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MACKINNON - 2015 ASSH - Nerve Transfers for the Hand - Part 1 - Introduction and Radial Nerve

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Andrew Yee

on 1 January 2016

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Transcript of MACKINNON - 2015 ASSH - Nerve Transfers for the Hand - Part 1 - Introduction and Radial Nerve

I
II
IV
III
V
VI
Median Nerve
Radial Nerve
Ulnar Nerve
Radial Nerve
Median to radial transfer
FDS
to
ECRB
transfer
FCR
to
PIN
transfer
Supinator
to
PIN
transfer
MEDIAN
ULNAR
RADIAL
Pronator Teres Nerve
Brachialis
to
pronator teres
transfer
ECRB
to
pronator teres
transfer
FDS
to
pronator teres
transfer
FCR
to
pronator teres
transfer
FCU
to
pronator teres
transfer

Anterior Interosseous Nerve of Median Nerve
Brachialis
to
anterior interosseous
transfer
ECRB
to
anterior interosseous
transfer
Supinator
to
anterior interosseous
transfer
FDS
to
anterior interosseous
transfer

Flexor Pollicis Longus of Median Nerve
FDS
to
FPL
transfer

Recurrent Thenar Branch of Median Nerve
Anterior interosseous (PQ)
to
recurrent thenar
transfer with graft
Deep Motor Branch of Ulnar Nerve
Anterior interosseous (PQ)
to
ulnar motor
transfer
End-to-end (ETE)
Supercharge end-to-side (SETS)
Radial to ulnar transfer
APL / EIP
to

ulnar motor
transfer
EDQ / ECU
to
ulnar motor
transfer
MOTOR
NERVE TRANSFERS
RADIAL NERVE
Nerve Surgery
Credits
Andrew Yee, BS
Peripherial Nerve Surgery Education
nervesurgery.wustl.edu

Surgical Video Library
https://youtube.com/nervesurgery/

Prezi Presentation
http://prezi.com/user/yeeandrew/
Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO
I, Susan E Mackinnon, am the co-inventor of the PGA Neurotube and have received research funding from AxoGen Inc.

Neuron Cell Body
Muscle / Skin
Schwann Cell
Axon
Nerve Injury
Degeneration
Cell Migration
Axonal Growth
Reinnervation
Nerve Regeneration
Neuron
Normal
Atrophy
"Irreversible" Atrophy
Time of Injury
0 - 12 Months
12+ Months
1mm / Day
3cm / Month
36cm / Year
"Irreversible" Atrophy
12+ Months
~1mm Growth / Day
3cm Growth / Month
36cm Growth / Year
Distance Time
Time Muscle
Muscle Function
Muscle
Neuron Cell Body
Anchorage, AK
St. Louis, MO
Thoracodorsal to Musculocutaneous
Nerve Transfer
Medial Pectoral to Axillary
Nerve Transfer
Muscle
Neuron Cell Body
Anchorage, AK
St. Louis, MO
Fairbanks, AK
Adjacent Neuron Fibers
NERVE INJURY AND RECOVERY
INDICATIONS...
donor nerve
near target muscle
expendable donor nerve
donor nerve with "pure" motor fibers
donor nerve with large number of motor axons
donor muscle is synergistic to target muscle
need to direct a large number of motor axons quickly to denervated muscle


source of nerve in close proximity to the denervated muscle
faster and superior muscle reinnervation
NERVE TRANSFERS PROVIDES...
NERVE TRANSFERS
RESULTS OF
NERVE GRAFTING
RESULTS OF
Favorable
Unfavorable
I, II, III
Degree of Nerve Injury
VI, V
Degree of Nerve Injury
Fibrillations + MUPs
Fibrillations + No MUPs
Recovering
Out
Fairbanks, AK
Adjacent Neuron Fibers
SUPERCHARGE
NERVE TRANSFER
ULNAR NERVE INTRINSICS
ACUTE INJURY
ACUTE/CHRONIC INJURY
FIBS
MUPs
+
+
+
II/III
CUBITAL TUNNEL
II/III
VI/V
collateral sprouting,
nascent
II/III
VI/V
_
End-to-End
+
+
_
collateral sprouting,
nascent
Nerve Transfer
Anticipate recovery...
VI/V
Martin-Gruber
+
normal
HIGH
ULNAR
MID
ULNAR
DEGREE
Median to Radial Nerve Transfers
INDICATIONS
SURGICAL TECHNIQUE
POST-OPERATIVE
Exposure of Radial Nerve
Exposure of Median Nerve
Median to Radial Nerve Transfers
Pronator Teres to ECRB Tendon Transfer
Initial Exposure
Step-lengthen Pronator Teres
Rehabilitation
Outcomes
Finger/Wrist Drop
Tendon Transfers
Nerve Transfers
no time limit
requires good passive ROM

