CC BY 4.0 · J Brachial Plex Peripher Nerve Inj 2023; 18(01): e32-e41
DOI: 10.1055/s-0043-1767672
Original Contribution

Redefining the Inclusion Criteria for Successful Steindler Flexorplasty Based on the Outcomes of a Case Series in Eight Patients

1   Restorative Neurosurgery Department, Romodanov Neurosurgery Institute, Kyiv, Ukraine
Ihor B. Tretyak
1   Restorative Neurosurgery Department, Romodanov Neurosurgery Institute, Kyiv, Ukraine
Jörg Bahm
2   Klinik für Plastische Chirurgie, Hand- und Verbrennungschirurgie, Sektion Plexuschirurgie in der Uniklinik RWTH Aachen, Aachen, Deutschland
Vitaliy I. Tsymbaliuk
3   National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine
Yaroslav V. Tsymbaliuk
4   Group of Chronic Pain Treatment, Romodanov Neurosurgery Institute, Kyiv, Ukraine
› Author Affiliations
Funding None.


Background (rationale) Steindler flexorplasty (SF) is aimed at restoring independent elbow flexion in the late stages of dysfunction of the primary elbow flexors. Selection criteria for successful SF have been defined.

Objectives The purpose of this study was to redefine the inclusion criteria for successful SF based on functional outcomes.

Methods Eight patients received SF after an average of 50.8 months after injury or dysfunction. Three patients (37.5%) met all five Al-Qattan inclusion criteria (AQIC), and another five patients (62.5%) met four or less AQIC. Patients were followed up for at least 9 months, and the maximum range of active elbow flexion (REF) was measured. Functional results of SF were assessed using the Al-Qattan scale (in accordance with Al-Qattan's scale).

Results The mean maximum REF was 100 degrees (70 to 140 degrees). Five patients reached REF greater than 100 degrees. One patient had a poor outcome, two patients (25%) had a fair outcome, three patients (37.5%) had a good outcome, and two patients (25%) had an excellent outcome of SF on the Al-Qattan scale. The impact of each AQIC on functional outcome has been critically reviewed from a biomechanical point of view.

Conclusions The sufficient number of inclusion criteria required for successful SF can be reduced from five (according to AQIC) to two; Normal or near-normal function (M4 or greater on the MRC scale) of the muscles of the flexor-pronator mass should be considered an obligatory inclusion criterion, while primary wrist extensors may be considered an optional inclusion criterion.

Informed Consent

Written informed consent was obtained from all patients for the publication of their anonymized data in this article.

Ethical approval

Romodanov Neurosurgery Institute does not require ethical approval for reporting individual case series.


All authors made a substantial contribution to the acquisition, analysis, and interpretation of data, drafted the article and critically revised it for important intellectual content.

Publication History

Received: 28 April 2022

Accepted: 03 February 2023

Article published online:
11 October 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

