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IC22-L: Hotwire or Rewire? The Role of
Nerve Transfers vs Nerve Repairs
Moderator(s): David M. Brogan, MD, MSc.
Faculty: Christopher J. Dy, MD, MPH, FACS, J. Megan Patterson, MD, Alexander Y.
Shin, MD, and Hari Venkatramani, MD
Session Handouts
Saturday, October 03, 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: meetings@assh.org
9/28/2020
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ICL #32: Hotwire or Rewire? The Role of Nerve Transfers vs Nerve Repairs
DISCLOSURES
David M. Brogan, MD, MSc.
Contracted Research: Depuy - Synthes
Course Objectives
Explain the principles of nerve transfer and relative advantages / disadvantages compared to primary nerve repair
Describe the indications for nerve repair secondary to traumatic injury at a variety of anatomic locations, along with expected functional outcomes
Have an improved appreciation of the application of innovative techniques to historically challenging problems
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Program & Faculty
•High Radial Nerve Injuries: Optimal Management in 2020 •J. Megan M. Patterson, MD (University of North Carolina)
•Reconstruction of the Mangled Forearm with Nerve Repair / Transfers•Hari Venkatramani, MC, MCh, DNB (Ganga Hospital)
Peroneal Nerve Injuries – What to Do and When•Alex Y. Shin (Mayo Clinic)
Cubital Tunnel Disasters – How to Salvage Intrinsic FunctionChristopher Dy, MD, MPH
Case Presentations David Brogan, MD, MSc (Washington University in St. Louis)
DISCLOSURES
J. Megan Patterson, MD
Speaker has no relevant financial relationships with commercial interest to disclose.
High Radial Nerve InjuriesOptimal Management in 2020
J. Megan M. Patterson, MD
Department of Orthopaedics
University of North Carolina, Chapel Hill
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Disclosure
No conflict of interest to declare
Radial Nerve Injury
• Common nerve injury
– Trauma/fracture
– Compression
– Iatrogenic
• Causes significant functional disability
• Proximal nerve injuries commonly have a poor prognosis, even under the best circumstances
Recovery After Nerve Injury
• Depends on:– Time from injury.
• Time = muscle.• Time = pathway.
– Age of patient.– Type of repair. – Location of injury relative to
target muscle/sensory territory.
– Associate injuries (soft tissue/muscle/bone).
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Options for Treatment
1. Repair (primary repair/nerve graft)
– Outcomes after grafting are unpredictable
– 5/13 reached Grade 4 wrist extension and Grade 3 finger/thumb extension (Bertelli, 2016 J Neurosurg)
Options for Treatment
1. Repair (primary repair/nerve graft)
2. Tendon transfer
– Have been used for >100 years
– Predictable results though limitations
BRAND BOYES JONES
WRIST PT to ECRB PT to ECRB +/- ECRL PT to ECRB
FINGERS FCR to EDC FDS (LF) to EDC/EDM FCU to EDC
THUMB PL to EPL FDS (RF) to EIP/EPL PL to EPL
Options for Treatment
1. Repair (primary repair/nerve graft)
2. Tendon transfer
3. Nerve transfer
– Median most common donor
– Close to radial nerve
Nerve Transfer Options
– FDS/PT/AIN → ECRB
– FCR → PIN
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Tendon Transfers vs Nerve Transfers
Tendon Transfers
✅No time limit
✅Reliable
✅Faster return of function
❌Altered biomechanics of hand and wrist
❌Requires good passive motion and supple tissue bed
❌No independent finger extension
❌One donor one function
❌Risk of adhesions
Nerve Transfers
✅Independent finger extension possible
✅Less dissection
✅Maintain normal musculotendinous units
✅Minimal donor morbidity
✅One donor, multiple functions
❌Time limit (<10 months post injury)
❌Longer time to recover function
❌Post op therapy (motor re-education) needed
• 14 patients treated with nerve transfer (AIN to ECRB and FCR to PIN)
• 13 patients treated with tendon transfer (PT to ECRB, FCU to EDC, PL to EPL)
• Results:– Better recovery of wrist flexion/extension in nerve transfer group
– Better recovery of grip strength in nerve transfer group
→ Better outcomes in nerve transfer group vs tendon transferJHS 2020
Radial Nerve Palsy: Tendon Transfer vs Nerve Transfer
Patterson JM, Russo S, El-Haj M, Novak C, Mackinnon SE
• 16 patients treated with nerve transfer
• 30 patients patients treated with tendon transfer
• Results:– Strength
• Pinch and grip strength significantly improved in both groups
• Post op grip strength significantly better in nerve transfer group compared to tendon transfer group
– Functional – DASH and QOL scores were significantly improved in both groups with no difference between the 2 groups.
