in a second, and the game plan today is to review tendon transfers for brachial plexus from shoulder to hand. We will modify the order a little bit and have Dr. Alassane speak at the end because this portion is the largest, so we'll just start with elbow, then do hand, and then end off with shoulder. I'll do a quick little introduction on the principles of tendon transfers, and then we'll get going on the talks. We have Eric Wagner from Emory, Dr. Alassane from Boston, and Mary Ellen will be here from Lyon, France, in which she gets here in a couple minutes. So to get started here, we'll overview brachial plexus injuries, timing of intervention, principles of tendon transfers, and current concepts in tendon transfers. So based on the level of injury, that's pretty much what's going to end up with your type of things you'll need to restore function. So if you have a total plexus injury, a flail arm obviously, but if it's just hand involvement, that will kind of focus your tendon transfers on the hand. As far as what to do with these injuries when they show up to your office, focus on understanding the anatomy, recognizing the type of injury it was, the mechanism of injury, as well as the exam. That's usually the critical portion of it, and understanding if it's a complete or incomplete type of injury, whether you're going to be monitoring it, and how long you'll monitor based on the type of injury it was, the mechanism of injury, and the extent of the injury. And as far as the diagnostic testing, I think it's important to do EMG at, you know, the 2-3 month mark, as well as a CT myelogram to understand the root involvement, and whether you have avulsions. And I think that's gonna help guide you, whether you do it earlier or later, your nerve transfers or tendon transfers. As far as, you know, a lot of, oftentimes now, for the primary treatment for brachial plexus injuries early on, there's more and more interest in nerve transfers, so as far as nerve reconstruction. So it's, I think, immediate nerve repair or grafting is done in cases where you have a sharp laceration, iatrogenic injury, you find that you have a progressing deficit, secondary potential to hematoma, that would drive you to go to do that surgery quicker than just waiting and seeing how things work out. For early surgical intervention, between three and six weeks, if you identify a patient who has a total plexus injury, that's very high energy, you could consider doing a nerve type of procedure, a tendon transfer procedure, if you suspect that there will be no recovery in the long run, particularly if your imaging shows nerve revulsions. So for more routine surgical intervention from a nerve transfer standpoint or a nerve repair standpoint, typically, in my practice, happens closer to six months. You watch these patients and watch their exam closely and see what's coming back, what's not coming back. You know, EMG, I think, is deceiving. Sometimes they'll show a little bit of renervation, but the, you know, for example, deltoid or rotator cuff is totally flail and not working at six months, then I think at that point you consider doing a nerve transfer or a tendon transfer, if that's kind of your preference. And again, in the more delayed situations, if you're really encouraged with how things are progressing and have a strong suspicion that it will return, but as you get close to a 12-month mark, you don't have the strength you're looking for, you could do either supercharge or, again, augment with the tendon transfer. And then these are the patients that we're kind of more focused on today, these late presenters who are out of the window for a nerve transfer after the 12-month mark, where the motor end plates and the muscle are pretty much gone at that point and not amenable to nerve renervation, I should say. So things you consider are free functional muscle transfers, joints fusions or tendon transfers, and obviously one of the most important things with these patients is pain management. So principles of tendon transfers, it's important to consider this when you exhausted all non-operative management, you're pretty much convinced that there'll be no further recovery spontaneously. And then at that point, you're thinking about reconstructive options for either the shoulder, elbow, or a hand or all. And again, the important key thing here is you can't do a tendon transfer if the joint's stiff. So pretty much you have to make sure that you work with OT immediately to mobilize the joints because that's pretty much going to be the downfall of your procedure. If you don't have any, you have motion before your procedure, you're not going to have it after. And then I think it's critical to have these patients understand what to expect. Because you're doing a fancy nerve transfer, tendon transfer, it doesn't mean that their shoulder is going to act normally. So I think having them understand that before you put them through this, you know, three to six month to 12 month recovery, or in some nerve transfers, three years, I think they have to understand it won't be perfect. So these are just the overall overarching principles of tendon transfers. I always go through these individually. So again, prevention, correction, contractures. Prevention is better, obviously, but if you find yourself in a situation where you have a tight elbow or tight shoulder doing a release with therapy prior to doing your procedure is very important. So tissue equilibrium, again, if you're in a trauma situation with tons of scarring, wounds, I think it's very important to wait for all the scars to mature, for the wounds to heal, and then for the tissues to basically get back to a state where it's safe to put a tendon through there so it doesn't just scar and your procedure fails. So again, important here is adequate strength. So if you're transferring a tendon, like a palmaris, for example, for wrist extension, you probably won't be very successful. So making sure that your donor is going to be powerful enough to basically create function because you know your transfer is going to weaken by a grade at least. So to have that strength before your transfer is important, particularly in muscles that are just recovering from a nerve injury standpoint. They're just healing and patients are getting more and more strength. You have to wait long enough for that transfer to be actually effective. Amplitude of motion, I think it's important to understand the excursion of the tendon you're transferring. So the general thumb is 3, 5, 7 centimeters for the wrist flexors, extensors, wrist extensors, EPL, and wrist finger flexors respectively. And again, this is proportional to the length of individual muscle fibers. I think it's critical to think about your line of pull. If you zigzag your transfer and put it through tissues, that's going to eventually work its way through planes to kind of reproduce that straight line of pull and your transfer will loosen up and weaken and not be so effective. So again, think about the vectors and what you're trying to achieve with your transfer. Again, one tendon, one function. You won't be transferring, you know, for example, in the wrist a tendon to recreate both flexion and extension of the wrist. This won't work. It'll just basically work primarily where you do it tighter and the other function that you're hoping for is going to fail. It is important to consider that one transfer can power multiple tendons like the FCRTDC. That's something that you could get from a single transfer. Synergism