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FDS to Pronator Teres Nerve Transfer

FCR to Pronator Teres Nerve Transfer

Results of Nerve Transfers

Thoracodorsal to Axillary

Nerve Transfer

Distal

Recipient Nerve

Medial Pectoral to Musculocutaneous

Nerve Transfer

Classification of Nerve Injuries

Results of Nerve Grafting

Nerve Transfers

Adjacent Neuron Fibers

Fairbanks, AK

Neuron Cell Body (Gateway Arch)

St. Louis, MO

Muscle

Anchorage, AK

Nerve Injury and Recovery

Neuron Cell Body (Gateway Arch)

St. Louis, MO

Muscle

Anchorage, AK

Nerve Anatomy

(+)

II Degree

Distance Time

Time Muscle

Muscle Function

Supercharge

Nerve Transfers

Credits

Comprehensive Review of Neurosurgery

Andrew Yee, BS

Acute Nerve Injury and Repair

(+)

III Degree

Part II - Supercharge Nerve Transfers and Nerve Transfers in the Hand

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

Susan E. Mackinnon, MD

Plastic and Reconstructive Surgery

Washington University School of Medicine

St. Louis, MO

Peripherial Nerve Surgery Education

nervesurgery.wustl.edu

Surgical Video Library

https://vimeo.com/user6062882

Prezi Presentation

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

Nerve Transfers

Indications

Recipient

  • 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

Nerve Transfer provides:

  • source of nerve in close proximity to the denervated muscle
  • faster and superior muscle reinnervation

Supercharging the Injured Nerve

Supercharge

End-to-side

Clinical

Research

Supercharge Nerve Transfer

Adjacent Neuron Fibers

Ulnar Nerve Injury

End-to-end

Fairbanks, AK

Clawing

2nd / 3rd Degree Nerve Injury

(Axonotmesis)

Post-operative Outcome

Neuron Cell Body (Gateway Arch)

Muscle

Orientation

Anchorage, AK

St. Louis, MO

Revision Ulnar Nerve Transposition

Supercharge AIN to Ulnar Motor Nerve Transfer

Guyon's Canal Release

2 Years

Proximal Regenerative Front

II.

1st Dorsal Interosseous Wasting

Donor

Pinch / Grip

Right - 23/102

Right - 3/58

Functional Results

Muscle Force Analysis

DONOR - Anterior Interosseous Nerve

Post-operative

Pre-operative

Partial Injury Model

Supercharge in

Incomplete Injury

  • 2nd / 3rd Degree Injury - Axonotmesis

Transection

  • Partial Injury - Graft
  • Supercharge Nerve Transfer

Specific Force (N/cm2)

Donor

Supercharge in Incomplete Injury

Partial Injury

Supercharge

Partial Injury

Supercharge

Supercharge in Incomplete Injury

with Donor Transection

RECIPIENT - Ulnar Motor Fascicle

Supercharge

Anterior Interosseous to Ulnar Motor Nerve Nerve Transfer

I.

