A-0053 The neurovascular V-Y advancement flap. A novel technique to bridge digital nerve defects up to 1.5 centimetres.
Lucy Homer, Samuel George, Irfan Khan
Whiston Hospital, Liverpool, UK
Introduction and Aims
The few reports in the literature about digital nerve repair techniques are mostly regarding the use of allografts
and conduits. We present a novel technique that can be used to bridge nerve gaps of up to 1.5 cm to achieve a primary, tension-free repair.
Patients and Methods
A V-Y advancement flap, of the overlying skin and soft tissue is used to achieve advancement of the
underlying neurovascular bundle to approximate the ends of the nerve. This was raised similar to the Venkataswami flap used for fingertip injuries but designed more proximally. We present the case of a 48 year old
male right hand dominant company director who suffered a complex circular saw injury to his left thumb and
index finger with tissue loss to both fingers, a defect of the extensor pollicis longus (EPL) tendon and a
13mm defect in the radial digital nerve of his index finger.
The technique enabled us to achieve a tension-free coaptation of the digital nerve and close the soft tissue
defect. A Foucher flap from his left index was used to reconstruct the left thumb after an EPL turnover flap
and this did not affect the nerve repair on the index finger. Follow-up at 3 months showed full recovery and in
particular the index finger had similar sensation and 2-point discrimination when compared to the contralateral
side. Photographs of all stages are presented.
A tension-free coaptation is the goal of any nerve neurorrhaphy and we know from the literature that
achieving a primary closure will give you better outcomes when compared to a graft or conduit. We present a
simple, yet effective technique to treat the moderate <1.5cm nerve defects saving the more expensive, less reliable
conduits and grafts for the larger defects.
A-0079 The mental health implications of obstetric brachial plexus injuries (OBPI) on parents
Karan Dua 1, Catherine Miller 2, Joshua M Abzug 3
1 SUNY Downstate Medical Center, Brooklyn, USA; 2 University of Maryland Medical Center, Baltimore, USA; 3 University of Maryland School of Medicine, Baltimore, USA
Objective: Obstetric brachial plexus injuries (OBPI) can have mental health implications on parents coping with this injury to their newborn. Previous studies have reported increased rates of depression in mothers of children with an OBPI and parents having unresolved feelings of sadness and anger. The presence of post-traumatic stress disorder (PTSD) and depression are well established in parents of babies that require a neonatal intensive care unit (NICU) stay. The purpose of this study was to assess the mental health of parents with newborns with an OBPI as compared to parents of NICU babies and babies in the healthy newborn nursery.
Methods: Three groups of parents were prospectively given a 10-minute self-reported survey: 1) Newborns with OBPI; 2) Newborns in the healthy newborn nursery without OBPI; 3) Newborns in the NICU. The survey consisted of demographic questions, the PHQ-9 and PCL-S screening tools, and parents’ exposure to community violence, family support, and use of drugs or alcohol. The PHQ-9 is a 10-item depression survey that asks respondents to rate their mood symptoms on a Likert scale and the PCL-S is a 17-item PTSD survey that rates symptoms on a Likert scale.
Results: 51 parents were enrolled including 41 mothers and 10 fathers. 33 mothers took the PHQ-9 portion of the survey and 4 screened in for depression (15.4% for NICU, 0% for newborn nursery, 9% for OBPI). 41 mothers took the PCL-S portion of the survey and 18 screened in for PTSD (46% for NICU, 0% for newborn nursery, 45.5% for OBPI). Of the 10 fathers, two in the OBPI group screened in for depression.
Conclusions: The birth of a child with an OBPI can be very difficult to cope with for parents. The rate of PTSD is equal, being nearly half (46%), between mothers with newborns with OBPI and children in the NICU. These rates are significantly higher than the national average of 3.5% for PTSD following pregnancy. PTSD is treatable and possibly preventable with appropriate psychosocial care following newborn delivery. In contrast, untreated PTSD in parents with a child with an OBPI can affect the entire family and society. OBPI clinics should be staffed similarly to the NICU with clinical social workers that can appropriately screen and treat parents with PTSD symptoms. Orthopaedic surgeons who treat OBPI should be aware of the mental health implications on families and employ an interdisciplinary team to address these needs.
A-0084 Assessment of current epidemiology and risk factors surrounding brachial plexus birth palsy
Joshua M Abzug 1, Charles Mehlman 2, Jun Ying 3
1 University of Maryland School of Medicine, Baltimore, USA; 2 Cincinnati Children's Hospital Medical Center, Cincinnati, USA; 3 University of Cincinnati College of Medicine, Cincinnati, USA
Objective: Brachial plexus birth palsy (BPBP) is quite common, however, the current incidence is unknown and more than 50% of infants with BPBP have no known risk factors. The purpose of this study was to determine the current incidence of BPBP, assess known and unknown risk factors, and evaluate the length of stay (LOS) and costs of children with an associated BPBP injury.
Methods: Data from the 1997-2012 Kids’ Inpatient Database data sets were evaluated to identify patients with a BPBP injury and various risk factors. Evaluation of LOS data and cost was also performed. Multivariate logistic regression analysis was utilized to assess the association of BPBP with its known and unknown risk factors.
Results: The incidence of BPBP has steadily decreased from 1997-2012, with an incidence of 0.9 ± 0.01 per 1,000 live births recorded in 2012. Shoulder dystocia is the number one risk factor for the development of a BPBP injury, (OR 166.01). Hypotonia is a newly recognized risk factor for the development of BPBP (OR 1.93). Fifty-five percent of infants with BPBP still have no known risk factors. The initial hospital LOS is approximately 20% longer for children with a BPBP injury and the hospital stay costs are approximately 40% higher.
Conclusions: The incidence of BPBP is decreasing over time. Shoulder dystocia continues to be the number one risk factor for sustaining a BPBP injury. Children with a BPBP injury have longer length of stays and hospital costs compared to children without a BPBP injury.
A-0091 Pedicled Adipofascial Flap for Anterior Transposition of the Ulnar Nerve: A Single Institution Retrospective Outcomes Report
Steven M. Koehler, Ronnie L. Shammas, Fraser J. Leversedge
Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
Purpose: To assess outcomes of ulnar nerve decompression and anterior transposition at the elbow using a pedicled adipofasical flap.
Methods: A retrospective cohort of patients who underwent primary or revision ulnar nerve decompression and anterior transposition using an adipofascial flap for a preoperative diagnosis of ulnar neuropathy at the elbow at a single center between 2006-2016 was examined. Pre-and post-operative visual analogue scale scores, modified McGowan classifications, complications, and physical exam findings were used to assess patient outcomes.
Results: 22 patients underwent ulnar nerve decompression with anterior transposition using an adipofascial flap, and 16 patients were eligible for inclusion in the study. 11 cases were primary nerve procedures and 5 patients were revision ulnar nerve surgery with a mean postoperative follow-up time of 352 days (range: 122-701). There was a significant mean improvement in global intrinsic strength when comparing pre- and post-operative measures (3.7/5 v. 4.6/5, p<0.05 ). 50% of patients had improvement in their two-point discrimination postoperatively. Following the operation, all patients experienced a significant reduction in their VAS pain scores (4/10 v. 0.6/10, p<0.05). 12 of 16 of patients were classified as demonstrating an improvement in their modified McGowan classification score, while 4 out of 16 were classified as having no change. No patient had a worse post-operative score. All patients maintained preoperative elbow range of motion. There were no perioperative complications.
Conclusions: Use of the adipofascial flap for anterior transposition of the ulnar nerve at the elbow generally provided patients with significant improvement in measured clinical outcomes, even in the revision setting. Ulnar nerve sensation and global intrinsic strength improved postoperatively, corroborating the initial published report that analyzed this technique. In patients for whom ulnar nerve decompression with or without anterior transposition is indicated, anterior transposition using an adipofascial flap may be a valuable technique for improving nerve function and for improving overall patient outcomes.
A-0100 The creation of a Tetraplegia Hand Surgery Service in Cyprus
Constantinos Kritiotis 1,2, Jan Friden 3, Sabrina Koch-Burner 3, Christiana Fakonti 4
1 Manchester Hand Centre, Salford Royal NHS Foundation Trust, Manchester, UK; 2 Iasis Private Hospital, Paphos, Cyprus; 3 Swiss Paraplegic Centre, Nottwil, Switzerland; 4 Paraplegic Department, Nicosia General Hospital, Nicosia, Cyprus
Background : Hand Surgery in Tetraplegic patients has been described as the ultimate method of rehabilitation. It has been around and evolving for more than 50 years and it can significantly improve the upper limb function in selected tetraplegic patients, providing these patients with an extra level of independence. We present the story as well as our first results of our service since it was created three years ago.
Methods : Following lectures in the Paraplegic Department of the Nicosia General Hospital as well as the Cypriot Paraplegic Organization, fifteen patients were reviewed for prospective surgery. The patients were evaluated using the ICSHT (International Classification for Surgery of the Hand in Tetraplegia) and three patients that were suitable candidates decided to go ahead with surgery. In these three patients four procedures were carried out, two posterior deltoid to triceps transfers as well as two grip reconstructions.
Results : No complications were noted. In the case of triceps recosntruction, both patients recovered a significant strength in their reconstructed triceps and were able to use their transfers for independent mobilization. Especially one of the two patients used a hoist for his transfers prior to the procedure and now he can transfer independently using a sliding pad.
The grip reconstruction procedures were done in an ICHST grade two patient (who was one of the patients that had the triceps reconstruction) and an ICHST grade four patient. Mean operating time for both procedures was 5.5 hours. Both patients had a change of dressings the next morning and started a targeted rehabilitation program. Both patients saw an increase in the functionality of their operated hands and a significant increase in their COPM scores
Conclusions : Hand surgery reconstructive procedures should be offered in every suitable tetraplegic patient. The triceps reconstruction using the posterior deltoid to triceps transfer can significantly improve these patients' ability to transfer and the grip reconstruction can increase the functionality of their hands.
A-0211 Peripheral Nerve Regeneration Using a Bio 3D Conduit from Undifferentiated Bone Marrow Stromal Cells
Hirofumi Yurie 1, Ryosuke Ikeguchi 1, Tomoki Aoyama 2, Akira Ito 2, Mai Tanaka 2, Junichi Tajino 2, Souichi Ohta 1, Hiroki Oda 1, Hisataka Takeuchi 1, Sadaki Mitsuzawa 1, Shizuka Akieda 4, Koichi Nakayama 3, Shuichi Matsuda 1
1 Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan; 2 Department of Physical Therapy, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan; 3 Department of Regenerative Medicine and Biomedical Engineering Faculty of Medicine, Saga University, Saga, Japan; 4 Cyfuse Biomedical K.K., Tokyo, Japan
OBJECTIVE: The treatment of the peripheral nerve injuries with nerve defect include end-to-end suturing, autologous nerve graft and nerve conduit. Recently, the implantation of neural stem cell, undifferentiated bone marrow stromal cells (uBMSCs), or fibroblasts to the nerve conduit has been shown as a beneficial effect on peripheral nerve regeneration. However, the seeding efficacy and viability of the implanted cells remain unclear. And, synthetic nerve conduits are associated with a risk of infection and low biocompatibility. So as previously reported, we created a scaffold-free Bio 3D conduit from normal human dermal fibroblasts. To promote peripheral nerve regeneration, we have made a Bio 3D conduit from uBMSCs. So, in the current study, we examined the efficacy of the peripheral nerve regeneration using a Bio 3D conduit from uBMSCs (uBMSCs group) compared to the control group from fibroblasts.
METHODS: Primary uBMSCs were isolated from bone marrow of femurs of female Lewis rats and fibroblasts were from subcutaneous tissue of the skin. Using Bio 3D printer, we have made Bio 3D conduits from both cells in same procedure as we previously reported. These conduits were interposed to the rat sciatic nerve at the mid-thigh level with a 5 mm nerve gap. Eight weeks after surgery, several assessment were conducted. Data were analyzed by using student t test. Values of P < 0.05 were considered statistically significant.
RESULTS: Electrophysiological studies revealed significantly higher compound muscle action potential in the uBMSCs group both in the gastrocneminus and pedal adductor muscle compared to the control group (P < 0.05). Morphometric studies revealed that the uBMSCs group exhibited a significantly greater myelinated axon number compared to the control group (P < 0.05). In the uBMSCs group, the nerve gap was bridged successfully and Bio 3D conduit was maintain tube-like structure around the regenerated axons at eight weeks after surgery. Immunohistochemical examination revealed abundant angiogenesis in the regenerated nerve and uBMSCs composing Bio 3D conduit were positive for S-100 in the eight weeks after surgery.
CONCLUSION: In the present study, we created scaffold-free Bio 3D conduits from uBMSCs and confirmed peripheral nerve regeneration in a rat sciatic nerve model compared to the control group. Recent studies have demonstrated uBMSCs facilitate peripheral nerve regeneration because uBMSCs differentiated into Schwann cell-like cells and produce various types of neurotrophic factors. The immunohistochemistory suggested uBMSCs composing Bio 3D conduit differentiated into Schwann cell-like cells. And the stability of the tube-like structure even in the eight weeks was advantageous for axonal regeneration.
There are several limitations associated with the current study. First, the 5-mm nerve gap was not long enough to assess the efficacy of the Bio 3D conduit from uBMSCs. Second, the duration of the observation period after transplantation was insufficient to evaluate nerve function.
In the present study, we confirmed that Bio 3D conduit from uBMSCs contribute to peripheral nerve regeneration. Further studies of Bio 3D conduit are needed for clinical applications.
A-0255 An Innovative Nerve Repair Simulation
B Jagannath Kamath, Premjit Sujir, Mithun Pai Arkesh
Kasturba Medical College, Mangalore, Manipal University, India
AN INNOVATIVE NERVE REPAIR SIMULATION
Traumatic nerve injury and its repair or reconstruction are an integral part of hand surgery.
Unpredictability and the critical time have been the hallmarks of results of Nerve repairs. Clinical and
Investigative modalities to confirm the success or failure of results take time. With the advent of the nerve transfers the training has acquired a new Importance. An ideal stimulatory exercise in micro neural repair should not only mimic the technical challenges but should also allow the trainees to evaluate their own techniques. Apart from the tension at the anastomotic site the important factor for favourable outcome during repair is the ability of obtaining the coaptation of fascicles. We are describing a simple method of simulation of nerve repair emphasising the method of evaluating the fascicular coaptation following the repair.
The method that is being described involves preparing the 2 conduits of desirable size using the
sterile disposable hand towels available in operation theatres. The conduits are cut into a size of 2.5
cms to mimic the proximal and distal cut ends of nerve to be repaired. Three or four pieces of small
hollow plastic tubes of length 2.5 cms obtained by trimming the middle thirds of the cotton ear buds
to simulate the fascicles. Three or four such white coloured tubes are inserted into one of the
Conduits (proximal segment) and through the other conduit (distal segment) the same number of different coloured plastic tubes are inserted to mimic the 2 segments of nerves for simulated repair. The 2 segments can now be transfixed using a nerve apporximator to suture the anterior wall . The trainees are now allowed to bring about simulated repair keeping in mind the fascicular alignment. Once the repair is complete we know use the Android flexible HD Camera with a diameter of 3.5 mm, to evaluate the degree of coaptation at the anastomotic site of the simulated repair. The flexible camera is placed at a distance of 1-1. cms from each of the white coloured plastic tubes, and the image is captured on the laptop using the appropriate App. The overlap of the coloured circles on the white circles on the monitor, and the configuration of the overlap will give the evaluator an idea of the degree of coaptation. This can even be evaluated depending on the overlap as Grade 4 (100- 75%), Grade 3 (75-50%), Grade 2( 50-25%), and Grade 1 ( less than 25%). It will thus be possible to evaluate the coaptation obtained for each of the fascicle in the simulated repair to assess the competence of the trainee
The above described method of nerve repair is not only simple but also allows the evaluation of
degree of coaptation of the fascicles following the simulated nerve repair.
A-0321 Intraneural fascicular dissection of lipofibromatous hamartoma of the digital branches of the median nerve: report of two cases and review of literature
Mohamed Elsaid Abdelshaheed
Faculty of medicine, Mansoura university, Mansoura, Egypt
Lipofibromatous hamartoma (LFH) is a rare and benign fibro-fatty tumor of the peripheral nerves. Only a handful of cases are available in the literature with the median nerve is the most common site of affection. Cases with LFH of the digital branches of the median nerve have also been documented. Different lines of treatment of LFH were described according to the clinical presentation.
Here, I am presenting two cases of LFH of the digital branches of the median nerve undergone intraneural fascicular dissection and mass excision.
Good results were obtained in the form of disappearance of numbness and regain of intact sensation.
Intraneural fascicular dissection and mass excision is a good option for management of lipofibromatous hamartoma of the digital branches of the median nerve.
A-0324 Transfer of a pronator teres motor branch to achieve finger flexion in tetraplegia: case report
Renata Paulos, Emygdio José Leomil de Paula
Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo. São Paulo, Brazil
Objectives: To describe the use of pronator teres motor branch as a donor nerve for achieving fingers flexion in a tetraplegic patient. Although it is used as a donor nerve in brachial plexus lower trunk lesions, it is the first description of its use in tetraplegia.
Methods: a 29 years-old tetraplegic patient had both upper limbs operated on one year after injury. Upper limb function was classified as group 4 ICSHT at both sides. We performed bilaterally transfer of the supinator motor branches to posterior interosseous nerve and transfer of one branch of the pronator teres to the anterior interosseous nerve. During the procedure, we identified on each side two branches destinated to the pronator teres muscle, and we used just one as a donor nerve. At the right side, we identified the branch to the flexor digitorum superficialis along with the AIN and it was included in the suture.
