Early Results of 3-Dimensional Planning and Customized Cutting Guides for the Treatment of Severe Madelung Defofrmity.

PURPOSE: Surgical treatment of Madelung deformity can present challenges due to a need for multiplanar correction. Developing customized cutting guides for osteotomies may improve surgical outcomes by enhancing the surgeon's understanding and surgical correction. METHODS: All patients who underwent forearm osteotomies for Madelung deformity using computed tomography planning with 3-dimensional-printed customized cutting guides were retrospectively reviewed (n = 8). Seven patients underwent a double osteotomy of the radius, and 1 underwent a single osteotomy. RESULTS: Ulnar tilt was improved in all cases. Correction of deformity was significant on anteroposterior but not on lateral views. The mean preoperative and postoperative radial bow was measured in 2 planes, with an average preoperative bow of 32° (± 21°) on anteroposterior radiographs and 36° (± 17°) on lateral radiographs, and an average bow of 10° (± 6°) on anteroposterior radiographs and 7° (± 6°) on lateral films after surgery. The predicted radial bow was calculated to be 9.1° (± 8°). CONCLUSIONS: Three-dimensional planning allows predictable deformity correction across multiple but not all parameters. Future studies comparing clinical and radiographic outcomes of guided versus nonguided osteotomies are required to justify the additional expense and preoperative planning efforts. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Polydactyly a review and update of a common congenital hand difference.

PURPOSE OF REVIEW: The purpose of this review is to describe various forms of hand polydactyly and their different treatment approaches. Hand polydactyly is commonly classified as ulnar (small finger) or radial (thumb). Polydactyly can be sporadic, genetic, and/or associated with syndromic conditions. RECENT FINDINGS: Both ulnar and radial polydactyly can be surgically treated to optimize hand aesthetics and function. Timing of surgery is based on multiple factors, most notably including safety of anesthesia and socialization of the affected child. The pediatrician should be aware of potential associated conditions, such as chondroectodermal dysplasia or Ellis-van Creveld syndrome for ulnar polydactyly. SUMMARY: Polydactyly is a common congenital hand difference and can be broadly be classified by radial or ulnar involvement. Polydactyly warrants hand surgical referral, as surgical treatment is often indicated. Pediatricians should be aware of treatment options, as well as of commonly associated anomalies and syndromes.

The Effect of Distal Radius Fracture Location on Distal Radioulnar Joint Stability: A Cadaveric Study.

PURPOSE: To investigate whether the location of distal radius osteotomy/shortening relative to the radial insertion of the distal interosseous membrane (DIOM) is correlated with distal radioulnar joint (DRUJ) instability. We hypothesized that distal radius osteotomy and shortening proximal to the DIOM insertion would result in increased DRUJ instability because of induced laxity in the DIOM. METHODS: Osteotomies of the distal radius were performed proximal and distal to the DIOM insertion in 14 fresh-frozen cadaveric specimens. Using a volar plate, 5 conditions were tested: anatomical radius alignment; 2- and 4-mm shortening at the proximal osteotomy site; and 2- and 4-mm shortening at the distal osteotomy site. Basilar ulnar styloid osteotomy was performed to simulate triangular fibrocartilage complex (TFCC) detachment-specimens were tested with the ulnar styloid detached and the ulnar styloid fixed (to restore normal anatomy). The DRUJ stability was quantified using dorsal-volar displacement of the radius in response to 20 N of force using a force-displacement probe in neutral, pronation, and supination. Posttesting specimen dissections assessed DIOM and distal oblique bundle (DOB) anatomy. The DRUJ stability in each experimental condition was compared with a multifactor repeated measures analysis of variance with the specimen treated as the repeated factor. RESULTS: There were no significant differences in dorsal-volar translation of the radius (ie, DRUJ stability) between radial osteotomy/shortening proximal and distal to the DIOM insertion, regardless of forearm rotational position or magnitude of shortening. Five (36%) of the 14 specimens had a DOB present. There was a significant increase in DRUJ instability in the setting of TFCC detachment (via basilar ulnar styloid osteotomy). CONCLUSIONS: No difference in DRUJ stability was observed between distal radius osteotomy/shortening proximal and distal to the DIOM radial insertion, regardless of forearm rotation, magnitude of shortening, and/or TFCC detachment. CLINICAL RELEVANCE: Distal radius osteotomy and shortening did not affect DRUJ stability regardless of location relative to the DIOM insertion.

