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MACKINNON - 2015 UoT - Peripheral Nerve Surgery

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Andrew Yee

on 24 March 2015

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Transcript of MACKINNON - 2015 UoT - Peripheral Nerve Surgery

WHO
WHERE
WHAT
WHEN
PASSIO
PASSION
SUFFERING, ENDURING
1mm / Day
3cm / Month
36cm / Year
"Irreversible" Atrophy
12+ Months
Regeneration Rate
3cm Growth / Month
36cm Growth / Year
PERIPHERAL
NERVE SURGERY
NERVE
GRAFTING
Muscle Atrophy
Long Distance
Results of Nerve Grafting
NERVE
TRANSFERS
CLINICAL
RESEARCH
Seddon Sunderland
Leonard Goldner
Sterling Bunnell
James Murray
William Littler
Hanno Millesi
Alan Hudson
NERVE
GRAFTING
TENDON
TRANSFERS
NERVE
REPAIRS
NERVE
TRANSFERS
Susan Mackinnon
POOR RESULTS OF NERVE GRAFTING
BRACHIAL PLEXUS INJURIES
Nerve Allotransplantation
Transgenic Models
Histomorphometry
Muscle Force Measurement
Walking Track Analysis
Retrograde Labeling
Microscopic Analysis
Operating Microscope
Fluroscenct Microscope
Confocal Microscope
Light Microscope
Electron Microscope
Translational Research
Piecing a puzzle together...
Motor Branch
Sensory Branch
Femoral Nerve
End-to-side Coaptation
Proximal Crush Injury
Neurectomy
(N) AIN fascicle
(N) pronator fascicle
(N) median
Internal Neurolysis
Lewis (Host) - Lewis (Graft)
Lewis (Host) -
Fisher (Graft)
Lewis (Host) -
ACI (Graft)
1990s
1978
First allograft paper...
"Quantitative Immunological Study"
Developing a nerve allograft model...
...with host immunosuppression.
Lewis / Lewis Autograft
Lewis / ACl Allograft
with
Steroid (Hydrocortisone)
Lewis / ACl Allograft
with
No Immunosuppression
NERVE
TRANSFERS
Interfascicular Anatomy
Results of Nerve Transfers
Thoracodorsal to Musculocutaneous
Nerve Transfer
Medial Pectoral to Axillary
Nerve Transfer
Double Fascicular Nerve Transfer
Post-operative Results
ELBOW FLEXION
No Elbow Flexion
Shoulder Deficit
(-) Axillary Nerve
(-) Suprascapular Nerve
(-) Musculocutaneous Nerve
Normal Wrist Flexion
(+) Flexor Carpi Radialis
(+) Flexor Carpi Ulnaris
C5,6 Injury
Shoulder
Nerve Transfers
Restores...
Double Fascicular Nerve Transfer
SURGERY
DONOR
RECIPIENT
Muscle
Neuron Cell Body (
Gateway Arch
)
Anchorage, AK
St. Louis, MO
Nerve Injury
and Recovery
Muscle
Neuron Cell Body (
Gateway Arch
)
Anchorage, AK
St. Louis, MO
Fairbanks, AK
Adjacent Neuron Fibers
Nerve Transfers
~1mm Growth / Day
NERVE
REPAIRS
BREAD AND HEART
Neurotization
Nerve Crossing
1915
1911
Nerve Anastomosis
Philipp Erlacher
Charles Elsberg
Arthur Stiendler
1933
Lewis John Pollock
Loyal Davis
Idea of Nerve Transfers
Erik Moberg
Herbert Seddon
Harry Buncke
Joseph Boyes
Sterling Bunnell
Hanno Millesi
Donald Brooks
Leonard Goldner
Raymond Curtis
The Controversy...
...of Nerve Grafts
Gabriele Ferrara
1608
First documented nerve repair...
1800s
Popularity of nerve repairs...
1934
Loyal Davis
David Cleveland
First comprehensive review of the history of nerve repairs...
1914-1918
WORLD WAR I
WORLD WAR II
1939-1945
AMPUTATIONS
...however still amputations.
Median to Radial Nerve Transfers
INDICATIONS
SURGICAL TECHNIQUE
POST-OPERATIVE
Median to Radial Nerve Transfers
Finger/Wrist Drop
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
(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) FCR
DONOR
(N) PIN
RECIPIENT
(N) ECRB
RECIPIENT
(N) FDS
DONOR
2 Years Post-operative
Median (FCR/FDS)