Results: Patient didn’t lose the ability to pronate his forearms immediately after surgery. Five months after surgery, he presented some movements of his left hand (M2 finger extension). Eighteen months after the surgery, he has on the left side M4 fingers extension and M3 fingers flexion (FPL and FDP) and on right side M3 fingers extension and M2 fingers flexion (only FDS).
Conclusion: Pronator teres motor branch can be an option of donor nerve to achieve fingers flexion in tetraplegic patients.
A-0335 Outcome of nerve allografts in nerve injuries of the hand – single unit experience
Amir Adham Ahmad, Sellakkuddy Selvaganesh, Vaikunthan Rajaratnam
Khoo Teck Puat Hospital Singapore
Outcome of nerve allografts in nerve injuries of the hand – single unit experience
Nerve injury results are still to be improved. The nerve gap bridging needs nerve graft. The nerve auto-graft is still the gold standard. The donor site morbidity, delay in mobilization and limited availability are still significant clinical problems. Nerve allograft is an off the shelf option negating the above issues with the auto graft.
We are doing a prospectective interventional study in our unit using processed allografts which do not need immune suppressive therapy as there is no cellular lines in that. Axogen allograft from 1-2mm to 4-5mm size grafts varying from 15mm to 70 mm are used in this study. All the operations were done using microsurgical techniques and the measurements were taken to the nearest mm. All the data collected by interviewer administered questionnaire. The analysis done using excel spread sheets.
Majority of our patients were foreign workers and there was difficulty in following them up due to less turn over in follow up visits. We were able to review around 50% of them. All had insurance cover and no one had previous nerve injury of the related nerve. More patients were digital nerve injuries and the clinical outcome (Sensory nerve - 76%, Motor nerves -71%, Mixed Nerves - 54%) was satisfactory in majority.
It has given good outcome without donor site morbidity. Chances of immediate mobilization for pure nerve injury patients were possible. But cost is a concern.
A-0345 Expanded Outcomes from an International Registry Study on Processed Nerve Allografts in Upper Extremity Nerve Repairs
Bauback Safa 1, Jaimie T. Shores 2, Yasser El-Sheikh 3, Timothy R. Niacaras 4, Leon J. Nesti 5, Ian Valerio 6, Dominic M Power 7, Mehir J. Desai 8, Gregory M Buncke 1
1 The Buncke Clinic, San Francisco, USA; 2 Johns Hopkins University, Baltimore, USA; 3 North York Hospital, Toronto, Canada; 4 JPS Health Network, Forth Worth, USA; 5 Walter Reed National Military Medical Center, Bethesda, USA; 6 Ohio State University, Columbus, USA; 7 Queen Elizabeth Hospital, Birmingham, UK; 8 Vanderbilt University Medical Center, Nashville, USA
Processed nerve allografts (PNA) have been shown to be safe and effective option to repair nerve gap injuries in a growing number of clinical studies. The RANGER registry is an active database designed to collect outcomes data for processed nerve allografts (Avance® Nerve Graft, AxoGen) on sensory, mixed, and motor nerve repairs. The registry has continued to collect long term follow-up and has also expanded to include data from additional centers. Here we report on meaningful recovery of the expanded cumulative registry for injuries spanning 70 mm and on higher thresholds of recovery in PNA repairs with long term follow-up as compared to historical controls for nerve autograft and tube conduit.
The RANGER database was queried for nerve repairs in the upper extremity using PNA that reported a minimum of 6 month of quantitative outcome data. Reported sensory and/or motor assessments included 2-point discrimination, Semmes-Weinstein Monofilament (SWMF) testing, range of motion, strength test. Reported outcome data were incorporated into the MRCC scale for sensory and motor function. Meaningful recovery was defined as ≥ S3/M3 on the MRCC scale. Higher thresholds of recovery, defined as S3+/M4 or greater, were evaluated in repairs reporting a minimum of 15 months of follow-up. Demographics, outcomes and covariate analysis were performed to further characterize the sub-groups.
The current RANGER® registry has sufficient quantitative outcomes data on 303 repairs (255 sensory and 48 mixed/motor nerve injuries). Mean age of the cohort was 42 ± 16 (18 – 81) years. Mean gap length was 22 ± 14 (3 – 70) mm with an average follow up time of 11 months. Meaningful recovery was observed in 85% of all repairs. Further analysis by nerve type observed meaningful recovery in 85% of sensory and 79% of mixed nerve repairs. Among repairs reporting longer term follow-up, mean follow-up 22 ± 7.3 (15 –42) months, 79% reported higher thresholds with S3+/M4 or greater. No related adverse events were reported.
Processed nerve allografts continue to be a safe and reliable off-the-shelf alternative for the reconstruction of nerve deficits. Quantitative data demonstrate meaningful recovery in 85% of all repairs. Repairs with longer term follow-up demonstrated higher levels of recovery at 79%. These results compare favorably to historical outcomes for autografts and exceed those for conduits. The registry remains ongoing and will continue to expand to further collect outcomes data on processed nerve allografts.
A-0346 Use of Processed Human Umbilical Cord in Peripheral Nerve Surgery: Clinical Case Series
Bauback Safa 1, Andrew Watt 1, Paul Sibley 2, Robert Hagan 3, Mark S Rekant 4, Harry Hoyen 5, Brendan Mackay 6, Gregory Buncke 1
1 The Buncke Clinic, San Francisco, USA; 2 Hand and Upper Extremity Surgery, Allentown, USA; 3 Neuropax Clinic, St Louis, USA; 4 The Philadelphia Hand Center, Philadelphia, USA; 5 MetroHealth System, Cleveland, USA; 6 Texas Tech University, Lubbock, USA
Inflammation, scar formation, and adhesions are inherent following injury or surgical intervention. When peripheral nerves are involved, resultant scarring and inflammation around nerves can lead to poor outcomes and make re-access difficult in the event of secondary surgical procedures. Placental membranes, historically used as wound dressings and coverings, while containing beneficial biological properties lack the qualities ideal for surgical applications as an interpositional barrier. Human umbilical cord is a naturally resorbable and permeable membrane that’s shown to modulate inflammation, separate tissue layers, and contains essential extracellular matrix molecules and endogenous growth factors. Avive® Soft Tissue Membrane (AxoGen, Alachua FL, USA) is processed human umbilical cord membrane (cord membrane) intended for use as a soft tissue covering. This material is designed to overcome specific shortcomings of placental membranes and remains intact at least 16 weeks making it ideal for use during the critical time of scar formation and maturation. Here we report on the use of cord membrane as an interpositional barrier for exposed peripheral nerves.
Case evaluation was conducted on the utilization of cord membrane during peripheral nerve surgery when post-operative scar and inflammation were a concern. Following relevant consents, data was collected in cases where cord membrane was used during a surgical procedure on an exposed nerve. Information on injury, placement, and outcomes were collected. Data was reviewed to evaluate clinical application and outcomes after use in peripheral nerve surgery.
This series included 13 patients undergoing surgical procedures with exposed nerve in the zone of injury. The average age was 45(11-62) years. Pre-operative and surgical procedures were based on institution’s standard of care. Procedures included nerve decompression, reconstruction after traumatic injury, and planned reconstructive procedures. A majority of these nerves were in the upper extremity (radial, median, ulnar nerves). After exposure and neurolysis, cord membrane was hydrated and placed as a covering over the nerve. In eight cases, sutures (6-0/8-0) were used to secure in place. All surgeons reported the membrane conformed well, easily positioned, and remained intact. The average follow-up was 6 months. There were no reported complications /revisions and patients are recovering as expected. Additional follow-up is on-going.
Processed human umbilical cord membrane can be used as a soft tissue covering during nerve surgery. This series included multiple injury types where the potential of post-operative scar and inflammation were a concern. Placement was successful in all cases. There were no reported complications or revisions and patients continue to recover as expected.
A-0351 Characterization of Minimally Processed Placental Umbilical Cord Membranes Developed for use as a Surgical Implant for Peripheral Nerve
Curt Deister, Stefanie Villender, Anne Engemann, Brian Romot; Erick DeVinney
AxoGen, Alachua, USA
Introduction: Inflammation is a normal component of wound healing and can result in increased scar formation and adhesions. Placental tissues have been studied as possible mediators of inflammation but their use as an implant for internal surgical applications has suffered from inherent limitations in mechanical properties. This work describes minimally processed placental membranes, isolated from human umbilical cord membrane that retain the beneficial placental properties of the tissue, with its known potential for reducing inflammation and adhesion formation. Processed umbilical cord membrane provides ideal mechanical properties appropriate for a surgical implant while remaining in the wound throughout the wound healing cascade.
Methods: Human umbilical cord membrane tissue was obtained and minimally processed following established procedures. Proteins were quantified using Milliplex® kits and analyzed using a Luminex 200TM. Resorption rate was determined by subcutaneous implant in a rat model followed by macroscopic and histological evaluation of resorption at 16 weeks. Thickness was determined by use of a push-gauge as the average of 3 sites along the graft. Tensile strength was measured at a rate of 25.4 mm/min. Suture retention strength was measured with 6-0 suture, bite depth of 3-6mm and a rate of 25.4mm/min.
Results: Protein quantification included identification of 28 proteins detected at either higher (13), similar (5) or lower (10) levels compared to unprocessed controls. Proteins found at relatively high levels included several interleukins, TIMP-4 and several growth factors including EGF, FGF, PDGF, VEGF and TGF-β3. Macroscopic and histologic evaluation methods determined that approximately 75% of the implant was resorbed at 16 weeks. Average thickness of the processed umbilical cord membrane was 176µm compared to <25µm for placental amnion. Mean tensile strength of processed umbilical cord membrane was 12.3N and the mean force required for suture pull out was 1.47N.
Conclusions: The results of these studies demonstrate that minimally processed umbilical cord membrane retains the inherent properties of native tissue, when implanted remains present for at least 16 weeks, is approximately 8 times thicker than placental amnion, and possesses sufficient mechanical properties to allow normal handling and use in the surgical environment.
A-0373 Cortical changes may be responsible for the limited functional recovery in patients with Obstetrical Brachial Plexus Injury
Zeynep Tuna 1, Deran Oskay 1, Oktay Algin 2, Orhan Murat Koçak 3
1 Gazi University Faculty of Health Sciences Department of Physiotherapy and Rehabilitation, Ankara, Turkey; 2 Atatürk Education and Research Hospital, Ankara, Turkey; 3 Kirikkale University Faculty of Medicine Department of Psychiatry, Turkey
Obstetric Brachial Plexus Injury (OBPI) may cause permanent disability through into adulthood. Persistent disability is recently thought to result from central problems rather than peripheral ones. However, studies investigating the cortical changes after OBPI are very poor. Therefore, aim of this study is to investigate the cortical activity during impaired movements by functional magnetic resonance imaging. Five adult patients with right upper trunk involvement and 5 age-matched healthy volunteers participated in the study. Participants watched videos of 2 movements (hand to mouth and neck) of either side inside the scanner with the integrated eyeglasses. Statistical Parametric Mapping (SPM) was used for statistical analysis. The cortical activity level during action observation in the patient group was significantly lower in the control group (p <0,05). Areas of difference were middle temporal gyrus, premotor area and inferior parietal lobule. Region of Interest (ROI) analysis showed that the signal change in these areas was significantly lower in the patient group than in the control group (p <0,05). Observing right and left arm movements in the patient group resulted in similar activity in the cortex (p> 0,05). In conclusion, OBPI causes neuroplastic changes in the cortex, although it is a birth injury and involves peripheral structures. The motor representation of some movements does not appropriately develop as those patients have to grow up into adulthood with significant input lack. Therefore, it is concluded that even if the patients observe the correct pattern of the movements, the motor representation is still impaired in the associative areas.
A-0409 Epidemiology of Major Peripheral Nerve Repair at a Level-1 Trauma Center Over a 15 Year Period
Karan Dua 1, Lucas Fishman 2, Nathan O’Hara 2, Raymond A. Pensy 2, Walter A. Eglseder 2, Joshua M. Abzug 2
1 SUNY Downstate Medical Center, Brooklyn, New York, USA; 2 University of Maryland School of Medicine, Baltimore, Maryland, USA
Introduction: Injury to major peripheral nerves can occur as a result of direct penetrating trauma or crush injuries and subsequently require surgical intervention. Previous studies have mainly reported on digital nerve injuries, whereas the purpose of this epidemiologic study was to characterize patients who have undergone surgical repair of major peripheral nerves at a Level-1 trauma center over a 15-year period.
Methods: A retrospective review was performed, assessing all patients who underwent major peripheral nerve repair at a level-1 trauma center over a 15-year period. Patients who underwent digital nerve repair were excluded from the study. Demographic data, type of nerve injured, mechanism of injury, and if the injury occurred as a result of poly-trauma were recorded. Qualities of the nerve repair were assessed including the type of repair and nerve gap distance. The epidemiology of injuries was described using univariate analysis. Nominal logistic regression was used to estimate the effect of model variables on the type of surgical procedures performed.
Results: One hundred sixty-four patients were identified that underwent major peripheral nerve repair. Of these patients, 74.1% were male, 55.1% were African American, and the mean age was 31.0 years (SD: 12.0). The most common mechanism of injury was a laceration (36.0%), followed by a gunshot wound (17.7%), and then motor vehicle accidents (16.5%). The most commonly injured nerve was the ulnar nerve (n=39, 23.5%), followed by the median nerve (n=38, 22.9%), and then the radial nerve (n=29, 17.5%). The overall reoperation rate was 9.8%. 20% of patients who underwent either autograft or allograft repair required a reoperation. Nerve gap distance was the only significant predictor of the type of surgical repair performed (p<0.0001). Age (p=0.42) and gender (p=0.65) did not have a significant influence on the type of surgical repair performed.
Conclusion: Ulnar and median nerves are the most commonly injured major peripheral nerves. Nerve gap distance was found to be the most significant predictive factor in deciding which repair technique was utilized. Patients who underwent autograft and allograft repair were more likely to require a reoperation.
A-0445 Neurotisations in brachial plexus injuries – results of 7 years
Ulrike Schnick, Richarda Boettcher
Unit for reconstructive Surgery in Brachial Plexus Injuries, Tetraplegia and Cerebral Disorders, Unfallkrankenhaus Berlin, Germany
Objectives: Active elbow and shoulder function are prerequisites for the usability of an affected arm and should be reconstructed. Intra- and extraplexal neurotisations are established surgical techniques. A long term follow-up of several years is necessary to record definite results. Constant assessments of follow-up are required to compare results.
Methods: 79 patients with brachial plexus injuries were treated by 95 operations between January 2010 and November 2017. In 53 cases different neurotisations like transfers of intercostal nerves to axillary nerve (15), intercostal nerves to musculocutaneus nerve (21), accessory nerve to suprascapular nerve (30), triceps branch to axillary nerve (19) and modified Oberlin transfer (18) were performed. Neurotisations of musculocutaneus, axillary and suprascapular nerves were usually combined in one surgical session.One year between operation and follow-up was the minimum of this evaluation. Range of motion and muscle force of shoulder and elbow were reported. Comparison with the literature showed limited comparability due to different assessments.
Results: Follow-up of 39 patients until December 2016 was included. Shoulder abduction of ≥40° was achieved in 9/12 cases by transfer of intercostal nerves to axillary nerve with median MRC of 3 and in 9/12 cases by transfer of a triceps branch to axillary nerve with median MRC 4. Transfer of accessory nerve to suprascapular nerve led to a satisfying shoulder function in 18/22 cases - mainly in combination with reconstruction of axillary innervation. Elbow flexion of ≥ 90° and MRC ≥ 3 was successful in 12/17 cases by transfer of intercostal nerves to musculocutaneus nerve. A better success rate was achieved by modified Oberlin transfer(12/13). Median muscle force rated 4/5 MRC in all transfers for the musculocutaneus nerve including intercostal transfers and for the neurotisation of axillary nerve by triceps branch.
Elbow flexion and shoulder function were both reconstructed in 32 patients. 19/27 (70,4%) of the assessed patients achieved a combined MRC ≥ 3 strength movement of shoulder and elbow. Thus they regained a suitable upper extremity which allowed to use grip and grasp by residual lower plexus innervation or further reconstructive procedures.
Conclusion: Nerve transfers are a successful method to regain function in partial or complete plexus injuries. They are the first choice in treatment of root avulsions and long-stretched lesions. In addition pain is significantly reduced by shoulder stabilisation. Better results have been attained by intraplexal neurotisations like Oberlin procedure and transfer of triceps branch to axillary nerve than by extraplexal neurotisations as intercostal transfers. This is probably due to the shorter distance to the recipient muscle.
According to other studies short latency between trauma and surgery has a prognostic value. An early and comprehensive diagnostic is determinative for success.
In combination with extended contralateral transfers and/or free muscle transfers it might be possible to gain useful results for the whole arm including a simplified grip and grasp.
A-0451 The introduction of human adipose derived Mesenchymal Stem Cells to clinically available nerve replacement treatments
Femke Mathot 1,2, Nadia Rbia 1, A.T. Bishop 2, S.E.R. Hovius 1, A.Y. Shin 2
1 Erasmus Medical Center, Rotterdam, The Netherlands; 2 Mayo Clinic, Rochester, Minnesota, USA
To optimize the biological support and to enhance the functional outcomes of clinically available nerve replacement treatments (the Avance Nerve graft and the NeuraGen Nerve guide), we attempted to seed adipose derived Mesenchymal Stem Cells (MSCs) on the surface of these nerve substitutes. Subsequently, we studied the MSC viability, the optimal seeding time and the distribution of the MSCs throughout the nerve substitutes.