Arthroscopic Diagnosis of the Triangular Fibrocartilage Complex Foveal Tear: A Cadaver Assessment.

PURPOSE: To determine whether the arthroscopic hook and trampoline tests are accurate and reliable diagnostic tests for foveal triangular fibrocartilage complex (TFCC) detachment. METHODS: Wrist arthroscopy was performed on 10 cadaveric upper extremities. Arthroscopic hook and trampoline tests were performed and videos recorded (baseline). The deep foveal TFCC insertion was then sharply detached. Arthroscopic hook and trampoline tests were repeated. Subsequently, the foveal detachment was repaired via an ulnar tunnel technique and the hook test was repeated for a third time. Videos were independently reviewed at 2 time points by 2 fellowship-trained hand surgeons and 1 hand surgery fellow in a randomized and blinded fashion. Hook and trampoline tests were graded as positive or negative. Proportions of categorical variables were compared via 2-tailed Fisher exact test. Inter- and intraobserver reliabilities were assessed via Cohen kappa coefficient. RESULTS: The sensitivity and specificity of the hook test for foveal detachment diagnosis were 90% and 90%, respectively. There was 90% agreement among all 3 observers for the baseline and foveal detachment hook tests. Cohen kappa coefficients for the inter- and intraobserver reliabilities of the hook test were 0.87 and 0.81, respectively. Seventeen percent of trampoline tests were positive at baseline versus 43% after foveal detachment. The trampoline test had 45% agreement between the 3 observers. Cohen kappa coefficients for the inter- and intraobserver reliabilities of the trampoline test were 0.16 and 0.63, respectively. Following ulnar tunnel repair, 20% of hook tests were positive. CONCLUSIONS: The hook test is highly sensitive, specific, and reliable for the diagnosis of isolated TFCC foveal detachment. The trampoline test has insufficient reliability to assess foveal detachment. A TFCC foveal repair using an ulnar tunnel technique returns the hook test to baseline. CLINICAL RELEVANCE: The hook test is a sensitive, specific, and reliable test for the diagnosis of isolated TFCC foveal detachment.

Radiographic Results and Complications of 3 Guided Growth Implants.

BACKGROUND: Temporary, implant-mediated hemiepiphysiodesis (ie, guided growth) is an effective and popular treatment method for lower extremity angular deformities. The purpose of this study was to retrospectively evaluate the safety profile of 3 different implants used to correct lower extremity angular deformities in pediatric patients. METHODS: We retrospectively reviewed a consecutive series of pediatric patients with lower extremity angular deformities who underwent implant-mediated guided growth by 2 surgeons at our institution between 2004 and 2014. Implants were selected according to surgeon preference and included the Biomet peanut plate, Orthofix eight-plate, and Pega Medical hinge plate. Medical records and radiographs were reviewed to assess deformity correction, implant integrity, and complications. RESULTS: During the study period, 115 plates (63 Biomet peanut plates, 30 Orthofix eight-plates, and 22 Pega Medical hinge plates) were implanted in 52 patients (24 males, 28 females). Average age at implantation was 11.7 years (12.3 y in males, 11.1 y in females). Average length of follow-up was 18.4 months. There was no significant difference in rate of deformity correction between the implant types (P=0.08).Three broken screws (2.6%) were observed, all of which involved cannulated screws in peanut plates. Four peanut plates (6.3%) had an implant-related complication: 3 broken screws and 1 screw pullout. Three eight-plates (10.0%) had screw pullout. No complications were observed within either the hinge plate or solid screw groups. Implant-related complications were significantly associated with increased body weight and cannulated screw use (P=0.02 and 0.03, respectively), but not bone age, sex, plate type, or rate of deformity correction. No deep infections, premature growth arrests, or plate breakages were observed. CONCLUSIONS: Implant-mediated guided growth is a safe technique for pediatric lower extremity angular deformity correction with a low complication rate. This study demonstrated that overweight patients had a significantly higher rate of implant-related complications. Screw breakages were only observed with cannulated screws in peanut plates. Thus, we recommend using solid, noncannulated screws in overweight children who are at an increased risk of implant failure. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Online Patient Ratings: Why They Matter and What They Mean.