Manuscript under review 2020
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Tendon Transfers vs Nerve Transfers
• Both procedures improve function
• Consider nerve transfer in patients who:
– Present early
– Are able to tolerate a longer recovery time
– Have activity demands for finger dexterity
• Shared decision making
• Establish appropriate expectations
Median to Radial Nerve Transfer
Patient Selection
• Injury to radial nerve in the brachium (intact PIN and ECRB)
• No recovery clinically or on EMG (no MUPs) 3-4 months post injury
• Less than 10 months post injury
• Intact median nerve function
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Incision
• Lazy-S incision from proximal forearm to mid-forearm
• Extend more distal if planning concomitant PT to ECRB tendon transfer
Identify superficial head of PT• Between radial vessels and RSN
Identify superficial head of PT
• Step-lengthen PT (if no tendon transfer planned)
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Identify superficial head of PT
• Elevate PT with strip of periosteum if tendon transfer planned
Exposure of Median Nerve
• Ulnar to radial vessels
• Release deep head of PT
Exposure of Median Nerve
• Divide tendinous edge of FDS
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Exposure of Median Nerve
• Identify branches of median nerve and stimulate with nerve stimulator
• Dissect donor branches (FCR and FDS) as distal as possible and tag with vessel loop
Exposure of the Radial Nerve
• Identify RSN on underside of BR muscle and follow proximally
• Release tendinous leading edge of ECRB transversely
• Divide tendinous leading edge of supinator and decompress the PIN
Exposure of the Radial Nerve
• Identify branches of radial nerve and confirm absent function with nerve stimulator
• Dissect recipient branches (ECRB and PIN) as proximal as possible and tag with vessel loop
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“Donor Distal, Recipient Proximal”
Consider PT to ECRB tendon transfer
Outcomes: Median to Radial Nerve Transfers
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Outcomes: Median to Radial Nerve Transfers
Thank You
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Reconstruction of the Mangled
Forearm with Nerve repair/Transfer
Dr Hari VenkatramaniMS.,MCh.,DNB.,EDHS
Sr. Consultant,
Plastic and Trauma Reconstructive Surgery,
Ganga Hospital , Coimbatore, India
www.gangahospital.com
Infraclavicular Brachial Plexus Injury
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Outcome at 8 Months
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Long segment Median and Ulnar N. grafting
ECRL-FDP, BR-FPL
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First needs Flap cover
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All the critical structures are exposed
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At 3 months follow up
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Secondary median
nerve grafting
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Primary nerve repair even at high level works
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Nerves Banked
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2 year Post operative result
Secondary nerve grafting
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In avulsion injuries finding the proximal end is difficult.
When primary repair is not possible, bank it
Sub cutaneous placement of the distal
nerve end at the time of replant
Sub cutaneous placement of the distal
nerve end at the time of replant
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In avulsion injuries finding the proximal end is difficult.
When primary repair is not possible, bank it
Sub cutaneous placement of the distal
nerve end at the time of replant
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10:02 pm
10:09 pm
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10:15 pm
Scapulo Thoracic Dissociation
11:01 pm
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Circulation restored with vein graft
11:45 pm
00:51 am
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Lacks shoulder abduction and elbow flexion
Partial Nerve Transfer for Elbow flexion
and Shoulder Abduction
10-04-2007
04-03-2008
Partial Nerve Transfer for Elbow flexion
and Shoulder Abduction
10-04-2007
04-03-2008
17-08-2009
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6 Months follow-up
Electrical Burns Result in Loss of Tendons, Nerves, Blood
Vessels and Bone
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First requirement is excision of scare tissue and good soft tissue cover
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Now we are left with insensate and Movement less hand.
Challenge is to reconstruct long segment Gap of multiple tendons and nerves.
We need to source sufficient grafts and Properly utilize them.
