Good morning, everyone. So I'd like to start by wishing Mike and the Aussies good luck in the smackdown on Friday against the Women All-Stars. We're not hiding to nothing. I'm expecting some beer either before or afterwards. I'm not really sure when it's going to occur. So my task is to talk about brachial plexus birth poly selected surgical technique. It's kind of an interesting topic, really. It gave me free reign to talk about virtually anything. So I thought what I would talk about is what I consider doable operations, meaning those of us that do tons of plexus is one camp, but a lot of us do some plexus, right? Not tons of it. So I'd rather pick what's doable rather than what's difficult. And just like David has hypothesized and said is that these total lesions, when there's all these avulsions, I think that operation is really hard. I think it's incredibly difficult. We actually have this little ritual before we start, regardless of your religion or sex, we say a little quiet prayer for exons. Because you all know when you do a case and there's three ruptured roots and you have a global lesion, you're going to have an adequate outcome. You do one and there's one root, it's just a bad day. And then you end up taking ericostyls on a baby and you're like, you're cursed and all those kinds of things. I just think that those operations are too difficult. I think an upper plexus is totally doable also, but a global plexus, I'm not sure. So what I'm going to talk about really, or what I think are doable, and I think nerve transfers are doable. I think they can be done by a competent surgeon that's comfortable with nerve surgery. Why? Because the anatomy is normal. You're not messing with the plexus, there's no subclavian artery, there's no lung, there's nothing in the way. And I think they're versatile, and I'm going to run through a couple of these. So for elbow flexion, your recipients are biceps and brachialis, and your donors are ulnar or median. Simple. They're right in the same field, it's a medial arm incision, there's no scar. All of us can find the muscutaneous nerve, all of us can find the ulnar nerve and median nerve. And then you're going to do one or two transfers, meaning you're going to transfer just the biceps, or you may be a double nerve transfer, one to the biceps, one to the brachialis. Because remember, ulnar motor is C8 and T1, median motor is primarily C8 and T1. So anybody that has a lower trunk function that's working is appropriate for this type of transfer, for elbow flexion. How's it done? I'm just going to run through the technique. It doesn't take long. So it's a medial arm incision, again, with normal anatomy. And through the medial arm incision, you find the muscutaneous nerve. Often the biceps is a little bit stimulatable, if you can't find it, look up, it's stuck under the biceps. And then you're going to find the ulnar nerve, you want to try and find the FCU branch, because elbow flexion with FCU is synergistic with FCU function. When you flex your elbow, you tend to fire FCU. And you're going to isolate this little teeny fascicle, usually the ulnar nerve has three group fascicles, and then you transfer it. That's the operation, right? And you can suture it or glue, I'm a gluer, I don't suture anymore, there's no tension. And then if you want to do it for the brachialis, you just go more distally, you find your other donor, whether it's median or ulnar, and you do the same transfer. And I think that's really doable operation. Now pearls, pearls are don't panic. And I do most of my operation now with Dan Z, so if one of them is panicking, the other one's not panicking. Because if sometimes you can't find the muscutaneous nerve, a couple things happen. Number one, it's up, it's under the biceps. Number two, the biceps is denervated, so it looks too chickeny, and you can't find it. And number three, there can be variable takeoffs from the M as you find the muscutaneous. If you just stay calm, you're going to find it. And I will always say is look up if you can't find it. Pearls, recite donor distal, recipient proximal 1,000 times before you cut the nerve, right? If you don't want to do it in the opposite direction, that would be a really bad day because then your ends won't meet, right? So donor distal, donor distal, donor distal, recipient proximal, okay, cut, and glue, all right? Now the results, right? And now this is interesting. And I think the tide is changing in pediatric plexus, just like the tide has changed in the adult plexus, meaning nerve transfers are a pretty cool operation and work fairly reliably. So this is myself, obviously, in Guatemala with my friend Francisco. We looked up, and this is Roger Cornwall over there with Kevin Little somewhere. And we looked up our results of nerve transfers for elbow flexion. And this is pending JBS publications. We had 31 patients who, and we looked up elbow flexion. The chances of an AMS, which is what Don went over, of greater than or equal to six was 87%. It's pretty good results. And the chances of a seven were 77%, right? And that's with one or two different transfers. And then at the same time, we had 24 patients that we looked up that had supination data. And the supination data wasn't as good. And AMS greater than or equal to six was in 21%. But in those that are ulnar and median, they had full supination, all of them, all five patients or whatever, right? So