this rashard Degas today I'm discussing
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the anterior interosseous to hona nerve
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transfer or the so-called supercharged
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transfer here we're diagramming jion's
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canal you can see the hook of the hamate
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in the pisiform in this patient we're
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releasing jion's canal and then
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extending our incision approximately
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this is a patient who had a laceration
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in the forum with the ulnar nerve repair
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but now at six months continues to have
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difficulty with sensory and motor
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function we'll extend our incision
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distally starting against here's a
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burner incision across the wrist joint
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and then we'll extend our incision
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volley and radially to try and
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incorporate our visualization of the
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pronator quadratus here any of ask
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crossing the vessels are cauterized you
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can see here here's the FCU tendon the
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FCU tendon is opened on its radial side
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and then as extent things dissection is
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descended distally this allows for
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visualization of the ulnar nerve here
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and then careful dissection distally
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towards jion's canal you can see proper
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visualization of the nerve also note
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that the the artery is radial to the
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nerve as we send this lee in here into
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jion's canal this portion is released
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again following the nerve and neural
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icing throughout some hypothenar
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musculature is is identified and
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retracted and we can see the different
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areas of jion's canal and as we extend
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further distally we can see the
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bifurcation of the nerve
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any crossing vessels are cauterized at
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this point and now we can see as the
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deep motor branch has begun to take off
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and the sensory branches is now heading
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distally well now extend our incision
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approximately in a curvilinear type
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fashion to get towards the midline with
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this we're now dissecting and again
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dissecting RFC you ownerle we've
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identified our digital flexors and now
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deep tart digital flexors we're
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attempting to identify the pronator
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quadratus at its proximal edge here the
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pronator quadratus is now visualized
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interesting in this patient he had also
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had an open reduction internal fixation
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of his distal radius with elevation of
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his pronator quadratus approximately
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there was no evidence of disruption here
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we can see the anterior osseous nerve as
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it enters the muscle itself we're
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dissecting now distally the nerve into
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the muscle belly of the pronator
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quadratus we're using cautery to help
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remove the muscle and separate we're now
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further releasing the muscle here again
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with care taken throughout to preserve
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the nerve you can see here the nervous
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being skeletonized
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at this point our goal is to obtain as
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much length as possible so that we can
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transfer the nerve as distal as possible
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here we're elevating the nerve and
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separating it from any vascular
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structures and the caliber of the nerve
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is noted here to be higher than we
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suspected the nerve is in transected you
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can see the muscles response to nerve
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transection will now maintain that in
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the field and now - now we're dissecting
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on the ulnar nerve
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we're knowing that the sensory branch as
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well as the ulnar branches can be
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neuralyzed
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and here our goal is to neural ice the
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motor branch which is a which is here
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illustrated on the dorsum with a nerve
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we're now using microscopic instruments
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here for further neural Isis
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our goal at this point is is to provide
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additional impulses with the anterior
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osseous nerve as the nerve repair
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approximately had been confirmed by
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recent electromyography we're now doing
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nerve stimulation with our goal trying
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to assess the motor portion versus the
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sensory we're now simulating the sensory
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portion we saw no motor response now
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using an I know nylon suture and the
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microscope we're now planning to
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approximate the anterior interosseous
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nerve in an in decide manner into the
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motor portion of the ulnar nerve care is
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taken here to ensure that there is not
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significant tension at the repair site
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three sutures are placed and at the
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conclusion we ensure that there is no
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excessive tension with wrist range of
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motion the the O one is an irrigated the
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skin is closed using a thrill Vicryl for
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the subcutaneous tissues and then thrill
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nylon and interrupted mattress type
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fashion for the skin patient is placed
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in a dorsal bloc splint splint is kept
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in place until suture removal