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We find fasia lata is the good source for tendon grafts
Distal end Of IndexFlexor
While Tendons grafts need to be directional,
Nerve Grafts need not follow anatomical plane.
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Both extensors and flexor tendon grafts
and nerve grafts must be done in one go.
Conclusions
• Primary nerve works even over long distance
• Secondary nerve grafting once wound
settles down also gives outcome
• Intrinsic recovery is poor
• Early tendon transfer for claw correction and
opponensplasty is ideal
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Thank You
Alexander Y. Shin, MD
Royalty: TriMed Orthopedics/Mayo Medical
Venture
Consulting Fees: Hologic
Peroneal Nerve Injuries
Alexander Y. Shin, MD
Mayo Clinic
Rochester, Minnesota
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Current Concepts of Management of Peroneal Nerve Injuries
Alexander Y. Shin, MD
Professor & Consultant
Department of Orthopaedic Surgery
Mayo Clinic, USA
Disclosures
• None related to this topic
Peroneal Nerve
• Terminal branch of sciatic n (L4-5, S1-2)
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Branches of the Common Peroneal Nerve
• Articular branches• Deep Peroneal
• Anterior compartment• TA, EHL, EDL, PT
• Superficial Peroneal• Lateral compartment
• Peroneus longus/brevis
Peroneal Nerve Sensation
•Lateral aspect of leg•Lateral sural n•Superficial peroneal n
•1st web space•Deep peroneal n
Mechanisms of injury
•Direct trauma•Laceration• Iatrogenic
•Meniscal repair
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Mechanism of Injury
•Knee Dislocation
Considerations in Treatment
•Mechanism of injury
• Traction vs laceration
•Time from injury
•Patient age/regenerative capacity
•Concomitant injuries
Treatment Options
Hotwire
Re-wire
Salvage
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Hotwire: Nerve TransferTibial nerve branch to Anterior Tibialis Motor Branch
Incision
Peroneal nerve
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Develop soleus/peroneus interval
(at visible fat stripe)
Reflect soleus origin from fibula
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Superficial peroneal nerve
Deep peroneal nerve branches
Articular br + Tibialis Anterior br
Branches to tibialis anterior
1.Articular + tib ant. br
2.Tib ant. motor br
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Divide soleus vascular pedicles
Posterior tibial art
Tibial nerve
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Develop IOM windlw
Tibialis anterior
Branches
(fibrin-glued together)
and passed behind fibula
Fascicle providing FDL
function of equal size
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Nerves rest together without tension
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Epineural sutures
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Wrapped in collagen nerve guide
14 months post transfer
Rewire: Primary Repair, Grafting, Conduits
•Acute laceration
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12 month follow up
Rewire: Nerve Grafting
Serially cut
back until good
looking
fascicles
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Proxim
al
Distal
Findings: >6 cm, Need bilateral
sural nerve to get 3-4 strand cable
graft
Decision: NO SURAL
GRAFTING
Rewire: Nerve Grafting
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What is the Data
•11 patients
•Direct vs 4-14 cm cabled sural nerve graft reconstruction
•29.1 mo follow-up
• If <6 cm graft – excellent/good
• If >6 cm graft – fair/poor
CORR 1991
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Nerve Transfer
• 11 patients: tibial n transfer to tibialis anterior
• All with high energy knee dislocation
• 1 M4, 3 M3, 2 M2, 2 M1; 4 M0
• Variable outcomes, 4/11 could walk without assistive devices
Meta-Analysis
• Based on 14 articles, 41 patients, all nerve transfers
• Donor: tibial or superficial peroneal branches
• Recipient: deep peroneal or tibialis anterior
• Mean BMRC tibialis anterior = 2.1
• Conclusion: variability in dorsiflexion strength. Need future studies
What is the Data
• 28 study meta-analysis – 1577 repairs
• M4 considered good outcome
• Good outcomes
• 80% for neurolysis
• 37% direct repair
• 36% nerve grafting
• If<6 cm – 64% good
• If >6 cm – 11% good
• If <6 mo 44% good• If >6 mo 12% good
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What is the data
Early diagnosis & evaluation
Nerve graft for <6 cm
Possible nerve transfer
Tendon transfer for delayed cases
Hotwire or Rewire
• Our algorithm (isolated peroneal n)
• Rewire – sural nerve grafting
• < 6 cm
• < 6 month
• Hotwire
• Loosing enthusiasm in high energy injuries
• Combine with Bridle procedure for optimal outcomes
Hotwiring
•Outcomes of lower extremity nerve transfers for peroneal n are fair to poor in general
• High energy trauma
• Soft tissue injury
• Much more strength required
• M3 or less inadequate
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Conclusions
• Surgeons need to carefully distill the literature
Individualize Treatment
Don’t Merge All Peroneal Nerve Treatments into a
Single Solution
Thank You
Mayo Clinic Brachial Plexus Team
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DISCLOSURES
Christopher J. Dy, MD, MPH, FACS
Speaker has no relevant financial relationships with commercial interest to disclose.
