2012 VuMedi - Transmuscular Transposition of the Ulnar Nerve- 010713

Transmuscular Transposition of the Ulnar Nerve

2012 VuMedi Webinar - AAHS - The Ulnar Nerve

Disclosure

Credits

Andrew Yee, BS

I, Susan E. Mackinnon MD, am the co-inventor of Synovis PGA Neurotube and have received research funding from AxoGen.

Transmuscular Transposition of the Ulnar Nerve

Susan E. Mackinnon, MD

Peripherial Nerve Surgery Education

nervesurgery.wustl.edu

Surgical Video Library

https://vimeo.com/user6062882

Prezi Presentation

http://prezi.com/user/yeeandrew/

Plastic and Reconstructive Surgery

Washington University School of Medicine

St. Louis, MO

(2012 VuMedi - Transmuscular Transposition of the Ulnar Nerve)

Cubital Tunnel Surgery

Meta-analysis - Procedure Camps

+1 Submuscular Transposition

+1 Simple Decompression

Subcutaneous Transposition

vs.

Transmuscular Transposition

In Situ Release

Endoscopic Release

Improving Patient Outcomes

Important Strategies and Topics

No "best" surgical

procedure

Shoulder

• Thoracic outlet, postural/muscle imbalance

Elbow

• Avoid injury to MABC nerve

• Complete release of compressive anatomical structures

• Prevent new compressive points with transpostion

Hand

• Guyon's canal release with deep motor branch

• "Supercharge" intrinsic ulnar motor nerve

• FDP tenodesis for early extrinsic function

III.

II.

I.

Surgical

Management

Physical

Examination

Post-operative Management

Pain Evaluation

Patient Education - Rate of Recovery

Surgical Procedure

Dynamic Ischemic Injury

• immediate recovery

Demyelination Injury

• 3-4 months for remyelination

Axonal Injury

• recovery rate at 1" per month

Mixed Injury

• mixture of recovery rates

Surgical Management

FDP Tenodesis

Operative Technique

Guyon's Canal Release

Operative Technique

Post-operative Outcome

Revision Ulnar Nerve Transposition

"Supercharge" AIN to Ulnar Motor Nerve Transfer

Guyon's Canal Release

Recipient - Ulnar Motor Nerve

Donor - Anterior Interosseous Nerve

"Supercharge"

AIN to Ulnar Motor Nerve Transfer

"Supercharge" AIN to Ulnar Motor Nerve Tranfer

Experimental Studies

"Supercharge" Nerve Transfer

Peripheral Nerve Worksheet

Scratch Collapse Test

Transmuscular Ulnar Nerve Transposition

Transmuscular Canal

Distal Intermuscular Septum - FCR / FCU

Medial Intermuscular Septum

Transmuscular Transposition

Scratch Collapse Points

Medial Antebrachial Cutaneous Nerve

Scratch Collapse Heirarchy

2 - Guyon's Canal

Orientation

1 - Cubital Tunnel

SCT(-) Guyon's Canal

Decompression

SCT(+) Guyon's Canal

Cubital Tunnel Surgery

SCT(+) Cubital Tunnel

SCT(-) Cubital Tunnel

w/ EtCL

Inital Test:

Secondary Test:

V.

Arcade of Struthers

EtCl

Scratch Collapse Heirarchy

IV.

Antebrachial Fascia

EtCl

III.

Cubital Tunnel

EtCl

II.

Deep Motor Branch

I.

EtCl

TOS

Ulnar Nerve Compression

Post-operative Management

Forward Flexion of Neck

Shoulder Ab/Adduction

Shoulder Flexion/Extension

Shoulder

Specifics for Transposition

• Thoracic Outlet
• Posture Imbalance
• Muscle Imbalance

• No "best" surgical procedure

• Avoid injury to MABC nerve

• Complete release of compressive anatomical structures

• Prevent new compressive points with transpostion

Elbow

Subluxation

Wrist

• Marcaine incision

• Marcaine infusion pump

• Suction drain

• Range-of-motion at 2 days post-operative

• Night sling for 2-3 weeks (per patient)

• Strengthen 4-6 weeks

Phalen's Test