The increasing focus on patient satisfaction and consumer-driven health care, combined with the recent rise in online social media, have resulted in the growing trend of patients rating physicians on publicly accessible Web sites. The number and use of such Web sites continue to grow despite potential concerns about the validity of these ratings and negative physician perception. These Web sites can influence patient decision making regarding physician selection. In this article, we review the literature regarding the use of such Web sites by patients, the validity of these ratings, potential implications for hand surgical practice, and methods to minimize or challenge inaccurate reviews.

Risk Factors for 30-Day Postoperative Complications Following Open Reduction Internal Fixation of Proximal Ulna Fractures.

PURPOSE: Fractures of the proximal ulna are common injuries in the elderly population. These fractures can be managed nonsurgically or with open reduction internal fixation (ORIF). Whereas nonsurgical management may lead to a relative loss of elbow extension and to nonunion, ORIF carries a risk of complications. Although complications specific to the orthopedic intervention have been reported, few studies have identified postoperative systemic complications in this higher-risk group. The purposes of this study were to determine the rate of systemic complications in patients undergoing surgical fixation of proximal ulna fractures and to determine risk factors for complications. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database for all cases of proximal ulna fracture ORIF between 2005 and 2013. Demographic, historical, and preoperative laboratory data and 30-day postoperative complications were recorded. Univariate and multivariable analyses were performed to identify independent risk factors for complications. RESULTS: A total of 650 patients met inclusion criteria. Within the 30-day postoperative period, 61 complications occurred in 45 patients (6.9%). Return to the operating room, which occurred in 19 patients (2.9%), was the most common major morbidity. American Society of Anesthesiologists class III or IV and dialysis dependence were independent risk factors for any complication. CONCLUSIONS: Proximal ulna fracture ORIF has a low rate of systemic complications. The most common morbidities are return to the operating room, blood transfusion, and urinary tract infections. Dialysis and American Society of Anesthesiologists class III or IV are independent risk factors for complications. These complications may be nonspecific and related more to the patient population than procedure. We believe that the relatively low risk of short-term complications makes operative treatment a suitable option even in elderly patients with multiple morbidities. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Online Patient Ratings of Hand Surgeons.

PURPOSE: To evaluate factors associated with positive online patient ratings and written comments regarding hand surgeons. METHODS: We randomly selected 250 hand surgeons from the American Society for Surgery of the Hand member directory. Surgeon demographic and rating data were collected from 3 physician review Web sites (www.HealthGrades.com, www.Vitals.com, and www.RateMDs.com). Written comments were categorized as being related to professional competence, communication, cost, overall recommendation, staff, and office practice. Online presence was defined by 5 criteria: professional Web site, Facebook page, Twitter page, and personal profiles on www.Healthgrades.com and/or www.Vitals.com. RESULTS: A total of 245 hand surgeons (98%) had at least one rating among the 3 Web sites. Mean number of ratings for each surgeon was 13.4, 8.3, and 1.9, respectively, and mean overall ratings were 4.0 out of 5, 3.3 out of 4, and 3.8 out of 5 stars on www.HealthGrades.com, www.Vitals.com, and www.RateMDs.com, respectively. Positive overall ratings were associated with a higher number of ratings, Castle Connolly status, and increased online presence. No consistent correlations were observed among online ratings and surgeon age, sex, years in practice, practice type (ie, private practice vs academics), and/or geographic region. Finally, positive written comments were more often related to factors dependent on perceived surgeon competence, whereas negative comments were related to factors independent of perceived competence. CONCLUSIONS: Physician review Web sites featured prominently on Google, and 98% of hand surgeons were rated online. This study characterized hand surgeon online patient ratings as well as identified factors associated with positive ratings and comments. In addition, these findings highlight how patients assess care quality. CLINICAL RELEVANCE: Understanding hand surgeon online ratings and identifying factors associated with positive ratings are important for both patients and surgeons because of the recent growth in physician-rating Web sites.

Matrilin-3 inhibits chondrocyte hypertrophy as a bone morphogenetic protein-2 antagonist.

