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EL HAJ - 2018 Israel - Paradigms in Nerve Transfers - Part 1

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Andrew Yee

on 30 March 2018

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Transcript of EL HAJ - 2018 Israel - Paradigms in Nerve Transfers - Part 1

BRACHIAL PLEXUS INJURY
Nerve Grafting
Nerve Transfers
Oberlin Nerve Transfer
Double Fascicle Nerve Transfer
ELBOW FLEXION
Review of 29 Cases
Review of 32 Cases
M4/4+ RESULTS
C5
C6
C7
C8
T1
C5
C6
C7
C8
T1
BULLET
High Median Nerve Injury
Anterior Interosseous
Nerve Deficit
Median Nerve Injury
Gunshot
Wound
Nerve Transfers
Pre-operative
Post-operative
1 Year
Post-operative Result
Proximal Regenerative Front
Partial Injury Model
2nd/3rd degree injury
Axonotmesis
Supercharge in
Incomplete Model
Partial Injury - Graft
Supercharge Nerve Transfer
Transection
Supercharge in Incomplete Injury
Supercharge in Incomplete Injury
with
Donor

Transection
II.
I.
Additional Regenerative Front
Supercharge Experimental Study
Histomorphometry
End-to-end
Nerve Transfer
Supercharge
Nerve Transfer
=
RESEARCH
CLINICAL
"Reverse"
Anterior Interosseous to Ulnar Motor Nerve Transfer
END-TO-END
Anterior Interosseous to Ulnar Motor Nerve Transfer
SUPERCHARGE END-TO-SIDE
Supracondylar Fracture and ORIF
Ulnar Nerve Deficit
OUT
RECOVERING
NORMAL
ULNAR
MEDIAN NERVE
NERVE
Favorable
Unfavorable
I, II, III
Degree of Nerve Injury
VI, V
Degree of Nerve Injury
FibS/PSW + MUPs
FiBS/PSW + No MUPs
Motor Unit Potential
Fibrillations
Recovering
4 Months Post-Injury
Out
Electromyography
Surgery
AIN
Motor Component of Ulnar Nerve
AIN
Motor Component of Ulnar Nerve
Post-Operative Results
2 Months
4 Months
Pre-operative
Pre-operative
LABC
ECRB
Anterior Interosseous Nerve
Sensory Component of Median Nerve
PROXIMAL
RECOVERY
PROXIMAL RECOVERY
Classification of Nerve Injuries
FAVORABLE
UNFAVORABLE
Neuron Cell Body
Muscle / Skin
Schwann Cell
Axon
Nerve Injury
Degeneration
Cell Migration
Axonal Growth
Reinnervation
Nerve Regeneration
for Reinnervation
Normal
Atrophy
"Irreversible" Atrophy
Time of Injury
0 - 12 Months
12+ Months
1mm / Day
3cm / Month
36cm / Year
"Irreversible" Atrophy
12+ Months
"Gold Standard"
Autograft
Allograft
Acellularized Allograft
NERVE GAP
Conduit
Immunosupression
<
<
<
-
Off-the-Shelf
"NERVE GRAFTS"
"NERVE TRANSFER"
PUBMED
PUBMED
1975
1975
1990
1990
Nerve Transfer > Nerve Grafting
NERVE INJURY AND RECOVERY
"Bronze Standard"
NERVE TRANSFERS
NERVE TRANSFERS
FOR SPINAL CORD INJURIES
NERVE TRANSFERS
IN THE LOWER EXTREMITY
1 Year
1mm / Day
3cm / Month
36cm / Year
REGENERATION RATE
Post-operative Result
Finger/Wrist Drop
FCR
PIN
FDS
ECRB
Finger Extension
Wrist Extension
Finger Flexion
Wrist Flexion
1
2
Synergistic
Median to Radial Nerve Transfer
Median and Radial Nerve Anatomy
(N) FCR
DONOR
(N) FDS
DONOR
(N) ECRB
RECIPIENT
(N) PIN
RECIPIENT
"DONOR DISTAL, RECIPIENT PROXIMAL"
POST-OPERATIVE RESULT
ULNAR NERVE TRANSECTION
POST-OPERATIVE RESULTS
SURGERY
PROXIMAL END
ULNAR NERVE
DISTAL END
ULNAR NERVE
MABC CABLE GRAFTS
ULNAR NERVE
SUPERCHARGE
NERVE TRANSFER
Anterior Interosseous Nerve
Ulnar Motor Component
15 Months
ST. LOUIS, MISSOURI, U.S.
WASHINGTON UNIVERSITY SCHOOL OF MEDICINE
Susan E. Mackinnon, MD
Thomas H. Tung, MD
Ida K. Fox, MD
Amy M. Moore, MD
Alison K. Snyder-Warck, MD
John M. Felder, MD
Lorna C. Kahn, PT
Muhammad T. Al-Lozi, MD
Robert W. Thompson, MD
NERVE SURGERY
Department of Neurology
Division of Vascular Surgery
Distance
Time
Muscle
Time
Muscle
Function
Neurodiagnostic Center
Thoracic Outlet Center
TIME WINDOW
REINNERVATION
30%
70%
DENERVATION
LOST OF FUNCTION
FOR FUNCTION
DENERVATION % FOR FUNCTIONAL LOSS
CLASSIFICATION OF NERVE INJURIES
1mm / Day
3cm / Month
36cm / Year
Hand Muscle
NERVE GRAFTING
FUNCTIONAL RECOVERY
PROXIMAL INJURIES
DELAYED REPAIR
POOR
INTERNAL TOPOGRAPHY
KNOWLEDGE IN
NERVE GRAFTING
THE NEED FOR
IN THE UPPER EXTREMITY
Spinal Accessory Nerve
C7 (Pectoral)
to
spinal accessory
transfer