immediate functional return
altered biomechanics
of wrist and finger
time limit (<10 months post-injury)
can include patients with stiff ROM

require additional time
for function
independent finger and wrist extension
PATIENT
GOALS AND EXPECTATIONS
Median to Radial Nerve Transfer
FCR
PIN
FDS
ECRB
Finger Extension
Wrist Extension
Finger Flexion
Wrist Flexion
1
2
Synergistic Transfers
+ Pronator Teres to ECRB Tendon Transfer
Radial Vessels
Radial Sensory Nerve
Pronator Teres Tendon
Superficial Head of Pronator Teres
+ Tendon Transfer
Proximal Exposure
ECRL
ECRB
RECIPIENT
Deep Head of Pronator Teres
Median Nerve
Radial Vessels
Superficial Arch of FDS
(N) PL/FCR
(N) FDS
(N) FDS fascicle
(N) anterior interoseous
MEDIAN NERVE ANATOMY
ECRB Tendon
Supinator Tendon
RADIAL NERVE ANATOMY
(N) superficial radial sensory
(N) posterior interosseous
(N) supinator
(N) ECRB
Release of ECRB / Supinator Tendons...
(N) FCR
(N) FDS
(N) PIN
(N) ECRB
DONOR
DONOR
RECIPIENT
RECIPIENT
(N) FCR
DONOR
(N) FDS
DONOR
(N) ECRB
RECIPIENT
(N) PIN
RECIPIENT
(N) PIN
RECIPIENT
(N) supinator
(N) FCR
DONOR
(N) PIN
RECIPIENT
(N) ECRB
RECIPIENT
(N) FDS
DONOR
ECRB
ECRL
Superificial Head of Pronator Teres
Superificial Head of Pronator Teres
ECRB
Pulvertaft Weave
2 Years Post-operative
Median (FCR/FDS)
to
Radial (PIN/ECRB)
Nerve Transfer
Typing Outcome
Median (FCR/FDS)
to
Radial (PIN/ECRB)
Nerve Transfer
FUNCTIONAL RECOVERY
PROXIMAL INJURIES
DELAYED REPAIR
FAVORABLE
UNFAVORABLE
CLASSIFICATION OF NERVE INJURIES
+
/
_
TYPE OF RECOVERY
NERVE
TRANSFERS
NERVE INJURY
AND RECOVERY
WINDOW FOR REINNERVATION
RAT MODEL
Permenant Atrophy
>1 Month
ATROPHY = FUNCTIONAL DEFICIT
Muscle Mass
Maximum Tetanic Force
REINNERVATION
30%
70%
DENERVATION
LOST OF FUNCTION
FOR FUNCTION
DENERVATION % FOR FUCTIONAL LOSS
ANIMAL MODEL ATROPHY EVIDENCE
REGENERATION RATE
TECHNIQUE
NERVE TRANSFER
DONOR
RECIPIENT
EXPOSURE
DONOR
DISTAL
RECIPIENT
PROXIMAL
MANTRA
TRANSECTION
NERVE
TRANSFER
NERVE
&
DISTAL
PROXIMAL
NERVE TRANSFERS
FOR THE HAND
Susan E. Mackinnon MD
POOR
INTERNAL TOPOGRAPHY
KNOWLEDGE IN
NERVE GRAFTING
THE NEED FOR
FOR THE HAND
CONDUCTION BLOCK
No Fibrillations
NERVE TRANSFERS
NERVE TRANSFERS
SUPERCHARGE
Ida K. Fox MD
Christine B. Novak PT PhD
Andrew Yee BS
We, Ida K Fox, Christine B Novak, Andrew Yee, have no disclosures.
2 Years Post-operative
Median (FCR/FDS)
to
Radial (PIN/ECRB)
Nerve Transfer
Typing Outcome
Median (FCR/FDS)
to
Radial (PIN/ECRB)
Nerve Transfer
Full transcript