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Residents and Fellows Papers Abstract Book Residents and Fellows Papers Abstract Book 73RD ANNUAL MEETING OF THE ASSH SEPTEMBER 13 – 15, 2018 BOSTON, MA 822 W Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Fax: (847) 384-1435 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. Paper 1: Neuroprotective Effect of Lidocaine Administration Prior to Nerve Transection Session 1: Nerve – Wednesday, September 12, 2018, 8:37-8:39 AM Nerve;General Principles N/A - not a clinical study Jeena M. Easow, MD Harvey Chim, MD Christopher J. Salgado, MD Nicole L. Miller, BS Denise Manfrini, BS Elizabeth Medina, BS COI There is financial information to disclose. Hypothesis Following coaptation of peripheral nerves in reconstruction, multiple limitations exist in the regeneration process. Lidocaine may serve as a neuroprotectant prior to nerve transection through inhibition of calcium influx and thus preservation of donor axons. The usefulness of this local anesthetic as a neuroprotective agent was investigated in a rat sciatic nerve model. Methods The sciatic nerves of 41 Sprague-Dawley rats were injected with normal saline (n = 9), 1% Lidocaine (n = 11), 1% Lidocaine w/ 10% calcium gluconate (CG) (n = 11), and 10% calcium gluconate (n = 10). Following injections, the sciatic nerves were transected, labeled with Fluorogold nerve tracer and microsurgically anastomosed. Animals underwent behavioral testing preoperatively and postoperatively at 8 or 12 weeks. Results Walking track analysis and gridwalk testing demonstrated enhanced recovery of locomotion in rats that were administered Lidocaine prior to nerve transection compared to other groups. At 8 weeks, Lidocaine and Lidocaine w/ CG-treated rats had significantly improved Sciatic Functional Index (SFI) scores compared to saline-treated rats (p < 0.05). At 12 weeks, Lidocaine and Lidocaine w/ CG-treated rats had significantly improved SFI scores compared to saline and CG- treated rats (p < 0.05). Gridwalk analysis of foot slip errors indicated Lidocaine-treated rats had significantly lower mean foot slips compared to saline-treated rats (p < 0.05), and Lidocaine w/ CG rats had significantly lower mean foot slips compared to saline, CG, and Lidocaine-treated rats (p < 0.05). At 12 weeks, Lidocaine-treated rats had the lowest level of mean foot slips, which was significantly less than that of Lidocaine w/ CG-treated rats (p < 0.05). Summary Points • This study affirms that administration of Lidocaine prior to nerve transection is an effective intervention to preserve donor axons for planned nerve transfers and may have potentially beneficial clinical applications that warrant further studies. Bibliography 1: Sulaiman W, Gordon T. Neurobiology of peripheral nerve injury, regeneration and functional recovery: From bench top research to bedside application. Ochsner J. 2013;13:100-108. 2: Yu P., Matloub H.S., Sanger J.R., Narini P. Gait analysis in rats with peripheral nerve injury. Muscle Nerve. 2001; 24:231-239. 3: De Medinaceli L., Freed W.J., Wyatt R.J. An index of the functional condition of rat sciatic nerve based on measurements made from walking tracks. Exp Neurol. 1982; 77:634-643. 4: Puigdellívol-Sánchez A. et al. On the use of fast blue, fluoro-gold and diamidino yellow for retrograde tracing after peripheral nerve injury: uptake, fading, dye interactions, and toxicity. J Neurosci Methods. 2002; 115:115-112 5: Lei B., Cottrell J., Kass S. Neuroprotective Effect of Low-dose Lidocaine in a Rat Model of Transient Focal Cerebral Ischemia. Pain Medicine. 2001; 95:445-451. Paper 2: Local Delivery of Supplemental Agrin at the Time of Injury Prevents Motor Endplate Degradation Session 1: Nerve – Wednesday, September 12, 2018, 8:40-8:42 AM Hand and Wrist;Nerve N/A - not a clinical study Winnie Palispis, MD Henry Hoang, BS Jennifer Uong, BS Justin P. Chan, BA Ranjan Gupta, MD COI There is no financial information to disclose. Hypothesis One reason for poor recovery after nerve injury is end-organ atrophy, i.e. degradation of the neuromuscular junctions (NMJ). Agrin has been well characterized as an essential component of NMJ formation; thus, we hypothesize that direct local delivery of agrin after traumatic nerve injury will preserve motor endplates. Methods A denervation model was created in 6-week-old wildtype and KOAGD (agrin deficient) mice by excising a 10 mm right sciatic nerve segment and suturing the proximal nerve stump to the gluteal muscle to prevent regeneration. Genotyping was performed by Transnetyx. To establish difference between KOAGD and wildtype mice after nerve injury, hindlimb muscles were harvested at 1,2 4,8, and 16 weeks post denervation. For the second part of the study, KOAGD