Increased chondrocyte hypertrophy is often associated with cartilage joint degeneration in human osteoarthritis patients. Matrilin-3 knock-out (Matn3 KO) mice exhibit these features. However, the underlying mechanism is unknown. In this study, we sought a molecular explanation for increased chondrocyte hypertrophy in the mice prone to cartilage degeneration. We analyzed the effects of Matn3 on chondrocyte hypertrophy and bone morphogenetic protein (Bmp) signaling by quantifying the hypertrophic marker collagen type X (Col X) gene expression and Smad1 activity in Matn3 KO mice in vivo and in Matn3-overexpressing chondrocytes in vitro. The effect of Matn3 and its specific domains on BMP activity were quantified by Col X promoter activity containing the Bmp-responsive element. Binding of MATN3 with BMP-2 was determined by immunoprecipitation, solid phase binding, and surface plasmon resonance assays. In Matn3 KO mice, Smad1 activity was increased more in growth plate chondrocytes than in wild-type mice. Conversely, Matn3 overexpression in hypertrophic chondrocytes led to inhibition of Bmp-2-stimulated, BMP-responsive element-dependent Col X expression and Smad1 activity. MATN3 bound BMP-2 in a dose-dependent manner. Multiple epidermal growth factor (EGF)-like domains clustered together by the coiled coil of Matn3 is required for Smad1 inhibition. Hence, as a novel BMP-2-binding protein and antagonist in the cartilage extracellular matrix, MATN3 may have the inherent ability to inhibit premature chondrocyte hypertrophy by suppressing BMP-2/Smad1 activity.

Accredited hand surgery fellowship Web sites: analysis of content and accessibility.

PURPOSE: To assess the accessibility and content of accredited hand surgery fellowship Web sites. METHODS: A list of all accredited hand surgery fellowships was obtained from the online database of the American Society for Surgery of the Hand (ASSH). Fellowship program information on the ASSH Web site was recorded. All fellowship program Web sites were located via Google search. Fellowship program Web sites were analyzed for accessibility and content in 3 domains: program overview, application information/recruitment, and education. RESULTS: At the time of this study, there were 81 accredited hand surgery fellowships with 169 available positions. Thirty of 81 programs (37%) had a functional link on the ASSH online hand surgery fellowship directory; however, Google search identified 78 Web sites. Three programs did not have a Web site. Analysis of content revealed that most Web sites contained contact information, whereas information regarding the anticipated clinical, research, and educational experiences during fellowship was less often present. Furthermore, information regarding past and present fellows, salary, application process/requirements, call responsibilities, and case volume was frequently lacking. Overall, 52 of 81 programs (64%) had the minimal online information required for residents to independently complete the fellowship application process. CONCLUSIONS: Hand fellowship program Web sites could be accessed either via the ASSH online directory or Google search, except for 3 programs that did not have Web sites. Although most fellowship program Web sites contained contact information, other content such as application information/recruitment and education, was less frequently present. CLINICAL RELEVANCE: This study provides comparative data regarding the clinical and educational experiences outlined on hand fellowship program Web sites that are of relevance to residents, fellows, and academic hand surgeons. This study also draws attention to various ways in which the hand surgery fellowship application process can be made more user-friendly and efficient.

Characteristics of glomus tumors in the hand not diagnosed on magnetic resonance imaging.

PURPOSE: To determine whether the diagnosis of hand glomus tumors by magnetic resonance imaging (MRI) is associated with tumor size, tumor pathology, tumor location, and/or clinical suspicion. METHODS: We reviewed our pathology database for patients with hand glomus tumors diagnosed between 2006 and 2013 and included those patients who had preoperative MRI at our institution. We excluded patients with recurrent and persistent tumors. Magnetic resonance imaging reports were reviewed for clinical history, tumor location, and associated bone erosion. Pathology reports were reviewed for diagnosis and tumor size. We classified MRI studies as positive (glomus tumor diagnosis), negative (no mention of glomus tumor as possible diagnosis), or indeterminate (glomus tumor mentioned as possible differential diagnosis). Fisher exact test was used to compare positive studies and those that were nondiagnostic (ie, either negative or indeterminate). RESULTS: Of the 46 patients who had pathologically confirmed hand glomus tumors, 38 had preoperative MRI studies. A total of 24 MRI studies were positive, 5 were indeterminate, and 7 were negative. Five patients had atypical pathology, 1 had a multifocal tumor, and 2 had extra-digital hand glomus tumors. Failure to diagnose glomus tumors on MRI was associated with atypical pathology, atypical location (ie, not located in the subungual region), absence of bone erosion, and lack of clinical suspicion. Tumor size was not associated with MRI diagnosis. CONCLUSIONS: In this series of 36 hand glomus tumors, one-third of MRI studies were nondiagnostic. Occurrence of nondiagnostic MRIs was more likely when glomus tumors were pathologically and/or anatomically atypical, without bone erosion, and with no or unrelated clinical history provided. These findings highlight the continued importance of clinical suspicion in glomus tumor diagnosis. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Long-term Outcomes of Triple Arthrodesis in Cerebral Palsy Patients.

