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A-1282 Peripheral nerve repair; the conduit option and management of end neuroma's
Tahseen Chaudhry, UK
Wednesday, June 13, 2018 · 1:19 p.m. · 23m 28s
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toss in charge of the um can some hand in person assertions basin bunyan same uh
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department is a tonic and i'm just gonna developing some within the doughnuts would
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spoke about um and hopefully just hang down into the contract option
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and see how that actually fits into some these concepts that we talked about so i do that
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like to come to some sort of a an idea about how complex fits into the
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the overall scheme of things and then secondarily i'll go on to speak about the management of
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engineering is very briefly and talk about a car that we're involved with um with that
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so just a touch again on the fact that um what attentions never that cannot be achieved because of a cap
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um i don't suppose nerve graft remains the gold standard and i think that
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that remains the case despite a number devices that of a paid
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and and i'm grainy gaining um increase nice but all this that perform uh any
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form of net surgeon if used nerve graft uh realise of course that
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um the technique has its downside including dan mobility a limited supply extra circle time and of
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course the results are not always as as good as you like a them to be
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when looking for a subject for have cost it would do well to look back at
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macy's original a definition was ninety one of coughed should um have its properties
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uh and there's a list he really that's essentially what something which is uh as a close
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mechanically and biologically ideally a tool autographed so easy options we have available to stay
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and these are the ones that are gonna be talking to about sony's new generation of observable a conduit
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and hopefully punitive how they they may fit into the contract is this
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concept has ensured elation off any of uh uh never pair
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isn't new it's been around for a long time and um way back um in the last
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at two centuries ago really a clock was using decals fight bench
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used to bridge gaps um human breaking large reason canine
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uh now have gaps uh it was last off that's intrigue um but really career begins with
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the with these pivotal studies in the early eighties a balloon but sweep 'em sharing
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um the uh effect of silicon chamber on of gap and looking
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at the regeneration cross that chamber and essentially used a rat
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model uh with uh gaps of varying lengths within a session of model and the city can choose to bridge that gap
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nice ensure the key findings no studies we with that you need to distill stumpy present and actually that is that
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a a significant effect uh in the regeneration and secondarily the volume
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of that cheap is very critical so beyond a certain length
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um you did not get regeneration as you can see that you generated
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speech route uh into nothing and number x. creep later on
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um did some clinical studies will say uh which interesting you showed that in very small gaps uh
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the sense recovery with the with the condors around it was actually better than for direct repair
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and that's that's a recurring theme if you look at the the data the image is uh a
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band conduct um very critically and and do some subtype analysis which oh i'll come and
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of course even converts onto man they had a number of problems in clinical use uh the coarse
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fibres congratulation because they were of course not global and subsequent compression what's going to automatically removed
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um so this really brings on to the current air the cepstral conduit and susan weakens
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group uh well early on in this uh round with a p. g. a. convict
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um this is one of their early and experiments with a used a p. j.
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conduit or two types of future condition compared it against um also grafting
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and actually they compared it's um in the three centimetre gap in a mixed since you
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mention of in a simian well that's the that's the on and that's the um
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conduct in such you know interesting when you look at the um re expiration up some months later you can see that the
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p. g. a. convex computer displays and you can see that it's replaced by something that looks very much like no that's
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and actually tested uh when it's just it's um you george
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physiologically um it was very much akin to an autographed
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the most interesting thing in that paper is actually the comments that they make in conclusion
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which is where they say that the state of the art marker surgical to secure repair where you actually don't happen you repair um
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um of you'll you'll to nerve ends may actually hit the
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potential new traffic affects exacted by the distal stump okay
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because it prevents a re guiding or um uh uh targeting of this last goes into the corporate distal connections
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so she says that with two close approximation to to note and the benefits of the distal stamp
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in directing a prepaid regeneration maybe lost i think that's that's a really um insightful point
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that same condos in using technical studies like shown this is the addition of
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um model where in gets a three centimetre less they had accent i'm a century recovery
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a slightly more robust it's a randomised control a heart uh by favourite channel
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and this is p. j. conduit for us is uh stand repair an interesting when you do a sub group analysis
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in very short gaps actual condor repair seems to give a
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better recovery of century function than a direct repair
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and this is this is repeating theme in many of the papers looking at this and actually sometimes the
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poll results in the larger gaps when this man was altogether they kind of bring the overall um
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um forcible recovery down actually just look at the very very small
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uh gaps independently then actually visit visa potentially best indirect repair
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which is interesting which which i think i'll come on choose maybe evolving role of the congress not gonna part is