is an important concept. So you think about wrist tenodesis, you know, when you flex your wrist, you get wrist finger extension. I think if you think along those lines, moving like an FCR to EDC, I think that's something that will augment your success with that transfer. Again, important to use an expendable donor. So if you have a cut ECRB, you should probably consider not taking the ECRL where you're going to really weaken the function that you're transferring. It's going to create one problem for another. You switch one problem for another. So don't do that. And again, moving on to just quickly here, advances in tendon transfers. We're going to go through each of the more advances in each area, but for just overarching themes here, you know, tendon transfers are something that you could improve upon, but it's hard to create more tendon transfers because there's only a certain amount of tendons to begin with. So that's not going to change. The things that you could change are improving the way you sew them together. You're going to see a couple papers on that in a second here. And optimizing existing transfers like Elisan's work of actually thinking about the vectors and improving the function of the transfer and kind of reproducing the original function of the muscle you're trying to restore. So these are just three studies here in a row that just shows you the type of work that's coming out with tendon transfers. However, you're not so much reinventing in Dr. Elisan's situation. Sometimes you are, but in most of these studies, you're not. You're just trying to improve what you're doing. These studies compare pulvoteft weave to side-to-side repairs, and in all three studies, they demonstrated that you could reproduce a stronger repair with less bulk with a side-to-side repair. And then this is just one example of Dr. Elisan's work, trying to kind of rethink what you're actually doing with the transfer to better reproduce the original anatomy. All right, so let's introduce Eric here. He's going to start with the elbow portion, and Mary Ellen will walk here in a minute. Amazing, thank you. So Mary and I are going to sort of set the stage for BOSSUM later on. Part of this goal, at least from the elbow standpoint, I think there's been some beautiful talks earlier on in the Plexus section, both yesterday as well as coming up tomorrow, on how to evaluate and how to treat it from a nerve standpoint, how to treat from a free-functional gracilis standpoint. I'm going to touch briefly on that stuff, but I'm really going to focus more on some other ways that we have approached it, at least at Emory, and some other ways that BOSSUM have taught me to kind of think outside the box for some of these injuries. So disclosures, none are relevant to this presentation. So elbow functional loss is something that's not talked about as much as hand or shoulder, but I do think it's very important. I do think it's very relevant, whether it's trying to reach your mouth, whether it's trying to push up from wheelchairs or just push up from the bed. I do think patients have significant limitations. We'd like to focus on the shoulder. We like to focus on the hand because that's what patients often notice, but the elbow is also a really critical part of a loss of function, particularly in patients with these upper trunk or extended upper trunk injuries. In general, we went through this. There's different options to treat these, to work them up. I'm not really gonna spend a lot of time talking about that stuff. It's also important, and I've seen many patients with loss of elbow function from Parsonage-Turner, or at least it seems like it's from Parsonage-Turner, something to consider. You know, you have the viral respiratory illness usually that precedes it, but not always. The two most common presentations I see is an upper trunk or scapula, but the upper trunk, interesting enough, the elbow is one of the more prominent ones that patients initially notice. The other thing you have to, that's interesting to think about, or at least to pay attention to, some of the trick motions that some of these plexus patients can have. They can use their brachioradialis to flex their elbow, or at least appear that they can flex their elbow. Usually, this is putting the forearm in neutral versus supination. Not able to flex in supination, but with their neutral slight pronation, they are able to flex, and that's sort of a trick motion that if you pay attention to, that you'll see that they can trick you a little bit on. The Steinler effect is also an important one. So you flex the fingers, flex the forearm, and kind of are really using that flexor pronator mass to actually flex the forearm a little bit. And so in this case, what you do is you have them supinate and take out this to see if there's a difference between that finger flexion and forearm pronation. And then the reverse Steinler effect, this is something that I think is fascinating because it's something you don't think about as much, but when they extend their wrist, how they can sort of optimize the flexion in this kind of cool way. So these are some pictures of this reverse Steinler effect. So you can see how they're really flexing the wrist and the fingers, and it does appear like there actually is elbow flexion. If you prevent the wrist from doing this, you lose that ability. And so they really don't actually have functional elbow function. Even though it looks like they do, it's not really functional, it's not really meaningful. And so it's kind of an interesting trick that ones with especially more chronic injuries will present with. So some of the the triple S transfers you're going to hear about shortly, and we're going to sort of open the stage for this. And if you haven't already heard Bossom talk, your mind's about to be blown. But we're going to talk a little bit about some of the other ones that are maybe not as triple S, but I think also are important to understand and learn about. So nerve transfers, there's lots of options. Oberlin, McKinnon have really helped us to improve the ability to treat these in the acute setting. Single versus double Oberlin, intercostal versus the Oberlin transfers. There's all kinds of debate, there's all kinds of interesting studies on this. Western versus Eastern, you know, lots of considerations happen. The thing that happens though is not everybody gets back or they present too late for these problems. And so when that happens, that's when you start considering about other options. I'm going to briefly talk about the free functional gracilis, but I do want to talk about some of the other options, either if the patient doesn't want the free functional muscle or for whatever reason that's not an option. The bipolar latissimus is something that we've done and had some nice success with. I don't have experience with the unipolar, I do think the bipolar is a bit easier for it to reach. The triceps and biceps is something that's more for tetraplegia, but is reasonable. The sinoflexibility doesn't work as well and really is kind of a last-ditch option, but is something. And the free functional gracilis I think is a mainstay for a large portion of patients with elbow flexion. But if you look at outcomes of the bipolar latissimus, you can get pretty reasonable anti-gravity function with this. It's not gonna be strong, but it'll be anti-gravity. Similar if you look at the results of the free functional muscles, there's actually not a huge difference. Not to say that you should do these over