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A-1283 Evolution of my Algorithm for treating traumatic peripheral nerve injuries
Bauback Safa, USA
Wednesday, June 13, 2018 · 1:43 p.m. · 20m 03s
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mm kay
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up back excellent go thanks a lot for joining um prick internet today
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a couple great talks a tough act to follow but i'm i'm gonna just talk
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briefly about uh i kind of wish them algorithm for treatment of most
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it dramatic um performer boundaries um so i'm i'm at the back you click
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a and the only disclosure have with which are relevant here that
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work with oxygen um as in consulting role also um as a bit a recipient of
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the of research going for the ranger our match studies um refer me with her
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donkey was fatter click um before she passed away no wait but uh the rest of
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us are still doing the same stuff a lot of complex and from uh
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um the replant senate measurement metal hands you injuries and so mellow kind of talk in in general about
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kind of the algorithm as a kind of pertains to re primary repair of nerves of possible um
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these halted kind which which we still do you use um the use of the
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route graphs user about rats and i'll i'll use a kinda case based approach
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to eventually get to how all kind of it's in at least a malpractice
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so as a tertiary referral centre for complex traumas of all kinds
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um we're kind of a a good place um almost laboratory fuel to kind of you know
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experiments almost from the uh new products standpoint um that are proven so these are
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you know it's really good playground to be able you some these products and so most
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workspace comes from one is gonna complex injuries somebody use this case as um
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kind of a demonstration of of how i used to treat somebody injuries about maybe ten years ago versus how i treat them now
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um and then we go to some of the data is one so this is a table sundry dominant hand
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a pretty young guy maybe as late thirties or so um and as the disaster i just um
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a thumb and exploring fingers um and um clearly we know they're gonna be nerve gaps here from a table
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so injury so and as you know is typical with a wide exposure and kind of final the structures
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now ten years ago what i would typically using these cases um would most likely be college into but
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um by time which under back there's gonna be significant gap at least couple centimetres if not more
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um and so we didn't have anything available that time to fix that or at time zero
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if the gap was long into same as we close up when we come back later probably
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and bridge the gap without that with the autographs getting most likely stroller or other nurse
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so those are cover main options at at that time that we did use a lot of calling tubes
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and we were quite happy with the with the results now are a results really didn't near the web web or
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studying at the study was already mentioned and um their conclusions if you will we were basically that that
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you could use conduit switch and that's that was p. g. a. to the actually i'm up to two senators
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results were comparable fuel to um other rafting or even some of the primary repairs that they've done
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however in our hands gaps that were more than the sender so just didn't seem to do as well as we would've
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hoped so what we did is we actually went back and looked at the data for the web or study
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and what we saw was that they even those very large study if most of
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the gaps are actually quite short the average gaps actual only about seven millimetres
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um the me those any gap like they had one outlier twenty five millimetres but actually never tested a gap of the senators
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so we're still talking of of most of these injuries were short gaps um and if you look at the data
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to break it down gaps of less cynical four millimetres on the left you can see the actually these patients
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are doing quite well almost all excellent one patient did added good waiting however as you got the gap longer
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to five to seven but mulder millimetres actually had a significant amount of patience you didn't do as well
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so yeah basically forty percent of patients you did poorly for relatively short cab fibre submit millimetres and these are in
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the condor group of the web or study and the same holds true for want eight or above so
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the weather study really have it in my opinion doesn't really support you to use a kind of up to three
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centimetres 'cause even their own data for break down over form eight millimetres didn't really quite do as well
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so but batterer case now um now is we have autographed billable what we can do in these cases is just too aggressive
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i'm trimming other back to healthy level and we basically bridge those gaps with an hour after time zero
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i'm not ago did care why we think that's better um and
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so this is basically you know kinda showing all the
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nerves for the thumb and exploring fingers bridge with between two
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three summer long our raft at time zero aggressor section
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in crafting so we go from a pretty bad injury to this basically all the structures have been repaired in a pretty
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um durable fashion um a kind of at in in one stage basically now
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these patients is still brought to the early spent nine months or so
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um but the light has really excellent like touch a sensation still
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need some tendon work done these most things onto and so twice and so on but from understand points actually done quite well
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yeah i think this was also would to a bite has seen as far as the importance of structure
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now why i think in that in that acute setting um the autographed is superior to the conduit is because simply there
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is more structure so this is the the solar as human tissue and so those marker to bills are still there
