IC22-L: Hotwire or Rewire? The Role of Nerve Transfers vs ...

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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: [email protected]

http://www.assh.org/

mailto:[email protected]

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)



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



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


• Divide tendinous edge of FDS

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• 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



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In avulsion injuries finding the proximal end is difficult.

When primary repair is not possible, bank it



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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


Mayo Clinic

Rochester, Minnesota

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Current Concepts of Management of Peroneal Nerve Injuries


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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https://teachmeanatomy.info/wp-content/uploads/Overview-of-the-Anatomical-Course-of-the-Tibial-Nerve.jpg

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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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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


Why consider nerve grafting?You may not have better options…


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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Can THIS replace ALL OF THAT?

Leversedge, Goldfarb, Boyer – Primus Manus


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%


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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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


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


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


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GSW at elbow

3mo s/p GSW to medial epicondyleSubsequent medial epicondyle debridement with ulnar nerve decompression (OTS)



GSW at elbow

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GSW at elbow: neuroma-in-continuity


GSW at elbow: neuroma-in-continuity


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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GSW at elbow: excision of neuroma, primary repair after UNT + SETS


GSW at elbow: excision of neuroma, primary repair after UNT + SETS


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7mo s/p ORIF distal humerusIntrinsic atrophy, 2PD14mm RF/SFCMAP amplitude 0.5mA for FDI


Revision UNT + RETS + hardware removal + contracture release


Revision UNT + RETS + hardware removal + contracture release

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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


[email protected] @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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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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Treatment Options

• Tag nerve ends and return another day?

• Proceed with acute repair? Grafting?

• Autograft or allograft?

• Distal nerve transfers?

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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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IC22-L: Hotwire or Rewire? The Role of Nerve Transfers vs ...

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Transcript of IC22-L: Hotwire or Rewire? The Role of Nerve Transfers vs ...