Good afternoon. I think the best meeting is one that starts on the time, so it's 5 o'clock. We have a distinguished panel today for this instructional course, and I think after you finish this, everybody will run home and try to do one functional facility. It's not easy as you think, because this is a world expert. We have my younger brother, Scott Levin, who is running PAN program, the oldest orthopedic program in the country, and Alan Bishop from the Mayo Clinic. You heard everything from the Mayo Clinic, and I have two of my associates, Rachel Furb, she's in first row here, and Luke Nicholson. So I'll start the presentation with some introduction about three-functional muscle transfer. I run the Boyce Fellowship program, I have been there almost, next year will be 30 years. So we'll talk to you today and see how we can do three-functional muscle, when and how. So Trojan family is doing well, we are beating everybody now in football, hope we'll qualify for the finals. We'll see that there is really nothing that I can't do. Functional muscle transfer, just muscle transfer, is technically very demanding procedure, and if you have an injury like this, you know that you have to cover soft tissue, and you have walls that break, you know, biceps, tendon, you have to rotate the latissimus dorsi muscle, cover everything in soft tissue, and this is the functional outcome of this 22-year-old girl. We have to thank, as micro-surgeons, to the fathers of vascular surgery, which is Alex Karel, who in 2012 got Nobel Prize for putting three stitches on the dog femoral artery. He got for that. But I am so proud to tell you that University of Belgrade had a father of the vascular surgery, Vojislav Subotich, who is the first in the world who repaired the, you know, vein, femoral, and artery, and when he wrote vascular surgery, you know, history, he said that Karel got the Nobel Prize, and Gutierre, but Vojislav Subotich was 40 years ahead of everybody. So I had a privilege, you know, to meet, thanks to Scott, you know, to Norman Rich, who was the main vascular surgeon in Korean-Vietnam War and work, and so a lot of leading surgeons went there, coming here. Susumu Tamai is the first who did a TAM replant. This is, you know, slides that I got from him when I was invited to be guest speaker of the Japanese Microsurgery Society. He didn't know at that time that nicotine was very bad. So advancing in microsurgery, we are steaming from replantation to allow for the expansion of the microsurgical technique and functional reconstruction, which you are going to see here. So the first free functional muscle transfer was done by Tamai on the dog. He used the rectus abdominis muscle. This is a slide that he gave me one year rectus abdominis after he transplanted, and also he looked electron microscopy and histology. He never did any functional recovery of the muscle. During my tenure at Duke as a two-year microsurgical fellow, we were able to use sartorius muscle of the dog, generate 70% after three months. So the sartorius muscle, if you want to use it for experimental work, has a unique anatomical structure. It has a single pedicle. It's very close to the proximal third of the muscle, and we tested that and got these results, which we published in Journal of Microsurgery. So three months later, you look at this transplanted muscle. It looks almost the same size, you know, a little bit less. But I don't know how many of you know the skeletal muscle physiology has a unique biologic tissue capable of transferring chemical into mechanical energy. So that's a unique structure, skeletal muscle. I learned a lot from these two geniuses, you know, Ralph Mantello and Ron Zucker, but I also had a problem with them because Ron Zucker always said you cannot take more than one-third of the skin over the muscle, and I'll show you we beat that opinion later on. So I always say what they didn't show for the Mobius syndrome is a nice smile, that this kid who never be able to smile, you know, were able to do that. So what are the indication for a free-functional muscle transfer is deficiency of critical motor function with no suitable tendon transfer, no suitable rotation muscle transfer. So contraindications are relative. So you have age over 45, that's my opinion, and many people don't think about that. And obesity, because this muscle, if you especially use for the elbow flexion, a patient has 250 pounds, no way that he's going to produce good function of the elbow. An absolute contraindication is medical comorbidity, including diabetes, cardiac, and so on. So I like Mantello goals to supply useful range of motion, provide adequate strength on functional muscle, and you have to have a good soft tissue coverage, which we suffer for a long time until we discover that we can take all medial side of the thigh. So pinnate muscle are much stronger, you know, and like rectus femoris, but the strap muscle, you know, like gracilis and latissimus, has much better excursion. That's what we use. So gracilis is probably the most common one used, is ideal because it has a six to seven centimeter excursion, which is ideal to reconstruction of the finger flexion, finger extension. Also, you have to look at the type of the blood supply. So if muscle has one blood supply, it's type one, two dominant, like gracilis, you know, it has a dominant pedicle, and like latissimus is a type five, as you can see here in pectoralis major. So you have to minimize the ischemia time. Please, if you go over two hours, you better take another muscle because we had, you know, experience if we take more than two hours, they are not recovering well. So it's irreversible muscle loss with that time. So nerve consideration is very important because neurography should be done as close as possible to transplanted muscle. So this is muscle that I have experienced, gracilis, latissimus, tensor fasciae latae, and serratus anterior. So I like gracilis, really. You have to look that he can be used for trauma, brachial plexus, tumors, almost for everything. We do deltoid reconstruction, elbow flexion, elbow extension, finger extension, and finger flexion. The key points are that you have to achieve optimal muscle resting length. You measure that when you abduct the leg and extend the knee joint. So you measure every five centimeters for the musculotendinous junction distally, and you have to achieve that when you transfer the muscle. So establish strong