Suprascapular Nerve
Spinal accessory
to
suprascapular

transfer

Axillary Nerve
Medial triceps
to
axillary
transfer
Medial pectoral
to
axillary
transfer
Thoracodorsal
to
axillary
transfer

Long Thoracic Nerve
Double-level transfer
C7 (Pectoral)
to
long thoracic
transfer
Thoracodorsal
to
long thoracic
transfer

Intercostal
to
long thoracic
transfer
Musculocutaneous Nerve
Double fascicular transfer
Medial pectoral
to
musculocutaneous
transfer
Thoracodorsal
to
musculocutaneous
transfer

Triceps Brachii Nerve
Flexor carpi ulnaris
to
medial triceps
transfer
(N) suprascapular
Recipient
(N) spinal accessory
Donor
Acromion
Medial Border
Spine
Suprascapular Notch
(Suprascapular Nerve)
Spinal Accessory Nerve
END-TO-END
POSTERIOR
Anatomy
NERVE Transfer
Pre-operative Anatomical Markings
Orientation
Suprascapular Ligament and Nerve
Spinal Accessory Nerve
Transfer
HEAD
MEDIAL / SPINE
THORACIC
Suprascapular Notch and Ligament
PRONE RIGHT POSTERIOR SHOULDER
DONOR
RECIPIENT
RECIPIENT
Proximal Cut
DONOR
RECIPIENT
DONOR
RECIPIENT
Post-operative Outcome
LATERAL / ARM
RIGHT SCAPULA
VESSELS
LIGAMENT
NERVE
MEDIAL
LATERAL
Spine of Scapula
APPROACH
Post-operative Results
No Elbow Flexion
Shoulder Deficit
(-) Axillary Nerve
(-) Suprascapular Nerve
(-) Musculocutaneous Nerve
Normal Wrist Flexion
(+) Flexor Carpi Radialis
(+) Flexor Carpi Ulnaris
C5,6 Injury

Nerve Transfers
Restores...
Double Fascicular Nerve TRANSFER
DONOR
FCU FASCICLE
Ulnar Intrinsic Function
Flexor Digitorum Profundus
CONFIRM INTACT FUNCTION
Ulnar Nerve Stimulation (LEFT ARM)
Donor
Recipient
Combination
Motor Transfer
Sensory Transfer
Radial Sensory Component
to
Superior Lateral Cutaneous
Nerve Transfer
Post-operative Results
Radial Nerve Stimulation
ROOT
INJURIES
CORD
INJURIES
MUSCULOCUTANEOUS
SUPRASCAPULAR
AXILLARY
NERVE
RADIAL
ULNAR
MEDIAN
NERVE
NERVE
NERVE
NERVE
NERVE
ACCESSORY TO SUPRASCAPULAR
MEDIAL TRICEPS TO AXILLARY
DOUBLE FASCICULAR TRANSFER
MEDIAN TO RADIAL
ECRB TO ANTERIOR INTEROSSEOUS
ANTERIOR INTEROSSEOUS TO ULNAR MOTOR
Synergistic
(N) FCR
DONOR
(N) FDS
DONOR
(N) ECRB
RECIPIENT
(N) PIN
RECIPIENT
cASE #1
cASE #2
2-YEARS POST-OP
CASE #1
CASe #2
SUPERCHARGE
DOUBLE SHOULDER
NERVE TRANSFERS
SHOULDER
Radial Nerve
Median to radial transfer
FDS
to
ECRB
transfer
FCR
to
PIN
transfer
Supinator
to
PIN
transfer
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
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
Deep Motor Branch of Ulnar Nerve
Anterior interosseous (PQ)
to
ulnar motor
transfer
End-to-end (ETE)
Supercharge end-to-side (SETS)

Hadassah Hebrew University
Hand and Microvascular Surgery
Center of Peripheral Nerve Surgery
Jerusalem, Israel
NERVE TRANSFER
A GLOBAL LEARNING PARTNERSHIP
PARADIGMS IN
Madi El Haj, MD
PART I: UPPER EXTREMITY
PASSIOEDUCATION.COM
EDUCATING TOMORROW'S SURGEONS
CREDITS
SUSAN E. MACKINNON, MD
ANDREW YEE
DONOR
FCR Fascicle
DONOR
FCU Fascicle
MEDIAL ASPECT
OF MEDIAN NERVE
LATERAL ASPECT
OF ULNAR NERVE
Pronator Teres
Anterior Interosseous Nerve
Thenar Function
CONFIRM INTACT FUNCTION
Median Nerve Stimulation (LEFT ARM)
DONOR
FCR FASCICLE
AIN
FCR
PRONATOR TERES
VIDEO ORDER
OF STIMULATION
FCU
ULNAR INTRINSICS
VIDEO ORDER
OF STIMULATION
FASCICULAR ANATOMY
SURGERY
PREFERRED
FCU FASCICLE BICEPS BRANCH
FCR FASCICLE BRACHIALIS BRANCH
MEDIAN NERVE
MABC
BRACHIALIS BRANCH
BRACHIAL ARTERY
BICEPS BRANCH
ULNAR NERVE
FCR FASCICLE
FCU FASCICLE
DONOR
DONOR
RECIPIENT
RECIPIENT
BICEPS BRANCH
RECIPIENT
FCR FASCICLE
DONOR
FCU FASCICLE
DONOR
BRACHIALIS BRANCH
RECIPIENT
Expendable Nerve
NERVE TRANSFERS
ADVANTAGES
Decreases regeneration time
Avoids interpositional nerve graft
Not dependent on extent/location of injury
Early reinnervation = faster recovery
Decreased loss of axons across two coaptation sites
No donor site morbidity
Able to avoid operating in an scarred field
NO DISCLOSURE
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