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2013 UNC - Advances in Peripheral Nerve Surgery

3/11/13; Videos embedded with youTube.
by Andrew Yee on 11 March 2013

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Transcript of 2013 UNC - Advances in Peripheral Nerve Surgery

Paradigms Paradigm Shifts Paradigm Shifts Paradigm Paradigm Paradigm Shift Paradigm Paradigm Shift Adjacent Possible Slow Hunch Serendipity Error Liquid Networks Exaptations Stuart Kauffman - Theoretical biologist and research
in complex systems about the origin of life Adjacent Possible Present Idea Idea that is ahead of its time... Idea was right, but environment
wasn't ready for it yet... Adjacent Possible Adjacent Possible Find ways to explore the edges of possibility that surround you... Sparks Flashes Lightbulb Eureka Epiphanies A good idea is a network - a network of exploring adjacent possible connections An innovative network is plastic - capable of adopting new configurations Kevin Dunbar - psychologist Metaphoric Lone Scientist Research Lab Meeting 1990's in-vivo study - where ideas spawn in research Long incubation period is a strength... Wine Press Printing Press 1440-1448 Johannes Gutenberg Designed something to make people drunk into something for mass communication... Slow hunches need time to develop... Trouble with error is that we have a
natural tendency to dismiss it... When we're wrong, we challenge our assumptions
and adopt new strategies... Being wrong doesn't unlock new doors in the adjacent possible,
but forces us to look for them... Definition: The occurrence and development of events by chance in a happy or beneficial way. Horace Walpole, English novelist ...first coined in a letter in 1758... ...about a Persian fairy titled... Protagonists were "always making discoveries, by accident
and sagacity, of things they were not in quest of." NeXT Computer ENQUIRE Project Invention of the Internet Mesh Tangle Sir Tim Berners-Lee
University of Toronto
Spring 1991 Anterior Interosseous to Ulnar Motor Nerve Transfer Medial Pectoral to Musculocutaneous Nerve Transfer Nerve Transfer 1256 PubMed Search - "Nerve Transfer" Total Number of Articles 1000 500 Years 1950 2012 2000 1960 1970 1980 Thomas Kuhn Steven Johnson Dave Logan Anders Ericsson Paradigms Ideas Expertise Environment Controversy of Nerve Grafts Erik Moberg Herbert Seddon Harry Buncke Joseph Boyes Leonard Goldner Sterling Bunnell Hanno Millesi Donald Brooks Raymond Curtis Neurotization Charles Elsberg Arthur Stiendler Philipp Erlacher Lewis John Pollock Loyal Davis Nerve Crossing 1915 1933 1911 Nerve Anastomosis Nerve Surgery Nerve Repair Nerve Grafting Nerve Transfers Circa 1982 Sydney Sunderland Hanno Millesi Circa 1984 Donor Nerve Recipient Nerve Proximal Distal Donor Nerve Proximal Nerve Transfers Internal Topography Interfascicular Neurolysis Translational Research Leonard Goldner Distance Time
Time Muscle
Muscle Function Nerve Anatomy Nerve Allografts Susan E. Mackinnon, MD

Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO Advances in Peripheral Nerve Surgery I, Susan E. Mackinnon, MD, am the co-inventor of the PGA Neurotube and have received research funding from AxoGen Inc. NIH - 5R01 NS 033406-17
Nerve Allotransplantation for Traumatic Nerve Injury NIH - 2R01NS05170606A1
The Effects of GDNF on Peripheral Nerve Regeneration Peripherial Nerve Surgery Education
nervesurgery.wustl.edu

Surgical Video Library
https://vimeo.com/user6062882

Prezi Presentation
http://prezi.com/user/yeeandrew/ Credits Andrew Yee, BS Transgenic Rodent Models Histomorphometry Muscle Force Measurement Walking Track Analysis Retrograde Labeling Microscopic Analysis Operating Microscope Fluroscenct Microscope Confocal Microscope Light Microscope Electron Microscope Translational Research Finding Piecing a puzzle together... ...for a portrait. Transgenic Rat Models Transgenic Rat Models End-to-side Regeneration Schwann Cells vs Axons Bands of Fontana Motor Branch Sensory Branch Motor Regeneration Femoral Nerve Fluorescence Thy 1-GFP
Motor axons

