It's June 27, 2015, and we are here for our visiting professor weekend. We're lucky enough to have Dr. Scott Kozin, who is the chief of staff at the Children's or the Shriners Hospital for Children in Philadelphia. He's doing his second dissection for us this weekend, and this dissection is going to be focused on tendon transfers for tetraplegia. Scott? So what we're going to demonstrate today and discuss today is the principles of surgery in tetraplegia. So the most common level of tetraplegia is C5-C6, and C5-C6 kids tend to have good shoulder range of motion. They tend to have good elbow flexion. They may or may not have a single wrist extensor, but they don't have triceps, and they don't have grip, and they don't have pinch, and they don't have opening. So if you go back to the hierarchy of hand function we spoke about, if they have wrist extension, we're going to give them lateral pinch, and we're going to give them grip if we can, depending upon what they have. And then for the elbow extension to increase their workable reach space, make it easier for them to perform weight shifts and propel a wheelchair, we're going to do a biceps or triceps transfer. It was originally proposed that you do a deltoid to triceps transfer, which a lot of people still do. We did a prospect of randomized surgical research, which is always hard to do, and eight had each. So eight had biceps or triceps, and eight had deltoid to triceps. One of the eight deltoid to triceps was able to achieve anti-gravity extension, and seven out of the eight biceps or triceps. So we now do biceps. There's also some concern about loss of elbow flexion torque. They lose about 30% of loss of elbow flexion torque, but that has no clinical significance. It doesn't affect their ability to transfer, et cetera, et cetera. So we start with this big incision, an S-shaped incision, over the antecubital fossa. I'm going to elevate these flaps here. And the first thing we want to do is find our biceps muscle, which we just did like so. And then we're going to elevate. Why don't we put a suture in that when you get a chance, Nick, which would be good. And we'll elevate this flap back also so everybody can see. That's your brachioradialis there. And then I'm going to put this down one second. And then the first thing we do is we want to protect all the bad stuff, right? So we're going to come through here, and we're going to feel the biceps tendon, which we're going to see in a second. There are these big veins that you do have to quaggly and get out of the way, because they will really bleed. You can see the size of these mamas, right? So here's your lacertus that I'm exposing here, which means the biceps are going to be over here. Pull that. And pull that. And pull that. Mm-hmm. And you open up this fascia over the biceps here. And you can do this fairly quickly. Again, in any operation, there's a time to take your time. You've got to get down to this tendon. It should be right under here. So there's your biceps tendon. So now we're going to trace the biceps tendon in a distal direction. Do you have something that's a little, like a army navy-ish? That was perfect. So what we're going to do first, let me show you this. Yep. Let me just, I don't want to cut it. Pull that back. So here's your biceps tendon going down to your radial tuberosity, as you can see here. And you can push this. You put the form in supination, it's a movable object, right? Now some people take the lacertus as part of the transfer. I don't. You'll see why when we get to the back of her elbow in a second. Okay, let's try how we can get in there. Now, you want to get length on this biceps. Do we have, can you give me that Ray-Tech that we use, like the blue loop thing? Oh, sure. Yeah. So let's get under here. I'm going to bend the elbow just a little bit for a second. Hold it. Yeah, that's it. So once we bend the elbow, then we can get under this biceps tendon right here. Who's got a clamp or something? Okay, good. That's perfect. Yep. So there's your biceps tendon there. And we should take a look here and just show one more thing. See the cutaneous nerve in there? Yeah, yeah. So you want to be aware of the cutaneous nerve over here. You don't want to ding that because in these patients, that's one of the nerves that's working. So that's out of the way over there. So now we're going to take this biceps tendon, and we're going to try and go down. Yeah, it's hard. Let me push in here. So now we're going to walk this down. Exactly. Walk it down. And again, here there'll be big veins also. Yeah, sorry. And we're going to go right down to the biceps footprint, which is way down here. All right? And I like to take it until I can feel the bone. Now, once I'm down on the bone, we're going to cut it. So let me take this Army Navy. Take