and appropriately located origin and insertion proximally and distally. And you have adequate skin coverage, which we didn't for a long time. So we use skin graft or use groin flap, as you can see in this patient here. We learned that we can split a tendon into, you know, area because the obturator nerve has two fascicles. One innervate 30% of the gracilis, and another fascicle innervate 70%. So 70% you use for finger flexion and 30% for the thumb flexion. So if you cannot, you all at the same time can also repair and graft the median nerve, which is in a ballpoint contracture, as you can see here. So you always stimulate that, and if you cannot stimulate on the patient when you have blood supply, you can put on the table and separate that. They will show you how well this is working. So as I said, we suffered for a long time how to harvest gracilis with big skin pedicle. And thanks to my fellow, you know, Jerry Chydester, who I talk always to the fellow how I suffered for 10 years trying to get, you know, this on the cadavers. Next day, he said, Dr. Stvanovich, if you have the money, we'll do the deal, you know, and show you. I said the money is not problem, so call my exam because he want his pie. So he had sent me about six, seven of the zombs of the pie. So we'd be able, as you can see here, to inject and see how much territory you can get here on the left side with injection and have a chromatic flop, how much with the right side. So this is how much you can rotate the skin. This is big deal for the plastic surgeons who are dealing with carcinoma of the vulva, of the rectum, so on, because everything is radiated when they do this. So they here, they just need to cover that and the muscle should be inside the bag. So I am, complications are very small here, but we still have complications and I will finish with that. You know, we try to, is a demanding procedure, meticulous technique, and as Nelson Mandela said, we have to do education all the time because nobody know everything. So education is the most powerful weapon which can use and change the world, and I completely agree that. Think about your operative and constructive option, and thank you for your attention. Never give up. So next talk will be by Scott Levin. He's going to talk how to restore elbow flexion. Scott. Thanks, Milan. Hard to follow Dr. Stavanovich and be up here with Dr. Bishop. I've sent three or four of my residents to the Mayo Clinic to learn how to do this, and in the speaker ready room all my videos played, but I've been doing microsurgery. I'm impassioned about reconstructive microsurgery. I've been doing it for a long time. Nobody's a hundred percent perfect in terms of flap success, but I'd say 98-99% should be the goal. These are, as Milan said, and I'll pick up on this, and you know, good education, Milan, is repeating things to learners. Founder of our Hand Society, Sterling Bunnell. To those who have nothing, a little bit is a lot, and those of you who take care of the plexus patients, somebody comes in with a complete palsy. Alan, they're two years down the line. They were told in their community nothing can be done for you. First of all, we've missed our window, but that being said, you can be impactful, and so this is, Milan, I'm sorry, a BMI of about 45, this guy. You can see the tattoos, so probably I didn't learn very much from Dr. Stavanovich, but I want to emphasize some of the technical points and the complexities. Patient positioning, two teams, and at the end of the day, this is what you can hope for, okay? Maybe Alan M4, pretty good. He has his wrist splint on, and this is very hard to execute, and we do have sound here. I hope this plays. Can we have the sound up, please? The volume? That's what his arm looked like. March 20th of 2017, about nine months ago. Okay, show me what you can do now. Okay, bring your hand to your face. So, Bunnell. So, with AIDS and so forth, totally paralyzed and complete. See, this is it right here. Bend up again. Good man. Okay, that's very strong. And you see the large skin paddle, so then we talked to him a little bit more about what's next. Your functional muscle, we did a wrist fusion, right? Wrist fusion. So, we have you now, and now, squeeze. Wow. Relax. Squeeze. Relax. So, this is the best sort of Alan that I can do. I think that's adequate. They don't always go that well, but again, the hardest operation that I do in microsurgery. I've been the last 14 years in Philadelphia working with Scott Cozen and Dan Zadoloff, so we have a large experience in pediatric biceps, a team effort. Again, positioning, pre-op planning. Dr. Stavanovich mentioned the skin paddle. This is an old slide, but we have now probably 35 cases we've done, and no microsurgical failures. And as you'll hear, the donor nerves, certainly the obturator nerve, the selection of vasculature, inflow and outflow, these are all things that are called pre-op planning, and these are the things that we've seen at the Shrine. This is Scott examining one of our international patients, and we either see for biceps, brachial plexus, palsy that does not recover, spinal cord injury, traumatic avulsion, and failed nerve transfer and graft. So these are the children that we see that come predominantly for biceps. So as I said in the previous slide, what's the intention of the transfer? What recipient vessels are you going to use? And I think that's really, really important. Is it the thoracodorsal axis, rarely? Is it the thoracochromial axis? Are you going to go end to end, side to side, in the upper part of the brachial, not so common based on the length of the pedicle? So you have to really understand your inflow and outflow. One of the things that I think we've popularized, and I don't know if the Mayo Group or Milan, you do this, but I've been working the last many years, and I include the cutaneous territory that picks up the saphenous vein. So I have a secondary outflow through the saphenous vein that can go into the cephalic vein or into the subclavian vein. You have one and two draining veins that are going into the saphenous. Now we're going to flip this down and identify the fascia over the adductor, and then we'll come to the investing fascia, the gracilla. So my finger, my index finger is medial to the adductor. It's an avascular plane, and as I flip the gracilis here, you can see it contracting distally. So we've flipped the saphenous back. Here's the adductor