A UNIQUE DISTAL NERVE TRANSFER FOR RECONSTRUCTION AND FUNCTIONAL RESTORATION OF THE THENAR BRANCH IN A HIGH MEDIAN NERVE LESION
Keywords:
Distal nerve transfer, High median nerve injury, Peripheral nerve reconstrunction, Thenar muscle reinervation, Hand function restavrationAbstract
This article illustrates reinnervation of thenar muscles following high median nerve injury using fascicles from the deep branch of the ulnar nerve. We present a 30-year-old male with a history of open humeral fracture, soft tissue defect and total division of the median nerve. Six months after bone and soft tissue reconstruction, the median nerve was reconstructed at midarm level with sural nerve cable grafts. Immediate restoration of FPL and index finger FDP function was achieved using brachioradialis tendon transfer and side-to-side tenorrhaphy to the ring finger FDP. The thenar branch of the median nerve was reconstructed with 2.5 cm nerve graft using fascicle group from abductor digiti minimi. Pre- and postoperative nerve function was evaluated electroneurographically, with quantitative sensory-motor testing, photo- and video-documentation. Modified Bishop Rating Scale was used for endpoint analysis 18 months postoperatively. Early electroneurographic evaluations revealed clear evidence of innervation of thenar muscle targets by ulnar nerve axons. The abductor digiti minimi showed signs of chronic denervation. At 18-months, two-point discrimination was 4 mm for the little finger and 8 mm for the index and thumb, the middle finger not regaining this capacity. Pinch- and power grip strength reached mean values of 64% and 38%, respectively, compared to the unaffected hand. The presented data validates that fascicles from the deep branch of the ulnar nerve provide sufficient axonal power for challenging median nerve targets at early post-reconstruction, offering valuable window of opportunity in high or late median nerve reconstruction.
References
Pfaeffle HJ, Waitayawinyu T, Trumble TE. Ulnar nerve laceration and repair. Hand Clin 2007; 23(3): 291-299. doi: 10.1016/j.hcl.2007.06.003.
Secer HI, Daneyemez M, Gonul E, Izci Y. Surgical repair of ulnar nerve lesions caused by gunshot and shrapnel: results in 407 lesions. J Neurosurg 2007; 107(4): 776-783. doi: 10.3171/JNS-07/10/0776.
Terzis JK, Kokkalis ZT. Outcomes of secondary reconstruction of ulnar nerve lesions: our experience. Plast Reconstr Surg 2008; 122(4): 1100-1110. doi: 10.1097/PRS. 0b013e3181858f67.
Gesslbauer B, Hruby LA, Roche AD, Farina D, Blumer R, Aszmann OC. Axonal components of nerves innervating the human arm. Ann Neurol 2017; 82(3): 396-408. doi: 10.1002/ana.25018.
Vernadakis AJ, Humphreys DB, Mackinnon SE. Distal anterior interosseous nerve in the recurrent motor branch graft for reconstruction of a median nerve neuroma-in-continuity. J ReconstrMicrosurg 2004; 20(1): 7-11. doi: 10.1055/s-2004-818043.
Frank K, Englbrecht M, Koban KC, Cotofana SC, Stewart JK, Giunta RE, et al. Nerve transfer of the anterior interosseous nerve to the thenar branch of the median nerve - an anatomical and histological analysis. J PlastReconstrAesthet Surg 2019; 72(5): 751-758. doi: 10.1016/j.bjps.2018.12.017.
Feinstein B, Lindegard B, Nyman E, Wohlfart G. Morphologic studies of motor units in normal human muscles. ActaAnat (Basel) 1955; 23(2): 127-142. doi: 10.1159/ 000140989.
Terzis JK, Tzafetta K. "Babysitter" procedure with concomitant muscle transfer in facial paralysis. PlastReconstr Surg 2009; 124(4): 1142-1156. doi: 10.1097/PRS. 0b013e3181b2b8bc.
DeSmet L. Anterior interosseous nerve transfer to the motor branch of the ulnar nerve: a case report. Eur J PlastSurg 2005; 28(8): 523-524. Available from: http://link.springer.com/10.1007/s00238-005-0010-5.
Haase SC, Chung KC. Anterior interosseous nerve transfer to the motor branch of the ulnar nerve for high ulnar nerve injuries. Ann PlastSurg 2002; 49(3): 285-290. doi: 10.1097/00000637-200209000-00008.
Battiston B, Lanzetta M. Reconstruction of high ulnar nerve lesions by distal double median to ulnar nerve transfer. J Hand Surg Am 1999; 24(6): 1185-1191. doi: 10.1053/jhsu.1999.1185.
Wood MB, Murray PM. Heterotopic nerve transfers: recent trends with expanding indication. J Hand Surg Am 2007; 32(3): 397-408. doi: 10.1016/j.jhsa.2006.12.012.