In this study we used human adipose derived MSCs that are well described and characterized. An MTS assay was used to examine the viability of MSCs after different time intervals when a 2mm segment of Avance Nerve Graft or NeuraGen Nerve Guide was added to their environment (3 samples per group per time point). MSC seeding was obtained with a dynamic seeding method using a bioreactor, preserving the inner ultrastructure of the nerve substitutes. Cultured MSCs in growth medium were transferred to conical tubes containing either a 10mm Avance nerve graft or a 10mm NeuraGen nerve guide. An amount of 1 million MSCs per nerve substitute was used. The conical tubes were rotated in the bioreactor for 6, 12 and 24 hours after which cell counts were performed of the remaining ‘free floating’ MSCs in the medium in order to calculate the amount of MSCs attached to the nerve substitutes. For each time point 10 Avance Nerve Grafts and 6 NeuraGen nerve guides were used. The distribution of the MSCs was mapped with live/dead and Hoechst staining. Hoechst stain was also used to observe the distribution of cells on the inside of the graft, by staining fixed cross-sectional sections of multiple segments of the nerve substitutes.
Compared to the samples containing only MSCs or only medium, neither the presence of the Avance Nerve Graft nor the NeuraGen nerve guide negatively influenced the viability of the MSCs. For the Avance group, a seeding efficiency of 18% was obtained after 6 hours, increasing to almost 70% after 12 hours after which the efficiency decreased to 65% after 24 hours. For the NeuraGen group, the seeding efficiency increased from 52% after 6 hours to 94% after 12 hours and decreased to 53% after 24 hours. Live/dead stain on all time points showed an equal distribution of viable MSCs over the entire surface of both nerve substitutes. The Hoechst stains showed the same equal distribution on the surface of the nerve substitutes, and revealed that the MSCs were absent on the inside of the nerve substitutes and thus did not migrate into the nerve substitutes.
Our study has shown that MSCs are able to survive in the presence of the Avance Nerve graft and the NeuraGen nerve guide. With an optimal seeding time of 12 hours, we successfully seeded viable MSCs onto both nerve substitutes without harming the inner ultrastructure. Seeded MSCs did not migrate into the nerve and remained on the surface of the grafts. This study shows that our methods have great clinical potential to improve and individualize peripheral nerve repair in the future.
A-0453 Inter and Intra Rater Reliability of “Brachial Plexus Outcome Measurement” in Children with Brachial Plexus Palsy on Turkish Version
Safiye Özkan 1, Zeynep Hoşbay 2, Müberra Tanrıverdi 2, Atakan Aydın 1
1 Istanbul University, Faculty of Medicine, Department of Plastic and Reconstructive Surgery, Istanbul, Turkey; 2 Bezmialem Vakif University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, İstanbul, Turkey
Objective: Many scales have been developed to assess daily living activities and clinical functions of the patients on the brachial plexus palsy. “"Brachial Plexus Outcome Measure (BPOM)" was developed in 2012 by Emily Ho, activity and substance containing a total of 14 self-rating scale consisting of the components. Our aim in this study, make an intra-inter rater reliability of BPOM scale, is used to make clinical trial in patients with brachial plexus palsy.
Methods: The scale was translated into Turkish by following the appropriate translation step. The demographic data of patients were recorded. The ratings were repeated after 2 weeks. Inter- and intra-rater reliability in items was examined by using weighted kappa statistics.
Results: In our study, 18 female (37,5%), 30 male (62,5%) 48 patients were included. Mean age was 8,68±2,432, mean birth weight was 4054,86±538,504 gr. The mean intra-rater agreement in items was excellent (kappa 0.810) in the raters. Fit statistics showed too much variation in the rater, who also had only good (kappa 0.450) agreement in items. The mean inter-rater agreement in items was fair; kappa 0.620, between the experienced raters and kappa 0.50 between raters.
Conclusions: The BPOM is a valid and reliable measurement for assessing functions in children with OBPP in Turkey. Overall, the agreement was higher in the more experienced raters, indicating that reliable measures of the BPOM.
A-0455 Is There Any Relationship Between Range of Motion and Mallet Classification in Children with Obstetric Brachial Plexus Palsy?
Zeynep Hoşbay 1, Safiye Özkan 2, Müberra Tanrıverdi 1, Ömer Berköz 2
1 Bezmialem Vakıf University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Turkey; 2 İstanbul University, Faculty of Medicine, Department of Plastic and Reconstructive Surgery, Turkey
Objective: We aimed to learn the relationship between range of motion of shoulder and mallet classification, also seperately evaluated mallet scores which are abduction, external rotation and internal rotation in children with obstetric brachial plexus palsy (OBPP).
Methods: All datas of children with OBPP had shoulder tendon transfer operation called Modified Hoffer Tecnique were recorded from their file and parents. Range of motion was measured with goniometer by physiotherapist and function of shoulder evaluated with Mallet Classification. Parameters were analysied with SPSS packet program with descriptive, frequenciency and Pearson correlation analysis. The p<0.05 was accepted significantly statistically.
Results: Fifty-four (64.3%) boys and 30 (35.7%) girls totally 84 children with OBPP included in the study. When looked at demographics; 47 (56%) have right involvement, 42 (50%) have C5-7 involvement type by Narakas, mean age was 7.30±2.35, and birth weight was 4138.42±512.54. The correlation analysis performed using the results of this study found a positive, moderate, statistically significant correlation between the Mallet total score and mallet abduction (r=0.305; p<0.01) and external rotation (r=0.531; p<0.01) scores, and the Mallet abduction scores and range of motion of abduction (r=0.414; p<0.01), and the mallet internal rotation and range of motion of internal rotation (r=0.298; p<0.01). A negative correlation was found between the children’s the mallet external rotation with mallet internal rotation scores (r= -0.623; p<0.01) and range of motion internal rotation (r=-0.345; p<0.01).
Conclusions: The results show us; after shoulder tendon transfering increased external rotation and abduction, however limitation of internal rotation caused the Mallet Classification having wide range of motion. In future studies will focus on evaluating internal rotation with glenohumeral and scapulathorasic joints, seperately.
A-0458 The Relationship Between Involvement Type and Upper Limb Functions of Children with Obstetric Brachial Plexus Palsy
Safiye Özkan 1, Zeynep Hoşbay 2, Müberra Tanrıverdi 2, Ömer Berköz 1, Türker Özkan 1
1 Istanbul University, Faculty of Medicine, Department of Plastic and Reconstructive Surgery, Istanbul, Turkey; 2 Bezmialem Vakif University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Istanbul, Turkey
Objective: We aimed to investigate the relationship between involvement type and upper limb functions of children with obstetric brachial plexus palsy (OBPP).
Methods: Demographic characteristics and physical measurements of children with OBPP were recorded. The upper limb functions were evaluated by Brachial Plexus Outcome Measurement (BPOM) scale which that developed by Emily Ho, and contains 14 items. The BPOM has 2 subtitle – activity scale (AS) and self evaluation scale (SES). The AS scored by functional movement scale (1-5). High score, 5 means completes task with normal movement pattern, and lower score, 1 means cannot complete task. The AS has 11 items, totally scored between 11-55. The SES scored by visual analog scale which that 0-10 line. Three lines, first one “my arm works ..”, second one “my hand works …” and third one “my arm and hand looks …” are evaluated apperance and functions from children eyes. Lower score, 0 means bad and poor, high score, 10 means good and excellent. Totally 3 lines scored between 0-30.
Results: Forty-eight (18 (37.5%) girl, 30 (62.5%) boy) children with OBPP were included in the study. Mean age was 8.68±2.43 (min-max=4.5-14), when looked at involvement type of children 3 (6.3%) has C5-6, 19 (39.6%) has C5-7, 9 (18.8 %) has C5-T1 and 4 (8.3 %) children has C5-T1 + Horner Syndrome, and the means of BPOM subtitle scales are seperately, AS was 42.21±8.01 (min-max=17-52) and SES was 20.54±7.39 (min-max=2-30). The only statistically significant difference was found in involvement type between the BPOM AS (z= -.495; p<0.01) while no differences were found in other correlations between the scores and characteristics (p>0.05).
Conclusions: There is no statistically significant differences between AS and SES scale because of we are thinking that extremity is not participate in activity cause from body imagination, sociocultural levels of children and their parents. In our opinion; in future studies will study to develop on body imagination and participation.
A-0463 Brachial Plexus injuries associated with vascular lesions: primary vs secondary repair
Teodor Stamate 1, Camelia Tamas 1, Radu Budurca 1, Mariana Stamate 2, Ionut Atanasoae 1, Ionut Topa 1
1 University of Medicine and Pharmacy “Gr.T.Popa”, Iasi, Romania; 2 Laboratory of Neurophysiology – Neurosurgery Hospital, Iasi, Romania
Axillary vascular lesions associated with brachial plexus injury pose difficult decisional problems about the moment and the type of microsurgical reconstruction. Treating this kind of lesions at the same operative time has some strong advantages and should be regarded as standard.
82 cases of brachial plexus injuries were selected from which 27 had associated axillary neuro-vascular lesions and were treated by a mixed team: vascular surgeon – microsurgeon. Axillary artery reconstruction was done with saphenous vein interposition grafts in 25 cases and with PTFE grafts in 2 cases. In 21 cases vascular reconstruction was performed immediately and in 6 cases after 24-48 h, delayed emergency. Nerve lesions were located at the level of cords in 19 cases, retroclavicular in 3 cases and supraclavicular lesions in 5 cases. Retro- and infraclavicular nerve lesions were treated primarily in 19 out of 21 cases by external neurolysis and neuroraphy, the reconstruction for the other 2 being through secondary nerve grafting. Spraclavicular lesions especially in elongation and avulsion injuries required secondary reconstruction through combined methods: nerve grafts, nerve transfers (intercostals ± phrenic) and palliative muscular transfers (one pectoralis major, two latissimus dorsi and two triceps). Patients were reviewed at 6, 12 and 36 months postoperatively. The mean age of the patients was 29 years. The average posttraumatic interval prior to surgery was 6-9 months. Muscular reinnervation was evaluated according to BMRC scale. Emergency repair patients presented M3-4 results on BMRC scale in comparison with secondary reconstruction patients with rezults M1-2.
Neurological recovery was better in primary cases than in secondary reconstructions and nerve dissection was more difficult in these late cases due to scarring and the risk of iatrogenic vascular lesion.
Emergency repair of both vascular and nervous lesions is mandatory. Even if the evaluation of the nerves lesions dimensions is difficult in emergency, the clinical experience of the surgeons in replantations and reconstructions of the severe damaged tissue, allows - in many cases - a reasonable evaluation of nervous tissue which is going to be sacrificed or not. Lesions evaluation in combined surgical approach with vascular surgeon and microsurgeon is the best surgical attitude towards this kind of trauma avoiding scared tissue and allowing good anatomy viewing and restoration. Primary reconstruction avoids difficult scar tissue dissection, large nerve graft reconstruction
In conclusion combined neuro-vascular axillary lesions should be treated by a mixed team – vascular surgeon + microsurgeon – with primary repair of all structures as stated by G. Brunelli. Except for elongation lesions, the other type of brachial plexus injuries associated with axillary vascular lesions worth repairing in immediate emergency after vessel repair or in delayed emergency (5-7 days) after patient stabilisation, can lead to better clinical results than secondary reconstruction. This strategy avoids iatrogenic injury to the vascular graft possible and the difficult dissection in secondary brachial plexus repair.Primary repair by mixed surgical team guarantees the best functional results in complex cases.
A-0473 Nerve conduits for treating peripheral nerve injuries: A systematic literature review
J. Braga Silva, G. M. Marchese, C. G. Cauduro, M. Debiasi
PUCRS University, Porto Alegre, Brazil
Objective: systematic review aims to gather evidence regarding the use of nerve conduits for peripheral nerve repair peripheral nerve injuries are a major public health problem. Nerve conduits have been developed in the recent years, although it is still not clear if they should replace nerve grafting and neurorhaphy.
Methods: the following electronic databases were searched: MEDLINE, Cochrane Library (CENTRAL) and Embase. Study selection and data extraction followed the PRISMA guidelines. The systematic review of the literature retrieved 6767 articles. Only 27 studies were retained accounting for 1022 patients: 10 randomized controlled trials, 15 case series and 2 cohort studies.
Results: ten different types of tubes were described and a variety of evaluation methods were used to assess outcomes in terms of efficacy (motor and sensory recovery) and complications. The Semmes–Weinstein monofilament test and the static and moving 2-point discrimination test were the most commonly applied tests to evaluate nerve recovery. In general, outcomes showed no significant difference between groups.
Conclusions: synthetic conduits had more complications. Despite major methodological limitations in the studies, we can conclude that use of nerve conduits is preferable over suture repair and nerve grafting, as the functional recovery rates are above 80%. The choice of conduit is based on the surgeon’s expertise, but use of synthetic conduits is discouraged due to their higher complication rates.
A-0529 Long-term follow-up after vascularized contralateral ulnar nerve transfer to median nerve in total arm type brachial plexus injury: case report
Panupan Songcharoen, Panai Laohaprasitiporn, Saichol Wongtrakul, Torpon Vathana, Roongsak Limthongthang
Department of Orthopedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Background: Limiting source of donor nerve for primary nerve transfer has long been a great obstacle for restoration of function in total arm type brachial plexus injury (BPI) patients. Contralateral donor nerve transfer is an optional treatment for functional restoration of the injured limb. Ulnar nerve has advantage for transferring to contralateral side without using interposition nerve graft and its consistent vascular supply for vascularized nerve transfer.
Objective: To report long-term (over 10 years) functional outcomes after vascularized contralateral ulnar nerve transfer to median nerve in 2 total arm type BPI patients.
Material and Method: Two patients with total arm type BPI underwent vascularized contralateral ulnar nerve transfer to median nerve and end-to-side anastomosis of distal ulnar donor nerve stump to median nerve. Functional recovery of injured limb and residual deformity of donor limb were recorded during follow-up period.
Results: Two patients were male sustained motorcycle accident at the age of 17 and 32 years old. The index surgery was performed at 7 and 6 months, respectively, after the injury. Motor recovery of wrist flexor was regained to Medical Research Council (MRC) grade 2 at 2 years and grade 3 at 6 years follow-up. MRC grade 1 of finger flexion was detected at 6 years follow-up. One patient has been followed for 16 years and found recovery of wrist flexor to MRC grade 4. The thumb and finger flexor were recovered to MRC grade 3. All of the patients had initial sensory deficit along donor-side ulnar nerve distribution with claw deformity. However, sensory deficit and claw deformity gradually recovered in all of the patients at 3 ½ years after surgery.
Conclusions: Vascularized contralateral ulnar nerve transfer to median nerve with end-to-side anastomosis of distal ulnar nerve to median nerve can be a treatment option for total arm type BPI patients with limiting donor nerve.
A-0530 Intraoperative monitoring during peripheral nerve surgery under ultrasound guided selective nerve block anesthesia
Shigeya Suzuki 1, Masashi Abe 1, Kio Suzuki 1, Yosuke Usui 2, Takao Omura 3, Yukihiro Matsuyama 3
1 Fujieda Municipal General Hospital, Fujieda, Japan; 2 Mizutani Pain Clinic, Shizuoka, Japan; 3 Hamamatsu University School of Medicine, Hamamatsu, Japan
Objective: Intraoperative monitoring during hand surgery using WALANT (wide awake, local anesthesia, no tourniquet) is a powerful technique which is now utilized worldwide. However, when performing peripheral nerve surgery, tumescent injection of lidocaine with epinephrine into the area surgical field will also block the objective peripheral nerve adjacent to the injected area and is not an ideal method when the peripheral nerve is preferred to be intact and un-anaesthetized. Here, we report a novel ultrasound guided selective nerve block for ‘Intraoperative monitored peripheral nerve surgery ’. Methods: We performed ultrasound guided selective nerve block in three cases. Two cases were on cubital tunnel syndrome patients and one case was on a schwannoma arising from the median nerve. For cubital tunnel decompression, radial nerve, medial cutaneous nerve of the forearm, medial cutaneous nerve of the arm was blocked and the ulnar nerve was left intact in order to perform intraoperative monitoring. During operation, elbow flexion test was performed to ascertain the degree of decompression. The extent of ulnar nerve release was determined by the diminished symptom by elbow flexion test. For enucleation of the schwannoma arising from the median nerve, radial nerve, ulnar nerve, musculocutaneous nerve, medial cutaneous nerve of the forearm was blocked and the median nerve was left intact. 0.15% ropivacaine 4ml was used for each nerve block. 1:100,000 epinephrine was injected into the surgical field and no tourniquet was used. Results: Cubital tunnel decompression; In one patient, elbow flexion test became negative after Osborne ligament was released whether as in another patient, elbow flexion test persisted until the anterior nerve transposition was complete. Schwannoma enucleation; The intact median nerve enabled us to monitor the appearance of numbness or pain during incision of the nerve sheath until enucleation. The patient could feel the tactile sensation, when an intact fascicle was touched. This lead us to minimize the damage to the nerve fascicles and there was no neurological deficit postoperatively.Conclusions: Peripheral nerve can be monitored intraoperatively with our novel ultrasound guided selective nerve block anesthesia. Our technique enables more precise and safer surgery on peripheral nerve.
