Musculotendinous lengthening procedures and tendon transfers for upper limb spasticity

Central paralyses are not limited to a simple motor deficit; they are associated with spasticity and-over time-contractures, as well as major disturbances in motor patterns. Significant clinical variability complicates both their assessment and the formulation of a therapeutic strategy. For these reasons, indications for tendon transfers in this patient population are more limited than in cases of peripheral paralysis; such procedures are generally incorporated into a complex surgical program that variously combines tendon lengthening, selective denervation, and joint stabilization. Faced with clinical presentations involving widely differing objectives-ranging from functional restoration to mere comfort-it is difficult at first glance to devise a standardized surgical program. In this article, we therefore propose an evaluation method using a score (INOM) based on functional prognostic factors and parameters requiring surgical correction to improve grasp. Three key areas guide this program: a prognostic factor, proximal motor control of the shoulder and elbow, and the correction of abnormal postures alongside the restoration of active extension of the elbow, wrist, and fingers. The INOM score highlights treatment priorities, enabling the formulation of a surgical strategy. Spasticity often obscures the motor assessment of these patients; anesthetic blocks and botulinum toxin injections are essential tools for this analysis. They make it possible to distinguish between spasticity and contracture, as well as to unmask certain antagonist muscles. In this population, a tendon transfer will be just as effective through the function it restores as through the elimination of its detrimental effect on the development of a deformity. We thus report, for each joint segment, the indications for tendon transfers and their relative roles among the techniques with which they must be combined.