longus. You start to see the blush right through here of the obturator vessels to the gracilis, and at this point, again, you start to see the hint of the nerve and the fat here. So I don't have to belabor that. These are videos that are online, I think, through the Hand Society, and Dr. Stavanovich has described this, but there are some technical pearls, so this schematizes what we're doing, and that saphenous vein has rescued me a lot. So the adductor longus here. We're going to show you the myocutaneous gracilis. Magnus here. The pinnacle's been dissected. Let me sponge him there for you, show you. So the pinnacle is here, large vein, large vein, artery all the way up to the profunda underneath the adductor. This is sartorius, tendon of the myocutaneous gracilis. We take the investing fascia. You can see the whole fascial sleeve around the myocutaneous gracilis. So Dr. Stavanovich showed you the diagrams, but that's what we're talking about, including all of that, and then this particular case, different long thoracic nerve, thoracodorsal nerve, different options in the axilla that we used. Everything's hooked up, and then the skin paddle here, and most of the time, particularly in the post-traumatic injuries, Milan showed a humeral fracture earlier. You need to augment the soft tissue envelope because there's atrophy of the native muscles after plexus. You open up that skin, and we always use that to help inset. Here we are hooked up in situ, just to show you. So this is going to be used for biceps and wrist extension, all the planning and everything that goes into that. You can see the skin paddle on the upper right here, and that's what it looks like. And then again, in our pediatric series, this is what we have, and you can get some flexion. Now, why did I show that? Because every free flap you do has to be monitored. The Cooke-Schwartz Doppler probes are expensive, and children, the vessels are very tiny, and we don't use them. So obviously, capillary refill is one way to monitor, but we try to find the cutaneous perforators when we dissect the flap before we move it, and then we mark that with a proline stitch, and that's how we follow the patient. And you have to go back, if there's a slightest question, this is all or none, and you don't like to have failure. Milan and others, Alan's going to talk about Volkmann's, but the point of this is not only can you do nerve grafting, but this is the most important thing. You can do a perfect free flap, have living muscle and skin, and never have a gracilis re-innervate. Pooching fascicles, as my teacher Jim Urbanik used to say, Fumi Kanaya from Japan did some special stains that he described years ago. I don't use that, maybe Dr. Bishop or Dr. Stavanovich use special staining, but you find a good motor nerve, you have to have a good nerve. If you have a scarred recipient nerve, it'll never, never, never work. This is just a little child from Middle East who you can see here had a Volkman's and has done quite well. I won't belabor that. At the end of the day, with all the planning and so forth, again, just another example, and then again, the DOI operation and variations where you can not only create biceps flexion, but you can create some digital flexion depending on how you route the tendon for flexors or extensor tenodesis. This is a very, very rewarding operation. We do therapy in the way of galvanic stimulation. I don't know if it makes a difference. I don't think the basic science has really been able to treat the muscles, but we do it anyhow with our therapist to give some current to the muscle while the innervation process is occurring. Kids, of course, re-innervate much more quickly than the adults, but usually signs at about maybe five or six months. I'd be interested in the other panelists, and then maximal benefit continues to improve. The bottom line, at least in my experience, is the muscle gets stronger over time. I tell patients it's going to be about a two-year process before you get to steady state. It's not like we do the muscle transfer and then it works. I can tell you I have had muscles that have been transferred, skin powder, that patients never got anything back. One or two in my adult series we've gone on to amputation. Even though they have a live muscle and skin and the flap succeeded, they did not regain innervation. That's why the key neural coaptation is so important. Here's this young man. I just showed you flexion. He's playing basketball. Prior to that, he was sort of a recluse. He didn't do any sports. He wouldn't interact. Bunnell said, to those who have nothing, a little bit is a lot. I think these are some of the technical things that are very important. Milan described the tensioning. We've helped a lot of children. It's one of the most rewarding things I do. Some things in life, it's delayed gratification because you can do this operation, but you have to wait a fair amount of time. We've used more intercostals that I don't think are as strong as spinal accessory, but again, as I showed you in my earlier slide, a lot of these kids have been treated with an attempt to graft or transfer and so forth, so the donor nerve is more compromised and you have to use what you can find. Thank you very much. Thank you very much for being on the call. Now let me introduce to you Alan Bishop. It is one of the most amazing and the most honest hand surgeons in the United States. Everything that Alan, in the world, and everything that he writes, he writes honestly. There is nothing that I ever found is like Peter Stern, you know, if you want to get something. So Alan has a great experience. I remember when there was bombing in New York, we went to Baltimore for the Hand Society and he showed his elbow flexion. He did a series, I think about 20 cases or so. So Mayo Clinic has amazing experience, so Alan, we are so pleased that you can come here. Thanks. Well, thank you so much, Milan. It's a pleasure to be here. I'm going to share with you kind of our experience with gracilis flaps and our experience is largely limited to brachial plexus injuries. I guess I have to close this to get started. Yeah. Okay. There we go. Brachial plexus injuries have a lot of treatment options and neuralysis, if you find scar with some conduction crossing the zone of injury. You can repair nerves rarely in sharp injuries, which we typically don't see. Nerve grafting and nerve transfers are probably the mainstay