now we think that most likely one or two nerve transfers will give you adequate elbow flexion. But if you really want to push the supination, you probably want two nerve transfers, right? So it's a doable operation, and I think it's a worthy operation. And we're starting to do more and more and more, especially if isolated five, six injuries, leave the plexus alone and go elsewhere. But if you go elsewhere, you're going to have to reanimate the shoulder, right? So the shoulder has been another interesting dilemma. So we all started doing spinal accessories to suprascapular nerves from the front. And then we realized, at least in our practice and Malaysia's practice, they were OK at best. But the return of exonotation was unreliable, only occurred one third of the time. And then we realized, through a lot of contributions from a lot of people, that really the shoulder is different than the elbow. The elbow is a hinge, and reanimating one muscle is probably fine. The shoulder has a cuff and a deltoid, so we better go get both. So now the nerve transfer strategy is the recipients are the suprascapular and the axillary, and the donors are the spinal accessory and one of the branches of the radial nerve, whether it be the long head, lateral head, or medial head, I don't think it makes any difference, Now, I will tell you, I think this is more difficult. Why is it more difficult? And just like David said, we're not that comfortable yet coming from the back of the shoulder. You know, we're not used to doing it, but I think you will get used to it. Here's an example. This is clearly an adult, right? He was involved in an ATV accident. The reason I showed adult is because when you do it in a baby, it's really, really little, and it's really hard to see, right? And here's, this is an exam, decreased shoulder abduction. He actually had a spinal cord injury that resolved, he had a C1, C2 fixation, and then he was referred for a 5, 6 injury with a vulsions at 5 and 6. Here's lack of elbow flexion. Here's good strong elbow extension at C7, good strong trapezius function. Here he is with this asymmetric scapula winging because he had vulsions at 5 and 6, so his dorsal scapular nerve was not working. And here's his good wrist extension, and he can cross his fingers, so his lower trunk is working. Here's our surgical approach. We do it a little bit different than Susan described, and I think it's because we're just so comfortable in the axilla from the shoulder, which I'll show you next. But the spinal accessory, the suprascapular, is done from here, and we tend to do our radial to axillary through an axillary incision. It's just, again, whatever you're comfortable with. We go here so many times. We do dandas that we're just so much more comfortable here rather than that long incision down the posterior aspect, right? Find your suprascapular nerve going through your notch, right? Nice big nerve. And then you want to find your spinal accessory nerve, right? And then donor-distal, donor-distal, donor-distal, recipient-proximal, and then you want to cut and glue, right? That's not very difficult. And then through the axillary incision, again, it's hard to see in these pictures, but it's not that difficult. You want to find your radial nerve and axillary nerve. Remember, as you move more proximal into the arm, all your nerves kind of come together. So be careful. It may be your median, and it may be your ulnar. Make sure it's the right nerve. And then you're going to take your axillary nerve here, and you're just going to transfer, right? And then your arm exposure, in this case, we did a double transfer. So recipients were the muscutaneous nerve of the biceps, the muscutaneous nerve of the brachialis, and the donors were the ulnar and median, and I don't remember which way we did. I don't think it matters. And here's your double nerve transfer. And here he is one year later. Good elbow flexion, wonderful external rotation. Not so good shoulder motion, but be patient. Here he is at two years. Now he's able to learn to fire his elbow extension, which fires his deltoid, and now his shoulder range of motion is much better. I think that nerve transfer, just like certain tendon transfers, is a little bit harder for adults to learn. They've got to learn to fire their triceps, which then fires their deltoid, and then selectively learn how to fire their deltoid. It takes some time. Biofeedback works really well in the adolescents. There are some pearls, right? And the pearls are from the back, right? Your levator scapula is on the medial aspect of your scapula, and your omahyoid is directly adjacent to your notch. If you find your omahoid, just go a little bit more lateral, and you'll find your notch. Be careful, because everyone talks about, oh, there's the notch. Sometimes the notch is really hard and firm. You can't tell that's a ligament. It feels just like a bone. And then you'll see your artery going over and your nerve going under, and then you'll open it up. And again, just like the nerve transfer in the arm, don't panic. Take your time. We've made tons of mistakes. We thought the levator was the omahoid. We thought the omahoid was the levator scapula. Just stay calm, and you will find that nerve and be able to do that transfer. And I think that's a good one. Now, what's the results in babies? We don't know. We don't know the results of double transfer for shoulder