Tendon versus nerve transfers - balancing hand function in upper extremity high nerve injuries

IntroductionHigh peripheral nerve injuries disrupt the balance between flexor and extensor muscle groups and result in significant impairment of strength, coordination and dexterity. Primary nerve repair is widely accepted as the optimal treatment following transection injury, but outcomes after high-level nerve reconstruction remain unpredictable. Prolonged denervation commonly leads to irreversible muscle atrophy, limiting the potential for meaningful distal functional recovery despite technically successful nerve repair.Reconstructive strategies:Different surgical strategies are available to restore motor function after high peripheral nerve injuries. Tendon transfers have long been regarded as the reference standard for reconstructing lost muscle function, offering predictable and relatively early restoration of key movements. However, tendon transfers may compromise muscle balance, excursion, and fine motor control. Nerve transfers have emerged as an alternative strategy, aiming to prevent motor loss by reinnervating native muscles. While nerve transfers may better preserve physiological patterns of movement, they require prolonged periods for reinnervation and depend on patient factors, timing, and access to rehabilitation.Review focusMore recent reconstructive strategies seek to combine the advantages of both techniques, offering 'the best of both worlds' through hybrid approaches that integrate tendon and nerve transfers. This expert opinion review discusses the current opportunities and challenges associated with these hybrid strategies in the management of high upper extremity peripheral nerve injuries. The biomechanical principles, indications and limitations of tendon transfers, nerve transfers and combined approaches are compared, with particular attention to timing, patient selection, and functional goals.