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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