Hotwire or Rewire?Ulnar Nerve Disasters
Christopher J. Dy, MD MPH FACSWashington University Orthopedics
@ChrisDyMD
nerveresearch.wustl.edu | @ChrisDyMD
HISTORICAL CONTEXT
Limits of nerve grafting
Level of injury
Limits of tendon transfers
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nerveresearch.wustl.edu | @ChrisDyMD
NERVE REPAIR
# of patients G/E Motor % G/E Motor G/E SensoryMohseni: 2010 (Iran) 39 31 80% --Kokkais: 2012 (Greece) 32 12 38% --Bassar: 2014 (Turkey) 42 30 71% 26
Baltzer: 2016 (USA) 7 1 14% --
Koriem: 2017 (Egypt)* 10 4 40% --
TOTAL 130 78 60%
NERVE GRAFTINGMohseni: 2010 (Iran) 6 2 33.3% --Kokkais: 2012 (Greece) 32 20 62.5% --Karabeg: 2013 (Bosnia) 48 42 87.5% 28Flores: 2015 (Brazil)* 15 2 13.3% 6Sallam: 2017 (Egypt)* 28 16 57.1% 15
TOTAL 129 82 64%
ULNAR NERVE: 2000-2020
nerveresearch.wustl.edu | @ChrisDyMD
Why consider nerve grafting?You may not have better options…
nerveresearch.wustl.edu | @ChrisDyMD
1997Wang and Zhu – Chin Med J (Engl) – initial report
2002Novak and Mackinnon – J Recon Microsurg (n=8 end to end)Haase and Chung – Ann Plast Surg (n=2 end to end)
2012Barbour and Mackinnon – JHS (SETS technique)
46 publications in 2019
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nerveresearch.wustl.edu | @ChrisDyMD
Can THIS replace ALL OF THAT?
Leversedge, Goldfarb, Boyer – Primus Manus
nerveresearch.wustl.edu | @ChrisDyMD
NERVE TRANSFER # patients G/E Motor % G/E Motor G/E SensoryEnd to End
Novak: 2002 (USA) 8 8 100.0% --Haase: 2002 (USA) 2 2 100.0% --Flores: 2015 (Brazil)* 15 12 80.0% 6Sallam: 2017 (Egypt)* 24 20 83.3% 14
TOTAL 49 42 86%
nerveresearch.wustl.edu | @ChrisDyMD
NERVE TRANSFER # patients G/E Motor % G/E Motor G/E SensoryEnd to End
Novak: 2002 (USA) 8 8 100.0% --Haase: 2002 (USA) 2 2 100.0% --Flores: 2015 (Brazil)* 15 12 80.0% 6Sallam: 2017 (Egypt)* 24 20 83.3% 14
TOTAL 49 42 86%
Supercharge End to SideDavidge: 2015 (USA)trauma = 25 of40
Trauma-specific results NS; 28 of 40 with M3+ (70%)
Head: 2020 (Canada)SETS + UNT/decompressiontrauma = 1 of 17
Trauma-specific results NS; 12 of 17 with M3+ (71%)
Baltzer: 2016 (USA)trauma = 7 of 13 7 6 86% --
Koriem: 2017 (Egypt)all trauma cases (RCT) 11 10 91% --
TOTAL 18 16 89%
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nerveresearch.wustl.edu | @ChrisDyMD
NERVE TRANSFER
End to End 49 42 86%
Supercharge End to Side(for trauma) 18 16 89%
NERVE REPAIR # patients G/E Motor % G/E Motor G/E Sensory
130 78 60%
NERVE GRAFTING
129 82 64%
ULNAR NERVE: 2000-2020
nerveresearch.wustl.edu | @ChrisDyMD
FACTORS TO CONSIDER
Timing of referral
Location of injury: axilla, mid-brachium, elbow/forearm
Mechanism of injury: crush, sharp, ballistic, iatrogenic, compression
Patient characteristics: personality, timeframe, expectations
Options available to surgeon: donor nerves, donor tendons
nerveresearch.wustl.edu | @ChrisDyMD
ULNAR NERVEMechanism
SHARP
CRUSH
BALLISTIC
IATROGENIC
Early primary nerve repair (graft if needed).High injury: add AIN/PQ to ulnar motor nerve transfer
end-to-end if proximal brachium; RETS if near elbow
Observe – serial examination – motor, sensory, progressive TinelEMG/NCS at 6wks (if possible) and 3mo
