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2012 ASRM - Surgery and Innovation

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Andrew Yee

on 18 January 2015

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Transcript of 2012 ASRM - Surgery and Innovation

Susan E. Mackinnon, MD

Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO

A Path to Innovation
I, Susan E. Mackinnon, MD, am the co-inventor of the Synovis Neurotube and have received research funding from AxoGen Inc.
Paradigms
Paradigm Shifts
Paradigm Shifts
Nerve Surgery
Nerve Repair
Nerve Grafting
Nerve Transfers
Paradigm
Paradigm
Paradigm Shift
Paradigm
Paradigm Shift
Paradigm Shift
Expertise
Dedicated and repeated practice = deliberate practice

Hours of Musician's Cumulative Practice (by age 20)
Expert 10,000 hours
Second Tier 5,000 hours
Serious Amateur 2,000 hours
10,000 Hour Rule
Push the Envelope
Practice difficult takes, stretching skills
Elite Skater 68% demanding jumps
Second Tier Skaters 48%
Third Tier Skaters Practice what they know
The Coach
Regular, accurate critical feedback, coach
Adjacent Possible
Slow Hunch
Serendipity
Error
Liquid Networks
Exaptations
Environment
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 communcation...
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."
How do you create a serendipitous environment?
Stage 1 - "Life sucks"
Stage 2 - "My life sucks"
Stage 3 - "I am great, you are not"
Stage 4 - "We are great, they are not"
Stage 5 - "Life is great"

University of Toronto
Spring 1991
Keith Brandt
2011
Anterior Interosseous to Ulnar Motor Nerve Transfer
Medial Pectoral to Musculocutaneous Nerve Transfer
Nerve Transfer
Thomas Kuhn
Steven Johnson
Dave Logan
Anders Ericsson
Paradigms
Keith Brandt
1991
Desmond Tutu
Nelson Mandela
NeXT Computer
ENQUIRE Project
Invention of the Internet
Results of Nerve Grafting
Transgenic Mouse Models
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
Transgenic Rat Models
Transgenic Rodent Models
Bands of Fontana
Motor Branch
Sensory Branch
Motor Regeneration
Femoral Nerve
Schwann Cells vs Axons
Schwann Cells
Axons
S100-GFP
x
Thy1-CFP
End-to-side Regeneration
Without Injury
With Injury
Donor Nerve
Recipient Nerve
Proximal
Distal
Donor Nerve
Recipient Nerve
Proximal
Distal
Crush
Partial Neurectomy
Axons
Schwann Cells
Motor Endplates
Combined
Motor Endplates
Histomorphometry
Nerve Transfers
Muscle Force Measurement
Walking Track Analysis
Retrograde Labeling
Microscopic Analysis
Operating Microscope
Fluroscenct Microscope
Confocal Microscope
Light Microscope
Electron Microscope
1
2
3
4
5
2010
2009
2011
Cases per Month
Reverse End-to-side
Anterior Interosseous to Ulnar Motor Nerve Transfer
Neurotization
Controversy of Nerve Grafts
Erik Moberg
Herbert Seddon
Harry Buncke
Nerve Anastomosis
Charles Elsberg
Arthur Stiendler
Philipp Erlacher
Lewis John Pollock
Loyal Davis
Nerve Crossing
Distance Time
Time Muscle
Muscle Function
71 year-old male
Spinal Cord Injury: ~C7 Level
Interfascicular Anatomy of Median Nerve
Electrical Stimulation of Right AIN Fascicle
Interfascicular Anatomy of Median Nerve
Electrical Stimulation of Left AIN Fascicle
Donor
: Brachialis Branch
Recipient
: AIN Fascicle
2 Years Post-Injury
Restoration of AIN Function in SCI Patient
Right - Brachialis to AIN Nerve Transfer
Left - Brachialis to AIN Nerve Transfer
Histomorphometry
Post-operative Results
Functional Recovery - 1 Year
Pre-operative Examination
Left Arm Examination
Right Arm Examination
Melt My Wings
Melt My Wings
NIH - 5R01 NS 033406-17
Nerve Allotransplantation for Traumatic Nerve Injury
Results of Nerve Grafting
Internal Topography
Interfascicular Neurolysis
Innovation of Nerve Transfers
Supercharging
the Injured Nerve

Schwann Cells
Fluorescence
Translational Research
Results of Nerve Transfers
Medial Pectoral to Musculocutaneous
Nerve Transfer
Thoracodorsal to Axillary
Nerve Transfer
Nerve Anatomy
Distance Analogy
Nerve Allografts
Nerve Allografts
Jumping the Gap
in Spinal Cord Injury

Nerve Injury
1980
2000
2005
2010
1993
Brandt - Feasibility of Brachialis Branch
2003
Tung - Reinnervating the Biceps Branch and Brachialis Branch
2005
Mackinnon - Double Fascicular Nerve Transfer
2007 Discussion, 2011 Published
Carlsen - Single vs Double Fascicular Nerve Transfer
2007
Brachialis to Anterior Interosseous Nerve Transfer
2010
Brachialis to Anterior Interosseous Nerve Transfer in SCI
Brachialis and AIN Anatomy
Brachialis to AIN and Pronator Teres Nerve Transfer
Post-operative Results
Pronation and AIN Function - 2 Years
1980
1990
1996
January 2012
RETS Clinical Review - AAHS Presentation
August 2009
RETS First Clinical Surgery
Spring 2009
Reverse ETS Animal Studies
1984
Pronator Quadratus Flap for Nerve Injuries
1991
Anterior Interosseous to Ulnar Motor Nerve Transfer
Ulnar Nerve Transposition
RETS AIN to Ulnar Motor Nerve Transfer
Reverse End-to-side
Fluorescence Studies
High Ulnar Nerve Injury
AIN to Ulnar Motor Nerve Transfer
Pronator Quadratus Flap
Anterior Interosseous Nerve
Painful Nerve Injuries
Motor and Sensory Sprouting
End-to-side Nerve Transfers
Motor Pool
End-to-side Animal Studies
Circa 1982
Sydney Sunderland
Hanno Millesi
Circa 1984
Mesh
Tangle
1915
Donor Nerve
Recipient Nerve
Proximal
Distal
Donor Nerve
Proximal
Nerve Transfers
Internal Topography
Interfascicular Neurolysis
Translational Research
Perineurial Window
Dorsal Root Ganglion
1933
Brachialis Nerve
Anterior Interosseous
Nerve
Credits
Sir Tim Berners-Lee
2009
Clinical Review - Brachialis to Anterior Interosseous Nerve Transfer
Clinical Review
Case Series - Brachialis to Anterior Interosseous Nerve Tranfer
Motor Axonal Sprouting with Injury
Nerve Fibers: ~3222
Nerve Fibers: ~3512
1873
2008
Traumatic Regenerative Sprouting -
Motor
Spontaneous Collateral Sprouting -
Sensory
Joseph Boyes
Leonard Goldner
2000
1990
1985
Mackinnon - Sensory Nerve Transfer in Paraplegic
Sensory Nerve Transfer in Paraplegic
Sensory Nerve Transfer in Paraplegic
Sensory Nerve Transfer in Paraplegic
Leonard Goldner
Sterling Bunnell
Martin Robson
Post-operative Results
Pronation and AIN Function - 2 Years
Pronation and AIN Function - 4 Years
Hanno Millesi
Donald Brooks
Raymond Curtis
Full transcript