A-0537 Recovery of Motor Function after Mixed and Motor Nerve Repair with Processed Nerve Allograft
Bauback Safa 1, Jaimie T. Shores 2; John V. Ingari 2, Renata V. Weber 3, Mickey Cho 4, Jozef Zoldos 5, Timothy R. Niacaras 6, Leon J. Nesti 7, Wesley P. Thayer 8; Gregory M. Buncke 1
1 The Buncke Clinic, San Francisco, USA; 2 Johns Hopkins University, Baltimore, USA; 3 Multi-Disciplinary Specialists, Rutherford, USA; 4 San Antonio Military Medical Center; Fort Sam Houston, USA; 5 Phoenix, USA; 6 JPS Health Network, Fort Worth, USA; 7 Walter Reed National Military Medical Center; Bethesda, USA; 8Vanderbilt University Medical Center; Nashville, USA
Introduction: Severe trauma to the upper extremities often results in the transection of mixed and motor peripheral nerves. Without surgical management, these transection injuries result in functional loss that can seriously affect the patient’s overall quality of life. Clinical data demonstrate that PNA is safe and results in positive functional outcomes for the reconstruction of nerve gaps up to 70 mm in length. However, these studies mostly report on sensory outcomes. The RANGER® Registry is an ongoing observational study on the use and outcomes of processed nerve allografts (Avance® Nerve Graft, AxoGen, Inc.). Here we report on motor recovery outcomes for nerve injuries repaired acutely or in a delayed fashion with PNA and comparisons to historical controls in the literature.
The RANGER® database was queried for acute mixed and motor nerve injuries in the upper extremities, head and neck area having completed greater than six months of follow-up. All subjects with sufficient assessments to evaluate functional outcomes were included. Meaningful recovery was defined as ≥M3 on the MRC scale. Demographics, outcomes and covariate analysis were performed to further characterize this sub-group.
The sub-group included 33 subjects with 36 nerve repairs. The mean ± SD (minimum-maximum) age was 39±19 (16-77) years. The median time to repair was 8.5 (0-133) days. The mean graft length was 34±20 (10-70) mm with a mean follow up of 594±441 days. No significant differences were found in subject age, pre-operative interval or follow-up length among subgroups (P> 0.05, ANOVA test). Meaningful motor recovery was observed in 75%. When looking at higher thresholds of recovery, 53% of these demonstrated M4 or greater recovery in repairs with at least 1 year of follow-up. The cohort was also divided and analyzed in three subgroups based on gap length: 10-25 mm, 26-49 mm and 50 mm or greater. Meaningful recovery of motor function was reported in 69%, 77% and 86% of repairs in these subgroups, respectively. Subgroup analysis showed no differences between gap lengths or mechanism of injury. There were no related adverse events reported.
Processed nerve allografts provided functional motor recovery when used for mixed and motor nerve repairs. Outcomes compare favorably to historical controls in the literature for nerve autograft and exceed those for hollow tube conduit. Processed nerve allograft may be considered as an option when reconstructing major peripheral nerve injuries.
A-0542 Peculiarities of upper limb’s peripheral nerves recovery in patients with Volkmann’s ischemic contracture
Sergii Strafun, Oleksii Dolhopolov, Serhii Bezruchenko
State Institution «The Institute of Traumatology and Orthopedics by the National Academy of Medical Sciences of Ukraine”, Ukraine, Kyiv
The microsurgery technique development has considerably extended the possibilities of functional recovery in case of ischemic severe injury of upper limb.
During the period of 11 years 25 patients operated with injuries of peripheral nerves and posttraumatic ischemia of upper limb. Depending on the stage of ischemia process, the patients were subdivided into 3 clinical groups. The first clinical group included 9 (36%) patients with compartment syndrome and neurovascular injuries. The second group - 10 (40%) patients with injured peripheral nerves of upper limb in reactive-recovery period of ischemic contracture. The third group – 6 (24%) patients with Volkmann’s ischemic contracture in residual period and injured peripheral nerves of upper limb.
Patients of all clinical group underwent precise clinical and instrumental examination to exclude sensitive and functional disorders of upper limb as well as sonography and MRI examination in dynamics.
Among the 9 patients of the first group the most frequent was the suture n.medianus and/or n.ulnaris in the middle and lower part of forearm 6 (66.7%). In 2 (22.2%) patients the suture was performed at the edge of the middle and lower parts of shoulder. In one case (11.1%) there was a suture of finger nerves at the level of palm.
Special conditions for recovery of these nerves were adjustment of performance of fasciotomy wounds with approaches to neurovascular batches. In 5 (55.5%) patients with compartment syndrome the damage of peripheral nerves was combines with comminuted fractures of bones of upper limb. In these patient’s recovery of nerves has been performed after elimination of acute ischemia signs (3 weeks) and osteosynthesis by external fixation.
Among 10 patients of the second group in 5 (50%) cases we performed neurolysis of n.medianus and/or n.ulnaris. In 3 (30%) the suture of the abovementioned nerves was performed. Plastic by n.suralis has been performed in 2 (20%) cases.
Peculiarity of neurolysis of the abovementioned nerves was that it has been performed almost along the whole ischemic compartment. In some cases, the area of neurosis exceeded 9-12cm. While suturing the peripheral nerves we observed big areas (over 4cm) of intra-stem neuromas. In process of nerve plastics we tried to put the transplants of n.suralis out of limit of ischemia diseased compartments.
In the third group all 6 patients underwent plastics of peripheral nerves. It should be mentioned that even if a size of an initial defect of nerves was up to 2cm, after resection of neuromas in proximal and distal parts the size increased to 4-6cm, requiring plastics by transplants of n.suralis.
Long term results of treatment were assessed according to AOOS as modified by Kurinnyi I.M. (1996), for the period over 2 years. In 14 (56%) patient the achieved result was excellent, in 8 (32%) was good, in 3 (12%) it was satisfactory. The total increase of the function of ischemic upper limb in average was over 40%, being sufficient for medico-social adaptation of this complicated category of patients.
A-0588 Contralateral Medial Pectoral Nerve Transfere in Old Total Brachial Plexus Palsy
M Yavari, D Royeentan, H Mahmoudvand
Shahid Beheshti University of Medical Science, Tehran, Iran
there is a very small chance of success for nerve reconstruction in the patients with old total brachial plexus palsy who refer after two years or suffer from flail upper extremity after the failure of prevues operation.
for these individuals, the surge has to find a recipient motor nerve in order to perform free gracilis muscle transplantation. in this study, contralateral medial pectoral nerve from the intact side was transferred to the damaged side as a recipient nerve, then in the second operation, approximately 15 month later, free gracilis muscle transfer was performed. the gracilis muscle was removed and transferred to provide the elbow and finger flexion.
in a retrospective study (Over 10 years) we reviewed 68 patients, for whom this method has been performed, after 1 year , the result were investigated using MRC grading system. five patients did not participate in the study. muscle power of M3 and M4 was regained in 26 and 21 patients, respectively
contralateral pectoral nerve transfers followed by the free muscle transplantation can be used as a good option for patients with ld total racial plexus palsy
A-0607 Immediate Effects of Myofascial Releasing Technique in a Guitar Player with Upper Extremity Neurovascular Entrapment – A Case Report
Onur Seyrek 1, Burcu Semin Akel 2
1 Hacettepe University, Faculty of Health Sciences, Department of Physical Therapy And Rehabilitation, Ankara, Turkey; 2 Hacettepe University, Faculty of Health Sciences, Department of Occupational Therapy, Ankara, Turkey
Guitar players are at high risk of facing neuromuscular and musculoskeletal injuries. Guitarists are experiencing and reporting pain more than other instrumental musicians. The pain and discomfort they have may be due to neurovascular entrapment. In this study, we aimed to relieve the symptoms caused by neurovascular entrapment by using myofascial releasing techniques.
A 38-years-old guitar player with the diagnosis of Thoracic Outlet Syndrome had stiffness and coldness at the right hand for 6 months. Inspection of the upper limbs bilaterally showed vasomotor changes. Pain was present during forearm supination at 1 cm lateral to the extensor muscles’ belly. Symptoms aggravate while playing and patient had poorer performance due to the symptoms. Demographic information and painful movements were noted. Posture analysis of static erect posture and static guitar holding was made. Upper extremity neurovascular entrapment was assessed with Roos, Wright’s, Adson’s Tests and Suprascapular maneuver before and immediately after the session. The myofascial releasing session included releasing of right anterior and middle scalene, sternocleidomastoid, levator scapula, upper trapezius, pectoralis major and minor, subscapularis, teres major and minor, latissimus dorsi muscles and lateral and medial intermuscular septum of the right arm.
The patient was playing guitar for 15 years amateurly and 3 years professionally. Average daily practicing time was 3 hours. Coldness was present at all fingers and ulnar side of the hand. Static erect posture analysis showed forward and right lateral tilt of head, shoulder protraction, right shoulder elevation, left rotation of torso, right rotation of pelvis, external rotation of hips. Static posture analysis on guitar showed tibial and femoral external rotation, left rotation and lateral flexion of torso, right shoulder protraction and elevation, excessive thoracic kyphosis and head-neck flexion, right lateral tilt and rotation of head. Before the session Roos and Wright’s tests were positive for neurovascular entrapment. Patient graded the pain at Roos Test as 6/10 on visual analog scale. Adson’s Test and Suprascapular Maneuver was negative. Pain during forearm supination was 3/10. After the session Wright’s Test was negative and pain at Roos Test reduced to 2/10. Pain during forearm supination was absent. Coldness reduced at the ulnar side of the hand but not at fingers.
Asymmetrical posture while playing guitar for years may cause stiffness following muscle chains from bottom to top. Assessment of the playing posture made us think, constantly depressing upper body with thoracic kyphosis cause tightness at quadratus lumborum and abdominal muscles. Right laterally rotating and tilting head makes sternocleidomastoid muscle overactive. To balance the force generated by tight abdominals and forward head posture, upper trapezius, anterior and middle scalene will be overloaded. Tightness at abdominal muscles and right shoulder protraction compromises pectoral muscles and reduce subacromial space. Possible entrapment sites were between scalene muscles and under pectoralis minor. The immediate relief of symptoms contributes to the muscle chains mechanism. Therefore, myofascial releasing would be an effective approach to the guitar players who have neurovascular entrapment caused by soft tissues. Long-term follow up with larger sample is needed to provide further proof.
A-0635 Analysis of radial nerve paralysis caused by humeral shaft fracture
Ryo Okabayashi 1, Takao Omura 2, Takato Ohishi 1
1 Iwata City Hospital, Iwata, Japan; 2 Hamamatsu University School of Medicine, Hamamatsu, Japan
Humeral shaft fracture associated with radial nerve palsy post-injury mostly occurs in distal third of the shaft. However, it is sometimes difficult to decide whether these cases should be treated conservatively or surgically. The purpose of this study is to analyze the relationship between the location of humeral shaft fracture and the recovery of radial motor nerve paralysis.
Medical records of 11 patients who underwent open reduction and internal fixation for humeral shaft fractures with radial nerve paralysis which developed prior to injury between 2010 and 2017 were reviewed. The patients consisted of 3 male and 8 female with an average age 54.7 years old (21 to 90). Location of humeral shaft fracture, the distance from the proximal edge of the olecranon fossa to the fracture location measured using plain radiograph, the fracture type, the period from surgery to the recovery of extensor carpi radialis (ECR) and extensor digitorium communis (EDC) by MMT of 3 or more and the status of the radial nerve during operation were investigated. Children under fifteen years old were excluded from this study.
The fracture locations were one each at the proximal third and middle third, and 9 at the distal third. The average distance from the proximal edge of the olecranon fossa to the fracture location was 69.1mm(42~92mm). Four patients had spiral, 2 had oblique 1 had transverse, and 4 had comminuted fracture. The average recovery period for the recovery of MMT 3 in ECR was 3.7 months and 4.6 months for EDC. There was one case of an open fracture, which took five months for the recovery of ECR and 12 months for the recovery of EDC. There was no significant difference between the recovery period and the fracture type. Seven cases were surgically explored and all of their radial nerves were in continuity.
The recovery of the radial nerve paralysis does not depend on the fracture type and in most of the cases, the recovery of ECR can be achieved in less than 4 months.
A-0646 Tension at nerve repair sites: What is the effect of trimming a nerve?
Joshua M. Abzug 1, Alexandria L. Case 1, Orlando Merced-O'Neill 2, Eric DeVinney 2
1 University of Maryland School of Medicine, Baltimore, Maryland, USA; 2 AxoGen, Inc., Alachua, Florida, USA
Introduction: Tension at nerve repair sites is associated with impaired nerve regeneration and thus poor clinical outcomes. Additionally, lacerated nerve ends that have edema, scar, and/or hemorrhage, without exposed axons, limit the potential growth of regenerating axons. Thus, it is often necessary for nerve ends to be trimmed prior to direct repair or nerve grafting. The purpose of this study was to determine what effect trimming nerve ends has on the tension at the repair site.
Methods: The common digital nerves to the 2nd, 3rd, and 4th webspaces were exposed in six cadaveric hands. Each nerve was then sharply lacerated. Subsequently, with the aid of a digital caliper, one nerve was trimmed 2 mm (equivalent to trimming 1 mm of each cut end of a nerve) and one nerve was trimmed 5 mm (equivalent of trimming 2.5 mm of each nerve stump.) The nerve trimming distance (0, 2, or 5 mm) was randomized in each hand. Following transection and trimming, the nerves were reapproximated, such that they were just “kissing” and the tension required to do so was measured with a tyrolean tensiometer. The tension required to make the nerve ends oppose each other was measured 10 times for each nerve. Statistical analysis was then performed.
Results: Tension at the nerve repair site significantly increased as more nerve was trimmed. The average tension required to oppose the nerve when no trimming occurred was 1.3 N. Tension increased to 3 N when 2 mm of nerve was trimmed. When 5 mm of nerve was trimmed, the tension increased to 7.1 N (p<0.05).
Conclusion: Removing the damaged nerve tissue plays a critical role in preparing a transected nerve for repair. As one trims a lacerated nerve to expose “good” nerve ends, significantly more tension is required to permit a direct repair. The exact threshold of acceptable tension at a nerve repair site remains unknown. However, it is important to recognize that if significant trimming of the nerve ends is performed, one may want to consider utilization of a nerve conduit or nerve graft to minimize the tension at the site of the nerve repair.
A-0675 Great Occipital Nerve as a motor donor nerve in brachial plexus palsy: revision of the anatomy and results in our first patient
Sergio Daroda, Facundo Zabaljauregui, Fernando Menvielle, Rodolfo Cosentino, Paul Pereira
Clínica de la Mano GAMMA, La Plata, Argentina
The main purpose of this poster is to show the preliminary results in our first patient using the Great Occipital Nerve as a donor nerve in brachial plexus reconstruction.
The secondary objectives are to describe the path, the relations and peripheral nerve length and its mobilization to reach the suprascapular nerve.
Materials and methods:
Eight cadaveric specimens were used with dissections of the two Great Occipital Nerves (GON) with a total of 16 GONs. They were dissected from the outlet at the rachis up to its surface emergence. Length measurements were registered between these points; the topographic point of its emergence in the nape skin was identified. Also the mobilization from this point to the inner scapula angle was recorded. Finally, the number of axons before and after the exit of the motor branches for the nape muscles was histologically studied.
A 25-years-old patient with a total preganglionar brachial plexus palsy was operated on with a nerve transfer from the great occipital nerve to the supraescapular nerve using a nerve graft.
The time from the injury to the surgery was 18 months.
Anatomical results: Six and 2 specimens out of 8 were males and females respectively. The length from its exit between the first and second cervical vertebrae and its emergence in the nape skin was 62 mm average. With lateral nerve mobilization, a distance of 27 mm to the medial border and superior angle of the scapula was reached. Also the length to the suprascapular notch was measured obtaining an average distance of 73 mm.
Clinical result: after one postoperative year the patient shows an M3 activity of the supra and infraespinatus muscles confirmed by electromyography.
Using the mobilization, the GON can be reached close to the suprascapular notch. This is an alternative to neurotize the suprascapular nerve and to free the accessory nerve for another transfer.
Even though the sample is very low, we believe the GON can be a new source of nerve donor motor for brachial plexus reconstruction.
A-0703 Overuse injuries in patients with brachial plexus injury in the northern Netherlands
C.K. van der Sluis, J.M. van Bodegom, K. Postema, P.U. Dijkstra
University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, the Netherlands
A brachial plexus injury (BPI) has a restricting effect on the function of the arm. As a result, the non-affected arm performs more daily tasks or perform tasks unilaterally which normally are executed bilaterally. This could lead to overuse injuries of the non-affected arm, neck or upper back.
To assess the prevalence of overuse injuries of the non-affected arm, the neck and/or upper back in patients with BPI compared to a control group. Secondary objectives were to investigate factors predicting pain and disability.
Patients were recruited from three outpatient departments of rehabilitation medicine in the northern region of the Netherlands. Eligibility criteria were: Having a unilateral brachial plexus injury (not due to plexus neuralgia), aged 18 years or older, date of injury more than 1 year ago, understanding written Dutch language, no co-morbidities influencing upper limb function
Musculoskeletal pain was defined as pain in the muscles, tendons and/or bones not caused by an accident, sports injury, infection or joint disease. Prevalence of MSC was defined as the proportion of individuals with MSC in the preceding year. A survey was distributed by mail. The questionnaire comprised personal, work-related, social and pain specific questions: Upper Extremity Work Demands (UEWD), Pain Disability Index (PDI), Utrechtse Coping List (UCL) with active, avoidance, and support seeking questions and the RAND-36 with subscale health perception, mental health and pain.