BACKGROUND: Triple arthrodesis in the appropriately indicated cerebral palsy patient with a painful and/or rigid foot deformity can significantly alleviate pain and improve function. Limited data on long-term outcomes of triple arthrodesis in this patient population exist. In addition, there have been concerns about the long-term consequences of altered biomechanics in these patients on the tibiotalar (ankle) joint. METHODS: We retrospectively reviewed 21 cerebral palsy patients who had undergone triple arthrodesis for a painful and/or rigid foot deformity at our institution with at least 10 years of clinical or radiographic follow-up. Preoperative, and the most recent, clinical evaluations and radiographs were reviewed. In addition, all 21 patients and/or caretakers responded to a questionnaire at the time of this study by means of telephone to assess subjective pain, analgesia use, walking aid necessity, walking distance, and satisfaction with the procedure. RESULTS: In this series of 21 cerebral palsy patients, 5 patients had bilateral surgery, resulting in 26 operative feet. The mean age at the time of surgery was 19.4 years and most recent clinical or radiographic follow-up was 22.1 years postoperatively. Preoperative foot deformity was characterized by hindfoot valgus in 66.7% (14/21) and varus in 33.3% (7/21) of patients. Postoperatively, fusion was achieved in 96.2% (25/26) of feet. At final follow-up, 3 feet (11.5%) demonstrated tibiotalar joint arthritis, 1 (3.8%) had midfoot arthritis, and 10 (38.5%) had residual deformity. Of the total patients, 95.2% (20/21) were satisfied with the outcome and 61.9% (13/21) reported pain-free ambulation. There was no association between eventual functional outcome and preoperative diagnosis, preoperative foot deformity, postoperative tibiotalar joint arthritis, or postoperative residual deformity. CONCLUSIONS: Triple arthrodesis is a surgical option in cerebral palsy patients with painful and/or rigid foot deformities. From this series, successful outcomes can be expected as long as bony union is achieved. The incidence of tibiotalar arthritis is relatively low and not associated with long-term functional outcome. In addition, preoperative and residual postoperative foot deformity is not associated with long-term outcome.

Acetabular Protrusio and Proximal Femur Fractures in Patients With Osteogenesis Imperfecta.

BACKGROUND: Osteogenesis imperfect (OI) is a genetic disorder characterized by increased bone fragility, frequent fractures, and extremity deformities among other clinical findings. A frequent radiographic finding in OI patients is acetabular protrusio (AP). We hypothesized that AP incidence would be significant in OI patients and highest among type III OI patients, who have a more severe disease phenotype. In addition, we hypothesized that there would be a correlation between AP and proximal femur fracture incidence. METHODS: We retrospectively reviewed radiographs and medical records of 49 patients with OI evaluated at our institution. Demographic information and modified Sillence classification were recorded. AP was diagnosed using previously published radiographic criteria using the center-edge angle of Wiberg, acetabulum relative to the iliopectineal line, teardrop figure relative to the ilioischial (Kohler) line, and acetabulum relative to the ilioischial (Kohler) line. Medical record and radiographs were reviewed for evidence of proximal femur or acetabulum fracture. Associations between OI type, AP, and fracture incidence were examined with χ or Fisher exact tests. RESULTS: In this series of 49 OI patients, the overall incidence of AP was 55.1% (27/49) with the highest incidence among patients with type III OI (70.6%). There was an increased incidence of proximal femur, and particularly femoral neck, fractures among patients with AP compared with patients with normal hip anatomy. Overall, patients with AP had a 30% increased risk for proximal femur and acetabulum fractures (P=0.03). CONCLUSIONS: AP is a common deformity in OI patients (55.1%) and particularly type III OI (70.6%). Patients with AP have an increased risk for proximal femur fractures and particularly femoral neck fractures. This novel finding adds to the growing body of literature on clinical implications of AP in OI patients. LEVEL OF EVIDENCE: Level IV-Retrospective case series.

