Dr. Andrew Elkwood Featured for Stroke Awareness Month

Correcting Clenched Fist and Arm Paralysis and Foot Drop

By Walt Kilcullen

After a stroke, some survivors experience paralysis of one arm along with a clenched fist. If a nerve is injured, preventing that nerve from sending signals to a muscle or muscles, the result is limb paralysis and loss of muscle function. This result is virtually no use of the affected arm and hand, and, in some cases, discomfort. When a nearby tendon is not affected, it may be possible to transfer a functional tendon from its original attachment to a new attachment restoring some use to the non-functioning area.

What exactly is hand tendon transfer surgery?

Below the elbow, there are between forty and fifty muscles. When a muscle or muscles are neurologically destroyed due to the stroke, they can no longer signal the arm or hand to function. There are three major nerves in hand: the ulnar nerve, the radial nerve, and the median nerve. When any of these are injured or destroyed, paralysis, loss of feeling, and clenched fist is the result.

How successful is hand tendon surgery?

A hand tendon transfer may be successful in restoring some function to the hand or arm. In a 2008 study in the Netherlands (LC Heijnen et al.), six patients were followed who had hand tendon transfer surgery for clenched fists.

After the surgery, all six could passively open their hands in a resting position, and some flexible movement was gained in each case. There were no complications after nineteen months, and all six patients were still able to keep their hands open. There was also permanent improvement in pain reduction and hygiene.

I asked Dr. Andrew Elkwood how much success he has had doing this surgery. Dr. Elkwood practices plastic surgery at the Plastic Surgery Center in Shrewsbury, New Jersey. He is considered an expert in nerve reconstruction surgery for patients who have lost the use of a limb due to nerve damage.

He has also been featured on the T.V. show, “The Doctors.” Dr. Elkwood was reluctant to profile what a good tendon transfer surgical candidate looked like because diagnosis depends on so many factors, such as how many nerves and or muscles are damaged, and to what degree they are damaged. He stated, “I like to examine, evaluate, and then give my assessment as to the expected results of surgery.”

Dr. Elkwood also told me that the hand is more difficult than the arm to restore. After surgery, even if the function cannot be restored, at the very least, the patient will be able to open the hand. “No one gains 100% of function, but there are some who show great improvement, some who cannot be helped at all, and many who fall in between these two categories.”

Tendon Transfer Surgery for Foot Drop

Seven years ago, Sandy Smethers, a stroke survivor that I was mentoring (and still am), was recommended by a neurologist to consider tendon transfer for her foot drop. We went to Pennsylvania University Hospital in Philadelphia to see Dr. Mary Ann Keenan, an orthopedic surgeon.

Dr. Keenan recommended tendon transfer surgery, and she performed it shortly after our visit. Sandy’s surgery was only partly successful. Her foot was restored to a more normal position, but she still walks with a brace and a considerable limp. Her balance improved, and she walks freely without a cane,

Foot drop has many causes and varied symptoms. A stroke survivor who has a foot drop as a result of a stroke has difficulty lifting the front of the foot. As a result, the patient may drag the affected foot on the ground, making walking difficult. Many patients will trip with foot drop.

To compensate, one may raise the thigh unusually high and may swing the affected foot out to the side to avoid lifting the thigh upward. The immediate aid is to wear a brace from the upper calf, down past the ankle extending under the entire foot. This will keep the foot in a normal position.

I was able to reach podiatric foot and ankle surgeon, Dr. Lawrence DiDomenico by telephone. Dr. DiDomenico is a podiatric physician and surgeon at the Ankle and Foot Care Center in Youngstown, Ohio. Dr. DiDomenico stated,” with classic foot drop, the common peroneal nerve is affected and leads to anterior and lateral (front and outside muscles of the leg) muscle group weakness which controls the foot.”

Diagnosis of the cause is imperative as that will determine the course of treatment. Dr. DiDomenico told me that treatment options for foot drop include prescribing a brace, gait training, physical therapy, and tendon transfer surgery.

You, as a patient, must discuss these options with your podiatric surgeon or orthopedic surgeon. But once the diagnosis calls for tendon transfer, the tendon transfer surgery is performed with the goal of restoring the function of the foot and ankle to a more normal anatomical alignment so that the patient can walk on the sole of the foot with the heel touching the ground, improving gait and balance when walking in a shoe and without a brace.

Dr. DiDomenico told me that the large majority of tendon transfers for foot drops are done by podiatric surgeons and orthopedic surgeons that have expertise and interest in foot and ankle surgery. “The surgery involves rerouting the posterior tibial tendon, a tendon that functions well from the back of the leg, and transferring it to the front of the leg and connecting it to the top of the foot. This compensates for the loss of muscle function in the front of the leg as a result of the stroke. Although 100% improvement is not expected, between 40% and 50% is typical.”