Seventy-nine patients (mean age 51 years; 65% men) and 114 controls (mean age 50 years; 63% men) participated. The prevalence of MSC was significantly higher in the BPI-group (52%) compared to the control group (38%, P=0.041). Patients with BPI experienced more disability in participation (P=0.005). Mental and general health (RAND36), upper extremity work demands (UEWD) and coping styles (UCL) were similar in participants with BPI and the controls.
Presence of MSC was associated with worse self-reported mobility of the affected arm, an active coping style, and lower mental and general health. Higher disability was associated with the presence of MSC, worse self-reported mobility of the affected arm , female sex and a shorter time since injury.
Discussion and conclusions:
The high prevalence of MSC in individuals with BPI indicates that patients with BPI are at risk for developing musculoskeletal complaints in the non-affected arm, neck or back. The self-reported functional mobility of the affected arm seems to be a useful predictor for clinical practice, since it predicted MSC as well as disability. The influence of coping styles on MSC in patients with BPI needs further attention.
A-0708 Myo-electricity and gaze tracking data to improve hand prosthetics and neuro-cognitive examination.
Franco Bassetto 1, Manfredo Atzori 2, Matteo Cognolato 2,3, Diego Faccio 1, Gianluca Saetta 4, Arjan Gijsberts 5, Valentina Gregori 5, Mara Graziani 2,5, Francesca Giordaniello 2,5, Andrea Gigli 5, Francesca Palermo 2,5, Peter Brügger 4, Barbara Caputo 5, Henning Müller 2, Cesare Tiengo 1
1 Clinica di Chirurgia Plastica, Azienda Ospedaliera Universitaria di Padova, Padova, Italy; 2 Department of Business Information Systems, University of Applied Sciences Western Switzerland, (HES-SO Valais), Switzerland; 3 Rehabilitation Engineering Laboratory, Department of Health Sciences and Technology, ETH Zürich, Zürich, Switzerland; 4 Department of Neurology, University Hospital of Zurich, Zurich, Switzerland; 5 Department of Computer, Control, and Management Engineering, University of Rome “La Sapienza”, Rome, Italy
This work presents the Megane Pro project, which has three main objectives: first, to improve hand prostheses by reproducing eye-hand coordination in prosthetic hands; second, to better understand phantom limb sensation and the neurocognitive effects of hand amputations; third to better integrate surgical procedures with prosthetics. The overall aim is thus to improve the capabilities and quality of life of amputees, who are - despite recent scientific progress – still affected by the limited control of prosthetic hands. Phantom limb sensation is a good predictor of how well amputees can control a robotic prosthesis, but little is known about the mutual interactions between different types of sensation and the use of a prosthesis.
The data acquisition setup for detecting hand movements includes 12 surface electromyography electrodes, a pair of eye tracking glasses equipped with a scene camera and a laptop.
The acquisition protocol includes four exercises and a set of neurocognitive tests. The first exercise aims at improving robotic hand prostheses control. The subjects are asked to repeat 12 times several hand grasps on a set of various objects. The movements are collected from the hand movement taxonomy literature and they are presented to the subjects as videos. The grasps are repeated both as static and functional movements. The second, third and fourth exercise aim at better understanding phantom limb sensation and the neurocognitive effects of hand amputations. They include the repetition of executed and imagined movements as reported in Sirigu et al., the classical apparent motion paradigm with body parts introduced by Shiffrar and Freyd, and an experiment based on imagined and executed movement of the hand in presence of an obstacle, aimed to study obstacle shunning. The neurocognitive experiments are enriched with gaze and sEMG measures. Phenomenal characteristics of individual phantom limb sensations are assessed by structured interviews such as the interview on phantom sensations (RAM SIPS) and the phantom and stump phenomena interview. The multimodal data are analysed with statistical and artificial intelligence methods.
The results highlight the usefulness of the acquisition setup and protocol both for prosthesis control and for neurocognitive research. Surface electromyography, eye tracking and computer vision allow to obtain more complete data. The acquisition protocol allows for a qualitative and quantitative assessment of painful, not painful and residual phantom limb sensations and examines the properties of a phantom limb when brought “in contact” with material objects. The results suggest that the interaction between sensory-motor imagery and the visual observation of objects in the environment might critically influence the properties of a phantom limb.
This paper provides an interdisciplinary insight into hand amputations and hand prosthesis control. A proper integration between surgical procedures, neurocognitive analyses, multimodal data acquisition and artificial intelligence algorithms can make current prostheses more autonomous, restoring eye-hand coordination, leading to naturally controlled robotic hands with better performance. The experiments are highly informative regarding phantom limb properties, both painful and painless, and when a phantom gets “in contact” with external objects.
A-0709 Clinical evaluation of an innovative Polyactic Acid and Carbon Nanostructures interface for the peripheral nerve rigeneration: esperimental study
Cesare Tiengo, Arianna Gatto, Andrea Monticelli, Franco Bassetto
Plastic Surgery Department, Padova, Italy
Objective: Peripheral nerve injuries following traumas are an epidemiologically relevant problem due to their poor outcome. They still need an appropriate and effective management. In the last decades, improvements in the field of biomaterials and nanotechnologies have offered a suitable alternative to more invasive methods such as autografts or allografts, leading to the production of far more sophisticated scaffolds which are able to interact with cells and macromolecules on a nanoscale. Prompted by an in depth review of current biomaterials and nanotechnologies, by the encouraging results of various in vitro studies on a novel MWCNT-PhMO_PLLA(4-methoxyphenyl-functionalized-multi walled-carbon nanotubesand PLLA-nanofibers)-based scaffold, we tested this material, combined with an external CNTfree-PLLA-wide mesh supporting structure, in vivo on a murine model of injuried sciatic nerve. Our study aimed to evaluate its effectiveness when used as a wrapping sheat compared to the actual gold standard, the epineurial suture. Moreover, we aimed to demonstrate its biocompatibility, its ability to prevent adhesions and collateral sprouting and the absence of Wallerian degeneration downstream the injury. The latter would be the real improvement compared to wraps actually on the market which have only a protective function, preventing from adhesions as well.
Materials and methods: The right sciatic nerve of 7 mice was transected, repaired with an epineurial suture and then wrapped with our novel wrapping sheat. Other 3 mice underwent sciatic nerve transection and epineurial suture repair to be used as controls. All of them were monitored for the following 30 days and tested through functional tests, such as
De Medinaceli test, Open Field test, Walking Track test and EMG. On the 30th day nerves and muscles were taken to be histologically analyzed.
Results: Results from De Medinaceli, Open Field and Walking Track tests were statistically different between CNT-PLLA mice and sutured mice. The CNT-PLLA group showed a faster and greater improvement in all the performed tests. Friedman's test indicated improvement in the CNT-PLLA group has been far more relevant. Electrophysiology confirmed the absence of Wallerian degeneration and the presence of a biphasic compound muscle action potential (CMAP). Histology showed no adhesions and no fibrotic reaction. Muscle showed a certain grade of atrophy albeit higher among the suture group.
Conclusions: Statistical analysis highlighted the better results gained by CNT-PLLAgroup in functional tests. Electromiography excluded the presence of denervation downstream the suture site and confirmed the CMAP is restored. Therefore histology confirmed that no foreign body reaction has occured and adhesions and neuromas have been avoided and showed a higher grade of atrophy in the suture group. Our MWCNT-PhMO-PLLA nanofibers based scaffold has proved to prevent Wallerian degeneration, being fully biocompatible and protective from adhesions ande neuromas at the same time.
A-0716 The role of ultrasound examination in penetrating nerve injuries
Viviana Maja Rosero 1, Katalin Dévay 1, Zsuzsanna Aranyi 2
1 Merenyi Gusztav Hospital, Budapest, Hungary; 2 Department of Neurology, Semmelweis University Budapest, Hungary
Objective: To assess with high resolution ultrasound penetrating nerve injuries before or after nerve reconstruction.
Methods: Between 2016 and 2017, consecutive patients with complete or incomplete penetrating nerve injuries were included in the study prospectively. All patients underwent clinical, electrophysiological, and B-mode and color Doppler ultrasound examination. The size of the scar / neuroma at the injury site was measured, and correlated with the degree of reinnervation where reconstruction was carried out and sufficient time has elapsed. Intraneural blood flow was quantified.
Results: 30 patients with 34 injured nerves were included in the study. Most of the nerves were treated with epi- / perineural nerve suture. The earliest time point for assessment was 2.5 months, the latest was 30 years after the injury. No significant correlation was found between the degree of reinnervation and the size of the scar / neuroma. However, in a number of cases ultrasound has shown findings which prompted surgical intervention / revision. These included unrecognized neurotmesis, complete misalignment of the sutured stumps, and suture neuroma. A consistent finding was marked intraneural blood flow, not normally detected in intact nerves, proximal to the injury site. The hypervascularization was seen in all nerves, both in untreated and treated injuries.
Conclusions: Hypervascularization of the nerves proximal to injury site appears to be an essential element of nerve regeneration after penetrating nerve injuries. We hypothesize that hypervascularization reflects neovascularization triggered by axonotmesis. Ultrasound may also provide important information with respect to the therapeutic pathway.
A-0731 Optimising recruitment to an RCT in Neurolac-assisted tension free digital nerve repair
Dalia Mohamed, Dominic Power
The Hand and Peripheral Nerve Research Network, Institute for Translational Medicine, Birmingham, UK
Objective: Randomised controlled trials involving interventions in an emergency setting are notoriously difficult. Successful recruitment and retention of participants into research studies is critical for optimising internal and external validity. Balancing service pressures and the administrative burden necessary for robust trial methodology creates challenges that must be reconciled to maintain recruitment targets
Methods: The CoNNECT study is a randomised controlled interventional trial with three arms evaluating the role of tension in a digital nerve repair model. The study centre is a tertiary referral hand trauma service with approximately 600 new attendances resulting in approximately 350 hand trauma cases each month. Recruitment is through a 2-stage eligibility screening process with final confirmation of eligibility after surgical exploration of the wound. At this stage the nerve to be repaired is randomised with stratification for age. Repair is then completed with microsurgical suture, Neurolac protection of a suture repair or with a Neuralac-assisted tension free co-aptation with remote sutures. The complexity of the trial design requires co-ordination between several different clinical areas and co-operation between junior medical staff, hand co-ordinators and research nurses. Interim recruitment audit in the early phase of the trial identified missed recruitment opportunities. A bespoke electronic patient record for hand trauma has been re-engineered to provide automated prompts during initial assessment of all patients with potential nerve injuries.
The E-hand system was designed at the Birmingham Hand Centre for the assessment and management of hand injuries. Referral, assessment, surgery and therapy data is compiled in a single system that generates workload data for co-ordination of the patient pathway. Activity reports provide accurate data on trial recruitment and missed potential trial patients. Redesign of the assessment tool to create an automated alert regarding trial eligibility and confirmation of inclusion criteria has resulted in optimisation of trial recruitment. Patients can be provided with trial information that they can review in advance of a planned day surgery admission for surgery and the research team are alerted to the date and time of attendance for surgery.
Randomised controlled trials in trauma surgery are complex and there are challenges created by the short time available between presentation and surgery. Rotating junior staff are the first point of contact for new trauma patients and clinical pressures may limit trial recruitment. Redesign of the E-hands management system has ensured trial recruitment is optimised and that there is compliance with Good Clinical Practice guidelines.
A-0757 New method of decellularization of human nerve segments applied to the development of implantable prostheses for the repair of peripheral nerve lesions.
Belén García-Medrano 1, Nuria Mesuro Domínguez 2, Clarisa Simón Pérez 3, Fernando Moreno Mateo 1, Manuel Garrosa García 3, Miguel A Martín-Ferrero 1, Sara Gayoso del Villar 3, Manuel José Gayoso Rodríguez 3
1 Orthopaedic Surgery, Hand Unit, Hospital Clínico, Valladolid, Spain; 2 Otorhinolaryngology Department, Hospital Clínico, Valladolid, Spain; 3 Cell biology and Histology department, Faculty of Medicine, University of Valladolid, Valladolid, Spain
When a gap occurs in a lesion of peripheral nerve, the repair is possible by using a prothesis to bridge the gap between proximal and distal nerve ends. Many and of variegated origin prostheses have been employed, but none has rendered convincing results. The morbidity and limitations of the nowadays most employed treatment, opens the way to the search of surgical and biological alternatives.
To obtain segments of decellularized human nerve by a new chemical method as a basis for the manufacture of biocompatible prostheses useful in the repair of human nerve injuries.
MATERIAL AND METHODS:
Nerves from organ donors were decellularized by a chemical method patented by one of us (MJ Gayoso, P201531544) without detergents. These prostheses were subsequently implanted, after anesthesia, in receiving Wistar rats, in which a 7 mm defect was made in a sciatic nerve. The implants were maintained for a period of 2, 4, 8 and 16 weeks. After the implant period the animals were subjected to Sciatic Functional Index (SFI) test and after anesthesia sacrificed by intracardial perfusion to complete the histological study using light and electron microscopy.
Our decellularization method manages to eliminate Schwann cells, perineural and endoneural cells, preserving the extracellular matrix due to the absence of detergents. Functional test revealed poorer functional recovery in implanted rats as compared with our previous studies using allogenic grafts. Likewise, we have observed a greater graft rejection in this xenogenic grafted rats than with allogenic grafts.
Our method of decellularization seems adequate for the development of allogeneic prostheses for clinical use. A biological study has been initiated to establish which part of the defensive reaction that leads to rejection of the human prosthesis by xenogene implanted rats is due to interspecies response. This defensive reaction is expected not appear in an allogenic graft implanted in human nerves.
A-0814 Injury to the infraclavicular brachial plexus following dislocation of the glenohumeral joint
Isabel Guy 1, Daniel Guerero 1, Tahseen Choudhry 2, Simon Tan 2, Colin Shirley 2, Caroline Miller 2, Charles Edwards 2, Dominic Power 2
1 Birmingham University Department of Anatomy, UK; 2 The Centre for Nerve Injury and Paralysis, Birmingham Hand Centre, UK
Injury to the infraclavicular brachial plexus is an uncommon complication of dislocation at the glenohumeral joint that results in a devastating loss of upper limb function and debilitating neuropathic pain. The patterns of injury and associated injuries are poorly defined in this injury group. Recognition of injury patterns can guide management and prognosis.
We reviewed all cases of brachial plexus injury presenting to a regional peripheral nerve injury service during a three year period from 2012-2016 with at least 12 months follow up at final review. Medical records, therapy records, imaging and neurophysiology reports were reviewed and recorded in a database derived from a prospective peripheral nerve injury workload database where injuries were coded after first assessment. Demographic and injury details were recorded and a consensus on nerve injury grade was achieved by 2 reviewers and with senior author review where no consensus was reached.
2500 new patient episodes have been recorded since 2012. Database interrogation identified 110 infraclavicular brachial plexus injuries during a 3 year period to 2016 with at least 12 months follow up. Following exclusion of high energy injuries, stabs, gunshots and iatrogenic injuries there were 52 injuries classified as low energy and a sub-group of 40 cases of confirmed glenohumeral dislocation were included in the final analysis. There were 26 female and 14 male patients in this sub-group with a mean age of 61 years (range 24-86). 13 patients sustained a greater tuberosity avulsion fracture and 11 patients sustained rotator cuff tears. There were 5 vascular injuries. Nerve injury classification data was complete in 36 patients (90%). Review of the injury patterns identified axonopathy of all 3 cords (medial, lateral and posterior) in 21 cases (58%) although 2 had sparing of the axillary nerve. The medial cord was most commonly injured in 78% of cases. In 5 cases (14% of classified injuries) there was a medial cord injury with additional involvement of the lateral head of the median nerve but sparing of the musculocutaneous nerve and the posterior cord. This group has not been previously described and the outcome for the hand is generally poor due to loss of the intrinsic muscles and limited reinnervation of the extrinsic finger flexors.
Defining injury patterns can help to evaluate outcomes after brachial plexus injuries and assist in providing a prognosis. Early recognition of an injury sub-group with medial cord and lateral head of median nerve involvement (medial cord plus median nerve) and sparing of the posterior cord and musculocutaneous nerve may provide an opportunity for consideration of novel targeted nerve transfer surgery to restore hand function despite the long reinnervation distances necessary to reach forearm and hand motor targets.
A-0816 Nerve transfer strategies to improve hand outcome in isolated medial cord brachial plexus injuries: Staged motor nerve transfer through a reversed medial cutaneous nerve of forearm vascularised graft
Daniel Guerero 1, Isabel Guy 1, Tahseen Choudhry 2, Simon Tan 2, Colin Shirley 2, Caroline Miller 2, Charles Edwards 2, Dominic Power 2
1 Birmingham University Department of Anatomy, UK; 2 The Centre for Nerve Injury and Paralysis, Birmingham Hand Centre, UK
Axonopathy of the medial cord of the brachial plexus results in poor functional outcome for the hand due to loss of extrinsic digital flexion and paralysis of the hand intrinsic muscles. Nerve transfers for hand function are limited in efficacy due to the long reinnervation distances from intact proximal donor muscles to the distally placed denervated motor targets.