the bipolar, but I do think this is a reasonable thing to consider and a reasonable thing to sort of keep in your armamentarium. As overall from a technical standpoint, it's not actually that difficult of an operation. So unfortunately, my video on the bipolar latissimus, because of our OR lights, certain ORs have these terrible lights. And so my video on it, I realized when I was putting this together, is terrible. So I can't show you. I apologize. I'm gonna use these pictures. But basically, you just harvest the latissimus just like you're doing a latissimus transfer or a latissimus flap. It's very easy, very relatively quick harvest. And then you're going to isolate the pedicle and then around the pedicle, that's where you are going to do your rotation. You don't have to do a massive incision. I do think having skin ridges and doing subcutaneous tunnels really helps. You can see how you sort of flip it and then eventually have the latissimus origin insertion, where you're going to tie the latissimus origin into that distal biceps tendon. I do think, as has been shown with free-functioning grossosis, tying into the actual tendon itself and not into the finger flexors probably gives you a little bit better elbow flexion strength. But you'll see the the length of the muscle is almost perfect. And you don't actually have to tension as much as you think you would in these. And so you can get a really nice tension. That's one of the more challenging things on these tendon transfers. This one, you don't have to tension as much as some of the other ones, like for the radial extensors on the wrist. Other options, the Steiner flexor has been published on really a more traditional one, something not as done as much anymore. Triceps, biceps, you can get reasonable outcome. Obviously you're going to compromise your elbow extension. This is sort of a last-ditch option for you. And then the free-functioning grossosis. So Dr. Zielinski, Dr. Greave are two of my colleagues who really drive this at Emory. I've helped Dr. Greave on some of them. But it's something that I think is a really powerful transfer. Outcomes overall are very similar to the bipolar dissonance. But in general, the donor site morbidity is very little. And people do quite well. Obviously higher BMI, no matter what you're doing, is to be more challenging, whether it's the shoulder or the elbow. In general, though, people get back to grade three, grade four relatively predictably with the free-functioning grossosis. And Alex Shen has done a nice job of demonstrating how to do this in a minimally invasive technique, where you can use a couple sort of perconcisions, as Boston's going to show you in some of the shoulder transfers. And being able to harvest the grossosis in this sort of minimally invasive approach. And then eventually plugging it in and tying it into the biceps. There's been studies on the biceps versus the finger flexors. Not really relevant to this, but I do think the biceps tendon has shown pretty reliably to produce better elbow flexion, or I say elbow flexion. So elbow extension is one of the ones I think that's interesting that's not talked about too much. For those of you who have listened to Alan Palachowicz or Peter Rhee, you know, the posterior deltoid is a very interesting option for this in tetraplegia. There are nerve transfers for the triceps. This also is not talked about as much. Intercostals is one of the options. You theoretically could do a latissimus. I've not done this, but you could do a latissimus. And this was in the setting of a tumor where they use a latissimus with a skin paddle to reconstruct that tumor. Posterior deltoids was talked about in tetraplegia a lot. Makes sense, but if you have a posterior cord injury that or that posterior deltoid is not an option, which is the patients that we, I deal with a lot and have seen a lot and have shared with some of my colleagues who do tetraplegia as well as plexus, then and or they need more power than posterior deltoid can provide, this trapezius transfer is a beautiful operation and generally something that I first learned from Bossom, but others have sort of also popularized. And it's a really nice, powerful, powerful extender and it's outside the plexus. So you're gonna have it as an option for a variety of patients. This is just to show you one of the original descriptions, elevating that strip of fascia, you know, dissecting it, leaving it on its medial border and then rotating it over and eventually sewing it into that distal triceps tendon. And you can see how you can kind of pulvert half-weave it just like you would with some of the wrist tendon transfers. This is sort of another maximally invasive approach that they showed that you can see how they've kind of prolonging it with lumbar fascia. And I'm going to show you a quick technique art video and some pictures that I've done that Bossom, when I spent my time with him, taught me how to do this both for a shoulder as well as for elbow. So you can see in general, the lower trapezius is a huge long muscle. You don't have to do a massive incision. You can do a very small, not very small, but you can do relatively small incision. So you spare a little bit of the of the scar tissue and the issues from it. You can prolong it with some lumbar fascia, as you can kind of see here. And then you can mobilize it, mobilize it back to its insertion on the spine of the scapula. And then you can see you get pretty long length. So then you can transfer to the other shoulder or you can transfer to the elbow. So this is just a quick, a couple minute video showing the two incision technique. Lots of fat in the back, especially if you live in Georgia and I guess Minnesota as well. So it's really important, just like you're doing with a lot of these, to excise out a bunch of fat. First, you can actually start seeing some tissue planes. Now you can kind of see the muscle belly of the lower trapezius. So I've isolated that. I'm starting to define where that inferior border of the muscle belly comes in. I'm obviously being careful because your ribs are right below you. The fascia of your spine is also right next to you. And then once you've started to find that, and once you bring it down to the lumbar fascia, you want to go as distal as possible until the lumbar fascia really, really thins out. And then you start bringing it back. And you can sort of dissect it back, as you can see, lifting it up. And you're pretty safe here. The pedicle is very far north. So right here, there's really not a lot of danger. Maybe if you're plunging too deep, there might be some danger. But in general, elevating that muscle is not so difficult. So then you do your second incision and then you can sort of start connecting the two, working back and forth between the two incisions, and then eventually getting all the way back to its insertion on the scapula, on the medial bora scapula. So then you want to kind of mobilize as much as you can back to its insertion. And then once you're getting back to this point, that's when you want to start being a little bit careful for the pedicle. I do like, in this case, to find the pedicle and at least have an idea where it is. So then when I'm doing the transfer, I'll have an idea if there is some tension on it. Once again, getting rid of adhesions, getting rid of any fat that's around there, and then mobilizing as much as possible to then either transfer it to the elbow or if you're going to do a contralateral trapezius, to the shoulder, to the shoulder. You