Partial Flexor Tendon Injury Causing Locking: Illustration of the Utility of Dynamic Ultrasound.

Clinical diagnosis of partial flexor tendon lacerations is challenging because tendon function may be preserved. Although some partial flexor tendon tears can be managed conservatively, pain, stiffness, and triggering/locking may result, requiring surgical management. The mechanism by which this occurs has been investigated in animal and cadaver studies but has not been demonstrated in patients with real-time, in vivo imaging. Here, we present a case of partial tendon tear presenting with severe pain and locking that was diagnosed before surgery and characterized with dynamic ultrasound.

Incidence of Nerve Repair Following Endoscopic Carpal Tunnel Release Is Higher Compared to Open Release in New York State.

BACKGROUND: Carpal tunnel release (CTR) has traditionally been performed through an open approach, although in recent years endoscopic CTR has gained in popularity. QUESTIONS/PURPOSES: We sought to assess whether a difference exists between the rates of nerve repair surgery following open versus endoscopic CTR in New York State (NYS). METHODS: Patients undergoing endoscopic and open CTR from 1997 to 2013 were identified from the Statewide Planning and Research Cooperative System (SPARCS) database from the NYS Department of Health using Current Procedural Terminology, 4th Revision (CPT-4) codes 29848 and 64721, respectively. The primary outcome measure was subsequent nerve repair surgery (as identified using CPT-4 codes 64831-64837, 64856, 64857, 64859, 64872, 64874, and 64876). Other variables analyzed included patient age, sex, payer, and surgery year. RESULTS: There were 294,616 CTRs performed in NYS from 1997 to 2013. While the incidence of open CTR remained higher than endoscopic CTR, the proportion of endoscopic CTR steadily increased, from 16% (2984/19,089) in 2007 to 25% (5594/22,271) in 2013. For the 134,143 patients having a single CTR, the rate of subsequent nerve repair was significantly higher following endoscopic CTR (0.09%) compared to open CTR (0.04%). The Cox model showed that factors significantly associated with a higher risk of subsequent nerve repair surgery were endoscopic CTR and younger age. CONCLUSIONS: Endoscopic CTR has been increasingly performed in NYS and associated with a higher rate of subsequent nerve repair. This rate likely underestimates the incidence of nerve injuries because it only captures those patients who had subsequent surgery. While this catastrophic complication remains rare, further investigation is warranted, given the rise of endoscopic CTR in the setting of equivalent outcomes, but favorable reimbursement, versus open CTR.

Arthroscopic treatment of triangular fibrocartilage complex injuries in paediatric and adolescent patients.

We assessed outcomes of 43 paediatric and adolescent patients (44 wrists) undergoing arthroscopic triangular fibrocartilage complex surgery by a single surgeon between 2003 and 2016. Medical records were reviewed for clinical, imaging, and operative data. Preoperatively, 49% of patients had additional diagnoses and mean QuickDASH was 47. Patients were telephoned to assess current wrist pain, subsequent treatment(s), satisfaction, and to complete QuickDASH and Patient-Rated Wrist Evaluation questionnaires. Twenty-five patients responded with mean follow-up of 70 months (minimum 13 months). In those patients not reached by telephone, mean clinical follow-up was 21 months. Seven patients had subsequent surgery (most commonly ulnar shortening osteotomy); this was associated with lower satisfaction scores. At final follow-up, mean QuickDASH was 4, Patient-Rated Wrist Evaluation 8 and patient and parent satisfaction scores were 9 and 9 out of 10, respectively. In conclusion, arthroscopic triangular fibrocartilage complex treatment in paediatric patients yielded favourable outcomes and patient/parent satisfaction. Level of evidence: IV.

Technical Pearls of Tendon Transfers for Upper Extremity Spasticity.

Tendon transfers are an important surgical option when treating patients with muscular imbalance due to upper extremity spasticity. A successful surgical outcome requires a thorough preoperative clinical evaluation, an understanding of tendon transfer biomechanics, appropriate donor and recipient muscle selection, technical execution, and postoperative rehabilitation. This article reviews the principles, biomechanics, and techniques for commonly performed tendon transfers in patients with upper extremity spasticity.