Review of a clinical series of low energy infraclavicular brachial plexus injuries identified a sub-group of patients (14% of injuries) with involvement of the medial cord and lateral head of the median nerve with sparing of the musculocutaneous nerve and the posterior cord. Review of outcomes in this subgroup identified early prognostic predictors of poor recovery. A cadaveric feasibility study was designed to evaluate the use of an in-situ reverse innervated motor to sensory vascularised nerve transfer as an early intervention option to staged pedicled transfer of the neo-innervated motor nerve to a range of distal targets.
The medial cutaneous nerve of the forearm (MABCN) arises as a direct branch from the medial cord of the brachial plexus and has no branches in the upper arm. Following axonopathy of the medial cord there is Wallerian degeneration of the sensory axons in the MABCN. Mobilisation of the distal end at the proximal forearm enables a loop to be created and distal to proximal retrograde innervation may be achieved using the nerve to brachialis, the medial head of triceps branch, the nerve to supinator or the extensor carpi radialis branch of the radial nerve. Staged transfer of the vascularised motor graft can be achieved following axonotomy of the proximal end of the MABCN from the medial cord after reinnervation. A number of distal targets for these motor axons can be reached within the 9-12 month window necessary for a successful reinnervation. Targets include the anterior interosseous nerve, the flexor digitorum profundus branch of the ulnar nerve and the motor fascicle of the ulnar nerve in the distal forearm.
A novel staged motor nerve transfer using a reverse innervated in-situ vascularised sensory nerve graft can be used to reinnervate distal targets following medial cord brachial plexus injury.
A-0818 Supinator branch to lateral cutaneous nerve of forearm in situ staged motor nerve transfer for distal forearm targets in medial cord brachial plexus injury
Isabel Guy 1, Daniel Guerero 1, Tahseen Choudhry 2, Simon Tan 2, Colin Shirley 2, Caroline Miller 2, Charles Edwards 2, Dominic Power 2
1 Birmingham University Department of Anatomy, UK; 2 The Centre for Nerve Injury and Paralysis, Birmingham Hand Centre, UK
Axonopathy of the medial cord of the brachial plexus results in poor functional outcome for the hand due to loss of extrinsic digital flexion and paralysis of the hand intrinsic muscles. Nerve transfers for hand function are limited in efficacy due to the long reinnervation distances from intact proximal donor muscles to the distally placed denervated motor targets.
A review of a clinical series of low energy infraclavicular brachial plexus injuries identified a sub-group of patients (14% of injuries) with involvement of the medial cord and lateral head of the median nerve with sparing of the musculocutaneous nerve and the posterior cord. Review of outcomes in this subgroup identified early prognostic predictors of poor recovery. A cadaveric feasibility study was designed to evaluate the use of an in-situ reversed innervated motor to sensory vascularised nerve transfer as an early intervention option to staged pedicled transfer of the neo-innervated motor nerve to a range of distal targets.
The lateral cutaneous nerve of the forearm (LCNF) arises as a direct branch from the musculocutaneous nerve after the innervation of brachialis. In a patient with a functioning biceps the supinator branches from the posterior interosseous nerve can be sacrificed and used to reinnervate denervated targets, however they are too short for a direct nerve transfer. A cadaveric study was performed to identify the proximal branching patterns of the LCNF. There are no branches within the arm and before 5cm distal to the lateral epicondyle. Mobilisation of the distal LCNF and reverse innervation from the supinator branches through an anterior approach can provide a means of reinnervation of mid and proximal forearm motor targets when performed early as a prelude to staged distal transfer following reinnervation. Early prognostic prediction of poor outcome following medial cord brachial plexus injury can prompt use of this early transfer in isolation or in combination with a brachial to a medial antebrachial cutaneous nerve transfer for restoration of function to the digital flexors and the hand intrinsic muscles.
A novel staged supinator motor nerve transfer using a reverse innervated in-situ vascularised sensory LCNF nerve graft can be used to reinnervate distal targets following medial cord brachial plexus injury.
A-0827 Decellularized Nerve: Research of the More Reliable Method
Simona Odella 1, Stefania Raimondo 2, Arianna Lovati 3, Alessandro Crosio 4, Anna Maria Biondi 5, Francesco Locatelli 1, Stefano Geuna 2, Pierluigi Tos 1
1 Reconstructive Microsurgery and Hand surgery Unit, ASST Pini-CTO Milano, Italy; 2 Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, Orbassano, Italy; 3 IRCCS Isituto Galeazzi Cell and Tissue Engeneering Laboratory, Italy; 4 AOU City of Health and Science of Turin UO Orthopedics and Traumatology, 2 Hand Surgery, Italy; 5 AOU City of Health and Science of Turin, Muscolo-Scheletal Tissues Bank, Italy
Peripheral nerve injuries are more than 70% of upper limb trauma. In the case of large defects, end to end suture is not possible and conduit is not enough to obtain good results, thus the gold standard is the autograft, however this solution presents disadvantages: donor site morbility and longer surgery time. Allograft could be another alternative but nerves from donors frequently cause immunogenic response. Starting from 1980, several authors are looking for the correct way to decellularize nerves preserving both the extracellular matrix and basal lamina to improve nerve regeneration. In Italy, a recent law prohibits to commercialize human tissue for profit, thus the use of marketed human-derived devices is forbidden in the case of nerve injuries that need a graft. The purpose of this study is to find an easy, cost effective, standardized and reliable protocol for the allogeneic nerve decellularization to be stored in a nerve bank.
From a literature review, we concluded that the best method to eliminate cells and to remove cell debris is the chemical one. This method is able to maintain preserved basal lamina and collagen that are indispensable for nerve regeneration. In our study, we propose two chemical-based protocols for the nerve decellularization: one chemical (TritonX100 + sodium dodecyl sulphate- SDS- detergent) in association to sonication cycles, the other also chemical (phosphate-buffered saline- TBP- detergent) in association to a DNAse. According to these protocols, we decellularized human (median and ulnar) and rat (sciatic) nerves. We processed and evaluated samples by means of histology and electron microscopy compared to commercial decellularized allografts.
The results showed that both of them could remove immunogenic components maintaining the basal lamina to improve nerve regeneration. . In particular, we found that the commercial specimens maintained some integral axons, many cellular and myelin debris within a preserved collagen structure and tissue organization. Differently, nerves decellularized with the chemical and sonication protocol showed a good tissue organization with oriented and intact collagen, but still present axons within the extracellular matrix. The best results were obtained by the chemical and DNAse protocol in which a rich matched connective matrix was maintained and no integral axons were present.
The purpose of this study is to identify an accessible method of decellularization that was also cost-effective, standardized and permitted to obtain a complete removal of immunogenic elements maintaining an intact basal lamina to help axon regeneration. Here, we identified the best procedure to obtain stable results even in long-term storage. In the next future, we will evaluate the nerve regeneration in an in vivo study through the implantation of decellularized allograft in a rat model.
A-0833 The amnion muscle combined graft (AMCG) conduits in the repair of wide substance loss of bigger trunks of peripheral nerves of the forearm and wrist. Our clinical and experimental experience
Michele Riccio, Angelica Aquinati, Pier Paolo Pangrazi, Andrea Campodonico, Letizia Senesi
Department of Reconstructive Plastic Surgery-Hand Surgery, AOU “Ospedali Riuniti” Ancona, Italy
The use of autologous sural nerve grafts is still the current gold standard for the repair of peripheral nerve injuries with wide substance losses, even if this technique have some limits like a limited donor nerve supply, and morbidity of donor site. Despite good microsurgical techniques for repair of peripheral nerve lesions and the use of nerve grafts and nerve conduits for bridging the defects, functional nerve recovery is generally partial and unsatisfactory. At present, tubulization through the muscle vein combined graft, is a viable alternative to the nerve autografts although this technique is currently limited to a critical gap of 3 cm with less favorable results for motor function recovery.
We present our experience regarding a new tubulization method, the amnion muscle combined graft (AMCG) technique. It consists in the combination of the human amniotic membrane hollow conduit with autologous skeletal muscle fragments for repairing the substance loss of peripheral nerves and recover both sensory and motor functions.rnWe also present the clinical and histological results of an experimental study on a rat model: Fourteen male Wistar rats were divided into two groups: 1.5 cm length gap on median nerve reconstructed by means of i) a reverse nerve autograft; ii) amnion-muscle combined conduits.rnFunctional recovery, evaluated using grasping test 30, 60 and 90 days after surgery, was observed in both groups. Moreover, the stereological analysis showed that, in amnion-muscle combined conduits group, regenerating median nerves have significantly more myelinated fibres with the same axon size, but significantly thinner myelin than autograft group. The experimental study on the rat model confirm the brilliant clinical results.
Follow-up ranged from 10 to 48 months. In a series of twelve patients with loss of substance of the median nerve (7 patients) and the ulnar nerve (5 patients) ranging 3–5 cm at the wrist and forearm, AMCG achieved excellent results graded as S5 in one case, S4 in seven cases, S3+ in three cases, and S3 in one case; M5 in one case M4 in seven cases and M3 in four cases according to the Sakellarides classification and the criteria of nerve injuries committee of the british medical research council modified by Mackinnin and Dellon. No iatrogenic damage due to withdrawal of a healthy nerve from donor site was done.
The clinical and experimental results suggest that the AMCG is a reasonable alternative to traditional nerve autograft in selected clinical conditions.
Amnion conduit, peripheral nerve repair, upper limb nerve
A-0837 Treatment of neuroma upper extremity by nerve capping
Bergman Clinics, Naarden, The Netherlands
Symptomatic neuroma may develop after a nerve dissection or bruising of a nerve following any trauma to a peripheral nerve, whether accidental or planned. Neuroma-induced neuropathic pain and morbidity seriously affect the patient’s daily life and functional status. The objective of this pilot study was to provide data to assess safety and effectiveness of the NEUROCAP®, a bioresorbable capping device, to protect a peripheral nerve end and separate the nerve from surrounding tissues in order to reduce the development of a symptomatic neuroma.
This prospective cohort study included ten upper limb non-reconstructable symptomatic primary or secondary end-neuroma patients at three hospitals in The Netherlands. Their neuroma was treated by surgical excision followed by capping of the transected proximal nerve end with the NEUROCAP®. This nerve capping device is a tube with one closed end consisting of the bioresorbable copolyester poly(DL-lactide-ε-caprolactone), which maintains its form for up to ten weeks and then slowly degrades within approximately sixteen months. Main outcome measures of the study were VAS Pain score, QuickDASH score, recurrence of symptomatic neuroma, adverse events and use of analgesics. Primary outcome assessment of all parameters was performed after 6 weeks, secondary outcome assessment was performed at 3, 6 and 12 months after surgery.
10 patients were enrolled (8 females and 2 males). Mean age was 39.3 ± 22.4 years. There were five patients with superficial radial nerve (SRN) neuroma enrolled, two with neuromas of dorsal branches of ulnar nerve, two median nerves and one radial nerve. Mean VAS Pain score at baseline was 69.1 ± 27.8 on a scale of 0-100. Preliminary results indicate that this decreased to 26.9 ± 25.3 at 12-month follow up. QuickDASH scores decreased from 64.9 ± 21.2 on a scale of 0-100 at baseline to 31.5 ± 15.2 at 12-month follow up. All patients reported to use analgesics at baseline, mainly comprising a combination of Paracetamol, Naproxen, Pregabalin and/or Oxycodon. At 12-month follow up, 8 out of 10 patients reported they were not using any pain medication and in 2 patients analgesics use was significantly reduced. There was one recurrent neuroma at 12-month follow up. Adverse events (AEs) mainly included minor sensory loss inherent to the treatment (2 patients). One patient had an AE, where the device was removed after a traumatic hit on the surgical area 3 months after implantation. There was one serious adverse event (SAE), where a patient developed seroma after the surgical area was hit on furniture several weeks after the implantation. The device was removed 2.5 months later. Assessment of the origin of this SAE is inconclusive as to whether is device-related.
This pilot study shows promising results regarding treatment with the bioresorbable NEUROCAP® device in peripheral symptomatic end-neuroma in up to 12 months of follow up. The pain reduction observed significantly improves patients’ quality of life and daily function. Result interpretation is however limited by the small study group size. Further information should be collected in a larger patient population.
A-0843 Episomal Induced Pluripotent Stem Cells Promote Functional Recovery of Transected Murine Peripheral Nerve
Aline Yen Ling Wang 1, Charles Yuen Yung Loh 1,2, Huang-Kai Kao 3,4, Fu-Chan Wei 1,3,4
1 Vascularized Composite Allotransplantation Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 2 St Andrew's Center for Plastic Surgery, Chelmsford, Essex, UK; 3 Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 4 College of Medicine, Chang Gung University, Taoyuan, Taiwan
Traumatic peripheral nerve neurotmesis occurs frequently and functional recovery is often slow and impaired. Induced pluripotent stem cells (iPSCs) have shown much promise in recent years due to its regenerative properties similar to that of embryonic stem cells. However, the potential of iPSCs in promoting the functional recovery of a transected peripheral nerve is largely unknown. This study is the first to investigate in vivo effects of episomal iPSCs (EiPSCs) on peripheral nerve regeneration in a murine sciatic nerve transection model.
Material and methods:
Episomal iPSCs refer to iPSCs that are generated via Oct3/4-Klf4-Sox2 plasmid reprogramming instead of the conventional viral insertion techniques. It represents a relatively safer form of iPSC production without permanent transgene integration which may raise questions regarding risks of genomic mutation. A minimal number of EiPSCs were added directly to the transected nerve.
Functional recovery of the EiPSC group was significantly improved compared to the negative control group when assessed via serial five-toe spread measurement and gait analysis of ankle angles. EiPSC promotion of nerve regeneration was also evident on stereographic analysis of axon density, myelin thickness, and axonal cross-sectional surface area. Most importantly, the results observed in EiPSCs are similar to that of the embryonic stem cell group. A roughly ten-fold increase in neurotrophin-3 levels was seen in EiPSCs which could have contributed to peripheral nerve regeneration and recovery. No abnormal masses or adverse effects were noted with EiPSC administration after one year of follow-up.
We have hence shown that functional recovery of the transected peripheral nerve can be improved with the use of EiPSC therapy, which holds promise for the future of peripheral nerve regeneration, especially in the extremity.
A-0886 Outcome Measurements and functional Benefit in Brachial Plexus Surgery
Richarda Boettcher, Ulrike Schnick
Unit for reconstructive Surgery in brachial plexus injuries, tetraplegia and cerebral palsy, Unfallkrankenhaus Berlin, Germany
Objectives: After reconstructive surgery in brachial plexus surgery a long term follow up of several years is necessary to record definite results. Published data for these cases show quite different patterns in recording and measurement of the outcome. Therefore studies are of limited comparability. Mostly only one item (Range of motion, muscle force, pain or function) is reported. Until now no data are available showing the relationship between measurable force and ROM and usability of the arm in daily activities.
Material and method: More than 50 patients after plexus lesions with different surgical treatment were long term observed. For shoulder and elbow function range of motion as well as muscle force were reported, while for the wrist and hand mostly functional items were examined. Comparing own results with the literature showed the limited comparability. Thus critical assessment of own results was limited.
Results: Based on this experience a draft for a combined chart to report functional and measurable results in a short and effective way was developed. It considers range of motion for the most important functions, muscle force, functional items, pain and sensory quality. Due to limited ressources the chart include only aspects with practical importance for usability of the arm in daily life.
Conclusion: The results in reconstructive brachial plexus surgery need to be comparable better with respect to function in daily life. Nevertheless measurable items are necessary to objectify the findings. A standardized chart to report long term results might help to support multicentric evaluation of defined surgical procedures or schemes of treatment and will be introduced for discussion.
A-0912 Complications Related to Harvesting Nerve Graft or Obtaining Nerve Biopsy
Ivica Ducic 1,2, Erick DeVinney 2
1 Washington Nerve Institute, McLean, VA, USA; 2 AxoGen Inc, Alachua, FL, USA
Objectives: Harvesting nerve autograft or obtaining sensory nerve biopsy for diagnostic purposes is expected to cause permanent sensory deficits. In addition, donor site wound complications, neuroma pain and post-denervational paresthesia may follow, mandating additional treatments due to negative effect on patient’s quality of life. Systematic review is undertaken to define the incidence, healthcare cost-related sequela and available solutions for these complications.
Methods: Literature search of available Pub-Med English reported studies was undertaken to address each of the three targeted goals.
Results: Although various sensory upper and lower extremity nerve donor site grafts are utilized, sural nerve is reported as the most common nerve autograft or biopsy donor site. The complication rates of chronic pain (>6months) range from 11-40%, while mild pain symptoms may persist up to 5 years or more. Diabetic patients have greater risk for chronic postoperative pain (40%, up to 44 months). Allodynia was presented in 19% of patients, while dysesthesia ranged from 35-47%. Donor site wound infection or dehiscence are reported in 3-15% of patients.
The extended operative time for autograft harvest was 30-75 min, with associated OR costs of $3200-$6500, and charges for prolonged stay, affected ambulation and pain management. If complication due to surgical site infection, wound dehiscence or neuroma management, health-care costs are reported in range of $9700, with $4-$22,000 cumulative hospital loses per incidence.