can just do a basic pullover taff weave. I'll do a pullover taff weave and I'll do a running baseball stitch on each side. So I have kind of two different ones or four different strands of sutures coming through it. And then you can see the mobilization you can get with this muscle. So you can see you can stretch it pretty far, you have a pretty long muscle belly, and this kind of just shows my taking, one, how long that muscle belly is, two, and all the different places you can make it reach. So this kind of shows, once again, how much muscle link you can get with this and how easily you can make it reach down into the elbow. So final considerations, it really depends on the patient's goal. There's lots of options. Hopefully you see some of the options that maybe you haven't heard about. Maybe you have, but maybe you've learned a little bit more about some of these options. And I know it's not as, it's not the triple S talk that my mentor and friend is going to teach you in a second, but hopefully at least opens your eyes. So free functional griseus I still think is a great one. I think it's a great option. People do well with it. Bipolar autism, it should not be something that's forgotten. It does work. We've had some nice success with it in getting back into gravity, elbow, and then the lower trapezius I absolutely love. I would argue it does much better than the posterior deltoid, even in tetraplegia. But for for brachial plexus injuries that you need the elbow extension, it's a beautiful transfer. You can get lots and lots of extrusion. It's just not talked about very much. So hopefully if anything, you can you can take it away from this. It's that that's a very reasonable and functional option. So thanks for time. Feel free to reach out to me and Joe. Thank you very much for the opportunity. Thank you, Joe and Eric, that was great, that was sexy, in fact, it was really nice, I click on it, right, it's thinking, so as it's thinking, it's just like, I was, I was gonna, philosophical question, like when we think about muscles and how they function around the body, why the pectoralis major has the shape that it has, why the trapezius has the shape it has, this is only a philosophical question, so if we took the trapezius and put it instead of the pect, how would it look like? It look very weird, so I think, two things, number one, the human body is amazing, because you can flip things around, it still work, number two, philosophically, each muscle is meant to be in one location to do certain function, but that muscle, if you try to reorient it, it's like any other muscle in the body, it can make it to function well, and this is why over the years, like I feel, tendon transfer in general, other than for the wrist, for the shoulder, it had bad reputation for years and years and years, until like we try to study it more biomechanically, anatomically, everything else, and eventually, we're able to come up with a better solution that's probably in the past did not work, did not work as well as now, but anyway, I do feel as long as you understand the principle of the muscle transfer, the type of muscle transfer, you're safe for the nerve and vessels, you know how to tension it, you know how to immobilize it, you know how to rehab it, I think you can still obtain a fairly good function of the shoulder with a tendon transfer, it's still loading, right, close, okay. So great, so I, and my history with this is like, I always try to put Alan Bishop picture because I came to Mayo and he told me like, Bassem, what can we do for these patients? So they were able to get elbow flexions for these brachial plexus, but also as Eric mentioned, in the Midwest, we have a lot of fluffy patients, so whenever they flex, they get stuck on their belly and for female, they get stuck on their breast, and what can we do for them? This is how we started this story, like to try what we can do to improve these patients. But we go back to some of the stuff both Joe and Eric talked about, like the shoulder, this is a tricky part about the shoulder compared to knee or compared to the wrist, because wrist, I know it's not completely by axial, but it's almost like you have flexion extension is the main axis, but the shoulder is complex because even now, shoulder surgeon look at the shoulder as scapula is independent of the glenohumeral joint, while in fact, it's all one unit, completely, completely one unit. And this will make it more tricky because we think, okay, shoulder is moving, rotator cuff deltoid, while in reality, you have trapezius, serratus, levator, everything's working at the same time as one unit. So this is why you have to understand it very well to be able to manage it. And this quote, I always put it for Albert Einstein, if you can't simply explain it simply, you don't understand it well enough. So the shoulder girdle is not a glenohumeral joint. The shoulder girdle is three joint, one articulation. Any problem with any of these is going to cause you problem in the shoulder. And you need muscle that work around all of these to allow the shoulder function to work. And this is like, I've put it so many times in my presentation, but with that, it's still kind of forgotten. There are 14 muscles that move the shoulder and stabilize the shoulder. But if you subdivide them, which means let's say the deltoid, you say anterior, middle, posterior, deltoid. If you want to say trapezius, upper, middle, or trapezius, you have 20 parts of muscle moving the shoulder, okay? And they have a different innervation. For the residents before, some of you are resident, but I know maybe none, they ask all the time about ITE, their innervation and stuff like this. The area that has really become tricky, because of so much subspecialization right now, a hand surgeon will be, if you tell them, go to this kind of accessory, or even serratus, they're comfortable, or plastic surgeon. Shoulder surgeon, don't put them in the back of the shoulder. Most of them, they don't want to deal with it. If you tell them, well, put the glenoid, posterior glenoid reconstruction, this is, you put them anterior, they're comfortable. This is their comfort zone. They sit there, and that's it. This is their mecca, they want to do it there. They want to do it there, that's it. But realistically, the shoulder is this whole unit. So this posterior part is the part that we spend a lot of time on to also try to improve it. So the scapula is the shoulder. Let's keep on talking more and more about it. And at the Mayo Clinic, I was very fortunate, me and Eric and Joe, but we spend a lot of time on anatomy, biomechanics, to try to understand the shoulder very well, and the vectors very well, because when you talk tendon transfer, what's tricky about it, you cannot just put the scapula. Yesterday, remember, in the lab, yesterday we have an amazing lab, by the way, done by the Hand Society, and it was tendon transfer and nerve transfer like half day. But we had, everyone had specimen which is like scapula and arm, except for the shoulder, they have the hemitorso. Because you want to show latissimus, trapezius, all of the stuff, you cannot do it just from scapula. This is the whole unit, the chest and everything else. So this is what we spend a lot of time studying. The simplest, simplest way to say it is, you need a stable scapula, number one. If it's unstable, it's not going to work. You need to have a stable glenohumeral joint, which means you need the rotator cuff that will keep the shoulder stable for the deltoid to act