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Tricks and Techniques to Maximize Success with Nerve Transfers

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Tricks and Techniques to Maximize Success with Nerve Transfers IC12-L: Tricks and Techniques to Maximize Success with Nerve Transfers Moderator(s): Susan E. Mackinnon, MD Faculty: Christine B. Novak, PT, PhD and J. Megan Patterson, MD Session Handouts Friday, October 02, 2020 75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1-3, 2020 822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: [email protected] All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain. IC12 – Tricks and Techniques to Maximize Success with Nerve Transfers American Society for Surgery of the Hand Annual Meeting, October 2, 2020 Susan E. Mackinnon, MD, St. Louis, Missouri J. Megan M. Patterson, Chapel Hill, North Carolina Christine B. Novak, PT, PhD, Toronto, Ontario Andrew Yee, BS, St. Louis, Missouri Overview: Following complex nerve injury, motor and sensory recovery can be less than optimal. For high median, ulnar and radial nerve injuries, nerve transfers can provide a distal source of motor and/or sensory innervation closer to the target end organ allowing for faster recovery and improved outcome. This course will focus on techniques to maximize success with upper extremity motor and sensory nerve transfers. Classification of Nerve Injury: Degree of Injury Tinel’s Sign Recovery Rate of Surgical Procedure Present Recovery I Neurapraxia No Complete Up to 12 weeks None II Axonotmesis Yes Complete 1” per month None III Yes Varies * 1” per month None or Neurolysis IV Neuroma Yes but no None None Nerve repair, graft or In-continuity advancement transfer V Neurotmesis Yes but no None None Nerve repair, graft or advancement transfer VI Mixed Injury Some fascicles Some fascicles Depends on Neurolysis, nerve (I to V) (II, III) (II, III) degree of injury repair, graft or transfer (I – V) * Recovery can vary from excellent to poor depending on the amount of scarring and the sensory versus motor axon misdirection to target receptors Modified from Mackinnon & Dellon, Surgery of the Peripheral Nerve, 1988. Reproduced with permission from Susan E. Mackinnon, MD Advantages of Nerve Transfers: 1. Directs a large number of axons to denervated muscle quickly. 2. Provides faster and superior muscle reinnervation then may be seen with primary repair or grafting. Surgical Indications and Management: Motor Nerve Transfers: 1. Motor donor nerve must: • Be expendable. • Be close to the motor end plates of the target muscle. • Contain a large number of motor nerve axons. • Allow for straightforward motor reeducation by using a donor muscles that is synergistic to the target muscle 2. Common motor nerve transfers: • Median nerve fascicle and ulnar nerve fascicle to biceps brachii branch and brachialis branch of musculocutaneous nerve for elbow flexion (Double Fascicular Transfer). 2 Reproduced with permission from Susan E. Mackinnon, MD • Anterior interosseous nerve to motor branch of ulnar for intrinsic muscle reinnervation. 3 Reproduced with permission from Susan E. Mackinnon, MD Sensory Nerve Transfers: 1. Sensory donor nerve must: • Provide sensation to a non-critical area. • Be a pure sensory nerve. • Be a good size match between donor and target nerve. 2. Common sensory nerve transfers: • Nerve to the 4th webspace to 1st web space transfer to retore sensation to the radial side of the index and ulnar side of the thumb. • End-to-side repair of 2nd and 3rd web space to ulnar digital nerve to the small to restore sensation to the 2nd and 3rd web spaces. • End-to-side repair of ulnar sensory and dorsal ulnar sensory nerves to median nerve to restore sensation to the small and ring fingers and ulnar dorsal skin. Tips and Pearls for the Beginner—in the OR: • Remind anesthesiologist—no long acting paralytics. • Don’t use Marcaine/lidocaine until after you want to stimulate the nerves. • Avoid use of a tourniquet especially if you are a bit slower—otherwise a tourniquet palsy may complicate intraoperative direct nerve stimulation. • Donor DISTAL, Recipient PROXIMAL. • ‘Neurolysis with your eyes’. 4 Reproduced with permission from Susan E. Mackinnon, MD Common injury patterns and treatment options: 1. Upper plexus injury—loss of elbow flexion: • Nerve transfers: • Double fascicular transfer (median/ulnar to nerve to biceps and brachialis). • Medial pectoral to musculocutaneous nerve. • Thoracodorsal to musculocutaneous nerve. • Other options: • Steindler flexorplasty. • Long nerve grafts. 2. Upper plexus injury—loss of shoulder function: • Nerve transfers: • Spinal accessory nerve to suprascapular nerve. • Triceps to axillary nerve. • Medial pectoral nerve to axillary nerve. • Other options: • Shoulder fusion. • Trapezius transfer (Saha procedure). • Long nerve grafts. 