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and that i'm ecstatic everyone seen it got about four meters so
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that was the cuts off um the plenty cadillac chain um
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it's a conduit um which one is the new black on which i was tested additional level
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um it's a very with the study and the average guy he was six twenty meters
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and again they have comparative a recovery uh we that's even differences between
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groups and this is uh actually study is a perspective can custody
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um it's non control series um but that would mean that thirty
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millimetres range of six to eighteen good wrecks in recovery
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in nine after twelve but actually again with the subtype analysis
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below ten minutes is significant better performance of conduct
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and then this um he study looking at a mixed and that's these are more
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proximal hasn't for wrong with a mixed a motion century um a nerve
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and actually uh what they found was that with opinion well what they looked at was sixteen is all
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all narrow gap and compare napping us cotton repair and interestingly even the motor
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no i've actually found at twenty four months that they had a
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good recovery that comparable to that of direct repair a bit slow recovery
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didn't didn't see that at the idea that test for twelve months
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many the studies mention that with a conduit your present time is reduced that's that's
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very good okay so just to talk briefly about modern converts so these
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numbers speeches which um which are desirable so they are semi permeable oh come
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on to that they allow option might connections to come in their biodegradable
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and hope that produce and the problems that that was seen with the um silicon converts of another generation
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they are mechanically robust and it's been increases since any of of using a vein croft
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or some of the other comments that made claps down vertically along the gaps
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so that mechanical robustness is important and often transparent and those are the study used
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um any form condors i think we'll probably vouch for the fact the transparency is fairly t. 'cause the flashy to see exactly how you
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know then the sitting and the congress and i think that that's probably a pretty critical a factor that one should look for
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so that just illustrates the by actual ability of these one converts on the a lifetime
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site competitive reasons so we can conduct which uh which does not by the great
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so currently on the market there are these principle devices that are available
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the one thus far what's the x. the guards not actually marked as a conduit it's actually um
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a um it's a wrap or sort of connected device um but just as inherent second completeness
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you can see the bottom here the um mechanical strength um last
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between six straight weeks along with the product or products and
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uh which um wants a main campus in the slower regeneration if there's um other performers the compromises never covered
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right on many studies actually comparing different conflicts uh i'm sort of latency
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whether they whether they perform differently there is this study by shannon colleagues and this year's
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gives a rat's model so we've all right studies in everything you got to
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take the results with a little bit of caution um but they do show that uh
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you get pretty good results across the board p. shape concrete performed little bit
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uh at weston was across the new black a cheap appear to perform better than the others um but that's one study um
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to take in control comparison okay so in terms of how they actually what what's the what's actually going on under
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contract hat will um has never cover uh when you place commas around you repair disk on this essentially
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in case the two cousins than as a increase alignment analysis fluid that comes
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out of the ends and i have to be contained within that chamber
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and within that food you can get a rudimentary finding matrix which then supports um say the migration
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between of and and then you write griffin follows the bans okay so that being said
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obviously the whole process then is dependent quite hard on the volume of the cheap because depend on the volume up button events
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so as that gap increases or indeed is the damage of the nerve increases the volume in
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that gap is gonna be quite so and so you have a certain volume you farmed
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uh that there just isn't enough fruit volume to fill the gap and you get this out last appearance
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uh in the matrix and therefore i think you'll know every generation williams about an hour's points um in that
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in that out last and again if you look back at the regional studies bloomberg it so you can see that heartless appearance even in studies
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um and you can see the bottom there at some let's be only outlaw spins the regeneration just disappears altogether
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she volumes critical and a small gaps otherwise great um i don't actually this cross
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and i think it's probably um was just real business because i think
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it's difficult to know where you where the technology six not cross why or in the midst of
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in the midst of it and it's it's probably with retrospect one can see where things stand but it may
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be that um converts cough finding their role for the last half that are often we kind of defining
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with a fifteen to set even the data option you see smoke out to be the the way forward for converts
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probably since really in terms of the most robust x. that we've got a and
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most people evil perhaps as an six device to stand up in your repair
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and of course if this is the proposed role for conversion future uh and that means
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that the the the the number of cases in that the volume of work that
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they may be applied to is huge 'cause if you saying that it's a and
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assist device to any opinion repair well that's uh that's potentially huge huge market
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the question is can accomplish what meant or even the place the traditional happen you repair