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and what you get is longer gaps of two three senators are you more for five centimetres
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um do you do need a structure as opposed to fibre in kind of cable that
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can that uh forms within the a hole to conduits and so if you compare
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the autograph to the our rat you can see that the structure is similar now obviously
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the cellular components are not there so we do rely on sean so migration
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and so on uh to be able to kind of um uh you know uh run along that scaffold
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however when compared to a conduit or vain any kind how to especially this collapsible but even
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if it's not if you get the scanner hourglass shaped regenerate which doesn't really support
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the regeneration of as many x. sounds as you need to get really need for recovery and this is a even more to the longer the gap gets
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so that's one the main the limitations alaska why in in our hands the gaps of less in the same to say
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five notices monitors do quite well the kind would they tend not to do as well as you go longer
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okay and this is actually born out not just from our experience but also from data so there are many papers talking about
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kind of the regeneration um uh using conduits in as we see in these studies that
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um uh do uh the uh as long as one guy 'cause longer you
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regeneration going down to about maybe forty percent or so as far as meaning for recovery um so this is basically
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mirrored in the historical data as well i apologise for the call this picture but this is just a
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then you example of this where we had a multiple digital or injuries or repaired with that kind of it
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prior to hammer average right click any developed a very painful aromas support because under section in my opinion
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and so we we we basically so she respected the promos putting some nerve um i'll i'll graphs
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um and this is just gonna partial recovery but uh i even it will muncie basically
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had some really nice uh two point discrimination um especially considering the delayed presentation
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with a long gap uh up to the cap yet be joining this has
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an advance intel's now um there's now a whole kind of series
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the data out there with regards to sensory gaps and this is just a summary of some of the papers that they're looking at
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i'm mean for recovery be it from and um s. three and above standpoint or a sleepless in about which
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is the love for this column on the right and you can see the average gaps in these cases
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um and this is arranged in order of shortest mean gap length all the longest um the
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shortest kept the tops couple papers there about eleven millimetres but the bottom papers you can
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see the actually um as long as almost seven centimetres so and in gap like if ending
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of recovering these cases are you know consistently in the eighties or so percent wise
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um and if use a higher threshold best b. plus it does drop 'em but that's to be expected and i
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think if you compare them to sorta controls the conduits you can see that's abruptly but for deciding two percent
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versus our grass is roughly kind of comparable so it's pretty much in line with that
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that's why not practised our standard nowadays for an acute from a sensory nerve is basically to just to train back aggressive the
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input an hour after thing it it it makes sense that it saves a lot of time and and often times
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um it saves the patient another operation later to be to have to do an autographed and bridge along gap
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now another case this is a revulsion this is another kind of example location or just
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we just one operation on and he didn't want any revisions later but we were
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able to bridge a very very long gap with too long our grass who's going down
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a slide at a bar got as rain caught and social gathering of option
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and you can see typical of also mechanism where the soft tissue injury extends from the
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peppy jaundiced early and has a disk articulation at the t. i. p. joint
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and you can see the nerves are quite stretched out so just looking at this case you you it's pretty
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apparent that your gap is is gonna be probably at least before senators this case was almost five cent
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so what we did is we basically replanted the digit and acutely from the nurse back to avoid very healthy level
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to be on that stretched out attenuated i'm kind of a phase them or put in couple long our grafts
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um and then we went and wrapped those cooperation sites as was mentioned previously we do think that
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kind of helps with kind of cooper to protecting the site minimise some of the pain
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potentially minimising scarring growth and potentially minimising accents cape um so that's kind of our our
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a two minute time zero in here is roughly about six seven months out
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of 'em excellent um two point uh uh this discrimination in light touch especially for
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assertion of also my cousin along gap this is one at one operation
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and he's happy with the result thing is the of people for is not great so i would like to do it you know to
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license on and but we haven't done that yet but again one operation i think this is something that if you gonna do this
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people get that come back later and do a an autographed on i'm considering
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those gaps this so the question then is this protecting um winners actually
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work difficult to study in human setting um we do have a a
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kind of paper from joe's all those as group in phoenix arizona
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i'm looking at a corporations um with our our grass versus our grass plus a wrap
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um again there's some heterogeneity in in in that kind of the charm mechanisms and that kind
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of stuff which is to be expected with that kind of clinical study like this
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however there there seems to be even those that's significance in in its differences seems to potentially a trend