reanimation from the posterior approach. I can tell you that one nerve transfer in our practice is not enough, in a Malaysia series is not enough. Two, I think, may be enough. So hopefully, we're going to combine our series again with our series with Francisco from Spain and the guys from Cincinnati Children, Roger and Kevin, and we'll have something for you hopefully by next year. Hopefully. I don't think it's going to be good as the biceps, but I think it will be okay. All right? Now, moving on to secondary surgery, we're going to talk really about the shoulder and forearm, and we're going to stick with what's doable operations. The shoulder imbalance that David talked about is rampant in kids with plexus, especially upper or 5, 6, 7 injuries. And they get deformity extremely early, extremely, extremely early, right? There are two ways to reduce the joints that's dysplastic. So when you have this joint in a kid that's 1 or 2, you can do an arthroscopic reduction, which we've done a lot of, but I don't also think that that's a quote-unquote doable operation for those that aren't accustomed with shoulder arthroscopy. But I am going to talk about open reduction, because I think open reduction is a fairly straightforward operation that can be done by those of us that are comfortable with shoulder anatomy. So open reduction. Here's a technique. So this child's in the lateral acutus position, which you'll see here in a second. We tend to position, and we put some marcaine and epi into the incision before we incise because shoulders always bleed. And the first thing you want to do is come down through the fascia by electrocordery, and you'll want to find the following four muscles. You want to find your latissimus dorsi, teres major, long head of your triceps, and posterior border of your deltoid, right? You want to put this retractor into the axial that's protecting the radial nerve. And then there's always this we call confusing fascia, because we have no other name for it. This confusing fascia resides over your lat teres, right? So we just cut it. It looks like it's something. It's never anything, right? And then once you incise that, then the anatomy becomes clear, right? So there's your long head of your triceps here. There's your teres major up above a little bit. Put a Penrose around, protect the axillary nerve, which is going to be deep. So now you have your lat teres tracing them into the humerus. You want to look behind the lat teres for the periosteum. There's axillary nerve. We call it the white stripe. I think we're typical orthopedics. We call nothing by what it should be called. It's classic. And then you want to release these tendons from the bone, right? You want to be careful of the axillary nerve that's in the axilla. This will show you the more anterior latissimus tendon. And then once they're released, you're going to transfer them superficial to the long head of the triceps. I use an insulated electrocordery so it doesn't fry the radial nerve. Dan Z uses a Kleiner to release the periosteum. And here's your tendons released here. And then you simply want to transfer them over the long head of the triceps, right? This is showing the open duction of the shoulder. So now you're going to… If you want to reduce the shoulder for your dysplasia, you want to find your circumflex scapular vessels here. So now the lat teres is up. In between your axillary nerve and your circumflex scapular vessels, you're going to find the joint. That's the subscap going up to the screen. There's a malleable retractor put into the subscap to retract it. And then you want to find your capsule. Now is the time to take your time in the operation. You don't want to enter the joint through the physis of the glenoid. That's bad. You want to enter the joint through the joint, right? So if you follow the long head of the triceps to the glenoid, then you'll pop right into the joint. Now once the joint's reduced, then you're going to transfer these tendons to the posterior humeral head to provide some humeral head depression and some external rotation, just like that. We use a modified arthroscopic technique to pull these tendons down, right, so you see them get pulled down to the bone. We use a non-absorbable suture. We don't use any suture anchors or anything like that. We just put the sutures right through the bone. So I think, let me come over here a second, there are pearls to isolate the joint. You want to find your circumflex scapular vessels, right, and you want to find your axillary vessels. You want to use the long head of the triceps to drop into the joint. And again, another very doable operation. From the results, can we obtain reduction, can we maintain reduction, can the joint remodel, and can reduction improve over time? And I think the answer to all these questions are yes. We can obtain joint reduction. We can maintain reduction. And the young kids can remodel, especially if they're younger than two, and reduction can improve motion. And these are just some results. I'm going to skip through this, right. I want to show you one more thing, and then I promise I'll step down, Michael. And one more doable operation, which I think is good to have, because Michael and David spoke about this, is that we have a really good remedy for fixed forms hypersupination, right. So the problem with kids with rachial plexus and the problem with kids with tetraplegia