for many patients, but there certainly is a role for functioning free muscle transfers. And we tend to also down the road have some other additional abilities once the initial acute care is provided in the form of joint fusions or tendon transfers or even amputation and prosthetic fitting. But as my colleagues have said, free muscle transfers do allow us to salvage difficult situations where nerve grafting or transfers can't be done or don't work as well. And in some cases, free muscles may be better than nerve grafting or nerve transfers. We'll talk a little bit about technical details, indications, our reported experience, and what the future might hold. The requirements are very similar to those for tendon transfers. You need to have a supple joint, adequate skin cover, and a bed that will permit tendon gliding. But you need to have an available motor nerve, as Scott said, that's normal in quality, and vasculature that permits a microsurgical repair. And some of the plexus patients don't have that. There's a significant incidence of axillary and subclavian vessel injury. And again, supple joints. The gracilis anatomy is most favorable for plexus reconstruction. It's a long muscle that can reach into the forearm to move the wrist or the hand, and therefore allows us to cheat the system. We don't have to rely on nerve regrowth from supraclavicular to somewhere in the forearm to operate the finger flexors. We can do our nerve transfer very proximal at the level of the shoulder joint and expect to generate some hand motion. The harvest technique I'd like to just share with you. It's nice to see it kind of clearly spelled out. You do need to have two surgical teams to minimize ischemia time. So typically, this is Alex Shinn and I, but usually Alex is harvesting the muscle and I'm getting the donor, the recipient site ready. And then we come together with the microscope in place ready to go, and our ischemia time is often less than half an hour. We harvest the gracilis through three separate incisions. We used to make a long incision years ago, but it's not necessary. You can tunnel between these. So they're located at the vascular pedicle behind the knee over the tendon and at the tibial insertion. We identify the gracilis typically first over the tibia, and then we can pull on, tug on the tendon and feel the course of the muscle in the thigh, and then we use a Doppler to outline the source where the scutaneous perforators are, and we use that to make a football-shaped skin paddle. We initially had some problems with skin paddle survival. We learned from Kazutaro Doi and other colleagues that it's very necessary to visualize the fascia of the adductor longus, and that slide didn't work for some reason, but here you can see where the black arrow is pointing on the left, that you raise the fascia of the adductor longus along with the skin paddle and the gracilis, and then you visualize the adductor longus muscle with the skin paddle already getting some additional protection for its blood supply, and you elevate the adductor longus, and you'll identify at that point the major vascular pedicle of the gracilis, and it's a little hard to see in this bright room, but there are multiple little vessels that go into the adductor longus that you need to bipolar cauterize or ligate in some fashion, and you can progressively dissect the vascular pedicle all the way to the profunda femora vessels, and at the same time, you'll notice there's a white arrow pointing at the obturator nerve branch to the gracilis. It comes from proximal and meets the vascular pedicle at the muscle. It comes in at about a 45 degree angle. You'll always find the nerve proximal to the vessels and coming in at that angle. We follow that nerve well proximal, almost underneath the pubis, and you cut it as long as possible. One of the basic principles that I have for microsurgery is nothing is ever long enough. You try to get as much vessel and nerve as you can get, and it'll save your butt a few times down the road. You've made the anterior incision. You've reflected the adductor longus, and maybe I can even use the pointer here. So you've done this dissection already, and you've got skin and fascia here. Now you want to make a posterior incision on the back of the skin paddle. Once again, you need to find the adductor magnus, and you need to raise the fascia of the adductor magnus again up with the skin paddle to protect it. As we do this, we usually suture the fascia above and then below to make sure that the skin stays centered. And some of our BMI 40 patients, like Scott showed, you end up with a skin paddle perched on top of several inches of fat, and you're wondering how can that possibly survive. But it does with this kind of technique. At any rate, you complete the gracilis harvest by detaching the distal tendon. You tunnel between all of the incisions, and you can end up with the gracilis nearly fully mobilized. And once the recipient site is prepared and ready to go, the microscope's in place, we complete the harvest by detaching the proximal tendon right off the pubis. The amount of tendon there is not much, and you need to really work to get as much tendon as you can. And then you can divide the vessels and move it. There are some minor differences in how the gracilis is harvested, but for the most part, we find that when you're doing a muscle for grasp, you need to prolong that distal tendon. We tend to use an available tendon in the forearm, and plexus patients with paralysis will take the FCR, for example, commonly, but you can use an allograft tendon as well. We'll talk about some of these things. One of the things we discovered in our learning experience with the gracilis early on was that there are some key points to the technique that are very important that improved our results. Scott said you should have 98% survival. We do at this point, but I certainly didn't at the beginning, and it was always humbling to me to come to these lectures and hear others talk about their fabulous experiences. We began doing what some of our Asian colleagues were doing, wrapping the gracilis tendon beneath and around the proximal top of the clavicle, and we experienced about 8% cases of late clavicle fracture. We realized that Doi was laying the muscle directly on top of the clavicle and securing it with sutures or drill holes or suture anchors, and when we switched to that, we no longer had any