very, very well. That's very, very simple. And all of them will act as one unit. So if you need to have a very good function of the shoulder, you need to have a stable glenohumeral, and you need scapulothoracic motion with stable muscle around them to keep it on the chest and moving to have a very good motion. And this is, this is first time I present, in fact, in France. I was thinking about it also theoretically. This is the shoulder, by the way, like when you think about it, yesterday we spoke about it in the lab as well. When you take the scapula out here, that is the rotator cuff. So when you say anterior and posterior rotator cuff, please remember anterior and posterior with respect to what? What are we talking about? That's, that's the rotator cuff. Everything is in this block of bone. So when we say anterior and posterior, we're talking about anterior and posterior with respect to the chest. So please don't forget this. When we talk about tendon transfer, conceptually over the year, they say, yeah, the subscap is anterior, you need to transfer the pect, because it's anterior. It is very, very wrong because all the rotator cuff are sitting on the scapula, which is the house of the rotator cuff. And that scapula is sitting on the posterior chest. So everything is posterior. And it is this block of bone holding everything. And at one time I thought theoretically, why the scapula is on the posterior chest? Like, why is it not in the mid axilla? Why don't have the scapula in the front of the chest? Did anyone ask this question before? Why? Really? But then I thought about it, because if the chest is not like that hollow shape, if it's more flat, maybe you can put it in the front. It doesn't matter. Because this is how you, if you put Legos, this is what you do. You put them and they move them everywhere. But because it's only one ax. But when you have this kind of hollow shape, like this ballet shape, I feel the most ideal position of the scapula on the chest will be posterior. And these muscles are oriented to be able to move the scapula in the best way possible and have this very amazing motion of the shoulder. And for when you talk about the scapula, which is the shoulder, but that the scapula, you have six muscles that work on the scapula that move it and stabilize it. There are two massive ones that are incredibly important and we don't spend time looking at them. It's Serratus anterior and the trapezius. Serratus, I'm not very sure how many of you in this room have seen the Serratus other than, you know, have seen it. Yeah, like I can see some hands. Exactly. So, but if you are in a, uh, I'm not sure how many of you are shoulder specialists, like really shoulder. How many in the room? Yeah. So except if you are shoulders, if you're shoulder specialists, by the way, you don't see the Serratus. Very uncommon, except if your practice mandate to do some kind of flaps or looking into it or you do some muscle transfer. Otherwise, Serratus is, you examine it indirectly. All the example of the Serratus are indirect and you don't do it. You don't see it, but it is a massive muscle coming from the chest, attaching to the scapula and stabilizing. Very important. And the trapezius as well is very important. So because for the sake of time, like I cannot present everything today, but, uh, as I spoke to Joe and Eric, I'm going to try to at least summarize, uh, some of these, because this will take a lot, a lot of time. When the Serratus is not functional, this is the shoulder is not functional. You can have a beautiful deltoid, amazing rotator cuff, normal brachial plexus, but the patient can be really, really limited in function because the scapula will be unstable. We have session later today. We're going to talk about the pain from the scapula. I'm going to talk more about exams. So what do we do if the Serratus is paralyzed? The most important function of the Serratus is to stabilize the scapula on the chest wall. So what will be the muscle transfer of choice? As Joe talked about, and Eric talked about, you need a muscle that has, this is what we spoke about this morning, like earlier, like the pec transfer is meant to be on the chest. But if you look at the fibers, the fibers that are, if you look at the fiber of the pec and fiber of the Serratus, they're very, very close to one another. By the way, the Serratus is more medial. This is more, sorry, more lateral. This is more medial. The insertion of the Serratus is all on the medial scapula. The insertion of the pectoralis is on the humerus. So if we cheat and say, okay, well, this is very close to the Serratus origin. Let's change the insertion and change it from here to here. It will become like a Serratus. And in turn, when it comes to tension and excursion in terms of strengths and shortening, they're very similar. So it will make it an ideal transfer. So, and a lot of technique about it. My preference, and this is what, what modified is anytime you can take a tendon with a piece of bone to transfer it, it will be ideal. So we usually, we separate the clavicular from the external head. I do detach the clavicular head and suture it to repair it later. We take the external head with piece of bone and usually it has a small twist in it. We untwist it and we pass it from the front to the back to mimic. You can see where they are. This is here the back. This is Serratus. They're very close. So, but now we're going to try to cheat and put it here on the distal scapula to stabilize the scapula and become like a Serratus. And because we created the hole, the bony at the bony insertion, we can attach the clavicular head in it. And now this is the new construct. This is a new anatomy that the body has to learn. And this is a very quick video. This is, again, we don't do big incision, small incision. This is external head. We do an oscillating saw or a pencil tip burr to get it out. You can see the twist in the tendon. You kind of untwist it because it's not going to affect any neurovascular. They're all medial. We give you more length. You expose the distal scapula and then they breathe it. And you put a lot of suture. I do usually five double number two orthocort sutures. And this is, this is a passage. The passage is going to be from anterior to posterior deep. The only thing you can injure is long thoracic nerve, which is already injured. So you're not going to injure anything else. But don't go through the chest. Don't aim it down on the chest. I had one time one fellow did this. I'm not going to say who. They're not in this room. Don't worry. So because they told me, have you ever had pneumothorax from this? I said, never. And it happened that day. So just make sure, like, it's very easy. But don't poke it down. Go out. Anyway, and this is how you attach it. And because the clavicular head is reattached and intact, if you look anterior, it looks as if you haven't done anything. So and for those of you who have done rupture of the pectoralis repair, this is why if you open, if you don't, respectfully, if you don't know the anatomy very well, you're going to go in and see everything is normal. Because the sternal head is deep to the clavicular head. If you don't pull the clavicular head to look down, you don't see the rupture. So the rupture usually is deep. This is why now we transferred fully the sternal head. You look at it as this normal delto-pectoral interval. And because it's bone-to-bone healing, usually the patient, you can start to move them very well after you get the CT scan to confirm