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and i think that's where we are at the moment so listed propose converts has a subscription of autographed but actually
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the current days are showing you suggest that it may be an alternative or plantation the traditional opinion repair
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we all know that never pays technically demanding him any within its remit of possible never up as we know that
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the final result is often not as good as we'd like it to be also this intention
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and even when you got the opinion together very nicely maybe to
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secure overlap which is which is fairly a disastrous underneath
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um and often chooses not protecting your son you do and that with
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the procedures uh that may cause scarring deep down that women have
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uh i may cause a situation you can see the middle picture there with this
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uh new lyman continuously with actually probably very little um worked across anyway i'm
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so is revolving of a complex action to improve the course of our test that's with the question is there's plenty of evidence
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pointing towards it um you know it may reduce the risk of tension intentioned used scheme yeah at the upper side
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uh when it provides a physical barrier preventing and controls passions the periphery
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uh and infiltration surrounding tissues and makes any permeability of some of the conduit maybe an advantage
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okay we need to caution sheep's there's a molecular penny budget cuts off that sixty two adoptions
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and so that that may have an interesting effect because it may allow small molecular weight metabolism grace that just uh
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come enough so freely into the conduit zone production things and have great
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site which a much larger molecules may remain in the newman
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um and of course fibre jen excels are excluded so that's important um
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the criticisms of that a sentence of colleges that perhaps some the scottish invasion some studies the founding and
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some syringe precise um may be an issue um and perhaps less parameters is better the mall
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and as i mentioned i think the numbers you've got all this be decreased and social time we decreased
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or which ontologies i think this concept of allowing to still suture placement away
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from the actual pass out because of the tonic sort of touched on
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um maybe key because it reduces the inflammatory a reaction maybe
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set of having a white at that regenerating site
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and of course off retention out from the competition site factory sharing tension over slightly larger a segment enough
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those comments that are transparent and as i said there's there's just use condoms i think
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the transparencies is very key that will have a precise alignment of the nerve ends
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and in effect if you use your conduit simply as a device sits
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around yep in your in and is necessary bridging that gap
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well then the transplanted probably even more important than the actual mechanical robustness because maybe
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there's no doubt that but you do want to see the unit indecision together
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yeah we can involve the trial that hopefully is going to add to this
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current a quandary about how converts converts sitting in current have practised
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so this is a single since rossi t. i.'s investigates let's study it had also been planning on
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uh in the sessions with our industry partner up organics i sent you exploring the idea
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the stooges never pat and looking at the role of convicts um in that
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so these are three groups that were randomised empty so for us is the simple stand repair and there to
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convert groups one within happy new repair with a calm which around the outside of its recent detention sutures
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and secondly assumption a speechless repair with detecting sutures either and converse around it
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so i think that's gonna be really interesting see how um that goes we're looking for a
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t. and there's an age group and these these are for what protocol essentially outcomes
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um hand with from score twelve months um but as they that's ongoing
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um we've got a a very nice day to catch to which um
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it's pasta post it notes uh that the surgeon um is
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required actually to um great his will uh never panned is almost impossible
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but how i'm good about they've they think that's um come together
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since summary with the congress it's clear that we need more day so we don't see that connects study in another studies
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um because in the absence of solid evidence i think that the the the only guy the
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certain has it really anecdotal opinion um and it tends to be industry driven over time
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that's my bits on congress or talk briefly about a new rhymes about study
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that we're involved with um he would collect what i've already said
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so i think anybody that has a hand weapon impacts probably sees lots of uh patients
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with new roma pain and we all know what dilemmas that these patients can be
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um i'm not gonna get into the generosity of new i'm too
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much um suffice to say by instruction that dreams are inevitable
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a process where a proximal a nerve has been unable to
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i'm finding appropriate just to target and that diagram illustrates how
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um spade of that history innovation results in your home
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you then and we sensed i see fibres and pain which is that the misery patients with you very much um can
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be within the new remote cell from a chemical or mechanical stimulation but also from higher up in the parkway
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and of course one sentence and starvation setting and you got features that highlighting in harper's these yeah it from can be really intractable
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another thing i need to um tell you about the huge button economically past me and
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uh in in some pancakes of these problems some seven cents patients
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requiring routine energies yeah so so it's potentially huge problem
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and of course there's no clear solution out there that can be down to to solve the problem you
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very much over a hundred fifty methods described which i think tells a story in and of itself
