Quantitative and Qualitative Functional Evaluation of Upper Extremity Tendon Transfers in Spastic Hemiplegia Caused by Cerebral Palsy Ann E. Van Heest, MD,*Þ Vimala Ramachandran, MD,* Jean Stout, PT, MS,Þ Roy Wervey, BS,Þ and Louis Garcia, MDþ Background: The purpose of this study was to determine if upper extremity function and joint positioning improved after tendon transfer surgery in patients with spastic hemiplegia caused by cerebral palsy. Methods: Thirteen patients with spastic hemiplegia underwent tendon transfer surgery at a mean age of 10.8 years (range, 7Y24 years). Before surgery, all patients were evaluated with a standardized motion laboratory analysis protocol. At a mean follow- up of 3.6 years (range, 1Y10 years), 13 patients returned for a repeat motion laboratory analysis using the same protocol. The motion laboratory studies were then compared quantitatively, comparing times for completion of the Jebsen-Taylor hand test, and qualitatively for elbow, forearm, wrist, finger, and thumb positions using the validated Shriner’s Hospital Upper Extremity Evaluation protocol. Results: In timed testing on the Jebsen-Taylor hand function test, 5 patients improved, 5 patients remained the same, and 3 patients worsened. No statistically significant change in timed testing was noted for any of the 6 subtests. A qualitative assessment of limb position during completion of tasks showed a significant improve- ment in position for the elbow (P G 0.01), forearm (P G 0.02), wrist (P G 0.02), and fingers (P G 0.02). There was no significant change in thumb position (P G 0.85). Conclusions: Tendon transfers, especially for wrist extension, can be beneficial in improving upper extremity joint positioning in children with spastic hemiplegia. However, significant impairment in hand function persists. Key Words: cerebral palsy, motion laboratory, spastic hemiplegia (J Pediatr Orthop 2008;28:679Y683) C erebral palsy (CP) is a nonprogressive injury to the developing central nervous system that produces motor dysfunction, movement disorders, weakness, and impaired function of the hand and upper extremity. In CP, surgery of the hand and upper extremity has included tendon transfers, tendon lengthening, and joint stabilization procedures. Out- comes of these procedures have primarily focused on mea- surement of strength and range of motion (ROM). 1Y3 Other measurements of outcomes have included the dynamic posi- tioning portion of the Shriner’s Hospital Upper Extremity Evaluation (SHUEE), 4 assessment of the functional use of the upper extremity, 5 or the Assistive Hand Assessment. 6 Each of these tests measures a different aspect of hand function after tendon transfer surgery in CP. The goal of this study is to present the outcomes of tendon transfer surgery in CP as a quantitative and qualitative assessment of hand function comparing preoperative and postoperative video movement analysis. Quantitative assess- ment is comparing times for completion of the Jebsen-Taylor hand test, 7 and qualitative assessment is comparing elbow, forearm, wrist, finger, and thumb positions using the validated SHUEE dynamic joint positioning protocol. 4 The hypothesis of this study is that children undergoing tendon transfer surgery for treatment of the upper extremity dysfunction caused by spastic hemiplegia from CP have improved joint positioning and function after surgical intervention. METHODS In 1993, the upper extremity motion laboratory analysis protocol was developed for evaluation of upper extremity function in children with spastic hemiplegia caused by CP. 9 This protocol involves the use of 2 fine-needle electrodes placed in the pronator teres and flexor carpi ulnaris muscles, and 2 surface electrodes placed over the biceps and extensor carpi radialis longus/brevis muscles. These electrodes were chosen as they allow a dynamic electromyography (EMG) evaluation of the most affected spastic muscles (pronator teres and flexor carpi ulnaris) paired with their antagonist muscles (biceps as a supinator and wrist extensor muscles). During the motion laboratory testing, dynamic EMG monitoring is synchronized with a split screen recording the child’s affected limb function while performing a standardized test, the Jebsen-Taylor Hand Function Test. This test has 6 subparts and evaluates the child’s ability to turn cards, pinch small objects, scoop beans with a spoon, stack checkers, lift light cans, and lift heavy cans. Each subtest required the child to repeat the task 5 times, with the exception of stacking checkers, which had only 4 checkers. This constituted one trial. Inclusion criteria for this study require each of the following: (1) children with spastic hemiplegia in the upper extremity caused by CP evaluated with preoperative upper extremity motion laboratory analysis between 1994 and 2003, ORIGINAL ARTICLE J Pediatr Orthop & Volume 28, Number 6, September 2008 679 From the *Department of Orthopaedic Surgery, University of Minnesota, Minneapolis; †Gillette Children’s Specialty Healthcare, St Paul, MN; and ‡San Ignacio University Hospital, Javeriana University, Bogota, Colombia. Supported by the Gillette Medical Education Research Account Grant. Reprints: Ann E. Van Heest, MD, 2450 Riverside Ave, Suite R200, Orthopaedic Surgery, University of Minnesota, Minneapolis, MN 55455. E-mail: vanhe003@umn.edu. Copyright * 2008 by Lippincott Williams & Wilkins Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.