the big end and pull like that. Mm-hmm. That's it. You got it. And now we're really in a hole, but we're about to get out of the hole. I'm going to cut the biceps tendon here. And you don't want to pass point. You want to see what you cut. And then once we cut the biceps, you'll see it come. Oh, no, I got YZ. That's disgusting. I have a hemostatic. Where'd that piece of fat land? On YZ. Nice, nice. Fellow abuser. Oh, gosh, that's funny. Okay, put the arm straight now. So then what you got to do, you have to dissect this muscle in a proximal direction to improve its excursion and improve its line of pull. And you want to make sure that you see the muscutaneous nerve, which is going to be down. Let me have a knife one second. I'm just going to open this more so they can see. Okay, bring that like that. And this is a fairly nice plane to come up on. There's a little bit of muscle I left behind. And what you'll see in a second is you'll see the muscutaneous nerve. See the muscutaneous nerve right here? You definitely want to make sure you don't cut that. And now it's going into that cutaneous nerve, which I showed you before, the IBC. And then you want to dissect this up pretty far. And this is how we do it in the OR, too. It's just really finger dissection. There's a great plane there. And we're getting up toward the motor nerve, but I don't think we're there just yet. Yes, we are. So there's as high as you can go once you see the motor nerve going into the biceps here. Could be an accessory one, but that's good enough. So now, where's your rake back a second? Yeah, hold that like that. YZ is staying out of my way now. He's not coming over. He's hoping his beeper goes off. All right, so here's your biceps. Now, you have to get your biceps around to the back of the arm to attach it into the olecranon, right? But I'm still not quite happy. I've got to open this a little bit more. When I look at the camera, I want to get some more. There we go. So you can see now this line of pull is going to be in this direction around the medial side. Now, we used to go over the median and ulnar nerve. With all the neuroregenerative medicine coming out, now we go over the median but deep to the ulnar, just in case they ever have a cure. I'm afraid that the tendon would be too tight on the ulnar nerve and cause compression. So let's have a rake again. So now we're going to go in this direction. Going deep to the median nerve and over the… Opposite. Okay. Yeah. So dissect in this direction. Superficial median and deep to ulnar. Yeah. No, he's got to come this way. We're just going to make a big old tunnel. Exactly. So Nick's just dissecting a tunnel that we're going to hopefully find the ulnar nerve eventually. Yep, exactly. And we're going to pass it around this direction. Right? And you know that we cut the lacerta so all the other structures are still protected over here. Good. Keep coming. Good. Yep. Mm-hmm. Good. Mm-hmm. There you go. Good. Yep. Yep. And we'll open all this up here. Exactly. Okay, there's your musculoskeletal septum there. See it? Mm-hmm. Good. Good. Do we see the ulnar nerve or not yet? All I see is a hole. Yeah. A wet hole. Mm-hmm. You can cut through that stuff. Yes, we can see. It's going to be right here. See it? Yeah, exactly. You got it. Mm-hmm. Did you see it pick up still? I got it. Mm-hmm. It's a little right behind that septum. So we're just looking for the ulnar nerve, which we're just about to get onto. It's a lot of fat. So this would more or less be the definition of an antagonistic tendon transfer, no? Well, that's a great question, but I actually consider the biceps more of a supinator than an elbow flexor. Mm-hmm. And if they ask how kids relearn it, meaning how do they learn the biceps to be an elbow extender, it's more in supination than it is more thinking about supination, elbow flexion. Remember, if you go to the gym, if you're at the gym and lift up the weights, the only way to get a big biceps is to flex all the way and then supinate all the way. Otherwise, you're just working your brachialis. Here, you look. It's right behind this tissue. That's a good tip. That's a good gym tip. Yeah. I'm going to be working on that. You know who I learned it from? Emily. In here. Hold on. Let's see this. Let me see this one second. Let's go up here. Where is that? There's that condom. We'll just go down here and find this thing. One of the prerequisites is they need to have an intact supinator for sure, right? Mm-hmm. So here's the ulnar nerve here, right? I saw it for a brief moment. Here's the ulnar nerve here, right? So what we're going to do now is just develop this plane beneath the ulnar nerve. We're inside this inner muscular septum. There's those veins. I think sometimes the ulnar nerve is hard to find. I think you have to just go