 291-293
        • Anderson K.D.
        Targeting recovery: priorities of the spinal cord-injured population.
        J Neurotrauma. 2004; 21: 1371-1383
        • Bryden A.M.
        • Sinnott K.A.
        • Mulcahey M.J.
        Innovative strategies for improving upper extremity function in persons with tetraplegia and considerations in measuring functional outcomes.
        Top Spinal Cord Inj Rehabil. 2005; 10: 75-93
        • DiPasquale-Lehnerz P.
        Orthotic intervention for development of hand function with C-6 quadriplegia.
        Am J Occup Ther. 1994; 48: 138-144
        • Krajnik S.R.
        • Bridle M.J.
        Hand splinting in quadriplegia: current practice.
        Am J Occup Ther. 1992; 46: 149-156
        • Mohammed K.D.
        • Rothwell A.G.
        • Sinclair S.W.
        • Willems S.M.
        • Bean A.R.
        Upper limb surgery in tetraplegia.
        J Hand Surg [Br]. 1992; 74: 873-879
        • Lamb D.W.
        • Chan K.M.
        Surgical reconstruction of the upper limb in traumatic tetraplegia.
        J Hand Surg [Br]. 1983; 65: 291-298
        • Freehafer A.A.
        Tendon transfers in patients with cervical spinal cord injury.
        J Hand Surg [Am]. 1991; 16: 804-809
        • Ejeskar A.
        • Dahllof A.
        Results of reconstructive surgery in the upper limb of tetraplegia patients.
        Paraplegia. 1988; 26: 204-208
        • McDowell C.L.
        • Moberg E.
        • House J.H.
        The Second International Conference on Surgical Rehabilitation of the Upper Limb in Tetraplegia (quadriplegia).
        J Hand Surg [Am]. 1986; 11: 604-608
        • Hentz V.R.
        • Brown M.
        • Keoshian L.A.
        Upper limb reconstruction in quadriplegia: functional assessment and proposed treatment modifications.
        J Hand Surg [Am]. 1983; 8: 119-131
        • Gansel J.
        • Waters R.L.
        • Gellman H.
        Transfer of the pronator teres tendon to the tendons of the flexor digitorum profundus in tetraplegia.
        J Hand Surg [Am]. 1990; 72: 427-432
        • Keith M.W.
        • Lacey S.H.
        Surgical rehabilitation of the tetraplegic upper extremity.
        Neurorehabil Neural Repair. 1991; 5: 75-87
        • Moberg E.
        Surgical treatment for absent single-hand grip and elbow extension in quadriplegia. Principles and preliminary experience.
        J Hand Surg [Am]. 1975; 57: 196-206
        • Ejeskär A.
        Upper limb surgical rehabilitation in high-level tetraplegia.
        Hand Clin. 1988; 4: 585-599
        • Johanson M.E.
        • Murray W.M.
        The unoperated hand: the role of passive forces in hand function after tetraplegia.
        Hand Clin. 2002; 18: 391-398
        • Smaby N.
        • Johanson E.
        • Baker B.
        • Kenney D.E.
        • Murray W.M.
        • Hentz V.R.
        Identification of key pinch forces required to complete functional tasks.
        J Rehabil Res Dev. 2004; 41: 215-224
        • Freehafer A.A.
        • Peckham P.H.
        • Keith M.W.
        New concepts on treatment of the upper limb in the tetraplegic: surgical restoration and functional neuromuscular stimulation.
        Hand Clin. 1988; 4: 563-574
        • van Zyl N.
        • Hahn J.B.
        • Cooper C.A.
        • Weymouth M.D.
        • Flood S.J.
        • Galea M.P.
        Upper limb reinnervation in C6 tetraplegia using a triple nerve transfer: case report.
        J Hand Surg [Am]. 2014; 39: 1779-1783
        • Bertelli J.A.
        • Tacca C.P.
        • Ghizoni M.F.
        • Kechele P.R.
        • Santos M.A.
        Transfer of supinator motor branches to the posterior interosseous nerve to reconstruct thumb and finger extension in tetraplegia: case report.
        J Hand Surg [Am]. 2010; 35: 1647-1651
        • Friden J.
        • Gohritz A.
        Brachialis-to-extensor carpi radialis longus selective nerve transfer to restore wrist extension in tetraplegia: a case study.
        J Hand Surg [Am]. 2012; 37: 1606-1608
        • Brown J.M.
        Nerve transfers in tetraplegia I: Background and technique.
        Surg Neurol Int. 2011; 2: 121
        • Burns A.S.
        • Ditunno J.F.
        Establishing prognosis and maximizing functional outcomes after spinal cord injury: a review of current and future directions in rehabilitation management.
        Spine (Phila Pa 1976). 2001; 26: S137-S145
        • Waters R.L.
        • Adkins R.H.
        • Yakura J.S.
        • Sie I.H.
        Motor and sensory recovery following complete tetraplegia.
        Arch Phys Med Rehabil. 1993; 74: 242-247
        • Waters R.L.
        • Sie I.H.
        • Gellman H.
        • Tognella M.