  • References

  • 1 Siqueira MG, Martins RS. Surgical treatment of adult traumatic brachial plexus injuries: an overview. Arq Neuropsiquiatr 2011; 69 (03) 528-535
  • 2 Marinello PG, Gaston RG, Loeffler BJ, Lewis DR. Steindler flexorplasty: a description of current technique and case series. Tech Hand Up Extrem Surg 2019; 23 (04) 165-169
  • 3 Hems T. Nerve transfers for traumatic brachial plexus injury: advantages and problems. J Hand Microsurg 2011; 3 (01) 6-10
  • 4 Hsueh YH, Tu YK. Surgical reconstructions for adult brachial plexus injuries. Part I: treatments for combined C5 and C6 injuries, with or without C7 injuries. Injury 2020; 51 (04) 787-803
  • 5 Chuang DC, Epstein MD, Yeh MC, Wei FC. Functional restoration of elbow flexion in brachial plexus injuries: results in 167 patients (excluding obstetric brachial plexus injury). J Hand Surg Am 1993; 18 (02) 285-291
  • 6 Loeffler BJ, Lewis DR. Restoration of elbow flexion. Hand Clin 2016; 32 (03) 311-321
  • 7 Martin E, Senders JT, DiRisio AC, Smith TR, Broekman MLD. Timing of surgery in traumatic brachial plexus injury: a systematic review. J Neurosurg 2018; (e-pub ahead of print) DOI: 10.3171/2018.1.JNS172068.
  • 8 Sechachalam S, O'Byrne A, MacQuillan A. Free functional muscle transfer tendon insertion secondary advancement procedure to improve elbow flexion. Tech Hand Up Extrem Surg 2017; 21 (01) 8-12
  • 9 Armangil M, Ünsal SŞ, Yıldırım T. et al. Outcome of free gracilis muscle transfer for the restoration of elbow flexion in traumatic brachial plexus palsy. Jt Dis Relat Surg 2021; 32 (03) 633-641
  • 10 Steindler A. Orthopaedic reconstruction work on hand and forearm. New York Med J 1918; 108: 1117-1119
  • 11 Saul KR, Murray WM, Hentz VR, Delp SL. Biomechanics of the Steindler flexorplasty surgery: a computer simulation study. J Hand Surg Am 2003; 28 (06) 979-986
  • 12 Alnot JY, Oberlin C. Tendon transfers in palsies of flexion and extension of the elbow. In: Tubiana R. ed. The Hand, Philadelphia, WB Saunders; 1991:IV: 134-146
  • 13 Atkinson RE. A fixation technique for the Steindler flexorplasty. A technique for fixation of the flexor pronator group to the anterior surface of the humerus is described. J Hand Surg Am 1989; 14 (04) 749-751
  • 14 Mayer L, Green W. Experiences with the Steindler flexorplasty at the elbow. J Bone Joint Surg Am 1954; 36-A (04) 775-789 , passim
  • 15 Stern PJ, Caudle RJ. Tendon transfers for elbow flexion. Hand Clin 1988; 4 (02) 297-307
  • 16 Brunelli GA, Vigasio A, Brunelli GR. Modified Steindler procedure for elbow flexion restoration. J Hand Surg Am 1995; 20 (05) 743-746
  • 17 Oatis CA. Kinesiology: The Mechanics and Pathomechanics of Human Movement. 3rd ed.. Philadelphia: Wolters Kluwer; 2017
  • 18 Kubota S, Kubo T, Kameda H, Itoh Y. Importance of the wrist extensor muscle training: two cases of elbow flexorplasty following traumatic brachial plexus injuries. Case Rep Orthop 2018; 2018: 4691796
  • 19 Al-Qattan MM. Elbow flexion reconstruction by Steindler flexorplasty in obstetric brachial plexus palsy. J Hand Surg [Br] 2005; 30 (04) 424-427
  • 20 Matthews WB. Aids to the examination of the peripheral nervous system. J Neurol Sci 1977; 33 (1–2): 299
  • 21 Zhang D, Varadharajan V, Bhardwaj P, Venkatramani H, Sabapathy SR. Considerations in the selection of donor nerves for nerve transfer for reanimation of elbow and shoulder in traumatic brachial plexus injuries. J Hand Surg Asian Pac Vol 2022; 27 (01) 10-21
  • 22 Domeshek LF, Novak CB, Patterson JMM. et al. Nerve transfers—a paradigm shift in the reconstructive ladder. Plast Reconstr Surg Glob Open 2019; 7 (06) e2290
  • 23 Moore AM. Nerve transfers to restore upper extremity function: a paradigm shift. Front Neurol 2014; 5: 40
  • 24 Davidovits P. Physics in Biology and Medicine. 5th ed. Chapter 1. Static Academic Press; 2019: 1-20
  • 25 Davidovits P. Physics in Biology and Medicine. 5th ed. Chapter 4. Static Academic Press; 2019: 45-58
  • 26 Park H, Choi JY, Yi SH. et al. Relationship between the more-affected upper limb function and daily activity performance in children with cerebral palsy: a cross-sectional study. BMC Pediatr 2021; 21 (01) 459
  • 27 Lemmens RJ, Janssen-Potten YJ, Timmermans AA, Defesche A, Smeets RJ, Seelen HA. Arm hand skilled performance in cerebral palsy: activity preferences and their movement components. BMC Neurol 2014; 14: 52
  • 28 Krumlinde-Sundholm L, Eliasson A-C. Development of the assisting hand assessment: a Rasch-built measure intended for children with unilateral upper limb impairments. Scand J Occup Ther 2003; 10 (01) 16-26
  • 29 Gates DH, Walters LS, Cowley J, Wilken JM, Resnik L. Range of motion requirements for upper-limb activities of daily living. Am J Occup Ther 2016; 70 (01) 7001350010p1-7001350010p10