right behind the septum and look right behind it. That's the best place to find it. So now this tendon transfer is going to come over the median nerve and under the ulnar nerve. Everyone see that? Ultimately, right? So it's going to go in that direction. But now before we bring it on the back, we have to go to the back. So let's go to the back. Oh, we can just turn it, right? Do you release it all the way down through a tube? I did a little bit, yeah. Just enough to get a pocket that's deep enough to it. So now on the ulna. Where is the ulna? Here's the ulna here. Especially in persons with tetraplegia, you don't want to make your incision right on the bone. You want to curve it in some way, shape, or form. Because that would be a bad idea. So we're going to bring it. I don't care. I don't care which way we curve it. Let's just curve it this way. So we're off the bone. Sometimes they don't have feeling on their olecranon, and it'll break down their skin incision. Got a little burst of crap there, see it? Who's got the scissors? I got them. So here's the tip of your ulna here. There's a little bit of a burst of stuff here that we've got to get rid of. What is that? Can you get me another knife? Whatever you have, I'll take it. There we go. Now we're starting to see the end of the ulna. So now what we need to do, we need to connect our dots. So we're going to roll this way a little bit. So here is the ulnar nerve. So I'm going to hold the ulnar nerve up in my finger, which is right here. And then we need to find a window in here for this to go. And I have these big vaginal packing forceps that I use for this, to make this tunnel. It's a huge, looks like a huge hemostat. It's about 12 inches long. I use it for my bipolar lat, too, to make that big tunnel. So now this is the biceps, coming from... Here, rotate the arm up. So it's coming from the front, which you see here. And now it's going into the back. Right? And then once it's in the back, turn to the back. We need to dock it into the triceps or into the bone. My preferred technique is to dock it in the bone. So I make a drill hole into the bone. And I weave it through the triceps tendon. And I drive it into the bone with a unicortical hole. And then pull it out the back with just two docking sutures. So this is not a situation where you typically have any trouble reaching? Great question. You have trouble reaching if they have an elbow contracture. So you want to resolve their elbow contracture at least to 10 or 15 degrees first. If they come in with a 40 degree elbow contracture, it ain't going to reach. And then you may be doing that string cheese thing or something, but it's not going to reach. Because you wouldn't feel comfortable just using a triceps tendon. You want to get to bone. In the adolescence, you want to get to bone. I also think it sets your excursion when you think about it. You take it off one bone and you stick it on the other bone. And the reason that this works so well is it's an easy operation once you do it once. The deltoid to triceps, the problem is you have your deltoid intervening graft and then your triceps. And any time there's an intervening graft, that just spells trouble. So you really want to make this reach. And this is the bone right here. And this is how it reaches. It just reaches perfectly. I noticed on the volar side, it's not as if you supinated the form to really get down to the bicep tuberosity and really fight for every centimeter. I do if there's a contracture. There's a 10 to 15 contracture and I'm on the bone. This guy didn't have one, so I knew it would reach fine. Do you do a contraction lengthening or brachioradialis release in the process of this? Do you do either of those? No. That's another great question. So I want to resolve their contracture by therapy. Botox and therapy and serial casting. Because I don't want to weaken their only remaining elbow flexor. So I've never done that. It's a good idea, I've just never done it. Do you release anterior capsule then? You don't need to release anterior capsule. Maybe if the guy's 30 or 40 you do, but you really don't. One thing we do a lot now, which we wouldn't talk about in the CP lecture, is in kids who are spastic. In other words, they have spastic biceps and they don't have good triceps. Like an incomplete spinal cord injury kid and the kid's 6 or 8 or 9. We know the natural history of that. The natural history of that is horrible. They're going to end up being bent at 90 and supinated to 120. More than 90, right? So we now have taken to doing early triceps transfers. You just can't put that in the bone, you have to put it in the tendon. Because the bone's still growing. It's a great way to get rid of the problem before it even occurs. Because when you see these high-level spinal injuries walk around