mice were injected with supplemental agrin (1uM Agrin) or phosphate buffered solution (PBS) at the site of injury, and hindlimb muscles were harvested at the same timepoints. Muscles were processed for immunohistochemistry. NMJs were visualized with confocal microscopy (n=6). Motor endplates were labeled with alpha-bungarotoxin, presynaptic terminals with synaptophysin, and axons with neurofilament. VolocityTM 3D software was used to quantify acetylcholine receptor (AchR) surface area and volume. Unpaired t-test was used to compare wildtype and KOAGD mice without treatment. Two-way ANOVA was used to compare agrin deficient denervated muscles treated with PBS or agrin injections at each time point. Significance is defined as p < 0.05. Results In this study, we found that KOAGD mice appear to have inferior morphometric qualities compared to control wildtype mice. AChR surface area and volume of KOAGD mice were reduced relative to control mice with a statistically significant reduction at 8 weeks post- denervation. Confocal images demonstrated a shift from pretzel like morphology to towards plaque like profiles. However, when these KOAGD mice were supplemented with agrin, these animals were able to retain superior motor endplate morphology over controls. Average surface area of agrin supplemented denervated endplates were significantly greater than control endplates in all analyzed timepoints (Fig.1). Agrin injected mice demonstrated stable motor endplates up to the 16 week timepoint while PBS injected mice did not have any motor endplates detected at 16 week post denervation (Fig. 2). Summary Points • KOAGD mice demonstrated inferior NMJ profiles and reduced surface area and volume compared to wildtype mice after denervation. • Supplemental agrin delivered locally is effective in preserving motor endplates in denervated mice hindlimbs. • Data from these experiments support that this adjuvant therapy will prolong the window of opportunity for surgical intervention. Bibliography 1: Bezakova G, Helm JP, Francolini M, Lømo T. Effects of purified recombinant neural and muscle agrin on skeletal muscle fibers in vivo. J Cell Biol. 2001;153(7):1441-1452. doi:10.1083/jcb.153.7.1441. 2: Furey MJ, Midha R, Xu Q-G, Belkas J, Gordon T. Prolonged target deprivation reduces the capacity of injured motoneurons to regenerate. Neurosurgery. 2007;60(4):723-32-3. doi:10.1227/01.NEU.0000255412.63184.CC. 3: Chao T, Frump D, Lin M, et al. Matrix metalloproteinase 3 deletion preserves denervated motor endplates after traumatic nerve injury. Ann Neurol. 2013;73(2):210-223. doi:10.1002/ana.23781. 4: Sakuma M, Gorski G, Sheu SH, et al. Lack of motor recovery after prolonged denervation of the neuromuscular junction is not due to regenerative failure. European Journal of Neuroscience. 2015. 5: Frank E, Gautvik K, Sommerschild H. Cholinergic receptors at denervated mammalian motor end-plates. Acta Physiol Scand. 1975;95(1):66-76. doi:10.1111/j.1748-1716.1975.tb10026.x. Paper 3: Primary Targeted Muscle Reinnervation in the Upper Extremity Reduces Neuromas and Phantom Limb Pain Session 1: Nerve – Wednesday, September 12, 2018, 8:43-8:45 AM Nerve;Diseases and Disorders;Practice Management Level 4 Evidence Joseph Meyerson, MD COI There is financial information to disclose. Hypothesis Approximately 40,000 Americans are living with a major amputation of the upper extremity. An estimated 25% develop a painful neuroma, and up to 67% experience phantom limb pain. Targeted muscle reinnervation (TMR) is a surgical procedure that reroutes transected peripheral nerves to the motor unit of freshly denervated muscle, potentially preventing neuroma formation and lessen the prevalence of phantom limb pain (PLP). Methods We performed a retrospective study of our centers TMR of upper extremity amputations undergoing primary (at index amputation) and secondary (symptomatic nerve pain after amputation) procedures. Data included reason for amputation, level of amputation, patient age, months of follow up, postoperative neuroma, postoperative PLP and time to prosthetic use. Results Thirteen patients with upper extremity amputations were identified (2 forequarter, 5 trans- humeral, 6 trans-radial). Oncologic resection and skeletal trauma were the most common indications for amputation. Only two patients had TMR performed secondarily, all others were concurrent with amputation. Ages ranged from 22-63 years old with average follow up of 13 months (range 1-29 months). None of the 13 patients developed a painful neuroma. Phantom limb pain at 1, 3, 6, and 12 months was 46%, 33%, 25%, and 20%. Patients began using their prosthetic 2-6 months after surgery, and at least one patient at each
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