Medical and interventional neuroma pain management have low long-term success rate as neither removed pain source-neuroma. In addition, overall 55% effectiveness of radiofrequency ablation is further troubled with high recurrence rate, while about 70% effective neuromodulation appears appealing, only about half are still effective beyond three year, with average of 39% complications. Aside from standard sterile surgical approach, previous reports of modified sural nerve biopsy aimed to minimize donor site complication, still failed to restore the original sensation. Even surgical removal of neuroma without reconstruction may have up to 20% of failure rate. Similar to other reports, sensory donor nerve reconstruction with Avance human nerve allograft appears the most promising as it restores the nerve continuity for up to 7 cm donor defects.
Conclusions: Donor site morbidity due to nerve autograft harvest or diagnostic biopsy may be associated with morbidity and costly complications. The awareness of such events should aid surgeon and patient when choosing nerve autograft vs allograft reconstruction. Newest technologies utilizing human allograft enable us to restore the original donor nerve continuity, thereby eliminating neuroma recurrence, in addition to restoring original nerve function. Further prospective studies are suggested to reinforce presented evidence based-data.
A-0915 Are Current Human Nerve Allograft Processing Methodologies Similar Enough to Use Their Data Interchangeably? An Assessment of the Key Factors Relevant to Regeneration and Functional Outcomes Data
Erick DeVinney 1, Anne Engemann 1, Curt Deister 1, Ivica Ducic 1,2
1 AxoGen Inc, Alachua, FL, USA; 2 Washington Nerve Institute, USA
Objectives: In the past few decades interest in nerve allograft technology has increased greatly. Numerous institutions have developed processing and preservation methodologies in an attempt to create a nerve graft that is safe, physically stable, immunologically tolerated, structurally intact, biologically active and conveniently stored. Unfortunately, achieving this has proven challenging, with only a few reaching commercialization. Nuances in tissue sourcing, processing reagents, processing conditions, quality controls, sterilization methods and storage conditions play a role in the final functionality of each type of nerve allograft. However, general statements are often made on availability, utility and functionality of nerve allografts as a group. To better characterize the similarities and differences between preparation methods, a review of the processes, their characterization assessments and critical factors to success was conducted.
Methods: A systematic review of MEDLINE and EMBASE databases was conducted using a comprehensive combination of keywords and a search algorithm according to PRISMA guidelines. Identified candidates were evaluated based on key criteria, categorized and compared to examine key similarities and differences.
Results: Since 1990, 16 institutions have developed and/or patented unique nerve processing methods. Globally, 3 of these methods have been successfully developed to a clinical stage. Processing methodologies were found to vary by tissue source, processing agents, structural preservation, growth factor content, growth inhibitor content, biological activity, mechanical integrity and sterility.
The most prevalent method for reducing the immunologic burden is chemical extraction, with or without detergents. Tissue sources included rat, rabbit, porcine and human. Assessments of cellular extraction, growth factor preservation and growth inhibitor modification/removal were rarely performed, and varied greatly between processes. Preservation of basement membrane structure and laminin assessments were available for many, but not all processes. The degree of structural preservation as well as functional regeneration in both short and long gap models varied greatly by processing methodology. Improved functionality was significantly correlated with a greater degree of structural and laminin preservation as well as enzymatic removal of growth inhibitors. All processing methods demonstrated a favorable safety profile.
Conclusions: Tissue source, processing methodologies, and both structural and bioactive laminin preservation play key roles in the utility of nerve allografts. While safety data and general utility data may be used interchangeably, functional data varied greatly between processing methods and should not be used interchangeably. Given the high degree of variability in the data examined, the tissue source and the processor and/or processing methodology used should be specified to avoid misinterpretation of relevant data.
A-0924 Artificial Intelligence Revealed Neuroprotective Drug for Nerve Trauma
Joaquim Forés 1, David Romeo-Guitart 2, Mireia Herrando-Grabulosa 2, Raquel Valls 3, Tatiana Leiva-Rodriguez 2, Elena Galea 4, Francisco Gonzalez-Pérez 2, Xavier Navarro 2, Valerie Petegniel 5, Assumpció Bosch 6, Mireia Coma 3, José Manuel Mas 3, Caty Casas 2
1 Hospital Clínic. University of Barcelona, Hand and Peripheral Nerve Unit, Spain; 2 Institut de Neurociències and Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona (UAB), Centro de Investigación Biomedica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Bellaterra, Barcelona, Spain; 3 Anaxomics Biotech, S.L, Barcelona, Spain; 4 Institut de Neurociències, Biochemistry and Mlecular Biology, UAB and ICREA, Spain; 5 Department of Brain Ischemia and Neurodegeneration, Tnstitute for Biomedical Research of Barcelona (IIBB), Spanish Research Council (CSIC), Institut d'investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain; 6INc and Department of Biochemistry and Molecular Biology, UAB and CIBERNED, Spain
Here we used a systems biology approach and artificial intelligence to identify a neuroprotective agent for the treatment of peripheral rood avulsion. Base bon accumulated knowledge of the neurodegenerative and neuroprotective processes that occurs in motoneurons after root avulsion, we built up a protein networks and converted them into mathematical models. Unbiased proteomic data from our preclinical models were used for machine learning algorithms and for restrictions to be imposed on mathematical solutions. Solutions allowed us to identified combinations of repurposed drugs as potential neuroprotive agents and validated them in our preclinical models. The best one NeuroHeal, neuroprotected motoneurons, exert anti-inflammatory properties and promoted functional locomotor recovery. NeuroHeal endorsed the activation of Sirtuin 1which was essential for its neuroprotective effects. These results support the value of network-centric approaches for drug discovery and demonstrate the efficacy of NeuroHeal as adjuvant treatment with surgical repair for nervous system trauma.
A-0931 Sensate nerve fiber transfer from the dorsal branches of the radial nerve for the 1st space to the deep motor branch of the ulnar nerve to protect intrinsic hand muscles from atrophy; an anatomical and histomorphometric study
Michele R Colonna 1, Vincent Casoli 2, Nikolaos Papadopulos 3, Francesco Stagno d'Alcontres 1, Konstantinos Natsis 4, Bruno Battiston 5, Paolo Titolo 5, Pierluigi Tos 6, Francesco Zanchetta 1, Alfio Costa 1, Pietro Micieli 1, Antonina Fazio 1, Gabriele Delia 1, Stefano Geuna 7
1 University of Messina, Department of Human Pathology of the Adult, The Child and The Adolescent, Messina, Italy; 2 Department of Hand Surgery, Plastic Surgery, Burn Surgery, CHU University of Bordeaux, Centre François-Xavier-Michelet, Groupe Hospitalier Pellegrin, Bordeaux, France; 3 Department of Plastic Surgery And Burns, Alexandroupoli University General Hospital, Democritus University of Thrace, Alexandroupoli, Greece; 4 Aristotle University of Thessaloniki School of Medicine, Department Of Anatomy And Surgical Anatomy, Thessaloniki, Greece; 5 Azienda Ospedaliero Universitaria Citta della Salute e Della Scienza di Torino, Depatment of Traumatology, Turin, Italy; 6 UOC Hand Surgery And Reconstructive Microsurgery Unit, Asst G Pini-cto, Milano, Italy; 7 University of Turin School of Medicine, Italy
Protecting distal muscle effectors from atrophy is a major challenge in patient’s care after proximal nerve trunk injuries (particularly ulnar nerve) and several distal motor nerve fiber transfers have been suggested for this purpose. More recently, sensate fiber protection has proven effective in this task, avoiding harm to motor donors.
The present study was designed to test whether through an easy dissection, the radial sensate dorsal branches to the 1st space were capable to reach in the palm the deep motor branch of the ulnar nerve to perform a comfortable coaptation. Moreover, a histomorphometric analysis was planned to show whether anatomical structures (diameter, cross-sectional area, number and density of fascicles and axons) of the donor sensate branches reached the standards proposed by the literature for efficient nerve transfer.
An anatomical study was undertaken on 16 fresh cadavers from the Anatomy Labs of Bordeaux and Thessaloniki Universities and from the International Center for Learning Orthopaedics in Arezzo (Italy). The study was approved by the Review Board for Anatomical Research of the Italian Association for Surgery of the Hand and by the Ethics Committee Academical Authorities. Through a careful subcutaneous dissection of the sensate radial nerve branches to the 1st web, the largest branch was cut at the metacarpal head level. A blunt dissection was then performed through the first interosseous muscle to reach on the volar aspect the terminal branches of the deep motor branch of the ulnar nerve, identifying this as the site for coaptation, whether in end-to-end or in reverse end-to side fashion. At this site, samples were taken from both the radial donor and the ulnar recipient nerve to perform histomorphometric analysis.
Nerve samples were fixed in glutaraldehyde 2.5% and processed to obtain semithin sections. Both qualitative and quantitative analysis were carried out on the specimens using a DM4000B microscope equipped with digital camera DFC320 and IM50 Image Manager System.
The expected donor-to recipient fiber count ratio to identify a successful nerve transfer is known as 1:3. A smaller diameter, as well as fascicular cross-sectional area, fewer fascicles and axons, and a smaller axon density were found in the donor radial sensate branch compared to the recipient ulnar nerve branch. However, a ratio of 1:5,7 was found, which identifies the sensate branches of the radial nerve as potential good fiber donors to the ulnar motor branch in the palm.
A-0965 Brachial plexus impingement secondary to ICD wires: A Case Report
Ishan Radotra 1, Natalie Jumper 1, N Campbell 2, Anuj Mishra 1
1 Department of Plastic and Reconstructive Surgery, University Hospital South Manchester NHS Foundation Trust, UK; 2 Department of Cardiology, University Hospital South Manchester NHS Foundation Trust, UK
Despite overall complication rates of 9.1% following implantable cardiac defibrillator (ICD) placement, brachial plexus injury is infrequently reported in the literature. We describe a 26-year-old female experiencing left arm pain, hand numbness and biceps weakness following revision ICD via subclavian vein approach. Nerve conduction studies identified severe partial left brachial plexopathy, which remained incompletely resolved after conservative management. Surgical exploration revealed lateral cord impingement by ICD loop fibrosis, necessitating neurolysis and ICD box repositioning. As increasing numbers of patients undergo cardiac device implantation, it is incumbent on practitioners to be aware of potential increases in the prevalence of this complication.
A-0971 Targeted Muscle Reinnervation of the Upper Extremity
Daniel Ruter, Joseph Meyerson, Ian Valerio
The Ohio State University College of Medicine Department of Plastic Surgery, USA
Objective: Approximately 40,000 Americans are living with a major upper extremity amputation. An estimated 5-25% develop painful neuromas and up to 67% experience phantom limb pain which can severely limit prosthetic tolerance and increase narcotic usage rates. Targeted muscle reinnervation (TMR) is a surgical procedure that reroutes transected peripheral nerves to the motor unit of freshly denervated muscle. First primarily utilized to improve myoelectric prosthetic signal generation, TMR has recently been advocated for the treatment of painful neuromas. Our group will report on the advantages of targeted muscle reinnervation performed at the time of index amputation rather than as previously reported mainly at delayed setting. Primary focus on neuroma prevention and prevalence of phantom limb pain will be highlighted.
Methods: A retrospective study of targeted muscle reinnervation performed on upper extremity amputees was performed. Data reviewed included reason for amputation, amputation level, patient age, postoperative neuroma and phantom limb pain rates, and time to prosthetic use.
Results: Thirteen patients with upper extremity amputations were identified (2 forequarter, 5 trans-humeral, 6 trans-radial). Oncologic resection and skeletal trauma were the most common indications for amputation. Only two patients had TMR performed secondarily, all others were concurrent with amputation. Ages ranged from 22-63 years old with average follow up of 13 months (range 1-29 months). None of the 13 patients developed a painful neuroma. Phantom limb pain rates at 1, 3, 6, and 12 months were 46%, 33%, 25%, and 20%. Six patients currently use a myoelectric prosthetic and three more are undergoing assessment and fitting. Average signal capture rates are greater than 96%.
Conclusion: Our data suggests that regardless of the cause of or level of amputation, upper extremity targeted muscle reinnervation prevents the formation of painful neuroma postoperatively compared to previous methods. Similarly, the prevalence of phantom limb is lower than reported rates in the literature and decreases precipitously over time. Throughout our entire cohort of targeted muscle reinnervation patients we have found significantly lower pain scores when compared to a control amputee population, leading to better tolerance of the prosthetic, and less narcotic use. In addition to the improved control of myoelectric prosthetics, the prevention of painful neuromas and reduction in phantom limb pain warrant the addition of targeted muscle reinnervation at the time of index amputation.
A-0996 Disparities in Treatment of Traumatic Nerve Injuries of the Upper Extremity
Abbas Peymani 1,2, Anna Rose Johnson 1, Samandar Dowlatshahi 1, Simon Strackee 2, Samuel Lin 1
1 Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; 2 Department of Plastic, Reconstructive and Hand Surgery, University of Amsterdam, Amsterdam, The Netherlands
Objective: Early recognition and treatment of traumatic upper extremity nerve injuries are paramount to optimize patient outcomes. Currently, a knowledge gap remains in regards to classification, distribution and variations in care delivery of nerve injuries treated in the emergency department (ED). The aim of this study is to evaluate racial, geographic and socioeconomic disparities in patients with upper extremity nerve injuries.
Methods: We used the National Trauma Data Bank to investigate the prevalence of upper extremity nerve injuries seen in the ED. Statistical analyses were performed to determine factors associated with longer emergency room wait times. Additionally, variations in hospital trauma level status were investigated.
Results: A total of 5742 patients with upper limb peripheral nerve injuries were identified. Patients had a mean age of 35.5 ± 17.8 and the majority were male (76.6%), Caucasian (56.3%) and had private insurance coverage (43.2%). Distribution of most commonly injured nerve in order of decreasing frequency included: ulnar (27.5%), radial (21.9%), median (19.9%) and digital nerves (19.4%). Average wait time in the ED was 249.2 minutes. Caucasians were more likely to have shorter ED waiting times compared to other racial groups (p<0.001). Level 1 Trauma Centers were associated with shorter ED waiting times (p<0.001). There was no association between insurance status and ED wait times.
Conclusion: There are existing racial variations in the treatment of traumatic upper extremity peripheral nerve injuries. Further studies are necessary to gain an increased understanding of these trends in order to ensure prompt recognition, eliminate dispsarities in care delivery and optimize patient outcomes.
A-1002 Restoration of the deltoid by nervous transfer of a triceps motor branch on the axillary nerve. Study of 19 patients.
Romain Detammaecker, Lionel Athlani, Yohan Kim De Almeida, Sandrine Huguet, Francois Dap, Gilles Dautel
Department of Hand Surgery, Plastic and Reconstructive Surgery. Centre Chirurgical Emile Gallé CHU, France
Objective : The transfer of a triceps motor branch to the anterior branch of the axillary nerve is a young technique that helps to restore one of the main function of the upper limb : shoulder abduction by deltoid reinnervation. The aim of the study was to evaluate, with a minimum of 2 years follow-up, the clinical, functional and professional outcomes and also to find out any prognostic factors of this nerve transfer in isolated axillary nerve lesions and in post-traumatic C5 C6 brachial plexus avulsion. Methods : This was a retrospective single-center study with 19 patients (17 men and 2 women) operated by 6 surgeons from 2007 to 2014. Their average age was 30 years. All had deltoid paralysis confirmed clinically and electromyographically, with an important functional disorder and triceps graded minimum M4+ (British Medical Research Council scoring). At last follow-up, we measured pain score by Analog Visual Scale, range of shoulder motion in abduction (ABD) and external rotation (RE1), strength (BMRC), donor site morbidity, presence of co-contraction, Disabilities of the Arm, Shoulder, and Hand (DASH) score and the feeling of satisfaction. We questioned the patient about their professional situation, before and after the surgery. A subgroup analysis was also performed. Results : The mean follow-up was 74 months. 11 patients suffered from isolated axillary lesion, usually post anterior shoulder dislocation (or iatrogenic for 1 case). 8 patients had C5 C6 brachial plexus avulsion. The operation was undertaken 9,3 months after injury. At last follow-up, shoulder abduction strength was graded M3 in 73% and M4 in 63% and the external rotation strength was graded M3 in 84% and M4 in 74% and M5 in 37%. Abduction recovery averaged 128° and external rotation (RE1) averaged 62°. No donor site deficit was observed. The mean EVA was 1,3. A strong fatigability was rated at 1,7/3 to the effort. The amyotrophy improved in 79% of the cases to reach a minimum of 50% of the opposite side deltoid. The average DASH score was 28. 9 patients kept the same job. 7 needed a working reconversion. There were 14 good and excellent results. Conclusions : This study shows good outcomes in term of deltoid strength and shoulder range of motion, as good as those found in the literature in nerve transfer of one motor branch of the triceps to the anterior branch of the axillary nerve. The proposed nerve transfer constitutes a valid strategy in C5 C6 brachial plexus lesions but also in isolated axillary nerve lesions. The delay of surgery appears to be one of the most important prognostic factors. The addition of a second transfer from the accessory spinal nerve to the suprascapular nerve improves clinical and functional outcomes in C5 C6 lésions. The evaluation of the rotator cuff, before and after the surgery should also be done to improve our clinical outcomes.
A-1006 Use of intercostal nerves in treatment of complete brachial plexus palsy
Mikhail Novikov, Timur Torno, Andrey Fedorov, Armen Karapetyan
N. Solovjov’s Emergency Medicine Hospital and Yaroslavl State Children’s Hospital, Yaroslavl, Russia
In cases of complete brachial plexus palsy (BPP) with multiple spinal nerve avulsions extraplexal nerve transfers to selected targets is the only means to obtain useful function of the involved upper extremity. The Intercostal nerve (ICN) is a well-known donor for brachial plexus (BP) reconstructions. However, there are some controversies concerning the indications and different technique versions.
