To maximize outcome in nerve transfers: 1- The recipient nerve reinnervated close to the target muscle. 2- Direct repair without intervening grafts. 3- Similarly behaving neuromuscular units (agonistic donors and recipients)

1. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Predictors of Patients’ Functional Outcome after Motor Nerve Transfers
in Management of Paralytic Hand. A Prospective Observational Study
Asser Sallam, Mohamed El-Deeb, Mohamed Imam
Presented by
Professor M. A. Imam
MD, MSc (Orth)(Hons), D.SportMed, Ph.D., FRCS (Tr. and Orth.)
Consultant Trauma and Upper Limb Surgeon, Rowley Bristow Orthopaedic Unit, Chertsey
Professor and MD, Smart Health Academic Unit, University of East London, London, UK
Email: Info@theArmDoc.co.uk
www.TheArmDoc.co.uk
@MoAImam

2. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University

3. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Nerve transfers
• are increasingly used as an alternative
• Numerous factors contribute to patient’s
outcome such as age, BMI, technical skills and
strategies of the surgeon
• Hsiao EC, et al.: Hand, 2009
• Novak CB, Mackinnon SE.: J Recn
Microsurg, 2002
• Ray WZ, Mackinnon SE. J Hand Surg, 2011
• Lee JY, et al.: J Hand Surg, 2012
Background

4. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
To maximize outcome in nerve transfers:
1- The recipient nerve reinnervated close to the
target muscle.
2- Direct repair without intervening grafts.
3- Similarly behaving neuromuscular units
(agonistic donors and recepients)
Background

5. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
To identify the factors that influence the
functional outcome of motor nerve
transfers in complete isolated high
injuries of median, ulnar or radial
nerves.
Aim of the Study

6. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
• Prospective single center study
• N = 55
• > 6 months (between January 2010 and June 2013)
• Study protocol, patients’ consent and information sheet are
approved by the higher ethical committee in our institute.
Radial nerve
(21 Patients, 38,18%)
Median nerve
(12 Patients, 21,82%)
Ulnar nerve
(22 Patients, 40%)
Patients and Methods

7. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Mean F/U: 14.4 (12-18) months
Radial nerve à Wrist/digit extension
Median nerve à Pronation, thumb opposition, finger flexion
Ulnar nerve à Intrinsic hand movements
• Muscle power by modified MRC scale.
• Pinch/grip strength.
Outcome assessment

8. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
AIN à deep motor branch of ulnar Nerve (Intrnisics)
Ulnar Nerve
Radial Nerve
Median nerve branch to FCR/PL à PIN (Finger extension)
Median nerve branch to FDS à ECRB branch (Wrist extension)
Median Nerve
Ulnar nerve branch to FCU à AIN (Finger flexion)
Radial nerve branch to ECRB à branch to Pronator teres (Forearm pronation)
Tension free end-to-end repair
Surgical Technique

9. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
• A 30 years old male patient presented with iatrogenic Rt radial
nerve palsy 8 months after humerus fixation.
Scar of the anterolateral approach X-ray of Humerus, AP and Lat. views
Cases Presentation

10. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Drop Hand
Cases Presentation

11. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Median nerve
Branch to palmaris longus
Branch to FDS
Identified with electrostimulation

12. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Branch to ECRB
PIN
Superficial radial nerve
Radial nerve

13. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Branch to ECRB
Branch to FDS

14. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University

15. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
After 1 year postoperative
Cases Presentation

16. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
• A 42 years old male patient presented with non-united fracture Lt ulna
and Lt ulnar nerve palsy 10 months after cutting wound in proximal
forearm
Wound scar
Claw hand
X-ray of the ulnar fracture
Cases Presentation

17. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Ulnar nerve
Dorsal cutaneous nerve

18. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Ulnar nerve
Superficial sensory branch
Deep motor branch

19. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
AIN
Pronator Quadratus

20. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Deep motor branch
of ulnar nerve
AIN

21. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Repair site

22. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
6 months after OP
Cases Presentation

23. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
6 months after OP
Cases Presentation

24. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Post-operative MRC functional scale
Results
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Good (M4) Satisfactory (M3) Moderate (M2) Bad (M0 - M1)
28.6%
47.6%
4.8%
19.0%
18.2%
54.5%
4.5%
22.7%
16.7%
50.0%
0.0%
33.3%
%
of
patients
MRC Muscle power grading
Wrist extensors Intrinsic Muscles Finger flexors

25. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Results
Mean of strength loss
Functional recovery p-value
(t-test)
Useful Non-useful
Radial nerve
Grip strength 37 ± 2.2 71.5 ± 23.2 < 0.001
Tip pinch 38 ± 2.4 77.5 ± 13.9 < 0.001
Palmar pinch 38 ± 2.1 77.6 ± 14.1 < 0.001
Key pinch 38 ± 2.6 77.4 ± 13.9 < 0.001
Ulnar nerve
Grip strength 36.7 ± 2.6 67.9 ± 21.4 < 0.001
Tip pinch 37.2 ± 2.2 65.9 ± 20.1 < 0.001
Palmar pinch 36.9 ±2.4 66.9 ± 21.2 < 0.001
Key pinch 37 ± 2.1 65.9 ± 18.4 < 0.001
Median nerve
Grip strength 49.9 ± 4.6 82.7 ± 8.8 < 0.001
Tip pinch 44.4 ± 3.4 81.7 ± 8.7 < 0.001
Palmar pinch 43.6 ± 3.8 80.7 ± 8.6 < 0.001
Key pinch 44.7 ± 4.2 82.2 ± 8.7 < 0.001
* Adjusted means for age, sex and hand dominance
Table 1: Adjusted* means of grip and pinch strengths loss for the useful and non-useful
functional recovery population

26. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
0%
10%
20%
30%
40%
50%
60%
70%
80%
Yes No
76.2%
23.8%
72.7%
27.3%
66.7%
33.3%
Percentage
of
patients
Return to pre-injury work
Radial nerve Ulnar nerve Median nerve
Distribution of patients according to return to work
Results

27. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Predictor OR 95% CI p-value
Affected dominant hand 0.167 0.09 - 0.31 <0.001
Compliance to hand therapy 15.58 3.71 - 65.53 <0.001
Educational level 0.167 0.05 – 0.61 0.004
Occupation 1.56 0.45 - 5.35 0.09
Gender 2.37 0.71 - 7.97 0.16
Age 0.01 0.00 – 0.02 <0.001
Injury-surgery interval 0.06 0.03 - 0.08 <0.001
BMI* 0.05 0.03 - 0.08 <0.001
* BMI; Body Mass Index
Table 2: Predictors for useful functional recovery
No statistically significant relationship between mechanism of injury (p >0.05) and useful functional
recovery

28. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Results
0
10
20
30
40
50
60
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5
Age
of
the
patients
(yr)
MRC grades of radial innervated muscles
Radial nerve Ulnar nerve Median nerve
Linear (Radial nerve) Linear (Ulnar nerve) Linear (Median nerve)
Fig. 1: The relationship between strength of radial, ulnar and median innervated muscles and age of the
patient (Rho = -0.483, P = 0.027, Rho = -0.565, P = 0.006 and Rho = -0.769, P = 0.003, respectively)
Inverse relationship

29. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
0
10
20
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5
Interval
between
injury
and
surgery
(mo)
MRC grades of radial innervated muscles
Radial nerve Ulnar nerve Median nerve
Linear (Radial nerve) Linear (Ulnar nerve) Linear (Median nerve)
Inverse relationship
Results
Fig. 2: The relationship between strength of radial, ulnar and median innervated muscles and interval
between injury and surgery (Rho = -0.676, P = 0.001, Rho = -0.628, P = 0.002 and Rho = -0.668, P =
0.018, respectively)

30. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
15
20
25
30
35
40
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5
BMI
of
the
patients
(kg/m2)
MRC grades of radial innervated muscles
Radial nerve Ulnar nerve Median nerve
Linear (Radial nerve) Linear (Ulnar nerve) Linear (Median nerve)
Fig. 3: The relationship between strength of radial, ulnar and median innervated muscles and BMI of
the patient (Rho = -0.683, P = 0.001, Rho = -0.713, P = 0.000 and Rho = -0.721, P = 0.008)
Inverse relationship

31. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
We recommend a cautious prognosis when
considering nerve transfer in
• Older age groups,
• Obese patients and
• Delayed presentations of more than 10 months.
The education levels significantly associated with
good outcomes.
No association between gender, occupation and
mechanism of injury with useful functional
recovery.
Conclusion

32. SC
Orthopedic Surgery Department
Faculty of Medicine
Suez Canal University
Thank You
Questions?
Suez Canal University Hospitals