is they don't stop at 90 degrees of supination. They just keep going. They'll go 100, 110, 120 degrees. So they're so spun over, and the problem with being spun over is it's very dysfunctional for ADLs. So if you're spun over, the only reason you want to stay spun over are two reasons. Number one, you don't have wrist extension, because if you don't have wrist extension, you don't want to be in pronation, because your wrist will drop into flexion. The second thing, though, is if you use ocular afferent, meaning you don't have any sensibility. If you can't feel these kids' hands, if they can't feel their hands, don't put them in pronation. We see that all the time. Leave them in supination, because then they can at least see what's in their hand. If you put these kids in pronation, it's just like a club right down. Now I love this operation. So this is a kid with a rachial plexus palsy from Egypt, really spun over, what, 120 degrees? And the way we do this is we'll do a Vohler incision, curvy linear, or whatever curve you like. And then you want to find everything, right, like here. And then the key is, you want to cut the radius short and the ulna a little bit long. Right, I'll show you what I'm talking about. So here's your bones cut at different levels, right? No, your ulna is short and radius long, I got it backwards. So your radius is cut longer than your ulna. This is ulna, this is radius. And then when you fix these bones, this remnant of the radius acts as an onlay graft that's vascularized, right? And then you can put these arms wherever you want. And there's what you get when you're healed. The whole thing heals together because you've saved all that periosteum. So cut your radius a little bit longer than your ulna and use your proximal radius as an onlay graft. And they'll heal within six weeks. And they heal, everything heals together, especially if you maintain the periosteal sleeve. And the results are impressive. You can take a kid like this that's hypersupinated, but he has afferents from C5, C6, and he has wrist extension. And then you can spin him like that. Thank you very much. Thank you. Thank you, Scott. Now we've got 10 minutes for questions. Any questions from the audience? All right, so the question is about... Can I go, Mike? Please. The question is about glue, right? And I don't have any financial interest in glue. I use the Baxter to Seal product. I've used it since 2000, actually. If you look at the data, and it is all data-driven about glue versus suture in animals and humans, the results are exactly the same, right? The only difference is if there's some tension across your repair, suture's stronger in tension. So if you didn't cut your proximal, proximal enough or your distal, distal enough, and then you need a little bit of tension, I'll add a suture and then glue. But I can tell you, especially if you are training residents and fellows, glue is much less obtusive to the nerve. You just put it together, and then you just glue. And the other thing about glue that I learned from Howard Clark is that it comes in a syringe like epoxy, like, you know, the stuff you do in your bathroom. Don't do it like that because you have to keep changing the needle. Keep the two syringes separate and then do what we call drip, drip, drip, drip, drip, drip. And you don't have to keep changing that single syringe. Is that making sense, Michael? Yes. Yeah, and it's so much better. It's so much faster. Now, you may get some argument that it's an expensive product. It saves so much OR time, right? And then the last thing, and again, I have no financial interest. The smaller the nerve, like intercostals in a baby, the better the glue is. You know, you can glue and then transfer and then cut the glue and put them together. Even if there's a little bit of glue in between, it doesn't make a difference. Because it biodegrades. But I do encourage you to give it a try. And I think you'll find that your OR time is less, your results are probably the same, but your stress level is also much less because it's just easier to do. David, glue or suture? I have this debate with my partner in the clinic. He doesn't. He hates glue. But I use a combination of suture and glue. I tack it together with a few sutures on the outside and then make a little cuff with a, I think Scott Wolfe was talking about this, a little taco to produce a nice cylinder of coaptation. Donald? Combination. Nick Smith? I just have a question for Scott regarding the double nerve transfer for elbow flexion. Basically, timing. How long are you waiting for them to, before they get elbow flexion, given that you're not using elbow flexion as a barometer for latter shoulder function, it's just for elbow flexion? Do you know what I mean? No, I missed the question. Oh, I got it. Great question. So if you look at, and Roger, you can chime in if I don't have it right. If you look at the results of the combined series, after a year, the results went down precipitously. Now what we don't know, though, is what about those biceps that are partially innovative but give 30 or 40 degrees of elbow flexion. But in general, we would like to do it prior to a year, and after a year, that series, the results really did go down. But I do think, just like David said, we're all fixated about elbow flexion, all about this stuff. Sometimes it's just the injury pattern, and sometimes nerve regrowth only occurs