Mersa B, Tiangco DA, Terzis JK. Efficacy of the “baby-sitter” procedure after prolonged denervation. J ReconstrMicrosurg 2000; 16(1):27-35. doi: 10.1055/s-2000-7538.
Hadlock T, Sheahan T, Heaton J, Sundback C, Mackinnon S, Cheney M. Baiting the cross-face nerve graft with temporary hypoglossal hookup. Arch Facial PlastSurg 2004; 6(4): 228-233. doi: 10.1001/archfaci.6.4.228.
Lee EI, Hurvitz KA, Evans GRD, Wirth GA. Cross-facial nerve graft: past and present. J Plast Reconstr Aesthet Surg 2008; 61(3): 250-256. doi: 10.1016/j.bjps.2007. 05.016.
Mackinnon S, Dellon A. Surgery of the peripheral nerve. 1st ed. New York: Thieme Medical Publishers; 1988.
Siemionow M, Brzezicki G. Chapter 8: Current techniques and concepts in peripheral nerve repair. Int Rev Neurobiol 2009; 87: 141-172. doi: 10.1016/S0074-7742(09) 87008-6.
Vastamäki M, Kallio PK, Solonen KA. The results of secondary microsurgical repair of ulnar nerve injury. J Hand Surg Br 1993; 18(3): 323-326. doi: 10.1016/0266-7681(93)90053-i.
Ruijs ACJ, Jaquet J-B, Kalmijn S, Giele H, Hovius SER. Median and ulnar nerve injuries: a meta-analysis of predictors of motor and sensory recovery after modern microsurgical nerve repair. PlastReconstrSurg 2005; 116(2): 484-494; discussion 495-496. doi: 10.1097/01.prs.0000172896.86594.07.
Gaul JS. Intrinsic motor recovery-a long-term study of ulnar nerve repair. J Hand Surg Am 1982; 7(5): 502-508. doi: 10.1016/s0363-5023(82)80048-8.
Brown JM, Mackinnon SE. Nerve transfers in the forearm and hand. Hand Clin 2008; 24(4): 319-340. doi: 10.1016/j.hcl.2008.08.002.
Mackinnon SE, Colbert SH. Nerve transfers in the hand and upper extremity surgery. Tech Hand Up ExtremSurg 2008; 12(1): 20-33. doi: 10.1097/BTH.0b013e31812714f3.
Papakonstantinou KC, Kamin E, Terzis JK. Muscle preservation by prolonged sensory protection. J ReconstrMicrosurg; 18(3): 173-182; discussion 183-184. doi: 10.1055/s-2002-28469.
Bölükbasι, O., Turgut, M. & Akyol, A. Ulnar to median nerve anastomosis in the palm (Riches-Cannieu anastomosis). Neurosurg Rev 22, 138–139 (1999). https://doi.org/10.1007/s101430050049
Ray WZ, Mackinnon SE. Management of nerve gaps: Autografts, allografts, nerve transfers, and end-to-side neurorrhaphy. ExpNeurol 2010; 223(1): 77-85. doi: 10.1016/j.expneurol.2009.03.031.
Beris AE, Lykissas MG. Chapter 13: Experimental results in end-to-side neurorrhaphy. Int Rev Neurobiol 2009; 87: 269-279. doi: 10.1016/S0074-7742(09)87013-X.
Bontioti E, Dahlin LB. Chapter 12: Mechanisms underlying the end-to-side nerve regeneration. Int Rev Neurobiol 2009; 87: 251-268. doi: 10.1016/S0074-7742(09)87012-8.
Geuna S, Papalia I, Tos P. End-to-side (terminolateral) nerve regeneration: a challenge for neuroscientists coming from an intriguing nerve repair concept. Brain Res Rev 2006; 52(2): 381-388. doi: 10.1016/j.brainresrev.2006.05.002.
Tos P, Artiaco S, Papalia I, Marcoccio I, Geuna S, Battiston B. Chapter 14: End-to-side nerve regeneration: from the laboratory bench to clinical applications. Int Rev Neurobiol 2009; 87: 281-294. doi: 10.1016/S0074-7742(09)87014-1.
Brenner MJ, Dvali L, Hunter DA, Myckatyn TM, Mackinnon SE. Motor neuron regeneration through end-to-side repairs is a function of donor nerve axotomy. PlastReconstrSurg 2007; 120(1): 215-223. doi: 10.1097/01.prs.0000264094.06272.67.
Pannucci C, Myckatyn TM, Mackinnon SE, Hayashi A. End-to-side nerve repair: review of the literature. RestorNeurolNeurosci 2007; 25(1): 45-63. PMID: 17473395. http://www.ncbi.nlm.nih.gov/pubmed/17473395.