Thy 1-YFP
Axons

Thy-1-CFP
Axons S100-GFP
Mature Schwann cells

Nestin-GFP
Immature Schwann cells GFP-GDNF
GDNF overexpression in CNS Axons +GDNF - Muscle Myo-GDNF
GDNF overexpression in muscle +GDNF - CNS Axons Schwann Cells Motor Endplates Combined Motor Endplates Schwann Cells Without Injury With Injury Crush Partial Neurectomy Schwann Cells Axons S100-GFP x Thy1-CFP Steven Johnson Paradigm Shifts Median to Radial Nerve Transfer FCR Wrist Flexion Finger Extension PIN FDS Finger Flexion Wrist Extension ECRB Nerve Transfers I II Radial Nerve Injury Wrist Drop Median to Radial Nerve Transfers Humeral Fractures Old Anatomy Median and Radial Nerve Anatomy Nerve Transfers Surgical Procedure Orientation Median Nerve Anatomy Radial Nerve Anatomy Median and Radial Nerve Removal of Supinator Branch Donr Distal, Recipient Proximal Median to Radial Nerve Transfers Median to Radial Nerve Transfers Outcomes Outcomes 9 Month Post-operative 1 Year Post-operative Median (FCR / FDS) to Radial (PIN / ECRB) Nerve Transfer Median (FCR / FDS) to Radial (PIN / ECRB) Nerve Transfer 4 Year Post-operative Current Anatomy Median to Radial Nerve Transfers Median and Radial Nerve Anatomy (N) flexor digitorum superficialis Donor (N) posterior interosseous Recipient (N) flexor carpi radialis Donor (N) extensor carpi radialis brevis Recipient (N) flexor digitorum superficialis Donor (N) flexor carpi radialis Donor (N) posterior interosseous Recipient (N) extensor carpi radialis brevis Recipient (N) posterior interosseous Recipient (N) supinator (N) flexor digitorum superficialis Donor (N) flexor carpi radialis Donor (N) posterior interosseous Recipient (N) extensor carpi radialis brevis Recipient (N) flexor digitorum superficialis Donor (N) flexor carpi radialis Donor (N) posterior interosseous Recipient (N) extensor carpi radialis brevis Recipient Results of Nerve Grafting Medial Pectoral to Musculocutaneous
Nerve Transfer Thoracodorsal to Axillary
Nerve Transfer Muscle Neuron Cell Body (Gateway Arch) Anchorage, AK St. Louis, MO Muscle Neuron Cell Body (Gateway Arch) Anchorage, AK St. Louis, MO Fairbanks, AK Adjacent Neuron Fibers Nerve Transfers for Restoring Function Nerve Injury and Recovery Nerve Transfers 1 2 3 4 5 2010 2009 2011 Cases per Month Supercharging the Injured Nerve 1980 1990 1984 Development of End-to-side in Animal Models 2008 Neuron Cell Body (Gateway Arch) St. Louis, MO Fairbanks, AK Adjacent Neuron Fibers Pronator quadratus flap
for nerve injuries... 1991 Case of AIN to ulnar motor
nerve transfer... Number of fibers through ETS coaptation... Retrograde labeling ETS fibers
to dorsal root ganglion (sensory)... More fibers through larger perineurial window... Motor ETS axonal sprouting requires injury... Retrograding labeling ETS fibers
to motor neuron pool (motor)... No Injury = Sensory Sprouting Injury = Motor Sprouting Types of ETS motor and sensory sprouting... Spontaneous Collateral Sprouting - Sensory Traumatic Regenerative Sprouting - Motor AIN to ulnar motor nerve transfer... 2002 1996 Publication... Spring 2009 Reverse ETS Animal Studies August 2009 First Clinical RETS Surgery What is a reverse end-to-side... Regeneration through a RETS coaptation... Muscle Anchorage, AK The RETS thought process... RETS AIN to ulnar motor nerve transfer... The 1-year post-operative results... Benchtop research to clinical... 2011 January 2012 RETS clinical review of cases... AAHS Presentation

Reverse end-to-side motor nerve
transferfor augmentation of ulnar
nerve intrinsic function.

Barbour JR, Boyd KU, Kale SS,
Bailey M, Mackinnon SE 2013 SETS AIN to ulnar motor nerve transfer
technical paper... October 2012 2012 SETS in a 2nd/3rd degree nerve injury... "Supercharge ETS" "Reverse ETS" 2011-2012 I. II. End-to-end
Nerve Transfer = Supercharge
Nerve Transfer Supercharge in
Incomplete Injury Partial Injury - Graft
Supercharge Nerve Transfer Functional Results Muscle Force Analysis Specific Force (N/cm2) Partial Injury Supercharge Supercharge in Incomplete Injury
with Donor Transection Functional Results Muscle Force Analysis Specific Force (N/cm2) Partial Injury Supercharge Additional Regenerative Front Proximal Regenerative Front 2nd / 3rd Degree Nerve Injury
(Axonotmesis) Supercharge in Incomplete Injury Transgenic Animal Models Supercharge Experimental Study Partial Injury Model 2nd / 3rd Degree Injury - Axonotmesis SETS enhances recovery in an
incomplete nerve injury... March 2013 1996-2008 1980 2000 2005 2010 1990 Jumping the Gap in Spinal Cord Injury 1985 Sensory nerve transfers in paraplegic... Mackinnon, SE 1993 Feasibility of brachialis branch for transfer... Brandt, KE 2003 Reinnerating the biceps branch and
brachialis branch... 2005 Double fasciclular nerve transfer... 2007 Tung, TH Mackinnon, SE 2011 Single Fascicular = Double Fascicular Carlsen, BT Single vs double fascicular nerve transfer... Discussion Published Review of cases
of brachialis to AIN nerve transfer... 2008-2010 Ray, WZ Interfascicular Anatomy of Median Nerve Interfascicular Anatomy of Median Nerve Electrical Stimulation of Left AIN Fascicle Donor: Brachialis Branch Recipient: AIN Fascicle
2 Years Post-Injury Left - Brachialis to AIN Nerve Transfer Histomorphometry Post-operative Results Functional Recovery - 1 Year Melt My Wings Nerve Fibers: ~3222 Nerve Fibers: ~3512 Right - Brachialis to AIN Nerve Transfer Melt My Wings 71 Year-old Male Spinal Cord Injury: ~C7 Level Restoration of AIN Function in SCI Patient Pre-operative Examination Left Arm Examination Right Arm Examination Electrical Stimulation of Right AIN Fascicle 2 Years Post-Injury 2 Years Post-Injury Post-operative Results Functional Recovery - 2 Year Case of brachialis to AIN nerve transfer
in a spinal cord injury... 2010 Published 2012 Mackinnon, SE 2012 Published 2007 Brachialis to anterior interosseous
nerve transfer... Results Pronation and AIN Function - 4 Years Martin Robson, MD Brachialis
Nerve Expendability Results of Nerve Grafting Results of Nerve Transfers Innovations of Nerve Transfers End-to-end
Nerve Transfer = Supercharge
Nerve Transfer Pronation and AIN Function - 2 Years
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