like this, supinated to 120 degrees, it's horrible. Yeah, it's nothing to do with that. Nothing to do with it, it's too late. Earlier in the weekend you said you hate the idea of transferring a spastic muscle. But in this case you're achieving both contracture release and you may as well transfer. Yeah, it's a good question. I'm not sure if it's just... Yeah, you're right, I am. You're totally right. It's sometimes spastic and I'm still transferring. I want it out of the way. It's too much of a deforming force. Right, it serves two goals, right? Yeah, it does. And that requires an educated parent usually to understand why you're doing it on a 6-year-old. You said bone tunnel? Like a crack-out stitch bone tunnel? Yeah, so I do a crack-out stitch. And so I have two ends out of the crack-out stitch, right? Make a unicortical hole right down the ulna. Like Charlie. You hold the olecranon like this, right? So Nick would do it. He'd be holding the olecranon like this. We'd bend the elbow, he'd drill it right down the middle. Let me just show you so you know. Okay, so the way we would do it is Nick would have a drill, a small drill. He would pass a small drill into the... Tell him you're going to pass a drill. Here, use this. Into the ulna, right down the pike, right? Then once he's down the pike, he takes a big one, a big mama-jama drill, right? And he then puts it down the hole, right? So now you have a hole for your tendon. Then I drill on the back surface two unicortical holes that connect to the single hole. I use a... Oh my gosh, I call it a purple people-eater. I use a... Yeah, that's it. The purple people-eater, a Houston suture passer. Go into the hole, grab those two sutures, pull like hell, and then tie them down. And then reinforce them with the triceps. It's a great way to do it. Years ago, this is another good attachment of research. Years ago, we went to the research lab to look at interference screws, right? We had done a couple. We had some issues with pull-out, and the suture was stronger than the interference screws. The suture is a big number two fiber wire. It's incredibly strong. So I don't use interference screws anymore. Does that surprise you? It seems like interference screws should be the answer. It really surprised me. Yeah, it should be so, so solid. No, it wasn't. The suture was better. Kind of like your study, right? But yours was the opposite. Okay, so now let's take this out. Any questions from there? I'm sorry. No questions from downstairs? No. So let's talk about... Let's assume this is the classic patient. Let's make it that way. So it's still a 5-6 patient, C5-C6 patient. So those patients will have a wrist extensor, but they won't have lateral pinch, right? So if you look at what they have below the elbow, in a C5-C6, they have a brachioradialis, which is the first muscle, and the second is the longest, right? And then the third would be a brevis. Right, so let's change it. Let's make it they have all three muscles. So they have a brachioradialis, and they have a longest, and they have a brevis, right? Then the brachioradialis is expendable, because he has elbow flexion, and the brevis is expendable, agreed? And then if you go to your hierarchy of hand function, they have wrist extension, so we don't need that, because they have the longest. The second hierarchy is lateral pinch. They don't have that. So let's transfer the brachioradialis to FPL for lateral pinch, and they don't have finger flexion, so let's take the brevis to the FTP for grasp. You got it? It's not complicated. It's really not. So it's wrist extension they have, lateral pinch they need, grasp they need, release is the fourth. We ran attendance. If you don't have ECU, wouldn't it make more sense to leave the B and take the L so you don't deviate radially? Did I say the opposite? Yes. No, I do that. I'm taking the L and leaving the B, right? Good point. I was thinking and not talking. And you've already done the biceps triceps on the same patient? Yes. Yeah, I've already done the biceps triceps on this patient. Wouldn't the B be weak because it's a C5-C6? No. It'll be weak. When I say it's a C5, let me just clarify, when I say it's a C5-C6, that's where their bony injury is, so their C6 nerve root is usually preserved. And they usually don't have a brevis. We're going to give it a brevis to make it more interesting. So turn this way. So now let's talk about a couple things. If you transfer the brachioradialis into the FPL and you fire the FPL, what are you going to get? You're going to get a Froman sign. You're going to get IP flexion. The best lateral pinch is just lateral pinch. So at the IP joint, we can do one of two things. We can fuse it, which is fine, or we can take half the FPL and put it to the EPL, called a split FPL transfer. And I usually