The role of distal nerve tranfers from Median to an injured Ulnar nerve, basic principals, surgical technique and reported results Ο ρόλος των περιφερικών νευρομεταφορών στην αντιμετώπιση υψηλών βλαβών του Ωλενιου νεύρου. Βασικές αρχές, χειρουργική τεχνική και δημοσιευμένα αποτελέσματα

1. Distal nerve transfersDistal nerve transfers
for the Ulnar n.for the Ulnar n.
N. A. Darlis, MD, PhDN. A. Darlis, MD, PhD
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2. Susan Mackinnon
Nerves are slow...

3. Susan Mackinnon
Nerves are slow...

4. 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

5. 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

6. 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

7. Pros
close 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)

8. Track record
• brachial plexus:
comparable if not better results with nerve
transfer rather than long nerve grafts

9. Indications
• very proximal nerve lesion
• delayed presentation
• extensive injury zone
• nerve defect
• in conjunction with primary repair (nerve
supercharging)
Contraindication
• Intrinsic atrophy/ clawing

10. Timing
Motor nerves:
Debated; viable target muscle;
within 3 months for ulnar nerve
Sensory nerves:
Sensory receptors wider margin for recovery
(months)

11. •Collateral Sprouting
•Chemotactism by distal
stump
•Axonal progression by
Contact Guidance
END to SIDE
nerve coaptation

12. END to SIDE
nerve coaptation

13. Courtesy, Marios Lykissas,
MD
END to SIDE
nerve coaptation

14. Barbour &Mackinnon, ©JHS(A), 2012
Nerve
“Supercharging”

15. dissect the donor nerve as distal as possible
and the recipient as proximal as possible

16. Sassu P, Libberecht K, Nilsson A.. Plast Aesthet Res 2015;2:195-201
Motor
Transfer
Overview

17. Motor
Transfer
Donor: AIN to PQ
•dissect into the muscle

18. Motor
Transfer
Recipient: Motor br Ulnar n.
•‘Sandwiched’ between
sensory branches
•Follow back from Guyon’s
•Stimulate (if within 72h of
injury- no tourniquet)

22. Motor
Transfer
Ulnar Nerve Supercharging

23. Sensory
Transfers
Deficient areas

24. Sensory
Transfers
Donor: Median n.
•3rd web fasicle
•Palmar cutaneous n.
•digital nerves

25. Sensory
Transfers
Recipients: Ulnar n.
•Sensory branch
•Dorsal cutaneous n.
•digital nerves

26. Mackinnon Transfer
3rd
web to ulnar sensory comp
Sensory
Transfers

27. Sensory
Transfers
Our preference:

28. Sensory
Transfers
Our preference:

34. 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

35. Alternatives for
COMBINED MEDIAN & ULNAR N. injuries 2
Copyright © 2014 American Society for Surgery of the Hand

36. Alternatives for
COMBINED MEDIAN & ULNAR n. injuries 2
Copyright © 2014 American Society for Surgery of the Hand

37. Cons
AIN 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 suboptimal
sufficient to prevent clawing of the ulnar digits
some require later tendon transfer to restore
stronger pinch
single center results reported so far

38. Adjuvant procedures
to Motor transfer
•Guyon’s canal release
•FDP tenodesis
to Sensory transfer
•Any Tendon Transfer

39. Paradigm shift
Nerve
repair
Nerve
grafts

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