Forty-eight patients with BPP underwent ICN transfers in our center (40 adults and 8 children). ICN transfers to the musculocutaneous (MC) nerve or its branches were performed in 37 cases. In 11 cases ICN were used for neurotization of free gracilis muscle transfer. In all cases only direct coaptations of ICNs and recipient nerves were used. The number of ICNs used depends on the target: main MC – 5 (adults) and 3 (children), branch MC to the biceps – 3(adults) and 2 (children), nerve of free gracilis muscle – 3 and 2.
Branches of MC to brachialis muscle previously neurotized by ICNs were utilized in 5 patients with free gracilis muscle transfer.
In our series only 4 (8%) patients did not obtain useful function after ICNs transfers. In 44 (92%) cases patients received sufficient muscle power M3-M4 (MRC).
Our favorite method for complete BPP with multiple avulsions is the transfer of five ICNs to the main trunk of MC for reinnervation of both biceps and brachialis muscles followed by the use of the nerve branch to the brachialis muscle for free gracilis muscle transfer for finger flexion or wrist extension.
A-1009 Treatment for Patients with Radial Nerve Palsy showing the Distraction of Fracture Gap in Transverse Humeral Shaft Fracture
Young Ho Lee 1, Jung Eun Lee 2, Jihyeung Kim 1, Hyun Sik Gong 3, Goo Hyun Baek 1
1 Seoul National University Hospital, Seoul, South Korea; 2 Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea; 3 Seoul National University Bundang Hospital, Gyeonggi-do, South Korea
Introduction: Radial nerve palsy associated with humeral shaft fracture(HSF) is known to be the most common nerve lesion complicating long bone fractures. Although there have been some studies on the treatment and prognosis of the radial nerve palsy, but it is still controversial. Most of the patients were recovered without surgery, but there is some consensus of early surgical exploration of radial nerve concomitant internal fixation in HSF with radial nerve palsy after high energy trauma, open fractures or accompanying vascular injury. This study is to investigate clinical outcomes and prognosis of radial nerve palsy with transverse HSF showing distraction of fracture gap.
Method: We retrospectively reviewed total 10 cases of the HSF patients who had radial nerve palsy immediately after trauma or who were transferred from other hospital for the same diagnosis from January 2001 to December 2014. All the cases were treated by open reduction and internal fixation with plate and screws, and radial nerves were explored under microscopy. There were 7 men and 3 women, and the mean age at the surgery was 32 years. The follow-up was more than 2 years and most common mechanisms of injury were traffic accidents.
Results: Every fracture was transverse middle or middle-distal shaft of the humerus in all 10 patients. Mean distraction gap on initial or preoperative radiograph was 9 mm (range, 5 - 31 mm). Distracted-segmental injury of radial nerve was detected in all radial nerve exploration, and mean size of nerve defect was 10cm (range, 9-12cm). All injured nerves were treated with autologous sural nerve graft and all fractures were treated with plate. In every case, bone union was achieved, Recovery of motor function was 8 cases of M5 and 2 cases of M4 after nerve graft.
Conclusion: In case of radial nerve palsy accompanying HSF with distracted fracture gap, there is a possibility of complete transection or long-segmental injury of radial nerve. Therefore, early exploration of radial nerve is recommended, and consider preparing for simultaneous nerve graft due to distracted-segmental injury of radial nerve.
A-1023 Isolated flexor pollicis longus nerve fascicle injury - a rare differential diagnosis of thumb flexion deficiency
Andreas Gohritz, Jan Fridén
Hand Surgery, Swiss Paraplegia Center, Nottwil, Switzerland
Loss of pinch power and thumb flexion can be caused by many traumatic or atraumatic origins, most frequently by carpal tunnel syndrome, flexor tendon injuries or anterior interosseous nerve (AIN) compression. A rare, but relevant differential diagnosis is an isolated flexor pollicis longus (FPL) nerve fascicle lesion.
The objective of this paper is to illustrate this phenomenon with a clinical case and provide a discussion of its anatomical, clinical background and differential diagnosis of incomplete AIN syndrome in the literature.
We present a 42-year-old otherwise healthy female patient who developed a weak thumb-to-index pinch and deficient right thumb flexion following the removal of osteosynthesis plates after a forearm fracture. Clinically,the flexor pollicis longus function was absent, yet index flexion and sensibility were unimpaired. Tendon rupture was excluded using a tenodesis test and the electro-physiological result of isolated interosseus nerve fascicle lesion was confirmed intraoperatively by inspection and electrostimulation. Tendon transfer using the extensor carpi radialis longus reconstruct strong thumb flexion during pinch.
In conclusion, due to its specific location and anatomy, the FPL branch is more prone to isolated neuropathy, e.g. by injections or operations, than to other fascicles of the anterior interosseus nerve. When confronted with sudden and isolated thumb flexion deficiency, specialists should be aware of this rare phenomenon.
A-1055 Nerve wrapping using cephalic and basilica vein for treatment of recurrent chronic nerve scarring of median nerve
Humanitas-Gavazzeni Institute, Bergamo, Italy
We report our experience with cephalic or basilic vein wrapped around scarred median nerve.
From 2008 from 2016 we reviewed vein wrapping for 15 median nerves. The autologous vein graft was harvested in the omolateral arm incided longitudinally and wrapped around the nerve scarring with the intima of the graft against the nerve. 11 cephalic veins and 4 basilica veins were harvested. Each patient underwent subjective and objective evaluations, VAS scale, and Semmes Weinstein test.
We report excellent results on median nerve with decrease of pain in 12 cases within 5-20 days, 2 within 2 months and 1 after 10 months with important decrease of VAS from 7-9 to 0-1.The Semmes -Weinstein test showed in 10 cases recovery of complete sensibility at the end of follow up, while 5 patients showed decrease of sensibility, respectively 3 of superficial, 2 of protective sensibility.
Wide neurolysis is always performed; no immobilization was applied encouraging early mobilization. 1 infection was observed; no defects in the donor area were observed
Among several techniques, vascularized or free flaps, lipofilling, synthetic interposition, vein wrapping represents a reliable option: use of a vein of the same arm instead of saphenous vein as classically used, is surely less invasive for patients with a good coverage of scarred nerve, especially for big nerves. This technique is recommended mainly for treatment of recalcitrant nerve compression.
A-1060 Management of shoulder internal rotation limitation in obstetrical palsy.
Atakan Aydin 1, Safiye Özkan 1, Zeynep Hoşbay 2
1 Istanbul Medical Faculty, Istanbul, Turkey; 2 Bezmialem Vakif University, Istanbul, Turkey
Objective: Muscle imbalance in a growing child can lead to bone and joint deformities. Obstetric palsy patients with incomplete recovery have glenohumeral joınt problems because of imbalance between shoulder adductor and internal rotator(IR) muscles & abductor external rotatuar(ER) muscles.
Although shoulder internal rotation concracture preventing shoulder abduction and external rotation in the most common problem in obstetric palsy patients with partial recovery ; shoulder internal rotation limitation or external rotational conctacture is a worse condition preventing hand to belly and back functions hence limiting daily activities.
An obstetric palsy child could have both shoulder external and internal rotation limitations and contractures at the same time.It is hard to explain this condition with muscles imbalance theory which is adductor and internal rotatory muscles are often out of balance with the abductor and external rotator muscle forces. May be, at incomplete recovery with C5,6,7 involvement, in every muscle unit, stem cells are differantiating to sarcomers which are short and less functioning causing contractures.
Since to improve shoulder abduction and ER, tendon transfers are commonly used ,postoperative transient loss in internal rotation is expected. But some patients could not get preoperative IR functions , long after the operations. Also there are some nonoperated patients whose main problem is internal rotation limitations. We operated on these two group of patients to achieve better internal rotation function.
Method: Fourteen patients had operation to improve shoulder ER and Abduction 3 years ago. Although their Abd and ER degrees improved dramatically; two years after the operation they had internal rotation limitation despite vigorous physiotheraphy. 15 patients did not have neither nerve nor palliative any operation before and had IR limitations preoperatively. During operation, posterior incision above spine of the scapula was performed, supraspinatus, infraspinatus and teres minor muscles ,and acromion bone were encountered. The intraoperative observationwas not only heavily scarred muscle fascias which needed relaxation but also shortenned external rotator muscles which needed release and lateralization with V-Y fashion so that passive shoulder internal rotation movements were possible. We did not cast or use orthosis for the patients postoperatively. At 3rd day postoperative rehabilitation program ,active range of motion exercises were initiated. All cases were evaluated by using range of motion measurement and Mallet scale.
Results: Average age of the children was 6,3 years and The average followup period was 21 months. The preoperative values in terms of IR were 2º and postoperatively 20º. Degree of abduction was mean 136 before the surgery. After surgery, it decreased to 105º but with theraphy it catched up preoperative values. Degree of external rotation value was mean 85º preoperatively. After the treatment, the external rotation value was measured 66,2º. The mean Mallet score improved from 18 preoperatively to 20 postoperatively.
Conclusion: Although shoulder abduction, ER problems are far more common in obstetrical palsy patients, there a group of patients which had internal rotation limitations either occured spontaneously or surgically. Facing with the reality we operated on these patients to achieve better hand to midline and back functions.
A-1063 Psychosocial assessment procedure for bionic reconstruction in patients with global brachial plexus injuries
Anna Pittermann 1 2, Laura Hruby 2, Agnes Sturma 2 3, Oskar C. Aszmann 2
1 General Hospital Vienna, Austria
2 Medical University Vienna, Austria
3 University of Applied Sciences FH Campus, Vienna, austria
Global brachial plexopathies cause major sensory and motor deficits in the affected arm and hand and lead to numerous psychosocial consequences including chronic pain, decreased self-sufficiency, and poor body image. Bionic reconstruction, which includes the amputation of the functionless limb, has been shown to restore hand function in patients where classic reconstructions have failed. Patient selection and psychological evaluation before such a life-changing procedure are crucial for optimal functional outcomes. Here we introduce a standardized psychological assessment procedure for bionic reconstruction in patients with complete brachial plexopathies.
Method: Between 2013 and 2017 psychosocial assessments were performed in eight patients with global brachial plexopathies. We conducted a semi-structured interview exploring the psychosocial adjustment related to the accident, the overall psychosocial status, as well as motivational aspects related to an anticipated amputation and expectations of functional prosthetic outcome. The interview was augmented by quantitative evaluation of self-reported mental health and social functioning, body image and deafferentation pain (VAS). Finally, the effect of bionic reconstruction on these parameters was analyzed over time.
Results: Qualitative data revealed several psychological stressors with long-term negative effects on patients with complete brachial plexopathies. After bionic reconstruction the physical component summary scale increased from 30,80 ± 5,31 to 37,37 ± 8,41 (p-value = 0,028), the mental component summary scale improved from 43,19 ± 8,32 to 54,76 ± 6,78 (p-value = 0,018). VAS scores indicative of deafferentation pain improved from 7,8 to 5,6 after prosthetic hand replacement (p-value = 0,018).
Conclusions: Bionic reconstruction provides hope for patients with complete brachial plexopathies, improves overall quality of life and reduces deafferentiation pain. Critical patient selection is crucial since high levels of adherence and compliance to a stringent prosthetic rehabilitation protocol determine optimal functional outcomes.
A-1092 Iatrogenic injuries of the radial nerve – a frequent problem?
Richarda Boettcher, Ulrike Schnick
Unit for reconstructive Surgery in Brachial Plexus Injuries, Tetraplegia and Cerebral Disorders, Department for Hand-, Replantation- and Microsurgery, Unfallkrankenhaus, Berlin
The risk of iatrogenic nerve lesions associated to surgical treatment is not clearly quantified. For the radial nerve a frequency up to 10% according to fixation of a humeral fracture seems to be likely. In 25% of all radial nerve lesions including primary appearance a complete reinnervation will not spontaneously occur. The study aims to define the effect of consequent diagnostic and surgical improvement on the functional result.
In a retrospective analysis all surgical treated patients between 01/2010 and 11/2017 with lesions of the radial nerve were identified. All cases with isolated lesions of the superficial sensory branch and all cases with compartment syndrome were excluded for the analysis. 89 patients received neurolysis, direct microsurgical repair, repair with grafts or muscle transfers. These cases were analyzed to define the rate of iatrogenic lesions according to the anatomical level, to identify risk factors for iatrogenic complications and to allow a statement concerning treatment and outcome.
48 lesions of the radial nerve at the axillary region and upper arm were treated surgically. Under them 20 (42%) lesions occurred according to further surgical treatment. Main causing procedures were intramedullary nail fixation, plate fixation and prosthesis of the shoulder. At the lower arm level including radial head 42 lesions of the deep motor branch were operated, among them 12 cases with clear iatrogenic cause. In this area plate fixation or removal were common reasons. Three cases showed previous radial head surgery. Previous schwannoma or lipoma resection was etiological in three cases. Treatment strategies were muscle transfers in 13 cases with good results and one missing follow- up. Isolated neurolysis, in some cases combined with correction of implants, showed reinnervation in all 10 cases, while two more cases were lost for follow-up. In 6 cases with microsurgical reconstruction by graft the result showed 1 missing reinnervation, 4 good results and 1 missing follow-up. For all 32 cases of iatrogenic radial nerve lesions 25 good results with functional benefit good be achieved. For two patients with additional palsies no changing of the findings was possible. In three cases the long term result is unknown.
The summarized results show a high probability to improve reinnervation or functional outcome by surgical treatment. Patients with an evidence for structural nerve lesions after surgical treatment should be revised early with an option for all different treatment methods. With this postulate permanent radial palsies following surgical treatment can be avoided better than by “wait and see”. Furthermore a better awareness of the endangered radial nerve in different surgical procedures might be reachable by interdisciplinary co-working and better instruction
A-1112 Tensegrity in the common digital nerves: A cadaveric pilot for the STRAIN study
Isabel Guy 1, Daniel Guerero 1, Manish Gupta 2, Petros Mikalef 2, Dominic Power 2,3
1 Birmingham University, UK; 2 Birmingham Hand Centre, UK; 3 Institute for Translational Medicine, UK
Tensegrity is an inherent property of biological tissues. Following nerve transection a nerve gap results and repair with microsurgical sutures may result in ischaemia, fascicle distortion and intrinsic scar formation as a result of stress concentration around sutures. A delay to repair results in a greater modulus of elasticity for a nerve. The increased strain is partially mitigated by creep, however it remains higher than for a fresh repair. Techniques to reduce tension at repair sites have been widely adopted, however little clinical evidence exists for increased neural regeneration. This cadaveric pilot study examines the effect of tensegrity on nerve gap after transection and evaluates different repair techniques using a validated grading tool and provides evidence to support the development of the STRAIN protocol for a prospective study of tension alleviation using allograft in acute nerve repair.
A workshop was conducted using fresh frozen cadaveric upper limbs. The procedures were completed by consultant hand surgeons. The common digital nerves (CDN) to the 2nd, 3rd and 4th webspace were transected proximal to the distal palmar crease. The digits were cycled through 5 flexion and extension arcs and the resulting nerve gaps were noted. Repairs were completed using microsurgical suture techniques, allograft interposition suture to fill the gap or using collagen connector assisted repairs. The quality of repair was graded by the operator and the study team. The repair sites were then repeatedly cycled through a full range of flexion and extension. Disruptions at the repair site were noted and the repair was regraded following the mobilisation.
Twenty-four CDNs were studied. The mean gap for the 2nd CDN was 6.4mm (range 2.7-9mm), 3rd CDN 6.1mm (range 3.5-9) and 4th CDN 5.3 (range 3-9). The grading of the repair was best in the epineural group. Allograft repair was better in quality than the connector assisted repair. Following repeated cycling of the repairs there was no change in repair quality in the epieneural or connector-assisted repair groups. There was one downgrading from good to fair in the allograft repair group. There were no repair ruptures.
Epineural repair was consistently performed with a higher grade than for connector-assisted and allograft interposition repairs. This is likely to represent the past experience of the operators and the relative inexperience of the de-tensioning techniques. The learning curve for these techniques needs to be established for any future studies in order to standardise repair quality. The repeated cycling of the repairs resulted in no dehiscence at any repair site. The effects of tension on neural regeneration and clinical outcome will be examined in the STRAIN trial.
A-1116 Scapulothoracic Dissociation with Floating Elbow in a Patient
Ahmet Savran 1, Kubilay Erol 2, Levent Kucuk 2, Erhan Coskunol 2
1 Katip Celebi University Ataturk Research and Training Hospital, Izmir, Turkey; 2 Ege University Medical Faculty Hospital, Izmir, Turkey
Scapulothoracic dissociation is a rare and mortal condition of "closed forequarter amputation". And it is usually associated with multiple trauma. In this case report ve present a 22 years old female patient with motor vehicle accident. Unconscious patient with Glaskow Score of E1M1V1 is intubated at emergency department. Humerus shaft fracture and forearm both bone fracture is seen at X-rays. Extravasation from subclavian artery is determined at CT-Angiography and endovascular embolisation is done. Emergent cardiovascular surgery for subclavian artery repair is perform and exploration of brachial plexus showed total avulsion of all roots. After fasciotomy and temporary stabilization of fractures with splinting, patient is followed at intensive care unit for two days. But exits of the patient is confirmed at the postoperative second day.
Scapulothoracic dissociation is a rare but mortal condition. Prognosis depends on nerve injury and associated injuries.