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towards some better recovery with um uh their progress with protectors my personal
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opinion is that it it makes the competition easier and more tidy
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um and adaptation minimises painted the quotation sites is gonna be difficult
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to show that actually improves every generation but it does
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make it the quotation quite easy couples to switchers rabbit and i think it's a much speedier way of doing it
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so this is our to kinda discuss i will go into much detail here would
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you know that they're number of of um commercially available competition is out there
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we tend to use um the interest also because of the kind of actual guard material
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it handles nicely it it's translucent transparent um and ended we models
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which is process really important um because it's gonna make sense
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because in sort of a degrading up there should be replaced by scar actually models into a into a tissue layer
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and this is a case a good been keys where you went back on a cute little town
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release sack is you end up having some recurrence sometimes proximal to where the nerve was released
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yeah you can see was able to have very easily people way that that layer off of uh the owner of um and so that
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for us i think i make sense in is in is pretty easy out understand why why why we like that i think
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so that with materials here can degrade and and some of them can
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be not his watch against different thing and and edge that function
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creases in maybe uh some some other challenge and then they actually have complication it's like you know a real interesting and so on
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and the last they'll talk about is our grass from a similar so this is somewhat more of a
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um controversial topic um and you know i'll caches in cases to kinda why we think that there is
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a role for them at this at least for gaps you know less than six seven centimetres
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and this was the first case that i actually uses on this is a young girl that's seventeen or
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so um to present in a delayed fashion uh maybe about three months after all nerve injury
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um and she had some kind of obvious signs uh of of of the order of being out instead of wasting already the
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first dorsal it in process and densely in um in the distribution on the nerve no crossover what's so funny mean interfere
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um so we can she would not consent to an autograph so at the time which is many years ago
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this was a good opportunity for us to use um the autographed to one in there there
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was a little bit attachment there but i was just scar we stimulated when stimulate
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after i get um we buy scope in the window kept intact rascals there so we just cut out roughly to send a gap
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put a couple cables um with the our raft we didn't have the connectors at that time somebody's using fabric would
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augment the quotation sides um so nice tension free you quite quotation there here she is by fourteen months out
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really good thing reduction already able to cross your fingers here um and you can see that our innovative muscles firing quite nicely
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um special hype within area there so this was really good kind of um first case for me to just gonna say you know this
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his clothes on that that could have some utility in our praxis and set from us as you step which also the very
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well but since we we already were convinced that time so what what that's that is is kind of um um
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in an upright as we tend to fix especially proximal injuries without wrapped securely into the
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solar transfers so here's a guy a guy went to about class um window
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and has a lot less ration it kind of the need break him level and the laceration
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display forcing was just skin deep sea did not have injure the on rotary other form
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so here's a proximal injury um want to turn back we have a rough we see
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three sender defect and we went ahead and fixes with a couple our rad cables
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so we're gonna do the solar transfer with uh and on the uh on the
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motor so the only thing we expect from the star from our standpoint
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um is gonna be the f. c. u. in our innovative f. t. p. tendons right um so
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we put this in them roughly three senators didn't and transfer distillery taker the hand hopefully
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here is about a year or so out maybe eleven months um and his f. c. u. is what i want you to kind of pay attention to
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there's a video the su fine against resistance some um i'm trying to extend his his wrist and these flexing is you have to
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you this is for at least an four plus um see really nice regeneration the granite is young kid twenty two years old
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um but i think it just shows that that you clearly are able support that mortgage
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regeneration with these are grass kept kept two senators pretty proximal than that humorous level
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and lastly summer show there's a six year old guy so six year old obviously
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older and this is a a scale signed rehab crosses non dominant to rest
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a so called spaghetti wrist but also the last crashed um um and he's now this
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was back in september so he's probably about nine months or so that no
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um so this was a full spaghetti wrist except for the f. t. p. the ring finger um any device christ them
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so we went and we've asked the thumb with a wide exposure as always
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to identify out all the structures um and he had um roughly five
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centimetre gap in both the median and the owners so in this case we're
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not i was talking about any kind of crossover both there's route
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and what i what i can assure here's a close up of the median or and you can see that
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the meeting or speed up pretty badly and it's very common for us to see this and just a
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very aggressive or section we have the autographs available you gotta take if you have someone is not that big