fractures. We also found that that position of the muscle, rather deep, often caused some kinking of the vessels, and we had, again, a rather high rate of initial failure in our first few cases. We very seldom get a failure now, simply because the muscle is laying on the top superficial surface of the clavicle and acromion. And then, again, the loss of the skin island we used to see occasionally, but not since we have begun carefully using adductor fascia on both sides of the skin. So just remember those points. We fixed the clavicle to the acromion with sutures and to the clavicle with suture anchors, usually two anchors and one suture. The vascular repairs are to the thoracoacromial trunk and cephalic vein, and we typically will use a spinal accessory nerve if it's available for the muscle transfer. We found that it, although both intercostals and spinal accessory work, the spinal accessory has much more voluntary control and more graded control of contraction strength. The intercostals tend to be an all-or-none contraction that looks very unnatural and probably doesn't function as well. Both reintervate in about five months in this report from our earlier experience, and we found that recovery was about equal at that time with spinal accessory and intercostals. And again, as Scott said, it takes about two years to get to maximum strength. We use it for elbow flexion when occasionally in trauma where the biceps is unreconstructable. We avoid using it for grasp if someone has a stiff hand and a supple elbow. We usually will, we found that we simply can't get useful grasp in that scenario, even with capsulotomies, and we'll limit our surgery to elbow flexion. Because we were following the dictum of the double fascicular transfer for elbow, thinking that two functions must be better. If we could do a gracilis plus something for biceps, we must be doing better. And I'll talk about that in a second. It didn't pan out to be true. And the gracilis is clearly indicated when you can't do a nerve graft. Nerve grafting does not work, or nerve transfers, when patients are beyond 9 to 12 months post-injury. And in those cases, your only options are free gracilis flaps. Andres Maldonado did a study with our group on patients who had intercostal to biceps or gracilis flaps, and interestingly, we found that gracilis flaps performed better than nerve transfers of intercostal or spinal accessory to biceps. Sixty-eight percent of our gracilis flaps were at least M3 or 4. Many of those cases Scott was just showing I would grade as M2. They had elbow flexion, but it was incomplete against gravity. Direct intercostal nerve transfers to the biceps that Tsuyama and Hara described years ago in Japan, only 42 percent of our patients M3 or M4. This was significantly different, and now we will always do a gracilis for elbow flexion rather than that sort of transfer. If you have an incomplete injury and you can transfer ulnar nerve to gracilis, of course that is the way to go. That's a very good procedure. And then are two things for elbow flexion better than a free muscle alone? Surprisingly also in this study by Maldonado, 65 cases in which about half had gracilis and half had gracilis plus something else, usually a nerve transfer to biceps. There was no statistical difference. One interesting thing we did find was that if we did a gracilis for finger flexion, we got stronger elbow flexion than if we did it for elbow alone. This goes against the dictum that you want to have one muscle, one function, and we asked ourselves how that could possibly be the case. What we discovered was that it seems to be a question of the insertion point of the gracilis. If it's more distal on the forearm, you'll have a longer lever arm and a more efficient elbow flexion. And so nowadays we're tending to attach gracilis for elbow flexion alone directly to the brachioradialis tendon with its more distal attachment. As long as we have an adequate pulley at the elbow, we believe this will likely get us better strength in the end. And grasp function, it remains challenging. You've seen the case that Scott showed with a little trace of elbow flexion or finger flexion. The contralateral C7 in our experience has not been successful. And the other options for grasp are a single or a double functioning muscle. We did 61 contralateral C7s and this was my best result. This guy, believe it or not, is 12 years old. He's a monster of a 12-year-old. But he's going to show you that's what he could do with his contralateral C7. And Doi does the double free muscle. This is a younger version of me with Dr. Doi with two stages, a gracilis for elbow flexion and finger or wrist extension and a second one for finger flexion. Doi reported 96% satisfactory elbow flexion and 65% prehension success, which he defined as 30 degrees of total active motion of the fingers, which isn't much. And we reviewed our cases. At that time in 2004, we had done seven and some had at least 30 degrees of total active motion. This is one of those people. You can see how his first gracilis works. And here you can see how he uses, can do the other for grasp. He ultimately did have to have a wrist fusion because Doi's technique for finger extension didn't control his wrist. He doesn't actually use the hand very much, though. And this shows what we do now with a single muscle and later wrist fusion and thumb position fusions. He doesn't sing very well, but he was able to demonstrate some success. Nevertheless, I think we're disappointed with grasp, I have to say. And I think the near future, we're going to be looking at other things. Alex Shin is interested in prosthetic fitting. And it may well be, whoops, I don't want to hear that again. At any rate, I'll close by just saying that at this point, we're interested in combining free gracilis flaps and later prosthetic fitting for grasp. We'll see how that works out. Thank you. Thank you, Alan, so much. Now I would like to call my associate, Luke Nicholson, to take podiums no more than 12 minutes. All right, great. Thank you, Dr. Stavanovich. It's certainly a privilege to stand up here with this podium. I'm on faculty with Dr. Stavanovich and one of his junior partners, and I'm very grateful for his mentorship and all he's taught me, not the least of which is how to try and restore finger flexion with devastating injuries. So to that end, I will be presenting his cases and sprinkling in along the way some of the