Fundamental principles of muscle-tendon units include the following:

• Correction of contracture
o In any patient with peripheral nerve palsy, all joints must be kept supple because soft tissue
contracture is far easier to prevent than to correct.
o Maximum passive motion of all joints must be present before a tendon transfer because no tendon
transfer can move a stiff joint.
• Adequate strength
o The tendon chosen as a donor for transfer must be strong enough to perform its new function in its
altered position. Selecting an appropriate motor is important because a muscle will lose one grade of
strength following transfer.
o Do not transfer muscle that has been reinnervated or muscle that was paralyzed and has returned to
function.
• Amplitude of motion
o Consider the amplitude of tendon excursion for each muscle. A wrist flexor with an excursion of 33
mm cannot substitute fully for a finger extensor with an amplitude of 50 mm.
o Although the true amplitude of a tendon cannot be increased, its effective amplitude can be
augmented 2 ways. First, the natural tenodesis effect can be used by converting a muscle from
monoarticular to biarticular or multiarticular. Second, extensively dissecting a muscle from its
surrounding fascial attachments can increase amplitude.
• Straight line of pull
o In the most effective transfer, the muscle passes in a direct line from its origin to the insertion of the
tendon being substituted.
o Although not always possible, this configuration is desirable.
• One tendon, one function
o A single tendon cannot be expected to simultaneously perform diametrically opposing actions, eg,
flex and extend the same joint.
o If a muscle is inserted into 2 tendons with separate functions, the force of amplitude of the donor
tendon is dissipated and less effective than that of a muscle motored by a single tendon.
• Synergism
o The use of synergistic muscles, eg, finger flexors acting in concert with wrist extensors and finger
extensors with wrist flexors, has been advocated for transfer.
o Muscle function is easier to retain after synergistic muscle transfer.
• Expendable donor
o The removal of a tendon for transfer must not result in an unacceptable loss of function.
o Sufficient muscle must remain to substitute for the donor muscle.
• Timing of tendon transfer
o No transfer should be performed until the local tissues are in optimal condition. The term often used
to describe this is tissue equilibrium. Tissue is in equilibrium when soft tissue induration has resolved,
when any reaction in the wound is absent, when joints are supple, and when the scars are as soft as
they are likely to become.
o Tendon transfers function best when passed between subcutaneous fat and the deep fascial layer;
they are not likely to be functional if placed in the pathway of a scar.