down the posterior division, for example, which is going to give you shoulder, and not down the anterior division, which is going to give you elbow, and vice versa. So I agree exactly with what he said. I think we're going to start dialing in both our nerve reconstruction combined with our nerve transfers. So if we extend that question, how long would you, how late would you be prepared to do the shoulder surgery by nerve transfers? So the posterior approach, accessory to suprascapular, and the radial nerve. Yeah, I think it's just like that 10-month was the number you showed, and I think that's about right. I think you're right. The problem with the comparison is tendon transfers work so damn well for external rotation if everything's innervated, so that's the question. And it is a difficult decision. One more thing I was thinking, I'm sorry, Michael, is the other thing I just want to emphasize is Howard Clark's cookie test. For those that aren't aware of the shoulder, a lot of times there's a false positive, a false negative. I don't know what the word is. Negative? False negative. Here's what I mean. When the kid's so internally rotated, they can't bring the cookie to the mouth, but it's not because they can't bend the elbow, it's because they can't externally rotate. So be careful, and we see that a lot, and I'm not picking on plastic surgeons or neurosurgeons, but in non-orthopedic surgeons. But if your arm's internally rotated and you can bend like this, but you can't bring your hand to your mouth, you literally fail the cookie test. You don't need an operation on the elbow, you need an operation on the shoulder. Uh, opinion from the audience. Those that routinely use MRIs to determine whether to operate. You have a show of hands? Those who routinely use nerve conduction tests and electromyography to determine whether or not to operate. Anybody? Those that use them once they've decided to operate to give them more information. So some. The only way we'll get some indication from that, those who deliberately don't use them at all. Probably a slightly greater number, actually. We find them very variable in our unit, and we certainly don't base the decision to operate on MRI or nerve conduction tests and electromyography. And I agree. The only caveat I have is Martin Malazy, who's in Leiden. He has an incredible team of people who do incredible imaging. And I think that's the problem that most of us are sitting up here or sitting in the audience don't have. You know, we don't have that reliable. He uses a CT myelogram, actually, to truly determine whether there's a pseudomeningocele, and that does affect his decision-making process in the OR for sure. And he's also the one that uses pathology, so he cuts back the nerve to those 50% axons. So, I mean, when I was over there, the first thing I was was envious of his team of imaging individuals and pathologists that were able to demonstrate such high quality. But most of us don't have that. So if we have better sensitivity of the test when clearly they're going to help us more. Anne? I was just wondering from the panel, from each of you, do you think there's any indication to just go straight to nerve transfer? Scott? I mean, why are we doing this operation on a nerve that's been injured in this OR? Are we talking about an upper trunk lesion? So I'm talking about an upper trunk lesion with, so C5, C6, with or without C7. At what point should we just decide I'm going to do a nerve transfer? When is the patient coming to you? Are you asking about different times, different ages, or just in principle? In principle. All right, we'll start at the far end, actually, David, if we may, Scott. I think that the results of grafting are good in this group. In the adult, it's a different organism, but the results of grafting are still good. And I think you do get good elbows, shoulders are moderate. Our approach is to do a dorsal suprascapular transfer. I think that's effective, and I think that we've got some data that shows that it reduces our requirement to do secondary shoulder surgery in those children. So I think that that is... So a combination, but you actually look at the pathology. Yeah, we still take the plexus down. Don, do you look at the pathology? So as a late operator, and as someone who tries to be more of a saver than a cutter, so if it's a two by two, I'm a late operator, and I have difficulties just cutting aggressively. I think nerve transfers have helped a lot, and I won't routinely look up top. So I'm not a baby like Don. I'm probably in the other corner of this diagram. You're not a kid. Right. But I just want to add one more thing. Surprise me. And, Roger, you can chime in if I get this data right or wrong. The interesting thing about our data, though, was the best results for elbow flexion and forearm supination were in those individuals that were avulsed. Right? Is that right, Roger? And there's some question whether as they re-innervate, they get some co-contraction. Go ahead, Roger, chime in. So I think my evolution of using nerve transfers is pretty similar to yours. And so instead of saying a prayer for excellence in a C5, C6, we'd say a prayer for avulsions. So if you explore and you see avulsions, your only option is nerve transfers. And the reason you hope to do that is because those results are very, very good. So then you start thinking, well, if the nerve transfers are so