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of a deal um and i think it's it's worse to put in an hour after our raft
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in in an area we're not quite sure of your fee if you outside the zone and then find out a year or two later that you were in the so
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so here's now i'm on the bottom you can see that two cables useful
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medium um injury and again wrapped with uh the uh um nerve rap
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and then just on the top right you can see close appear is actually that the two cables
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that we used for the older we separated the motor group from the the sensory
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group there um so again roughly five soon we got for for both
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so yeah we went from this to this in just one stage right one operation five santa gaps we've asked
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for um um and here is this is roughly about um i'd say that maybe five months or so
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i'm just kinda showing some you know the since extrinsic a function
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of this fingers um you can see pretty good function with
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you know without even having that you know i says i haven't you can already see some opposition here with them right
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so again there's a cross over here this is just you know the median nerve having been regenerated brink
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we're into into skinner's all the levers in quite firing at his out eight
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months this is about maybe two three weeks ago when i some aquatic
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and a cessation is really very quite nicely the thumb actually has really nice light
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touch annie's regenerate about the price small for ranges of its fingers we
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can see the lower burners index finger that's part still number decided about eight
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months down what i wanna show use now again is the opposition
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and this again is all his um uh the been the nerve graft roughly five senators again in a six year old guy
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so just kind of happen up here um we would when it when i had looked in the ranger database which
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is kind of our our kind of all covers um read registry of over thirty her patients now looked
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at the nixon motor subgroup um and most these were in the approach areas would be uh as as as
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makes sense and and we looked at the grappling so between ten to twenty five millimetres twenty six to
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forty nine also about fifty um now the biggest kind of one of the big i'm gonna draw backs this study
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is that there's a lot of heterogeneity there's you know twenty plus centres that are contributing patients many that
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many different surgeons different techniques um different patients' ages mechanisms of
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injuries so within that you know kind of context
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of the heterogeneity uh we can still look at the data 'cause it's a pretty robust um group
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our overall mean for recovery is about seventy five percent um and we defined
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that as an three or above and and an s. three and above
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um to compare ourselves historical data any consider where we're actually not seeing a significant difference between the different gap until
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is not yet it could be that with that will get there was we have larger numbers in these groups
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but so far the there's nothing even difference between those different groups and what we're saying is that
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the autographed is appeared kind would specially we compared to the to contemporary course with enron centres
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and we're also saying is that the comparable to autographs i'm using at um
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compare comparing it to our um content records and historical papers out there
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and we look at the the actual break down most these millionaires
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and one interesting observation which also mirrors not only our experience
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but also um kind of previous papers that there is that there is a significant difference between the generation thing median orders
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um and so this kind of mirrors are kind of clinical experience i'm sure those of
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us here in the audience to do for number performer vendors in the upper trendy
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i've also seen that on interviews for some reason doesn't do quite as well as an interrupt us and we we saw this major database as well
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so just a quick conclude um the general trends that uh in my taxes from the say the kitty go to today
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is first of all really aggressive or section at the time of injury what i've found myself doing early on
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was the rest in your kind of train back a little bit and say i know what i think it's okay uh
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i did try to get a primary pear or to be able to fit within a three centre kind of conduit
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um now i don't really care as much as i have an option off the shelf the freezer so just to um respect very aggressively
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um i've also been using more they are rafters use our uh for both sensory bottles but also for kinda makes monitors so that's kind of
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another trend in malpractice and also that's kind of been kinda mirrored um
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yeah the more we use now wrap the less we the conduits
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and the kind was really are are gonna reserve for short gaps um listen to senator uh 'specially not
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critical nerves and also the connotation i'd have you you've sauce the pictures using a lot of
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the good the wraps if you will to kind of created to hide your repaired try to minimise
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some of the scarring growth and the other half we still use it and especially if
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you know the longer gaps or oftentimes you have autographed in the field um the the mangled arm
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l. a. b. c.'s there and maybe caesar yes a spare parts so clearly there's all these are all for rafting
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and we also use autograph to augment the meditation we have few facing a big gap ascetic nerve
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you know you're just all players are yeah from sensory standpoint probably not needed the stroller didn't take the freebie
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and you can use that in conjunction with our rapture kind of a hard meant um the an energy you have
00:19:46
so um that's pretty much it for my talk um i do you wanna kinda make a point for um if
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there's more information you guys and interesting then we have another uh suppose him friday um on the fifteenth
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