3. Lower plexus injury—loss of pronation: • Nerve transfers: • Brachialis or ECRB (if C7 is spared) to pronator nerve branch. • Other options: • Biceps, brachioradialis, or brachialis muscle rerouting. 4. Lower plexus injury—loss of thumb and index finger flexion • Nerve transfers: • Supinator branch to anterior interosseous nerve transfer. • Brachialis branch to anterior interosseous nerve transfer. • Other options: • Tendon tranfers (brachioradialis to flexor pollicis longus and extensor carpi radialis longus to index finger flexor digitorum profundus). 5. Axillary nerve injury: • Nerve transfers: • Triceps to axillary nerve. • Medial pectoral nerve to axillary nerve. • Thoracodorsal nerve to axiallary nerve. • Other options: • Shoulder fusion. • Long nerve grafts. 5 Reproduced with permission from Susan E. Mackinnon, MD 6. Radial nerve injury: • Nerve transfers: • Median (flexor carpi radialis, flexor digitorum superficialis branches) to extensor carpi radialis brevis and posterior interosseous nerve branches. • Other options: • Tendon transfers (pronator teres to extensor carpi radialis brevis, palmaris longus to extensor pollicis longus, and flexor carpi ulnaris, flexor carpi radialis or flexor digitorum superficialis to extensor digitorum communis). 7. Loss of median innervated pronation: • Nerve transfers: • Extensor carpi radialis brevis to pronator teres nerve branch. • Other options: • Biceps, brachioradialis, or brachialis muscle rerouting. 8. Loss of median innervated thumb and finger flexion: • Nerve transfers: • Supinator branch to anterior interosseous nerve transfer. • Brachialis branch to anterior interosseous nerve transfer. • Other options: • Tendon tranfers (brachioradialis to flexor pollicis longus, extensor carpi radialis longus to index/long finger flexor digitorum profundus, side to side tendodesis to ulnar flexor digitorum profundus). 9. Isolated AIN injury: • Nerve transfers: • Flexor digitorum superficialis to anterior interosseous nerve branch. • Other options: • Brachioradialis to flexor pollicis longus tendon transfer and flexor digitorum profundus tenodesis • Fusion of interphalangeal joint of thumb. 10. Distal median nerve injury: • Nerve transfers: • AIN to median motor branch. • Other options: • Opponensplasty. 11. Distal ulnar nerve injury: • Nerve transfers: • Anterior interosseous nerve to ulnar deep motor branch. • Other options: • Various static and dynamic claw hand procedures. 6 Reproduced with permission from Susan E. Mackinnon, MD Rehabilitation following Nerve Transfer: Early Post-operative Management: • Early range of motion is important to decrease adhesions at the nerve repair site. • Postoperative dressing is removed on POD 2 to 3 and active/passive range of motion of uninvolved joints is started. • Protect repair site with a splint or sling for 7-14 days. • Following immobilization; regain and maintain full passive range of motion. Late Stage Rehabilitation - Sensory & Motor Reeducation: • Alteration in cortical mapping following nerve injury. • Following reinnervation, can regain cortical area by increasing the sensory/motor input. Sensory reeducation: • Begin by increasing the sensory input to the appropriate sensory distribution with different textures of material. • Progress to localization exercises and finally discriminatory tasks. • Cortical retraining requires repetition and purposeful movement. Motor reeducation: • Need to increase muscle strength and central mechanisms controlling motor function. • Nerve transfer requires motor reeducation similar to that required with tendon transfers. • Restore muscle balance – be aware of co-contraction of antagonist muscles, strengthen muscles weakened by disuse. • Biofeedback (visual and audio) more useful than muscle stimulation. • To facilitate relearning begin on unaffected side. • Initially need to contract muscle from donor nerve to achieve a contraction in the recipient muscle. Aim for control and initiation of muscle contraction. • Begin in gravity assisted or gravity eliminated position and progress to exercises against gravity and progressive resisted exercises. • Dissociate target muscle from donor muscle contraction. 7 Reproduced with permission from Susan E. Mackinnon, MD References 1. Anastakis DJ, Malessy MJ, Chen R, Davis KD, Mikulis D. Cortical plasticity following nerve transfer in the upper extremity. Hand Clin. 2008, 24: 425-44. 2. Barbour J, Yee A, Kahn LC, Mackinnon SE. Supercharged end-to-side anterior interosseous to ulnar motor nerve transfer for intrinsic musculature reinnervation. J Hand Surg Am. 2012, 37: 2150-9. 3. Battiston B, Lanzetta M. Reconstruction of high ulnar nerve lesions by distal double median to ulnar nerve transfer. J Hand Surg Am. 1999,
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