lessons that I've picked up from him. So beginning here, this is a child who had a supracondylar humerus fracture with a missed compartment syndrome and a Volkman contracture. These are images showing attempted extension and flexion. You can see that he's predominantly flexing through his intrinsics and not with his extrinsic finger flexors. And so he was indicated for a free functional muscle transfer. One of the important first steps is an aggressive first debridement of all devitalized tissues, and in this case, a median nerve reconstruction, after which the first lesson here is the anatomically appropriate origin and insertion for the functional gracilis. This is a schematic demonstrating that for finger flexion. You're going to want to insert it or originate it at the medial condyle and insert it into the FTP tendons distally. Here's a video demonstrating this. And one of the things that I picked up from him is that this is not a distal biceps reconstruction. You're not using a number 5 fiber wire to try to gain as much strength as possible. It's a very fine suture. You're just trying to get it to sit on top there and then let the scarring process allow it to gain your strength over time. This is what that looks like after insetting. And then distally is going to get to the next important point, which is appropriate tensioning. You've already heard about the importance of every 5 centimeters placing a suture to understand your tension when you transfer the muscle. In addition, how do you position the fingers? One thing I've learned from Dr. Stavanovich when you're doing radial nerve tendon transfers is you want to make it a little tighter than you expect. But it's a little bit different for a free functional muscle. He actually does it with the fingers fully extended. And that's to prevent flexion contracture from forming, which he's had in the past. So one tip that may not be obvious. So this is this patient's result at one year. You can see finger extension, finger flexion, independent opposition of the digits. And at two years, a good functional outcome. Here's a video showing this. One important point that he'll highlight for children is the need to maintain extension splinting at night until full skeletal maturity to make sure they don't develop a flexion contracture. The second case is also a Volckman contracture following a miscompartment syndrome from a supracondylar humerus. This is a patient who came in with an extrinsic finger flexion contracture. You see in the left-hand picture, both hands are flexing. And the right-hand picture, the right hand is trying to extend, but it can't. And this is the passive mobilization showing the same thing. It's going the wrong way here. So the first step in treating this patient is obviously going to be a flexor origin slide. Here's the result after the flexor origin slide and a video demonstrating it. If you ask me, this is a pretty good result, but I'm not Milan Stavanovich, so this patient gets a free functional gracilis. What he will mention about this video is that the size of the skin paddle is smaller than he uses now. So this is prior to the understanding of that fascia contribution to the ability to get a much larger skin paddle. These videos have already been shown, but this is from this case and demonstrates the importance of splitting the gracilis for independent FTP and FPL function. This is done on the table through selective fascicular identification and their innervation into two portions of the gracilis. One is about 2 3rds, one is about 1 3rd of the size. This is a schematic showing the same thing. In the bottom picture, you see the FPL as a separate muscle tendon unit from the rest of the finger flexors. And this is this patient's excellent results here a year later, independent opposition with that thumb and a video showing that. I believe this patient also had an EIP opponents plasty because of their median nerve deficit. All right, the third case, another Volkman contracture. This one I highlight to illustrate the need for the wide fascia and how big you can make the skin flap. So you can see the really huge amount of tissue that's taken with that investing fascia and that's necessary for the wide zone of debridement for this case. You've already heard Dr. Stojanovic mention the muscle in a bag, we call it the burrito. It's really one nice big muscle that has a nice fascial gliding surface and insets quite nicely into the form. This is this patient at one year, six years. And again at six years. The other thing that you don't see here but also illustrates the importance of dedication to your patients. Dr. Stojanovic got these videos in Las Vegas where he traveled to find this patient and these are taken in front of a hotel in Las Vegas. Second to last case here is a case of finger extension. This is a sad case, it's a graduate student who was using IV drugs and injecting into his forearm, had osteomyelitis which was treated with aggressive debridement and IV antibiotics and a temporizing split thickness skin graft. Once he cleared his infection, he was indicated for reconstructive options and as you may expect, the options in this type of a scenario are doing a gracilis or doing a flap for dorsal coverage and tendon transfers. I might expect, and I had a case recently where I did this where a flap in the tendon transfers is a little bit easier but again, I'm not Milan Stojanovic so this patient also gets a functional gracilis. This is the PIN dissection shown here. This is again that wide swath of fascia. and also had an FCU to ECRB tendon transfer for. So, with that said, the last case is my first foray into free functional muscle transfer. It's a case I did with one of our plastic surgery colleagues, a 57-year-old who noted a mass in his forearm after a rotator cuff repair and, unfortunately, was found to have an extra skeletal osteosarcoma. He elected for limb salvage with a free functional muscle transfer, and this is demonstrating his on-table appearance, a pretty large tumor. His median nerve was spared. His ulnar nerve was sacrificed. This is the on-table appearance after the flap. You can see I tensioned the index a little bit too much relative to the other digits. Unfortunately, he did get some congestion distally, which led to some distal flat necrosis, and I still haven't heard the end of it that I didn't take enough fascia, but I was able to debride that portion and get what