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ah yes that came to us with
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um he really had a surgery for new rain within the doors of change churches the omen of
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how did buried into the uh f. t. s. muscle and then re presented some years later
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with severe pain raced into the hand that was associated with a tad the pain
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when you select things thing is and is also getting the the spasms in the f. t. s. muscle just hold the last um
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hum stuff isn't how that may be made by captain an estimate since
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way d. m. uh which maybe catch for all parts movement
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deference of form the connection so it is i i think we've all had cases of success and failure using the same technique
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and i think that um the inconsistency of the of any any particular
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technique is is key here and i think both but put it
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very well when you said that the number up to techniques described is so large that it's clear that no one is highly reliable
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so i was just talked before i finish on f. tapping which is one of many techniques that could be used street in in your home
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and this is if you look for the mixture historically is a technique
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that's coming nasa's favour all relates had every now and again
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and this is the earliest reference to that i could find is from nineteen forty five the paper from chicago
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and it's looking at having the end of and uh with a resin that then hardens informs cap of
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the internet just to protect it pretty images from tearing into trying to she's it was turning around
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and that got some lovely long shouldn't sections through that uh that and
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uh and you can see that actually regeneration seems to peach wraps
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um and they say they didn't see any new rome is a form in the series that they did
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this some more recent studies in the eighties looking at um never generation
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into me to feel chambers interact model by at dobbins group
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an essential what they did was they uh use your concept to me to feel cheap and they
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put along cap on the end of an of uh to see whether that than have they would
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um p. trash we might get and the compared it to a new m. s. muscle fashion
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and we can assume silicon cheap actually using stimulated these nerve and mechanically and within waldron
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fusion more they spans across the bottom shows is that um in the
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fibres grabbing a nice long means even shields insulated from the
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spring three inches from any additions into the surrounding area and interest
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for many mechanical forces uh they found was no spontaneous activity
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so as say this this this concept has been revisited that's a fairly pivotal study that shares the potential of it
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um when you take sections through that means the new cheap you do notice that this lee
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um no fibre seem to peace route without causing any the chaotic new roman tight formation that you can see on
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the picture right which is what happened if you will happen it just for you uh next most of fashion
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so why should capping of an uh have um and work well there are
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a number of reasons but essential prevent having an addition to french issue
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um it'll prevent we innovation of guidelines can i um and
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unlike bearing into muscle pain should commonly used technique you don't have any tension
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on that note and uh as of today that's important factor also
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so this is the new it happened where involvement trial which image talked about um in the second
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uh unless it's essential probably probably can't black trench you uh with a closed and
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uh that's designed to go on to the end of uh and uh have
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um with a certain chain the length that allows enough to regenerate and hopefully p. scratch
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would not lead and prevent any decisions into periphery the slide from any animal studies
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the testing that helps uh and as you look at those sections of one of the
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top is a standard uh no that's just allowed to develop into new brain
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and one of the box and you can see how the the actual kept collapses of the end of
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the and um you fail to get that new i'm a form that yeah and uh and
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re section the same thing six months down the line uh showed decreased
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adheres surrounding tissue and minimal much more information compared to controls
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interesting when you looked at twelve months you actually get some um atrophy than of and also
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which obviously is very key the fasten human studies were done a complete in the last year
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the system you aim trial uh which i believe someone in in this fashion i think the results are gonna be reported
00:21:39
but actually the preliminary look shows the v. a. s. goals um will
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um largely at decreasing of the top one for what period
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so that the current shouts running is to protect you any trial which the most the
00:21:52
centre a trial that we're involved with um and the idea is to um
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put this company and even have to um reduce the formation of peripheral symptomatic and new by ms
00:22:04
primary endpoint is a visual pain school and second in points i yes i
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knew him scroll um as well as a pain medication use et cetera
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so i think that's coming to the end i think we're recruiting the last key and well i think we're counting the large creature
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thanks for which don't mix huge holes of even the patients that is going to make
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um but uh recruits any next you must uh if you'll be looking to
00:22:26
report on that in the future just to finish to show you a couple cases from that a trial so this was an interesting this is they uh
00:22:34
patient prevent presented with a huge much pain within a the tools approached her tree also a just one of
00:22:41
and that x. illustrates the uh point of maximum tunnels and that dotted line
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illustrates the the area where um the area of high precision pain
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and and you understand isn't she knew in the dorsal brunch which was an engine to trial
00:22:56
respected back and that you can see the cat that's placed on the end of that
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um and we get a lot of amputees with pain uh you know units um so the old neutrinos that we treated some of them have
00:23:07
i'm quite significant match the pain is just an example from that cold of
00:23:11
uh actually changes uh um enough that uh have to trim back
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