to
Radial (PIN/ECRB)
Nerve Transfer
Typing Outcome
Median (FCR/FDS)
to
Radial (PIN/ECRB)
Nerve Transfer
SURGERY
WRIST EXTENSION
FUNCTION
FUNCTION
Double Fascicular Nerve Transfer
Brachialis
Nerve
Expendability
Post-operative Results
Jumping the Gap in a
Spinal Cord Injury
Reinnervating the both the Biceps and Brachialis
2003
2005
Single Fascicular = Double Fascicular
Oberlin vs Double Fascicular Nerve Transfer
2011
2012
Brachialis to AIN Nerve Transfer
DONOR
2012
Spinal Cord Injury
Brachialis to AIN Nerve Transfer
Functional Recovery - 2 Year
Functional Recovery - 1 Year
1993
SUPERCHARGE
NERVE TRANSFERS
NERVE TRANSFERS
SPINAL CORD INJURY
NERVE TRANSFER
BRACHIALIS TO ANTERIOR INTEROSSEOUS
Post-operative Results
Functional Recovery - 1 Year
Functional Recovery - 2 Year
Melt My Wings
Outcomes
Pre-operative Exam
CLASSIFICATION OF NERVE INJURIES
I
II
IV
III
V
VI
FAVORABLE
UNFAVORABLE
NERVE TRANSFERS
NERVE TRANSFERS
SUPERCHARGE
MEDIAN NERVE LIPOFIBROMA
CASE
CARPAL TUNNEL RELEASE
2ND OPINION
MEDIAN NERVE
RESECTION
NERVE GRAFTING
RETURN VISIT
INNOVATIONS IN
1983
1982
PARADIGM
NERVE REPAIR
PARADIGM
NERVE GRAFTING
Sunderland
Millesi
1982
1984
Reinnervating Biceps Brachii
1985
Sensory Transfers in a Paraplegic Patient
ERICSSON
EXPERTISE
10,000 HOUR RULE
HAVING A COACH
LOGAN
ENVIRONMENT
STAGE 1
STAGE 2
STAGE 3
STAGE 4
STAGE 5
STAGE 4
JOHNSON
IDEAS
ADJACENT POSSIBILITY
SLOW HUNCH
LIQUID NETWORKS
FAILURE
EXAPTATIONS
SERENDIPITY
KUHN
PARADIGMS
CONTROVERSY
PARADIGMS
ADJACENT POSSIBILITY
Paradigm Shift
Paradigm Shift
Paradigm
Paradigm Shift
Paradigm
Paradigm
Paradigm Shift
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"
Desmond Tutu
10,000 HOUR RULE
Adjacent Possible
Present Idea
Adjacent Possible
Adjacent Possible
Find ways to explore the edges of possibility that surround you...
Nelson Mandela
Truth and Reconciliation Commission
Nerve Repairs
Nerve Grafting
Nerve Transfers
TAKING RISKS
PRINTING
PRESS
WINE
PRESS
THREE PRINCES
OF SERENDIP
LIQUID NETWORKS
Johannes Gutenberg
Erik Bruhn
Rudolf Nureyev
THE COACH
REGULAR, CRITICAL FEEDBACK
HOURS OF MUSICIAN'S CUMULATIVE PRACTICE
EXPERT
SECOND TIER
SERIOUS AMATEUR
10,000 HOURS
5,000 HOURS
2,000 HOURS
AGE 20
ELITE SKATERS
SECOND TIER SKATERS
THIRD TIER SKATERS
SKATERS
68% DEMANDING JUMPS
48% DEMANDING JUMPS
PRACTICE WHAT THEY KNOW
PRACTICE DIFFICULT TAKES
TAKING RISKS
DELIBERATE
PRACTICE
PRACTICE
DEDICATED AND REPEATED
=
EXAPTATIONS
1398-1468
SERENDIPITY
SLOW HUNCH
ADJACENT
POSSIBILITY
FAILURE
EPIPHANIES
EUREKA
SPARKS
FLASHES
GOOD
IDEA
PLASTICITY AND EXPLORING NEW CONNECTIONS...
1973
THE PRODIGAL SON
ROYAL OPERA
SUSAN E. MACKINNON, MD
ANDREW YEE
YOUTUBE.COM
/NERVESURGERY
NERVESURGERY.WUSTL.EDU
EDUCATION WEBSITE
EDUCATION VIDEOS
THIEME PUBLISHERS
NERVE SURGERY
CREDIT
WASHINGTON UNIVERSITY
PLASTIC & RECONSTRUCTIVE SURGERY
SCHOOL OF MEDICINE
DISCLOSURES
CO-INVENTOR OF PGA NEUROTUBE
RESEARCH FUNDING FROM AXOGEN INC
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
+
/
_
Anterior Interosseous to Ulnar Motor Nerve Transfer
SUPERCHARGE END-TO-SIDE
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
=
Incomplete Ulnar Nerve Injury
Orientation
DONOR

- Anterior Interosseous Nerve
RECIPIENT

- Ulnar Motor Fascicle
Anterior Interosseous to Ulnar Motor
Supercharge Nerve Transfer
1-Year Post-operative
AIN
to
Ulnar Motor
SETS Nerve Transfer
Post-operative Results
RESEARCH
CLINICAL
Full transcript