healing. And we've done more than 250 of these over the years. Now I do them much less because I am realizing there's more and more over-diagnosis of the serratus paralysis. But for the right patient, they do exceptionally, exceptionally well if you get the diagnosis correct. And you do it for them. And they do extremely well. Trapezius paralysis is more tricky, especially for the residents and the fellows, because the diagnosis is tricky. And I don't do medial, I don't talk about medial lateral winging. I think this is extremely, extremely confusing. This is why many times when you have a true trapezius paralysis, you don't see like big time stem or scapulothoracic abnormal motion. Most of the time when they present, they have an abnormal motion, but it's no big quote unquote winging of the scapula of the chest. Because it's drooping, the trapezius droop down. The serratus is still functional. And many times it keeps the scapula on the chest wall. And this one, I was asked yesterday by one of you just to do the exam. So that's quickly the exam because it's tricky. When you look from the back, look what happened. When you retract against resistance, the distal tip of the scapula comes close to the spine in the paralyzed trapezius. In the normal trapezius, it does not. It goes slightly more laterally. And regardless, the trapezius will be covering it. That's very, very important. Number one, okay? That's number one. You see it all the time. Number two, if you look at the alignment, they always have a drooping anterior tilt. Not only droop, droop and anterior tilt. Number three is when they try to abduct their weak in the scapula plane. So if you do a, also this we call the SFRT. This is a new test. I'm going to talk about it later today. If you flex against resistance at 30, 60, and 100, this is how you determine whether the serratus is paralyzed or not. Usually, if the scapula wing of the chest at 30 and 60, but negative at 100, it means serratus is normal. So you can see now, this is SFRT at 30. It's winging out, out, and then boom, at 100, she's stable. It means serratus is normal. Why do they do this? Because the pectomander pulled them forward. Number four, or number three, or number four, anyway, they're very weak in abduction. Because in abduction, by the way, you don't engage pect and latissimus as much. So when you put the scapula this way, you have the rotator cuff. You need to have a very stable scapula on the chest wall to keep it in place. If it's not stable, they're going to be very weak. They're going to drop. And this is very common also in the exam, see, they drop. But in the scapula plane anterior, they don't do as much. Now, the last one is this one. This is also a big mistake that I've seen it over and over. The serratus is normal. It means the scapula is sitting on the chest. It means the scapula compression test that all of you know, it will not help with the motion. So not every patient have, quote unquote, the stem. You do scapula compression test, it's going to work. I'll show you. I'll prove this to you. Why? Because the scapula is on the chest, is held stable by the serratus. The trapezius, when it's paralyzed, the scapula is down and anterior tilt. So we need to reverse this abnormality. This is compression. She's not improving. You reposition it because she's drooping down. Now she's abducting. So there are two tests. The scapula compression is for serratus paralysis. Scapular repositioning is for the trapezius paralysis. Okay. And for this one, we change. I do not, I don't think the Eden Lang procedure is a good procedure biomechanically because we're trying to stabilize the scapula on the chest wall. So we change the Eden Lang to a triple tendon transfer because the outcome has been very variable. And in fact, the first person who told me, JP Warner, he told me, like, I tried them. They don't work. And because biomechanically, I don't think it makes sense. This one is okay. These two are not. I showed you in the exam during retraction against resistance. The scapula go medially. You need to go lateral. And now you're taking two muscles instead of helping the scapula to protract, you're helping them even more to retract close to the chest, which is not supposed to be. With the help of OJD Werthel, our friends, Eric know him very well and his friends, we did the biomechanical and kinematic study. And we showed, like, our triple transfer is much better. With the triple transfer, we're mimicking, again, the trapezius. We're moving the medial muscles and we're lateralizing them. Remember, the trapezius is attached to the acromion and spine, not the body of the scapula. So instead of doing what the Eden Lang they do and they attach it on the body, you take this one, you lateralize more the levator scapulae to put the rhomboid boundary next to it and the rhomboid measure next to it. Now, all of this around the spine is exactly like a trapezius. And this is, again, a very quick video. This is an inverted L incision. We do it very often for rachial plexus and for this kind of surgeries. And you can see the salmon color, a paralyzed trapezius. Once you go deeper, you start to see the rotator cuff here. And you can see this very nice red color of normal muscles. Now, you put the hand behind the back, you pull the scapula down, and you start to expose each muscle. Levator scapulae, rhomboid minor, and rhomboid measure. And we start to attach them with piece of bone. These, they don't have tendons. Don't try to attach them without piece of bone, because they're going to shred. So you attach each one of them separately, and you put them on a suture. And the dorsal scapula nerve, usually around here. Now, we do a lot of dorsal scapula nerve arthroscopic decompression. In fact, Eric, I have to show you this. And it is really more than two centimeter medial to the spine. And now, we expose the spine. We go from the posterior acromion or medial acromion. And we do four double suture for the levator, two for the rhomboid minor, and four double suture for the rhomboid major. A lot of sutures. Why? Because the three muscles are going to hold the whole weight of the arm. So this is the levator scapulae lateralized, rhomboid minor. And we fish mouth the rhomboid major so that, because it's a broad, the proximal part, you put it proximal, and distal part, you do the distal. If you look at the anatomy now, this looks like a trapezius. And this is why this patient, the patient really do very, very well. This patient is 16 years old, I think. And he had an absent trapezius at birth. So he did not have, really, flexion or abduction. We did it for him. And this is him one year after surgery. And I have some, I have, like, I was lucky because some of these patients came back. This is patient eight years, also an absent trapezius. We did it for him. And he is doing extremely well. This is another one, eight years, again, after surgery. She's doing great. This patient, COVID time, everyone send you videos. Like, he wants to go to army. He's very mortified because he had, I think, personage turner syndrome from COVID. He had no trapezius. We did it for him. He's sending me videos. He was able to go back. He was able to be in the army. And he was very happy. This is a video for him, showing me, like, his motion. And the most important, he wants to make sure, like this, you can see the triple transfer here. And he was able to do a push-up. And he was, like, showing off about it. He was happy about it. So this is for the right patients. Really, it's a home-run