do that first. So let's do that first. So we'll need double skin hooks here. And I do it through a mid-lateral incision. So I'll make a little mid-lateral incision here. I'm going to make it bigger. I'm going to put this down. How do you choose between those two, Scott? It seems like the fusion would be so much more predictable, perhaps. So the question is how do I choose? The fusion is more predictable. In general, persons with spinal cord injury hate anything that's irreversible. Interesting. It's a total psyche thing. It's crazy, isn't it? Because they're waiting for the cure. So they almost always want a cure. And at least if I tell them, if I do all this stuff we did today, you can still get every benefit from the cure. But it's a psyche thing. So they're not biting infusions very often. They don't like infusions. They hate them. So through this mid-lateral incision, what we're going to do here, we're going to mobilize the norovascular bundle in a volar direction. Let's go back first. And what we're going to do is raise both skin flaps. And what I'm going to do to make it so everyone can see, I don't normally do this. I'm just going to de-skin this a little bit so you can see the tendon better on the back. So that's your EPL tendon. Everyone sees that, right? Okay, so now we've done that. So now I'll do the same thing on the volar side so you can see better. Now we're going to go find the FPL. There's the norovascular bundle. I'm moving that way. So I'm going to find the FPL in one second. Okay. So I found the FPL out of its sheath here. I'm going to open the sheath a little bit more distally, and then I'll show it to you. Small hemostats we have. Okay. So now I'm going to take the FPL out. And if you take the FPL out, there's always a raphe in it. Em, hold this for me. Yeah, that's it. And I'm just going to cut onto this raphe in between the two slips. And then I'm going to take a scissors or hemostat. Em, open that. I'll push it in, and then do the whole string cheese thing again. Okay, come out. Good. So now I just split my FPL into two slips. I'll bring it back out of the wound so you can see it. Oh, gosh. Push that thumb IP joint down, it's just so stiff. Okay. So we have one slip in this direction and one slip in that direction. So I'm going to let this slip go because I want to keep it in continuity. And I'm going to cut this slip. Okay. So now I'm going to take this slip and I'm going to make it kind of into a yoke. Let me just get some more proximal excursion. Mm-hmm. And I'm going to pass it over here through this EPL in one second. Mm-hmm. And the same thing holds true for the EPL. I'm just going to poke through it. Nick, can you take that? Can you have a suture for me? Okay, grab that. And pull it through just a little bit. Now, you don't want to make it, this is a good point, you don't want to make it too tight in the EPL because everyday texting, like we've been talking about, needs a little IP flexion. So I typically would pin it in a little bit of flexion, just a smidge, and then we'll pass this through and back to itself. And then we're just going to sew, pull that skin flap back, we're just going to sew this back to itself. But not too super tight, just tight enough. Is that an intraoperative pin or is that to be kept in postoperatively pinned? Four weeks. Four weeks. Because the nice thing about putting the pin, the rest of the tendon transfers, including the biceps, are pretty rigid, so I can start early rehab. Right? So remember, if adolescents are injured, this is a really good point, are you listening? Em? If adolescents are injured, their tendons have had time to grow, so they're big, like I talked about the other day, they're big linguine, and they're okay to be early rehabbed. In kids who are injured little, like in a car seat accident or something, their tendons never grow, so they're small like vermicelli. And you can't move them early. It's just a fact of life. You're getting hungry, is that it? Yeah, exactly. But I dictate in my op note the size of the tendons, and I use equates. So now we've done that. So now when the FPL fires from the brachioradialis, it's going to do that. Mm-hmm. Right? Okay? You with me? So now, let's go back to the form. What's that? What's that? A knife. Now this is also a pretty hefty incision, because you have to free up the brachioradialis to get adequate excursion so it'll work. So I take it all the way down to the styloid. In general, I like mid-radial incisions for a lot of my tendon transfers in the form because you can get everywhere with it. And I'm going to do this again. I don't normally tee it like this. I'm just teeing it so people can see easier. Okay. And again, if you dissect deep, you'll pick up the radial sensor nerve, which is here, or the, no, it must be LABC, right? Can