good, why don't we do them in the ruptures? And if it doesn't matter if it's ruptured or avulsed, why don't we just not even look and just do the nerve transfers, the triple transfers? Trouble is when you start to extrapolate the surgery out of the avulsion group into the rupture group, they don't do as well because those joints have contractures that you don't get in the avulsion state. So the rare C5, C6 avulsion have completely supple shoulders that don't get contractures. So it's a little bit confusing. I don't think it's necessarily the nature of the surgery, but the nature of the injury that actually determines the results of the surgery. So we're going to start to look at preserved afferent innervation of the muscle, which is the case in the setting of an avulsion where it's still connected to the dorsal root ganglion as actually protective against contractures and preserving muscle ability to be re-innervated later by transfers. So it's probably a nature of the injury, avulsion versus rupture, more than a nature of the surgery, transfer versus graphing. Yes, so deformity and contracture are a consequence of imbalance. The question of late nerve transfers or tendon transfers. Scott clearly is tending towards late nerve transfers, at least till 10 months, but believes that tendon transfers are also a very good option. Scott, do you have any problems with the loss of internal rotation following your tendon transfers? Nope. Only kidding. I see lots of Dons that do. But I think, again, this is an evolution, right? And again, this is how we approach them now. In kids who have 5, 6, 7 injuries... So let me just take you through this. 5, 6, 7 injuries. So 7 is a funny muscle or nerve root. 7 brings in a fair amount of latissimus, a fair amount of lower scap, and further denervates the pec, so it further jeopardizes internal rotation. Right? So in those kids, the 5, 6, 7 injuries, we're now only transferring one tendon, usually the teres major. Dan, my partner, does only one tendon, period. So we're... And you'll comment also that we're very sensitive to loss of internal rotation. And then the second thing that I just need to emphasize is a lot of Roger's work, is we know this renervated muscle gets so damn tight, it's just crazy. And sometimes when the joint is out, and the joint's not out just posterior, the joint is up and out. It's up and out. So when you put it in, it's down and in. Right? And when you put it in down and in, what you do is you increase your tension on these renervated short deltoid and rotator cuff, and these kids get these wicked abduction contractures. And I mean wicked. Like 60, 70, 80, 90 degrees. And that abduction contracture further jeopardizes midline. So even though we spend all this time talking about extra rotation, which I agree, because that restores joint congruity, I think we need to be very sensitive to loss of midline. And I'll be the first to admit I've done my own patients who I've overdone, and I've had to come back and cut the humerus and spin them the other way. Hopefully we don't do it as much, because we're more sensitive to it, and we're more sensitive to early joint reduction. Early, early, early. So, Scott, I'm just going to follow up on that. I'm curious what your thoughts are as well. Is there a number or a target that you have for what's enough and not too much? So it's a great question. They have to have an end point. I can tell you, if you've released a shoulder and there's no end point, that's a bad day. The shoulder's going to look great. I'm going to show you lots of great-looking MRIs of all this joint remodeling. But then the kid will never get to his flyer zipper again. So we did a case last week where we stopped. We're not convinced the joint was reduced all the way. But I'd rather have a kid that can come back to midline and touch his belly button and have some sense of balance than to have a kid that sits out externally rotated. And a lot of the data, and especially the arthroscopic data on releasing the capsule and the entire subscap I think was wrong. You have to preserve some of the subscap. You have to preserve some of it. And that is the advantage of an open reduction. I think I'm better at preserving some of the subscap actually being open reduction versus arthroscopic because I can release it from the scapula or release it looking at the tendon from the front. And I know Roger just releases only the tendon, ever arthroscopic. Leave the inferior muscle alone. Don't take it. I find the shoulder incredibly complicated. And the more I do of it, the less expert I find myself. The abduction contracture issue is significant, particularly with girls. It's not so much of an issue with the boys who wear a T-shirt and conceal it, but with the girls wearing a singular top, which they do in Australia because of the clement weather. But they end up with this quite ugly deformity of their shoulder. It's a real issue which I don't have a solution for, essentially. So the aim is to try and prevent it occurring. Perhaps we may even return to more aggressive nerve surgery. It seems to me that that's beginning to happen. So maybe Alain Joubert was correct all the time. So I'd like to thank Scott and his support staff. We've got 10 minutes for a break. Thank you.

surgical techniques

brachial plexus birth palsy

nerve transfers

elbow flexion

shoulder reanimation

open reduction surgery

contractures