appeared to be a good cosmetic result. I saw him in about six months, and he seemed to be getting some extrinsic flexion, and I was excited to get his case to show a video, but this really highlights the last point, which is that this is a complex surgery, but these are even more complex patients. Unfortunately, this patient did have a recurrence and is now scheduled for an above-elbow amputation. So with that said, I just wanted to end with a slide that I stole from Dr. Stavanovich, which is a quote from William Arthur Ward that the mediocre teacher tells, the good teacher explains, the superior teacher demonstrates, and the great teacher inspires, and he always includes his mentor, and I think it's appropriate since I get to present your cases today that I include you. Thank you for all you do. Thank you. Thank you, Luke, so much. You have a great future. My two associates now, Dr. Rachel LaFerbe, will show you our new jump for the emergency reconstruction of the finger flexion extension. Okay, Rachel. Okay, so thank you so much for allowing me to be a part of this panel, truly humbled to be up here with these surgeons. So I have to give a lot of credit, of course, to Dr. Stavanovich, but I'm going to talk about our experience at our institution about acute functional form reconstruction. So this can be a really powerful tool if you have a patient who has both a soft tissue deficit and a functional deficit, and using this tool acutely can give you coverage and also can help restore function for the patient. So I'll show that with a few cases. This is one of our patients who's a 16-year-old. He had a ballistic injury, initially treated at another hospital. He had radius fracture fixation at that hospital, had fasciotomies because he had an acute compartment syndrome. Unfortunately, related to the ballistic injury, he was incarcerated and did not have follow-up for weeks, and so when he came back to the hospital, had a very serious infection. So he underwent multiple debridements. This is what the dorsal side looked like, and this was the volar wound after multiple debridements, and it had been stabilized temporarily with a wound vac. This is a patient who did not have viable extrinsic finger flexors, you can see on the top here, and the FPL tendon is there with really no functional muscle belly that was left. So we treated the underlying infection with help from our infectious disease team. We removed the intramedullary fixation in the radius and placed an antibiotic-coated plate for the radius for fixation, but were left with a really significant soft tissue defect, and so this patient underwent a free functional muscle transfer with a gracilis, showing here the enveloping fascia, the investing fascia. You can see on the top, other speakers have alluded to this, but one of Dr. Stevanovich's techniques that he's passed on and teaches us about is these silk sutures that are spaced at 5 centimeters out when you're in the thigh. We do it before dividing the origin and the insertion so that you can try to recreate that proper tension, the function for the muscle when you transfer it into the recipient site. We take it with the investing fascia, so it's a large incision, but able to be primarily closed and we usually close over a few drains. In this case, because we had thumb and fingers, we used the splitting of the tendon, as other people have referred to. We split that tendon so that we had something going to the long flexor for the thumb and for the long flexor also going to the fingers. So this is the patient about a year after the surgery. Radius fracture has healed, infection has completely cleared, and the patient has pretty good functional motion. This was a patient who was interested in a little bit of recontouring later on in the forum, which I think is a good functional success. You can see here his pinch strength coming up regularly, 11, 12 pounds on his pinch. This is another case. This is Dr. Stavanovich's case that floors me every time. This is a patient he treated in his 50s who had an amputation with an industrial accident. So in addition, unfortunately, to the amputation, he had a significant crush injury and so the flexor and extensor muscles in the forearm were very badly damaged and mostly lost. So Dr. Stavanovich replanted this. So there's the vascular reconstruction. He grafted median and ulnar nerves, but unfortunately you can still see there's quite a bit of soft tissue loss. The tendons for the long finger flexors and the FPL have been isolated out, but we have a coverage problem and then there's also a functional deficit in terms of not having any muscle. So Dr. Stavanovich's style is to do a double gracilis, both for coverage and also for function. Here's his patient on the table, and then this is the outcome. So being able to use it as a helper hand I think is tremendous. Here in a lot of settings this may have resulted in an amputation for a patient. There's something that can actually function for him. It's incredible. In the last case I'll show you guys, this is a 40-year-old who was injured in an ATV injury. So he had an open both bone forearm fracture and he had a median nerve injury that was dense when he presented. And again, initially went to a different hospital. He was treated there by the orthopedic surgeons with IND and with plate fixation of his fractures. Unfortunately, he also developed an infection and then transferred his care to our institution. So this is what it looked like when he showed up. We had this open wound. There's unhealthy desiccated tendon and there's median nerve that's exposed inside of this wound in the forearm. So again, a multidisciplinary approach with our infectious disease colleagues. Debridement taking out all of this non-viable muscle. You can see it's got that white unhealthy appearance. And the median nerve that had a dense sensory and motor palsy was also very badly damaged. So in our operative treatment, we had revision, open reduction, internal fixation. An antibiotic spacer was placed into the radius for the infection and also for the traumatic bone loss. And the necrotic and the infected muscles were also debrided. So this was the revision fixation. And then we also had to reconstruct the median nerve. So we used a cabled serral nerve autograft to reconstruct 25 centimeters of the median nerve that was badly damaged as part of the trauma. We isolate out the finger flexors that you can see