Additional Regenerative Front

Recipient

Supercharge Experimental Study

Transgenic Animal Models

Nerve Transfers

IV

Supercharge

Nerve Transfer

End-to-end

Nerve Transfer

=

I

III

V

II

VI

Brachialis to Anterior Interosseous Nerve Transfer

Brachialis to AIN / PT Nerve Transfer

Donor

Recipient

Post-operative Results

Pronation and AIN Function - 4 Years

Pronation and AIN Function - 2 Years

SCI Brachialis to Anterior Interosseous Nerve Transfer

Melt My Wings

Post-operative Results

Functional Recovery - 1 Year

Restoration of AIN Function in SCI Patient

Spinal Cord Injury: ~C7 Level

71 Year-old Male

2 Years Post-Injury

Left - Brachialis to AIN Nerve Transfer

Right - Brachialis to AIN Nerve Transfer

Interfascicular Anatomy of Median Nerve

Electrical Stimulation of Right AIN Fascicle

Electrical Stimulation of Left AIN Fascicle

Interfascicular Anatomy of Median Nerve

Histomorphometry

Recipient: AIN Fascicle

2 Years Post-Injury

Donor: Brachialis Branch

Nerve Fibers: ~3512

Nerve Fibers: ~3222

Pre-operative Examination

Left Arm Examination

Right Arm Examination

Median to Radial Nerve Transfer

Outcomes

Surgical Procedure

Outcomes

Radial Nerve Injury

Median to Radial Nerve Transfers

Incision

Median (FCR / FDS) to Radial (PIN / ECRB) Nerve Transfer

Lateral Antebrachial Cutaneos Nerve

Nerve Transfers

4 Year Post-operative

Radial Vessels Landmark

(M) pronator teres tendon

(N) radial sensory

Humeral Fractures

Wrist Drop

Old Anatomy

radial vessels

I

9 Month Post-operative

FCR

PIN

Nerve Transfers

Median and Radial Nerve Anatomy

Step-lengthening Pronator Teres Tendon

Wrist Flexion

Finger Extension

Release of Deep Head of Pronator Teres

FDS

ECRB

II

Arch of Flexor Digitorum Superficialis

Finger Flexion

Wrist Extension

Median Nerve Anatomy

Median to Radial Nerve Transfers

(N) flexor digitorum superficialis

Donor

(N) flexor carpi radialis

Donor

Exposure of Radial Nerve

1 Year Post-operative

Radial Nerve Anatomy

Median and Radial Nerve Anatomy

(N) posterior interosseous

Recipient

(N) extensor carpi radialis brevis

Recipient

Median and Radial Nerve

(N) posterior interosseous

Recipient

(N) extensor carpi radialis brevis

Recipient

(N) flexor digitorum superficialis

Donor

(N) flexor carpi radialis

Donor

Removal of Supinator Branch

Current Anatomy

(N) posterior interosseous

Recipient

(N) supinator

Donr Distal, Recipient Proximal

Orientation

(N) extensor carpi radialis brevis

Recipient

(N) posterior interosseous

Recipient

(N) flexor digitorum superficialis

Donor

(N) flexor carpi radialis

Donor

Median to Radial Nerve Transfers

(N) posterior interosseous

Recipient

(N) extensor carpi radialis brevis

Recipient

(N) flexor carpi radialis

Donor

(N) flexor digitorum superficialis

Donor

ECRB to Anterior Interosseous Nerve Transfer

ECRB to Pronator Teres Nerve Transfer

(N) extensor carpi radialis brevis

Donor

(N) extensor carpi radialis brevis

Donor

(N) extensor carpi radialis brevis

Donor

(N) extensor carpi radialis brevis

Donor

(N) anterior interosseous

Recipient

(N) extensor carpi radialis brevis

Donor

(N) anterior interosseous

Recipient

(N) anterior interosseous

Recipient

(N) pronator teres

Recipient

(N) pronator teres

Recipient

Supinator to Anterior Interosseous Nerve Transfer

Complete Median Nerve Injury

(N) pronator teres

Recipient

(N) flexor digitorum superficialis

Donor

(N) flexor digitorum superficialis

Donor

(N) pronator teres

Recipient

(N) pronator teres

Recipient

(N) flexor digitorum superficialis

Donor

FDS to Anterior Interosseous Nerve Transfer

AIN Palsy

(N) anterior interosseous

Recipient

(N) anterior interosseous

Recipient

(N) anterior interosseous

Recipient

(N) flexor digitorum superficialis

Donor

(N) flexor digitorum superficialis

Donor

(N) flexor digitorum superficialis

Donor

FCU to Pronator Teres Nerve Transfer

FDS to FPL Nerve Transfer

Pre-operative Examination

Post-operative Results

(N) anterior interosseous

(N) flexor pollicis longus

Recipient

(N) remaining anterior interosseous

(N) flexor digitorum superficialis

Donor

(N) flexor digitorum superficialis

Donor

(N) flexor pollicis longus

Recipient

(N) flexor digitorum superficialis

Donor

Anterior Interosseous (PQ) to Recurrent Thenar Nerve Transfer with Graft

Anterior Interosseous (PQ) to Ulnar Motor Nerve Transfer

Post-operative Results

Adjunct Procedures

FDP Tenodesis

  • early recovery of ulnar extrinsic function

Guyon's Canal Release with Deep Motor Branch

  • prevent possible compression inhibiting regeneration

Nerve Transfer

Donor Anterior Interosseous Nerve (PQ)