        Functional hand surgery following tetraplegia.
        Arch Phys Med Rehabil. 1996; 77: 86-94
        • McDowell C.L.
        • House J.H.
        in: Green D.P. Hotchkiss R.N. Pederson W.C. Green's operative hand surgery. 4th ed. Churchill Livingstone, Philadelphia1999: 1597-1617
        • Connolly S.J.
        • Aubut J.L.
        • Teasell R.
        • Jarus T.
        • SCIRE Research Team
        Enhancing upper extremity function with reconstructive surgery in persons with tetraplegia: a review of the literature.
        Top Spinal Cord Inj Rehabil. 2007; 13: 58-80
        • Friden J.
        • Reinholdt C.
        • Turcsanyii I.
        • Gohritz A.
        A single stage operation for reconstruction of hand flexion, extension and intrinsic function in tetraplegia: the alphabet procedure.
        Tech Hand Up Extrem Surg. 2011; 15: 230-235
        • Wolfe S.W.
        • Hotchkiss R.N.
        • Pederson W.C.
        • Kozin S.H.
        in: Wolfe S.W. Green's operative hand surgery. 6th ed. Churchill Livingstone, Philadelphia2011: 1122-1145
        • Freehafer A.A.
        • Kelly C.M.
        • Peckham P.H.
        Tendon transfer for the restoration of upper limb function after a cervical spinal cord injury.
        J Hand Surg [Am]. 1984; 9: 887-893
        • Johanson M.E.
        • Murray W.M.
        • Hentz V.R.
        Comparison of wrist and elbow stabilization following pinch reconstruction in tetraplegia.
        J Hand Surg [Am]. 2011; 36: 480-485
        • Rothwell A.
        • Sinnott K.A.
        • Mohammed K.D.
        • Dunn J.A.
        • Sinclair S.W.
        Upper limb surgery for tetraplegia: a 10-year re-review of hand function.
        J Hand Surg [Am]. 2003; 28: 489-497
        • Freehafer A.A.
        Gaining independence in tetraplegia.
        Clin Orthop Relat Res. 1998; 355: 282-289
        • House J.H.
        • Shannon M.A.
        Restoration of strong grasp and lateral pinch in tetraplegia: a comparison of two methods of thumb control in each patient.
        J Hand Surg [Am]. 1985; 10: 21-29
        • Kirshblum S.C.
        • Burns S.P.
        • Biering-Sorensen F.
        • et al.
        International standards for neurological classification of spinal cord injury (revised 2011).
        J Spinal Cord Med. 2011; 34: 535-546
        • Mulcahey M.J.
        • Hutchinson D.
        • Kozin S.H.
        Assessment of the upper limb in tetraplegia: considerations in evaluation and outcomes research.
        J Rehabil Res Dev. 2007; 44: 91-102
        • World Health Organization
        International Classification of Functioning, Disability and Health.
        World Health Organization, Geneva2002
        • Dunn J.A.
        • Sinnott K.A.
        • Bryden A.M.
        • Connolly S.J.
        • Rothwell A.G.
        Measurement issues related to upper limb interventions in persons who have tetraplegia.
        Hand Clin. 2008; 24: 161-168
        • Sinnott K.A.
        • Dunn J.A.
        • Rothwell A.G.
        Use of the ICF conceptual framework to interpret hand function outcomes following tendon transfer surgery for tetraplegia.
        Spinal Cord. 2004; 42: 369-400
        • Sinnott K.A.
        • Dunn J.A.
        • Rothwell A.G.
        • Hall A.
        • Post M.W.
        The development of the NZ based International Upper Limb Surgery Registry.
        Spinal Cord. 2014; 52: 611-615
        • Revol M.
        • Cormerais A.
        • Laffont I.
        • Pedelucq J.P.
        • Dizien O.
        • Servant J.M.
        Tendon transfers as applied to tetraplegia.
        Hand Clin. 2002; 18: 423-439
        • House J.
        • McCarthy C.
        Intrinsic balancing in reconstruction of the tetraplegic hand. Current trends in hand surgery.
        Elsevier Science, Amsterdam1995
        • McCarthy C.K.
        • House J.H.
        • Heest A.V.
        • Kawiecki J.A.
        • Dahl A.
        • Hanson D.
        Intrinsic balancing in reconstruction of the tetraplegic hand.
        J Hand Surg [Am]. 1997; 22: 596-604
        • Leclercq C.
        Surgical rehabilitation for the weaker patients (groups 1 and 2 of the International Classification).
        Hand Clin. 2002; 18: 461-479
        • Kozin S.H.
        • D'Addesi L.
        • Chafetz R.S.
        • Ashworth S.
        • Mulcahey M.
        Biceps-to-triceps transfer for elbow extension in persons with tetraplegia.
        J Hand Surg [Am]. 2010; 35: 968-975
        • Endress R.D.
        • Hentz V.R.
        Biceps-to-triceps transfer technique.
        J Hand Surg [Am]. 2011; 36: 716-721
        • Dunkerley A.L.
        • Ashburn A.
        • Stack E.L.
        Deltoid triceps transfer and functional independence of people with tetraplegia.