you see over there? Yeah. This radial sensor should be lower. Yeah, it should be lower. All right, so now I've got to find, yeah, let's do that more. It's a good idea. There's FCR, right? Oh, my gosh, it's leaking. It's like the, it's leaking like the building that we went in. I know, like the roof, like the roof of my house. That comment will go down in history now. It is, it's recorded now. In 2015, my roof was leaking. She's going to love that. Good, now we've got good exposure. So, watch that knife. Let's turn this way just a shmidge. Here's your first compartment coming over. Here's your FCR. Your radial artery is going to be right in here. And what I'm looking for is the brachioradial muscle tendon. It's going to be coming this way, exactly. It's still this way a little bit. That's it. So, I'm just going to come down here on this tendon in a second. There it is. Let's mobilize the sensory nerve. Cut this vein. So, this is all now brachioradialis. Here. And it's all, you know, brachioradialis always goes more toward the middle of the form than you've envisioned. For me, at least. Like, it's coming way over here. We'll get that off in a second. So, what am I looking for right here? Radial sensory. Radial sensory, right. Remember I told you yesterday, right proximal to where this exits, which is right here. So, right here is pronator. It's the best way in the world to find pronator because you can then get it. All right, let me mobilize this a little bit more. I'm just going to get it over here. Just watching your dissection here, Scott, a couple of questions. I was thinking, one, if this is being used for FPL, how much of all this proximal dissection do you need to do? The trajectory is more or less similar. Yep, I'm going to show you in one second why. That's the radial sensory I just cut. Okay. Good. Get that over here. Always wanted to do that anyway. Okay. So, what happens is this. This is your brachioradialis, right. And it has all these fascial attachments, right. And here's where you're taught that it inserts. So, if you look at this. Jim, here's the answer to your question. If you release it from the styloid like we just did, it has no excursion. That's a great demonstration of it. I mean, it doesn't go anywhere, right. And then if you release it, I'm going to show you what we do next. Because we did this stuff with stimulation years ago. Release it up to the myotendinous junction, which we'll do next. So, the artery is going to be down there and the nerve is going to be here. I see it. Hey, Adrian, is there anything you can reset on the house system? Ken, I realize what's going on down there and we're seeing that on the screen up here too. There's the artery. All right, so now the point here was we were just saying, Scott, and the recording went down there, was that it's necessary to mobilize this nearly totally in order to get excursion off the brachioradialis. Correct, because you get, in this cadaver you get some, but in the stimulated, you get up to like seven centimeters when you free it up to here versus nothing down there. All right, so now we have, this is one donor. So, I like to get both my donors first. So, we decided that we're going to get one donor, so now I just put this guy away for now. And we'll go get our second donor. Our second donor, we decided was going to be the longest, which is right here, right adjacent to. So, I pick up the longest distal to the retinaculum, which is right here. Yeah. No. No, you don't have to. Just make a big skin flap, right? Because here it is, right? And sometimes there's an intermediate wrist extensor, which is confusing. But usually there's only two of them. You want to try and separate. Bring the wrist back a little bit for me. Okay. I'm trying to separate the longest from the breast here. Let's try it down here. Yep. Work it right here. You got it? Mm-hmm. That's it. And then lift it up a little bit. That's it. Okay. And then we need that. Oh, here it is. We need our retractor under here. All right, which we'll just do that. And now we'll go out here and find it. Okay. And this particular 10-inch transfer, length's not an issue, so you can just get it out here without any problems. Mm-hmm. Get under there. Bring the wrist back. That's it. Okay, nice. Ooh. Okay. Good. So now we have both. Donors, right? Yeah. Right? So now we've decided in this particular patient, they need pinch and grasp because they have wrist extension. So you're going to take this to the FPL, which I'll show you in a second, and this because it has even better excursion and it's more synergistic, the wrist, the finger flexion. Right. This is totally synergistic. This is a very easy transfer to learn. This is totally synergistic. This is a very easy transfer to learn. So now what I'll do first, we're going to go deep