surgery. It's fantastic surgery. Now, Joe, how long do I have? I just want to make sure, because I don't want to overtake the time. OK. So for the brachial plexus, I'm going to summarize quickly what do we do for them. Because I always emphasize in the brachial plexus the importance of the rotator cuff versus deltoid. When you don't have anything, the shoulder subluxate. If the rotator cuff are torn, this is what we deal with, pseudo-paralytic shoulder, which looks like paralysis, but not, because rotator cuff are torn. If the deltoid is working, if paralyzed, the rotator cuff is working, you can have a great motion, but you have fatigue. So this is why we try to focus on the reconstruction of the rotator cuff. I always say, in brachial plexus, you try to get something moving. But you cannot have a very nice, sexy car, because you don't have muscles. You have to try to use what you have. So what's available? I'm going to tell you what we usually use right now. Lower trapezius is our working horse for shoulder external rotation brachial plexus. That's the main transfer we use right now. This is the very first one in 2007, by the way. It's a big incision for the brachial plexus. And now we do it the same, but we do, yesterday, I showed it in the lab as well. If you expose the infraspinatus, you can do a direct transfer of the lower trapezius to infraspinatus and brachial plexus, because they don't have rotator cuff tear. And this, I have to put this one, because in the Midwest, you have to do fluffy classification, we call it, depending on the size of the patient, because we're worried whether they're going to do better or not. The BF is beyond fluffy when the height and width are the same. These are very troublesome. And we noticed that if you do them, even though they're harder to immobilize, but even for fluffy three and four, they still do very, very well. Of course, the fluffy zeros, they're great. So this is the external rotation. Now, the problem always is inferior subluxation and lack of rotation and, of course, elevation. All of these muscles we came up with, middle upper trapezius transfer, levator scapulae transfer, levator scapulae transfer, anterior upper serratus transfer, and for the deltoid, pedicle latissimus or pedicle pectoralis. And then at one time, I thought, maybe we have to reconstruct everything. And this is really one of the cases. And I was mistaken. It is like, you don't need to do all of this because it does not work. Like, you're just adding more and more muscle transfer for the same function. And this is our proof. Like, this is a paper we published very early on. Maybe it has been now 10 years. And we did all of the transfer. What we noticed with the outcome, they have stable shoulder external rotation, but minimal flexion and abduction. So we don't have to do all these transfers. So now, how do we manage this problem? I call it the three transfer of the triple transfer. This way, Eric Wagner will be not upset. So lower trap for infraspinatus, upper and middle trap for shoulder stabilization. And because you transfer all the trapezius, you take the levator scapulae to the spine of the scapula for stabilization of the scapula. This, we call it a three muscle transfer. This is our working horse for shoulder stabilization external rotation. So this is upper middle trapezius. This is lower trapezius. This is levator scapulae. So the levator scapulae, we take it to stabilize the scapula because we are lateralizing all the rotator cuff, all the trapezius. Lower trapezius for the infraspinatus, upper middle trapezius for shoulder stabilization. So what this will give you, it will give you a stable shoulder with good external rotation and stable scapula. I usually use Tenoglide. I don't have a financial interest with them. Just, it will decrease the scarring when you pass the trapezius on top of the acromion. And this is what you get. You get a stable shoulder. Patient now much more functional. They're able to do external rotation. They don't have as much flexion or abduction. But usually, you'll be able to get this kind of function. And patients who have weak elbow at Mayo, they use the Mayo Elbow Pro just to get them elbow flexion. You do the three muscle transfer, now they're much more functional. They can external rotate the shoulder and they have stable shoulder to be able to use their Mayo Elbow Pro. And what Eric talked about is I just want to show you this amazing muscle. I am a really very good friend with the trapezius for a long period of time. But I'll show you why. This is the origin and this is my artist. He's amazing. So you can take the origin and you can transfer it to the contralateral side or you can, what Eric showed, very elegantly transfer it to the elbow. So, and this is a very quick video. We used to do a big long incision, but now we don't do it. It's double incision. For the contralateral transfer, when you don't have trapezius, you have spinal access in your transfer. We take the distal origin of the lower trapezius with this fascia. And if you have paralyzed, like you're doing it for this reason, you can take also the opposite side as well because you can augment it because you don't have trapezius on the opposite side. And then you can take it from the proximal part and you can transfer it directly. You have a lot of length as Eric talked about and you can transfer it. And this is what you get. You get patient who have functional external rotation, like we had nothing before. This is another patient. You can see like this. I've done it a long time ago. Look at my hair. It was much shorter. And they get much better functional shoulder and external rotation. This is another patient who have done it this way. The last few minutes is going to talk about what to do for shoulder flexion. We do a pedicle pect. The first pedicle pect, we did it on this patient. The very first patient had the lower trapezius on. He had no external rotation and he likes to drink. So I usually, he wanted to drink with his right arm. We get him lower trapezius. Now he's very happy. He wants to get something for shoulder flexion. We did for him the pedicle pect transfer, which I don't have time to show. But essentially you take, this is a paralyzed deltoid. You elevate the pect and you flip it. Yesterday we showed it in the lab as well. You flip it on, it is pedicle and you attach it on the clavicle. You flip it 180 degrees. Now this is what I like to do. Now this is what I told you. Now the horizontal line become vertical line. So a doctor become a flexor and you attach it distally and it become like a deltoid. If you look at it, look at like a deltoid. And this is a patient 10 years after lower trapezius and pedicle pectoralis transfer. And you can see he has a flexion around maybe 1900 degrees and he have external rotation still maintained after 10 years. This is another patient. He's upper trunk and he's also pedicle pect, lower trapezius transfer and he's done very well. And if not, the other alternative pedicle latissimus, we're gonna pass it from posterior to anterior and flip it. We showed it in the lab yesterday as well. And this is one of the first patient I've done it on. She've done extremely well. And then I saw her in one of the meeting in San Diego and she wanted to show me six years after surgery how she was doing. Thank you very much. Sorry, I was running through this one. I appreciate it. Thank you. So good morning, everyone, and thank you to the kind invitation. I'm really pleased to be here with such