Intervene if recovery has plateaued: neurolysis + autograftIf long distance to target: AIN/PQ to ulnar motor nerve transfer
Sharp injury or proximate to hardware: early explorationUnknown mechanism AND ulnar nerve not visualized: early explorationUlnar nerve visualized/decompressed/transposed in prior surgery:
If CMAP amplitude loss or advanced exam: revision UNT +/- RETS
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GSW at shoulderVascular bypass grafting night of injury (5 wks prior)Ulnar nerve inspected same night – partially intact
Healed incision from emergent CTR/fasciotomies after vascular bypass
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Median nerve within Ragnell retractor; vascular graft deep to median nerve
Ulnar nerve within yellow vessel loops~33% of fascicles intact (lateral portion)
Intraop NAP across scarred segment of ulnar nerve; conduction present
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Internal neurolysis of ulnar nerveIntact fascicles left intact3 fascicles with 28mm gap
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RETS performed distallyAIN-PQ to distal ulnar motor branch
2.5 year follow-up
nerveresearch.wustl.edu | @ChrisDyMD
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GSW at elbow
3mo s/p GSW to medial epicondyleSubsequent medial epicondyle debridement with ulnar nerve decompression (OTS)
nerveresearch.wustl.edu | @ChrisDyMD
nerveresearch.wustl.edu | @ChrisDyMD
GSW at elbow
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nerveresearch.wustl.edu | @ChrisDyMD
GSW at elbow: neuroma-in-continuity
nerveresearch.wustl.edu | @ChrisDyMD
GSW at elbow: neuroma-in-continuity
nerveresearch.wustl.edu | @ChrisDyMD
Choudhry/Li JHS 2014 Smetana/PattersonJHS 2019
Mobilize nerve: Can gain 4-4.5cm(elbow/wrist neutral)
UNT+ wrist flexed 30’ + elbow flexed 60’: can gain 5.2cm
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nerveresearch.wustl.edu | @ChrisDyMD
GSW at elbow: excision of neuroma, primary repair after UNT + SETS
nerveresearch.wustl.edu | @ChrisDyMD
GSW at elbow: excision of neuroma, primary repair after UNT + SETS
nerveresearch.wustl.edu | @ChrisDyMD
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nerveresearch.wustl.edu | @ChrisDyMD
7mo s/p ORIF distal humerusIntrinsic atrophy, 2PD14mm RF/SFCMAP amplitude 0.5mA for FDI
nerveresearch.wustl.edu | @ChrisDyMD
Revision UNT + RETS + hardware removal + contracture release
nerveresearch.wustl.edu | @ChrisDyMD
Revision UNT + RETS + hardware removal + contracture release
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nerveresearch.wustl.edu | @ChrisDyMD
nerveresearch.wustl.edu | @ChrisDyMD
What are the indications for nerve transfer? ***
In 2020
1) lack of rigorous comparative studies
2) “babysitting” remains a topic of debate – do they ever go home?
3) Threshold for E-E vs SETS unknown
Level of injury
High Low
Reasonable chance of recovery Graft/repair + E-E transfer Graft/repair
Improbable recovery Graft/repair + E-E transfer Graft/repair + SETS transfer
“Maybe” Graft/repair + E-E transfer Graft/repair + ???
