. 2011 Oct 20;63(4):474–489. doi: 10.3138/ptc.2009-46

Table 3.

Surgical Intervention Literature with Sufficient Methodological Quality**

Author (date)	Modified SIGN score	Sample and characteristics	Objectives of study	Study design	Outcome measures	Effect and summary of study results
Laffont et al. (2007)⁶⁴	9	Chronic traumatic tetraplegia 12 patients (10 male, 2 female), 17 hands: C6/C7 Age 17–51 y Procedures included deltoid to triceps transfer, ECRL to FDP, and BR to FDP	To quantify the effect of tendon transfers	Cross-sectional study—3 groups: Group A: no elbow ext with passive tenodesis Group B: elbow ext Group C: elbow ext with finger flexion/ext	Tetra Ball Test to examine grasp and release control of various-sized balls in neutral supination and pronation of forearm	Analysis: ANOVA for statistically significant differences between groups Effect: Failures for grasping decreased from groups A to C (p<0.0001); duration of movement decreased from A to C (p<0.0001) Summary: Group C had superior ability over Groups A and B in terms of grasp and release and quickness of functions.
Johanson et al. (2006)⁶⁵	8	Chronic traumatic tetraplegia 10 patients (8 male, 2 female), 11 hands: C6/C7 Procedures included BR to FPL 10 y after surgery	BR activation during elbow flexion and thumb abduction after BR to FPL transfer	Cross-sectional study comparing transferred BR activity when used for elbow flexion and thumb abduction	Muscle activation with EMG	Analysis: Wilcoxon signed rank test for between-test conditions Effect: EMG of BR for thumb abduction was 34% and 55% (with elbow stabilized) of maximal BR force for elbow flexion, significantly less (p<0.05). Pinch force was 14N and 20N (with elbow stabilized). Summary: Postoperative difficulty exists in activating BR post transfer for thumb abduction.
Vastamäki (2006)⁶⁶	9	Chronic traumatic tetraplegia 6 patients (6 male), 10 hands: C5/C6 Mean age 55 y Procedures: deltoid to triceps transfer, BR to FPL	To investigate the long-term (24 y) and short-term (3 y) results after surgery	Longitudinal cohort study—1 group; comparisons at 3 y and 24 y after surgery	•LKP strength and elbow-extension strength.	Analysis: Descriptive statistical comparisons Effect: LKP and elbow ext strength decline at 3 years by 21% and 16% respectively. Functional status is maintained or slightly improved. Subjective information showed half the sample felt improvement and all participants felt they were stable. Summary: Early post-surgical gains are maintained to long-term status despite a loss of strength.
Rothwell et al. (2003)⁶⁷	10	Chronic traumatic tetraplegia 24 patients, 48 hands: C5/C6 Mean age 42 y Mean time post injury 20 y Procedures included BR to FPL, ECRL to FDP, BR to FDP, PT to FPL	To determine the long-term benefits of reconstructive hand surgery	Longitudinal cohort study Same-group comparison shortly after surgery vs. 12–18 years after surgery	Lamb and Chan Questionnaire: perceived improvement of independence QIF LKP and cylindrical grasp strength	Analysis: Descriptive statistical comparisons Effect: Cylindrical grip: slightly improved (not significant); LKP: slightly diminished QIF compared to functional status by memory. Summary: Individuals have objective long-term improvement in hook grip. Self-perception of function is questionable due to different measures used at baseline and follow-up.
Meiners et al. (2003)⁶⁸	8	Chronic traumatic tetraplegia 24 patients (21 male, 3 female), 25 hands: C5/C6 Mean age 37.5 y Procedures included BR to FPL, FCR to FPL or EPL, ECRL to FDP, BR to FDP	To examine the efficacy of wrist extension, lateral key pinch, and cylindrical grasp	Longitudinal cohort study Same group before and 9–51 months after tendon transfer	Lamb and Chan Questionnaire: perceived improvement of independence LKP and cylindrical grasp strength	Analysis: Mean of difference between pre and post measures Effect: Subjective questionnaire: 8.7-item increase. Strength increase, cylindrical grasp: 893 g; LKP: 488 g. Summary: Gains in ADLs and strength are made with surgery.
Lo et al. (1998)⁶⁹	8	Chronic traumatic tetraplegia 9 patients, 12 hands: C6 Age: 23–40 y Procedures: ECRL or B to FDP 4.5 y after injury	To evaluate, subjectively and objectively, improvements after tendon transfers	Retrospective cohort study Compared surgical hand with non-surgical hand	Lamb and Chan Questionnaire Grip and LKP dynamometry MRMT Carroll Upper Extremity Function Test Questionnaire rated pre and post state at time of study	Analysis: Descriptive statistical comparisons of surgical (S) vs. non-surgical (NS) hand Effect: Individuals perceived improvement from memory. Grip strength: 24kg (S) / 21.5kg (NS); LKP strength: 1.2kg (S) / 1.0kg (NS). MRM did not show a difference. Carroll Upper Extremity Test: 72.5 (S), 52.4 (NS). Summary: Objective measures show small differences between surgical and non-surgical hands.

Note: Table applies to the C5/C6/C7 complete sub-group of tetraplegia in Figure 1.

BR=brachioradialis; ext=extension; ECRL=extensor carpi radialis longus; EPL=extensor pollicis longus; FCR=flexor carpi radialis; FDP=flexor digitorum profundus; FIM=Functional Independence Measure; FPL=flexor pollicis longus; GRT=Grasp and Release Test; ISNCSCI=International Standards of Neurological Classification of Spinal Cord Injury; JHFT=Jebsen Hand Function Test; LKP=lateral key pinch; MMT=manual muscle testing; MRMT=Minnesota Rate of Manipulation test; QIF=Quadriplegia Index of Function; ROM=range of motion; SCI=spinal-cord injury.