Περιφερικές Νευρομεταφορές για βλάβες του Ωλενίου...
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Distal nerve transfersDistal nerve transfersfor the Ulnar n.for the Ulnar n.
N. A. Darlis, MD, PhDN. A. Darlis, MD, PhD
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Susan Mackinnon
Nerves are slow...
Susan Mackinnon
Nerves are slow...
Ulnar (and Median) n. Direct Repair
• intrinsic function recovery poor for injuries proximal to the elbow
Additional negative prognostic factors:• delayed presentation• extensive injury• nerve defect- grafting
Tendon transfers
•technically demanding (especially tension)•stiffness/ motor re-education•downgraded donor muscle strength•do not restore sensation•donor muscle shortage in multiple nerve
lesions
Nerve transfers
Cunningham RH. The restoration of coordinated, volitional movement after nerve "crossing".
Am J Physiol 1898
Flourens P. Experiences on the repair and healing of the spinal cord and peripheral nerve injuries.
Ann Sci Naturelles1828
Prosclose to motor end-plate; shortens the distance for axon
regeneration and time for muscle reinnervation
usually direct, tension-free sutures between donor and recipient n.
pristine, vascular repair bed
rehabilitation facilitated when synergistic donor nerve is chosen
do not preclude tendon transfers (especially in cases of later presentation)
Track record
• brachial plexus: comparable if not better results with nerve
transfer rather than long nerve grafts
Indications
• very proximal nerve lesion• delayed presentation• extensive injury zone• nerve defect • in conjunction with primary repair (nerve
supercharging) Contraindication
• Intrinsic atrophy/ clawing
Timing
Motor nerves:Debated; viable target muscle;
within 3 months for ulnar nerve
Sensory nerves: Sensory receptors wider margin for recovery (months)
•Collateral Sprouting •Chemotactism by distal stump•Axonal progression by Contact Guidance
END to SIDEnerve coaptation
END to SIDEnerve coaptation
Courtesy, Marios Lykissas, MD
END to SIDEnerve coaptation
Barbour &Mackinnon, ©JHS(A), 2012
Nerve “Supercharging”
dissect the donor nerve as distal as possible
and the recipient as proximal as possible
Sassu P, Libberecht K, Nilsson A.. Plast Aesthet Res 2015;2:195-201
Motor Transfer
Overview
Motor Transfer
Donor: AIN to PQ•dissect into the muscle
Motor Transfer
Recipient: Motor br Ulnar n.•‘Sandwiched’ between sensory branches
•Follow back from Guyon’s•Stimulate (if within 72h of injury- no tourniquet)
Motor Transfer
Ulnar Nerve Supercharging
Sensory Transfers
Deficient areas
Sensory Transfers
Donor: Median n.•3rd web fasicle•Palmar cutaneous n.•digital nerves
Sensory Transfers
Recipients: Ulnar n.•Sensory branch•Dorsal cutaneous n.•digital nerves
Mackinnon Transfer3rd web to ulnar sensory comp
Sensory Transfers
Sensory Transfers
Our preference:
Sensory Transfers
Our preference:
Journal of Hand Surgery 2013 38, 98-103DOI: (10.1016/j.jhsa.2012.10.010) Copyright © 2013 American Society for Surgery of the Hand
Transfer of the Extensor Digiti Minimi and Extensor Carpi Ulnaris Branches of the Posterior Interosseous Nerve to Restore Intrinsic Hand Function: Case Report and Anatomic Study
Thomas H. Tung, MD, John R. Barbour, MD, Gil Gontre, MD, Gurpreet Daliwal, MD, Susan E. Mackinnon, MD
Alternatives for
COMBINED MEDIAN & ULNAR n. injuries 1
Alternatives for
COMBINED MEDIAN & ULNAR N. injuries 2
Copyright © 2014 American Society for Surgery of the Hand
Alternatives for
COMBINED MEDIAN & ULNAR n. injuries 2
Copyright © 2014 American Society for Surgery of the Hand
ConsAIN aprx 506 axons vs ulnar motor 1523 axons
however less (reported 20%) are needed to restore meaningful function
the transfer is not synergistic
recovery is generally suboptimalsufficient to prevent clawing of the ulnar digitssome require later tendon transfer to restore stronger pinch
single center results reported so far
Adjuvant procedures
to Motor transfer•Guyon’s canal release•FDP tenodesis
to Sensory transfer•Any Tendon Transfer
Paradigm shift
Nerverepair
Nervegrafts
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