Recipient Proximal

Recipient Ulnar Motor Component

Nerve Transfer

SENSORY

MOTOR

(N) ulnar sensory component

(N) 3rd webspace of median

(N) ulnar motor component

Recipient

(N) ulnar sensory component

(N) anterior interosseous (PQ)

Donor

(N) ulnar sensory component

(N) ulnar motor component

Recipient

(N) ulnar motor component

Recipient

(N) anterior interosseous (PQ)

Donor

(N) dorsal cutaneous branch of ulnar

Restoration of Hand Function

LABC to Radial Sensory Nerve Transfer

3rd Webspace to Ulnar Sensory Nerve Transfer

3rd Webspace to Dorsal Cutaneous Ulnar

3rd Webspace to Ulnar Sensory

I.

II.

Non-critical ETS Nerve Transfer

Critical ETE Nerve Transfer

Median Sensory to Distal 3rd Webspace

3rd Webspace (Donor) and Ulnar Sensory (Recipient)

II.

3rd Webspace (Donor)

Non-critical ETS Nerve Transfer

DCU to Critical Median Sensory Nerve Transfer

RADIAL

Ulnar Sensory to 3rd Webspace

Dorsal Cutaneous Ulnar (Donor) and 1st and 2nd Webspace (Recipient)

Ulnar Sensory to 1st and 2nd Webspace

II.

Ulnar Sensory to Distal Dorsal Cutaneous Ulnar

I.

Critical ETE Nerve Transfer

Non-critical ETS Nerve Transfer

3rd to 1st Webspace Nerve Transfer

Ulnar Sensory to Distal 3rd Webspace

3rd Webspace to 1st Webspace

3rd Webspace (Donor) and 1st Webspace (Recipient)

II.

I.

Critical ETE Nerve Transfer

Non-critical ETS Nerve Transfer

Restoration of Hand Sensation

Sensory Transfers Summary

Sensory Nerve Transfers

Early Sensory Nerve Transfers

End-to-end (ETE) vs End-to-side (ETS)

  • critical sensation
  • non-critical sensation
  • preserving distal donor sensory nerves

Restoration of 1st Webspace

  • 4th to 1st Webspace (ETE) Nerve Transfer

Restoration of 2nd / 3rd Webspace

  • Ulnar Sensory to 2nd / 3rd Webspace (ETE) Nerve Transfer

Restoration of Ulnar Nerve Sensation

  • Median Sensory to Ulnar Sensory (ETS) Nerve Transfer
  • Median Sensory to Dorsal Cutaneous Ulnar (ETS) Nerve Transfer

Perineurial Window

ETS Neurorrhaphy

Spontaneous Collateral Sprouting

Larger perineurial window induces greater collateral sprouting.

Total Fiber Number

Pannucci C, et al . End-to-side nerve repair: review of the literature. Restor Neurol Neurosci. 25:45-63, 2007.

MEDIAN

Radial Nerve

  • Median to radial transfer
  • FDS to ECRB transfer
  • FCR to PIN transfer
  • Supinator to PIN transfer

Pronator Teres Nerve

  • 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
  • EDQ / ECU to ulnar motor transfer with graft

C5, C6 Palsy

  • 3rd to 1st webspace transfer

Median Nerve

  • Dorsal cutaneous branch of ulnar to 1st webspace transfer

Ulnar Nerve

  • 3rd webspace to ulnar sensory transfer

Radial Nerve

  • LABC to radial sensory transfer

ULNAR

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