amazing surgeons. So this is my topic. You've seen very elegantly the shoulder and the elbow, now about the hand. This is the outline. And we will follow three different scenario, the C81, C7 to T1, and the total brachial plexus palsy. First of all, the circumstances. Usually patients came to you after a primary failed nerve reconstruction or presenting after one year. We need to restore wrist stabilization, but we will consider in the interest of time. It is not the main topic today. We will focus on the figure's flexion extension and hand intrinsic function. The prerequisite, it was probably mentioned before, but the key question is, are there muscles available for transfer? And for this, we need muscles with at least M3 plus strength and an expandable muscle. This is the sheet we used to follow into the unit. And some muscle transfer roles. Just to remind us, we need a single new action, a pedicle preservation, donor muscle expandability, we used to forget that, adequate, of course, joint passive motion, and a direct line of pull with a good galleon. We know from different MRI study that there is no concern about the brain adaptation, which is absolutely fantastic with the tendon transfer. Another reminding, the Blick's curve. I know by some of you like it, and we have to remember not to put too much tension on our transfer, otherwise we go on the second part of the Blick's curve, and it's only about tenodesis effect, but not muscle contraction. We also have to remind Brent on the whole what he learned for us with the relative tension and the potential excursion of those muscles. The surgical strategy, usually we operate on this patient between 18 to 24 months after the palsy, and the timing is as follows. First, restoring fingers and thumb flexion, and six months after that, we can take care of the extension. So the surgical strategy, if you are only on a C8 T1 palsy, you can restore fingers flexion with either brachioradialis, ETRL, or brachialis. If you have plus C7 palsy for the extension, it will be more about either free gracilis reinervated with tendon transfer or a tenodesis, and the complete brachial plexus palsy is really different because, of course, before, we have to take care of the elbow to get some flexion to stabilize the shoulder, the wrist, and the thumb, and then we can restore finger flexion with either fascia latae or free gracilis reinervated. We will go to those different techniques. So first, our favorite technique is to transfer the ETRL onto the flexor tendon. With a single lateral incision, we can identify the ETRL. We can suture together the FDP, and then we pass the ETRL through the anterosseous membrane, and we can fix with either pulvertaf or direct suture to the FDP. And those are things to restore thumb flexion through the same lateral incision. You can harvest very distally the brachioradialis. You identify the FPL. You can see it's a very easy way, and then you can suture the brachioradialis to the FPL. Of course, it is not an ideal transfer because we know that the extrusion of the brachioradialis is not as good as the FPL, and you can perform the several pulvertaf suture to have a stronger fixation. The modify-making technique can help us to have a better thumb opposition by translocating the FPL between the IP and then performing an IP arthrodesis. This is the outcomes we can expect by combining the ETRL to FDP and brachioradialis to FPL. It's small series, as usual, with this patient. You can see the pulp-to-palm distance was two centimeter with the cap and G at three, and an acceptable K-pitch and grip strength. An alternative can be to use the brachioradialis transfer to the FDP and FPL to FPL with, again, a small series, but a finger flexion between M3 and M4. And Bertoli showed this technique by harvesting the brachialis muscle and extending with an FCR onto the flexor tendons. With this technique, about six patients at follow-up of one year, they achieved for all the patients a lateral K-pinch and a hook grasp with the pulp-to-palm distance between one and two centimeters. For the intrinsic function, of course, there is the usual zoncoli lasso technique, but an alternative can be a tenodesis of the FDS to the A1 pulley with the MCP at 30 degrees of flexion. Now, considering the extension, so six months after this procedure for the flexion, once the patient had a good grab, you can go to the extension. The point is we need to preserve the ECRL for active wrist extension, and the pronator teres for active pronation. So we will go more to the tenodesis procedure. So for that, of course, we need an active wrist flexion. This is the technique we use in the unit. It's a fixation of the extensor to around the retinaculum, so you cut the extensor as proximal as possible, and then you flip around the retinaculum, and you can see when you pull on it, you have extension of the MCP. Then you perform a usual tendon suture. We lack non-absorbable suture, and this is while you are flexing the wrist, you can see extension of the MCP. There are other fixation for this tenodesis, either to the radius or through the interosseous membrane to the FDS. You can see that there are different results. For the radius, you need to have a wrist at 30 degrees of friction to achieve extension of the MCP, and for the FDS, it's more flexion. Another option, it's hybrid between tendon transfer and nerve transfer described by Bertoli. You use the free gracilis transfer, reinnervated with the supinator, and you can achieve, in this very small study of three patients, 100% of extension between M3 and M4, but of course, it's not the same procedure. Now, the third scenario, a complex palsy. Of course, we said that before, we need to take care, especially of the elbow, we need to achieve at least M4 flexion of the elbow by nerve transfer. Then we stabilize the shoulder, the wrist, and the thumb, and we can think about restoring active finger flexion. This is another hybrid transfer, nerve transfer and tendon transfer, using the gracilis to the FDP. You have, of course, to select very carefully those patients that had active motion, and if you have a weak wrist extensor, you can use the brachioradialis to reinforce extension of the wrist. You can see there were a great digits range of motion at 100 degrees, and the gracilis recovered between M4 and M5 strength. Another option from the French team, described by Oberlin and Goubier, almost at the same time, is to transfer the fascialata between your strong biceps to the finger flexors. For this, of course, you need at least M3 plus or M4 biceps strength on the full passive finger's range of motion. This is their early surgery. You can see the biceps in all patients was M4, and they achieved a good grip strength, I mean, acceptable grip strength on the 55 degrees of digits range of motion. This is a patient we operated on in the unit. After performing the nerve transfer between the IC and the muscular cutaneous, we achieved a good elbow flexion. Then we stabilized with glenomaral arthrodesis, and then we stabilized the wrist and the thumb, and you can see the patient at one year follow-up. In summary, of course, you have, first, to deal with the patient, what they are expecting for, and then considering that, and considering there is no other nerve procedure to be done, these are the three different scenario you can follow for this patient. Thank you very much. Thank you.

tendon transfers

brachial plexus injuries

shoulder

elbow

hand

function restoration

stability

diagnosis

treatment timing