Ultimately comes down to prognosis of injury
nerveresearch.wustl.edu | @ChrisDyMD
dyc@wustl.edu @ChrisDyMD
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ICL #32: Hotwire or Rewire? The Role
of Nerve Transfers vs Nerve Repairs
Case Discussion
David M. Brogan, MD, MSc
Case #1
CC: Pulseless R hand
HPI: 22 yo F sustained GSW to R brachium in May 2019
• Initial evaluation at outside ED demonstrated pulseless R hand
• No sensation in median or ulnar distributions
• Entry and exit wound in mid brachium, no fx
Plan:
• Underwent emergent brachial artery bypass with reverse saphenous vein
graft
• Noted to have nerve injury by vascular surgeon, transferred to our
institution for further treatment
ICL #32: Hotwire or Rewire? The Role
of Nerve Transfers vs Nerve Repairs
Case Discussion
David M. Brogan, MD, MSc
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Case #1
CC: Pulseless R hand
HPI: 22 yo F sustained GSW to R brachium in May 2019
• Initial evaluation at outside ED demonstrated pulseless R hand
• No sensation in median or ulnar distributions
• Entry and exit wound in mid brachium, no fx
Plan:
• Underwent emergent brachial artery bypass with reverse saphenous vein
graft
• Noted to have nerve injury by vascular surgeon, transferred to our
institution for further treatment
Treatment Options
• Immediate or delayed exploration?
• Repair or nerve transfer
• Role and timing of tendon transfers?
Intra-operative Findings
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Treatment Options
• Repair/Reconstruction?
• Autograft or allograft?
• Nerve Transfers?
Reconstruction of median & ulnar nerves with sural
autograft
July 2020
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Case #2
CC: Absent finger extension
HPI: 32 yo M sustained stab wound to R arm 5 days prior to presentation
• Initial evaluation in ED night on injury
• Patient described pain in right arm, weakness in fingers
• 2 PD 5 mm in radial / median / ulnar nerve distributions
• Unable to fire EDC or EPL
• Intact ECRL / ECRB / FCR / FDS& FDP x 2-5 / FPL
• Hx of radial nerve tendon transfers in LUE s/p stab wound
Plan:
• Bedside I&D, referred for f/u to clinic
Treatment Options
• Immediate or delayed exploration?
• Repair or nerve transfer
• Role and timing of tendon transfers?
Injury Wound
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Intra-op findings
Repair of partial laceration
Case #3
• CC: Left forearm injury after roll-over ATV
• HPI: 20 yo M s/p ATV rollover on 11/23/16
• Seen at OSH, thought to have open fracture of humerus
• P.E.
• Cold, pulseless hand
• Absent sensation
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1 year post-op
2 years post-op
Case #4
CC: Referral for reconstruction of peroneal nerve
HPI: 58 yo M referred for discussion of reconstruction of peroneal nerve
• Diagnosed with large sarcoma in anterior compartment of right leg
• Planned wide excision of anterior compartment musculature
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Tumor
Branch to tibialisanterior
Branch to peroneus longus
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Anterior compartment defect after tumor resection
Common peroneal nerve transected as it
entered tumor
Anterior tibial artery branch proximally
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Treatment Options?
• Nerve resection and burying?
• Grafting to distal targets?
• Something fancier…..?
FFMT woven into tibialis anterior tendon distally
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79
1 year post-op
• Able to walk without AFO
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Case #5
CC: Intra-op Consult for ulnar nerve injury
HPI:
• 17F s/p GSW to L proximal brachium – emergently taken to OR by
vascular surgery
• After bypass grafting of brachial artery, complete transection of ulnar
nerve noted
Intraop consult from vascular surgery team17F s/p GSW to L proximal brachium – emergently taken to OR
Arterial bypass graft for brachial artery
Vein patch for brachial vein
PROXIMAL DISTAL
ULNAR NERVE transected by bulletEnds tagged by vascular surgery team
Medial brachial cutaneous nerve
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81
Treatment Options
• Tag nerve ends and return another day?
• Proceed with acute repair? Grafting?
• Autograft or allograft?
• Distal nerve transfers?
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82
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• Acute nerve grafting after aggressively judging zone of injury (3 cables,
12cm)
• Acute distal end-to-end nerve transfer (AIN/PQ to ulnar motor)
• Subfascial ulnar nerve transposition to facilitate nerve grafting
• CTR, GCR, forearm fasciotomies
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