to the radial artery. All right, so where did the artery go? Mm-hmm. See it? So there's our radial artery right here. See it right there? So we'll just mobilize the artery to get it freed up. And then when you go deep to the artery, Yeah, I need a rag or something. Yeah, that'll work. Now let's start with this. As you go deep here, this first tendon you pick up is usually the FPL. Yeah. Right, and remember, you're not going to get IP flexion because you got rid of that. You just did AF. Yeah. Right, so come on back around. So this is FPL. Right, and it's a really good size FPL. So now what we'll do while I got it is we'll get something on it because we got to do our other transfer first. So let's put something around. Do you have another one of those things? Just pull this muscle back. Push it in. Good. So there's your FPL, right? Just clamp that. And the way to find your FTP tendons, because that's what you're going to use, is you just put your finger in here like this, and if you go deep to the median nerve, right, you'll see this layer of tendons all lined up. We need two army navies. And voila. Can you see them all there lined up? So these are all your FTP tendons. Now, you want to make sure, though, that you don't include your ulnar nerve with your FTP tendons. Right? Good safety tip. So I'm grabbing this one, and it's moving the little finger. You probably can't see, but that's the little finger. Then what we're going to do next is we're going to... This is an important point. And you'll zoom out a little bit. So let's just talk about cascade and tension, right? So this is the way the normal hand rests. Right? So the small finger tends to come down before the index, and that's where we grab. Since we're creating a quadriga, right, and what we really care about more importantly rather than grasp is lateral pinch, you want your index to come down first. Right? You get it? Because if you set it the opposite way, and this hits and this doesn't hit, you'll miss. You see that? So what we're going to do, we'll take a suture. I think you're going to have to do this, Nick. You want to take a suture. And you can do it one of two ways. One, you can manually... Relax your fingers a second. Manually pull... These are just stiff. The index down. Or two, you can just push it down. So why don't I just push it the way I want it, and then you suture them en masse straight across. Does that make sense? Just take a suture and go... Go the other way, though. Make it easy. You have a bigger needle or no? No? Okay. Can you get a bigger stitch? So before I do my tendon transfer, I suture my FTP en masse. I do the same thing when we do STP transfers for really bad CP or spasticity. Yeah, exactly. I don't... What's that? Well, otherwise, too, it's a big deal if your transfer misses a tendon. Here, they're sutured en masse. If you miss a tendon with your weave, who cares? Maybe, Scott, while we're suturing this, I could ask you... Having an experience with tendon transfers in the skeletally immature, I can't help but wonder, and this is something that I don't do, anticipating extrinsic tightness, whether it's extensor or flexor side, with skeletal growth. And for that matter, even doing functioning muscle transfers and setting the length, and then the patient grows several centimeters later in life. Is this something you have to lead the passer, so to speak? Meaning? No. It adapts. It's weird, isn't it? The only time you get in trouble is if you don't have an antagonist. So, for example, if you do a free gracilis for elbow flexion in a kid, and they have no triceps, that's a problem. I don't do it anymore, actually. And you see them do well early, and then years later get tighter. They just continue to contract, but I'm not sure it's because the muscle gets tighter, they just don't have an antagonist, and they grow. It's weird. All right, so now we're kind of set, right? So now we have our FTP together, and then you just have to think about what you're going to do first. I always go from deep to superficial. Right? Exactly. So I'm going to take, here is my one donor, which is my brachioradialis, and here is my second donor, which is my ECRB. So ECRB is going to go first. I mean L. I keep saying B. L is going to go first, right? B is still back, right? So let's push this out of the way. Oh, one more thing I want to talk about, by the way. If you do this tendon transfer using the brachioradialis as a motor, whether you put it to the FPL or put it to the wrist extensor, that's another reason why you need a triceps. Because it's an elbow flexor. So otherwise, when they flex their pinch, they just bend at the same time. So you need an antagonist for elbow extension. When Moberg initially did his tetraplegic work, he did it in two stages. He did elbow extension first, got that