in the photo here. And then took a free functional gracilis. So this was to acutely cover the soft tissue defect and also try to restore some function for the patient. Interoperatively, we use nerve stimulation to try to separate out the portions of the nerve so that we can try to divide the two tendons. You can see the gracilis tendon being divided to try to independently power thumb flexion and finger flexion. So this is what it looked like before the free flap for coverage and for function. And this is it later with it marked out. We also used a skin graft as part of this case to complete the coverage. One of the things that I've learned from Dr. Stavanovich is that that surgery may not be the final surgery for the patient. So this one had an antibiotic spacer in. So we went back for bone grafting later. And the patient went on to heal that fracture beautifully. And the patient also went back to the operating room to have a tenolysis at the junction of the tendons between the gracilis and the FTP and the FPL juncture. Afterwards is about a year and a half afterwards. The patient has improving median nerve sensation but has protective sensation with that long nerve graft and has really tremendous function. He's got his opposition, his palmar abduction of the thumb is back too with that nerve graft. And here you can see him. He has excellent opposition. He has good wrist flexion and extension and really has a tremendous ability to get finger flexion from this. His pinch strength is great. So again, coming about to, you know, 11, 12 pounds with his pinch repeatedly. And this is what the donor site looks like from the thigh. So a really big incision wide surgical exposure but a cosmetically acceptable result. One of the things that was really important to this patient is that he was a police officer in our local L.A. police department. He was heavily motivated to get back to work. So you can see him pulling the slide. That's with the hand that has the free functional gracilis. Getting ready to take his shots. I think this has some impressive kickback but he has passed his shooting test and back on the force. And maybe even more impressive as part of his job he has to be able to use larger weapons. So here he is showing us that he can shoot. So, learning from Dr. Stavanovich, I'll echo some of the things that Dr. Nicholson said. The things that I've learned and continue to learn from Dr. Stavanovich is that carefully tensioning it will really optimize the functional outcome. And sometimes re-tensioning it or doing a tenolysis at the juncture between the gracilis and the recipient site tendons can be helpful. Specifically for the finger flexion, it's important to consider if there are adhesions at the level of the fingers as well. And sometimes that tenolysis can help improve the outcomes. I've also learned from Dr. Stavanovich that taking the investing fascia will reliably support a larger skin paddle, and especially in some of these acute cases where you have a large deficit you need to cover, that can be key. And having that additional venous outflow, Dr. Levin also talked about this, from the saphenous vein in the leg can help you avoid congestion in the flap. Also I think patient selection is key. These are complex cases. The patient has to be invested and understand that it's a long process. And we're really grateful to work with our tremendous hand therapists at USC who really customize the approach for these patients. I can't thank Dr. Stavanovich enough for everything that he does for us and for his patients. He knows no bounds. Thank you. Thank you. Thank you, Rachel. You know, my life is very easy now, Alan. I'm only babysitting the young attendees. You know, I don't do anything, you know. They do all of this job, and 90% of it is done by two of them. So I'm very lucky, you know, it's a very lucky Boys Fellowship Program. So now we are having about five, ten minutes for the questions. How many of you would go home and do the functional gracilis without dissecting and so on? Only two? Three, four, five? That's very good. You know, so on. You really need to go to the morgue, and you need to dissect the gracilis. You need to dissect the recipient side. It takes a lot of exercise, you know. You can make one mistake, and, you know, but, you know, you never gave up, because everything is possible, as you can see now. So what Rachel said, we suffered a long time to have it survive this big skin, but after we took it, it greatly softened us. No problems after that. So any questions? Yes, sir. For Dr. Bishop, you mentioned that you got better outcomes for the functional biceps if you got the spinal accessory nerve instead of the intercostal nerves. Will that mean that maybe it's because how many intercostal nerves you have? As much as three, two, four? Actually, two intercostal nerves are sufficient to satisfy the diameter of the major, of the obturator nerve branch. So you think it's related to that? No, I don't. I think you have a much more voluntarily controllable muscle, or nerve, with the spinal accessory. And Alex is, I don't know if he's published it yet, but he did, Alex Shin did a study. We asked our patients to look at a force display on an oscilloscope and try to vary the amount of force in a stepwise fashion from a little to moderate to a high level of contraction, and then go back down again. They could do it. Everybody with a spinal accessory could do it. Nobody with intercostals could. It was basically full on. How about the tension? I mean. That's what I'm talking about. The tension on the clavicle, will it reach the same way if you've got the intercostals and other? Yeah, nothing changes with the tendons. It's just the muscle. There's nothing wrong with intercostals. If you need to use them, you need to use them. And we often have to because we have nothing else, or we use spinal accessory for another purpose. Right. But, yes. Thank you. If you have a choice, I would use spinal accessory. Thank you very much for your question. Any other questions? If not, I want you to go. What is the name of the blues tonight for the party, and we have a nice time. So enjoy your meeting here. Thank you very much for coming here to share with us our experience.

functional muscle transfer

reconstructive surgery

indication

patient selection

harvesting the muscle

nerve considerations

successful outcomes

finger flexion

elbow flexion

forearm reconstruction