Περιφερικές...

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  • Distal nerve transfersfor the Ulnar n.N. A. Darlis, MD, PhDTo access this presentation on the web:

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  • Susan MackinnonNerves are slow...

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  • Susan MackinnonNerves are slow...

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  • Ulnar (and Median) n. Direct Repairintrinsic function recovery poor for injuries proximal to the elbow

    Additional negative prognostic factors:delayed presentationextensive injurynerve defect- grafting

  • Tendon transferstechnically demanding (especially tension)stiffness/ motor re-educationdowngraded donor muscle strengthdo not restore sensationdonor muscle shortage in multiple nerve lesions

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  • Nerve transfersCunningham RH. The restoration of coordinated, volitional movement after nerve "crossing".AmJPhysiol1898

    Flourens P. Experiences on the repair and healing of the spinal cord and peripheral nerve injuries.AnnSciNaturelles1828

  • 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 recordbrachial plexus:

    comparable if not better results with nerve transfer rather than long nerve grafts

  • Indicationsvery proximal nerve lesiondelayed presentationextensive injury zonenerve defect in conjunction with primary repair (nerve supercharging)

    ContraindicationIntrinsic atrophy/ clawing

  • TimingMotor nerves:Debated; viable target muscle; within 3 months for ulnar nerve

    Sensory nerves: Sensory receptors wider margin for recovery (months)

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  • Collateral Sprouting Chemotactism by distal stumpAxonal progression by Contact Guidance

    END to SIDEnerve coaptation

  • END to SIDEnerve coaptation

  • Courtesy, Marios Lykissas, MD

    END to SIDEnerve coaptation

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  • Barbour &Mackinnon, JHS(A), 2012Nerve 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;2:195-201Motor TransferOverview

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  • Motor TransferDonor: AIN to PQdissect into the muscle

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  • Motor TransferRecipient: Motor br Ulnar n.Sandwiched between sensory branchesFollow back from GuyonsStimulate (if within 72h of injury- no tourniquet)

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  • Motor TransferUlnar Nerve Supercharging

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  • Sensory TransfersDeficient areas

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  • Sensory TransfersDonor: Median n.3rd web fasiclePalmar cutaneous n.digital nerves

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  • Sensory TransfersRecipients: Ulnar n.Sensory branchDorsal cutaneous n.digital nerves

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  • Mackinnon Transfer3rd web to ulnar sensory comp

    Sensory Transfers

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  • Sensory TransfersOur preference:

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  • Sensory TransfersOur preference:

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  • Journal of Hand Surgery2013 38, 98-103DOI: (10.1016/j.jhsa.2012.10.010) 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 StudyThomas H. Tung, MD, John R. Barbour, MD, Gil Gontre, MD, Gurpreet Daliwal, MD, Susan E. Mackinnon, MDAlternatives for COMBINED MEDIAN & ULNAR n. injuries 1

  • Alternatives for COMBINED MEDIAN & ULNAR N. injuries 2

    controversial*

  • Alternatives for COMBINED MEDIAN & ULNAR n. injuries 2

    controversial*

  • ConsAIN aprx 506 axons vs ulnar motor 1523 axonshowever 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 transferGuyons canal releaseFDP tenodesis

    to Sensory transferAny Tendon Transfer

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  • Paradigm shiftNerverepairNervegrafts

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    controversial*controversial*

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