Intraoperative Measurement and Biomechanical Modeling of the Flexor Carpi Ulnaris-to-Extensor Carpi Radialis Longus Tendon Transfer

Abstract

Sarcomere length was measured intraoperatively in five patients undergoing tendon transfer of the flexor carpi ulnaris (FCU) to the extensor carpi radialis longus (ECRL) for radial nerve palsy. All measurements were made with the elbow in 20 deg of flexion. Prior to tendon transfer, FCU sarcomere length ranged from 2.84 ±. 12 μm (mean ± SEM) with the wrist flexed to 4.16 ± .15 μm with the wrist extended. After transfer into the ECRL tendon, sarcomere length ranged from 4.82 ± .11 μm with the wrist flexed (the new longest position of the FCU) to 3.20 ± .09 μm with the wrist extended, resulting in a shift in the sarcomere length operating range to significantly longer sarcomere lengths (p < 0.001). At these longer sarcomere lengths, the FCU muscle was predicted to develop high active tension only when the wrist was highly extended. A biomechanical model of this tendon transfer was generated using normative values obtained from previous studies of muscle architectural properties, tendon compliance, and joint moment arms. Predicted sarcomere lengths pre- and post-tendon transfer agreed well with intraoperative experimental measurements. The theoretical wrist extension moment-wrist joint angle relationship was also calculated for a variety of values of FCU muscle length. These different lengths represented the different conditions under which the FCU could be sutured into the ECRL tendon. Variation in FCU muscle length over the range 200 mm to 260 mm resulted in large changes in absolute peak moment produced as well as the angular dependence of peak moment. This was due to the change in the region of FCU operation on its sarcomere length-tension curve relative to the magnitude of the ECRL moment arm. These data demonstrate the sensitivity of a short-fibered muscle such as the FCU to affect the functional outcome of surgery. In addition, we demonstrated that intraoperative sarcomere length measurements, combined with biomechanical modeling provide the surgeon with a powerful method for predicting the functional effect of tendon transfer surgery.