        Spinal Cord. 2000; 38: 435-441
        • Netscher D.T.
        • Sandvall B.K.
        Surgical technique: posterior deltoid-to-triceps transfer in tetraplegic patients.
        J Hand Surg [Am]. 2011; 36: 711-715
        • Vanden Berghe A.
        • Van Laere M.
        • Hellings S.
        • Vercauteren M.
        Reconstruction of the upper extremity in tetraplegia: functional assessment, surgical procedures and rehabilitation.
        Paraplegia. 1991; 29: 103-112
        • Lo I.K.
        • Turner R.
        • Connelly S.
        • Delaney G.
        • Roth J.H.
        The outcome of tendon transfers for C6-spared quadriplegics.
        J Hand Surg [Br]. 1998; 23: 156-161
        • Johnson D.L.
        • Gellman H.
        • Waters R.L.
        • Tognella M.
        Brachioradialis transfer for wrist extension in tetraplegic patients who have fifth-cervical-level neurological function.
        J Hand Surg [Am]. 1996; 78: 1063-1067
        • Forner-Cordero I.
        • Mudarra-Garcia J.
        • Forner-Valero J.V.
        • Vilar-de-la-Pena R.
        The role of upper limb surgery in tetraplegia.
        Spinal Cord. 2003; 41: 90-96
        • Wangdell J.
        • Carlsson G.
        • Friden J.
        From regained function to daily use: experiences of surgical reconstruction of grip in people with tetraplegia.
        Disabil Rehabil. 2014; 36: 678-684
        • Sinnott K.A.
        • Brander P.
        • Siegart R.J.
        • Rothwell A.G.
        • De Jong G.
        Life impacts following reconstructive hand surgery for tetraplegia.
        Top Spinal Cord Inj Rehabil. 2009; 15: 90-97
        • Wangdell J.
        • Friden J.
        Satisfaction and performance in patient selected goals after grip reconstruction in tetraplegia.
        J Hand Surg Eur Vol. 2010; 35: 563-568
        • Hamou C.
        • Shah N.R.
        • DiPonio L.
        • Curtin C.M.
        Pinch and elbow extension restoration in people with tetraplegia: a systematic review of the literature.
        J Hand Surg [Am]. 2009; 34: 692-699
        • Kalsi-Ryan S.
        • Verrier M.C.
        A synthesis of best evidence for the restoration of upper-extremity function in people with tetraplegia.
        Physiother Can. 2011; 63: 474-489
        • Hentz V.R.
        • Leclercq C.
        Surgical rehabilitation of the upper limb in tetraplegia.
        WB Saunders, New York2002
        • Wangdell J.
        • Friden J.
        Activity gains after reconstruction of elbow extension in patients with tetraplegia.
        J Hand Surg [Am]. 2012; 37: 1003-1010
        • Lamberg A.S.
        • Fridén J.
        Changes in skills required for using a manual wheelchair after reconstructive hand surgery in tetraplegia.
        J Rehabil Med. 2011; 43: 714-719
        • Mulcahey M.J.
        • Lutz C.
        • Kozin S.H.
        • Betz R.R.
        Prospective evaluation of biceps to triceps and deltoid to triceps for elbow extension in tetraplegia.
        J Hand Surg [Am]. 2003; 28: 964-971
        • Meiners T.
        • Abel R.
        • Lindel K.
        • Mesecke U.
        Improvements in activities of daily living following functional hand surgery for treatment of lesions to the cervical spinal cord: self-assessment by patients.
        Spinal Cord. 2002; 40: 574-580
        • Woulle K.S.
        • Bryden A.M.
        • Peckham P.H.
        • Murray P.K.
        • Keith M.
        Satisfaction with upper-extremity surgery in individuals with tetraplegia.
        Arch Phys Med Rehabil. 2003; 84: 1145-1149
        • Mulcahey M.J.
        • Betz R.R.
        • Smith B.T.
        • Weiss A.A.
        A prospective evaluation of upper extremity tendon transfers in children with cervical spinal cord injury.
        J Pediatr Orthop. 1999; 19: 319-328
        • Waters R.L.
        • Moore K.R.
        • Graboff S.R.
        • Paris K.
        Brachioradialis to flexor pollicus longus tendon transfer for active lateral pinch in the tetraplegic.
        J Hand Surg [Am]. 1985; 10A: 385-391
        • Wangdell J.
        • Carlsson G.
        • Fridén J.
        Enhanced independence: experiences after regaining grip function in people with tetraplegia.
        Disabil Rehabil. 2013; 35: 1968-1974
        • Dunn J.A.
        • Rothwell A.G.
        • Mohammed K.D.
        • Sinnott K.A.
        The effects of aging on upper limb tendon transfers in patients with tetraplegia.
        J Hand Surg [Am]. 2014; 39: 317-323
        • Focks-Feenstra J.J.
        • Snoek G.
        • Bongers-Janssen H.
        • Nene A.
        Long-term patient satisfaction after reconstructive upper extremity surgery to improve arm–hand function in tetraplegia.
        Spinal Cord. 2011; 49: 903-908