rehab, then came back and used the brachioradialis. We figured we could do it in one, but that's the way he did it. So now we have ECRL, right? And what we're going to do, you're going to take the pig sticker. Are you putting another stitch in? So hold this for me, because I think it's got to come my way. So give me the pig sticker. Where'd the pig sticker go? Where'd the pig sticker go? Oh, here. Is that it? No, we lost our tendon right here. We can use a hemostat. Is that it right by the tip of the hand, or are those your scissors? Those are scissors. All right, so I'll use the hemostat. So now, what we want to do is just come across these tendons, get as many as I possibly can. Okay. Oh, bastard. Do you find that there's any- would there be any benefit to using the brachioradialis as the motor for grip, since it has a bigger cross-sectional area, or do you prioritize lateral pinch? I think the longest has more excursion, it's more synergistic. In general, the brachioradialis tendon transfers are hard to get. Because you've got to fire your triceps, even if you have triceps, at the same time. All right, so here is your weave, through, right? And then what we want to do is you want to put the fingers in a gentle flexion, and then Nick's going to sew that weave. If you do- I tend to do a couple weaves here, but remember, it's your first weave that sets your tension. Your second and third weave just gives you- Is the wrist pretty neutral? Wrist is neutral, yeah, and fingers are somewhat bent. Not super-duper tight, Marv, because then they can't open, they can't release. So that's your ECRL to your FTP. And then I'll either do another weave, or I've gotten away from the weave a little bit. And I've gone to some- You can just do a side-to-side here, Nick. See that? Yeah, just side-to-side it. Yep, and then run it and lock it. The reason I- Do you transect that non-functional portion of it? Not in this one, Nick. And the reason I've gotten away from the pulvoteff, really, is just that the side-to-side locking with the fiber wire has been shown to be as strong. And second is, it gives you- It's bulbous. So if you do something for a wrist extension, it's really bulbous in the dorsum. Especially in skinny people. Skinny people, yeah. So Nick's just running a locking suture, like a crack out. I'd probably use a little bit bigger suture, but it's fine. And the cool thing about this transfer is on post-op day number one, right, so I put- Let me just tell you what he's done. We put him in a cast with a ball web roll in their hand. Post-op, and the cast is a little bit intrinsic positive. And post-op day number one, you take out the web roll and you say, bend your fingers, and they bend. Because they fire their wrist extensors and they're like, the mom's crying, the kid's crying, it's great. That's a good moment. I was just looking for that tendon weaver, and I bet I'm about to repeat a question Mike already asked, but did you cut the profundus of the muscular tendon structure? No, I didn't. I usually don't do that. Scissors? Good. So now once that's done, then you're kind of out of the hole a little bit, and we move to the next tendon, which is here. So this is going to be your FPL here. It's going to free off some of this muscle. I want my tendon going through the tendon, not the muscle. And I'll take the, where is this? Let's see where it's going to reach. Yep, good. And I'll take my pigstick or tendon braider, and I'm going to put it through the tendon. And I'm going to weave it through. I don't cut this one either. It gets a little tricky when you get into the vermicelli tendons, about which tendon you're going to weave through which tendon. All right, can you stand a second? Yep, good. And then this is set where the wrist is in extension, and then, let me show you what I do. We can take one second. Alice. So the way I, so this is, I want to make this fairly tight, this brachioradialis. So I put my Alice on the FPL, hold the wrist just like that. I pull some tension on the FPL with my Alice, and I pull my other tension like that. And then put a stitch in that. Uh-huh. Oh, cutting needle. So when you're setting tendon transfer tension, this is the way I like to do it almost always. An Alice on one and a hemostat on the other, and make sure you stay in the wound. The tendency is for your resident trying to help you, exactly, and they pull it out of the wound, which gives you the wrong tension. It makes it too loose. So I usually have them sew, and I do what I'm doing just now. And then we'll add another suture or something, and we can weave it again. It's interesting. I always think the only time I would not cut at a musculotendinous junction of the recipient would be if I thought there was a potential for ongoing re-innervation down the normal pathway. Obviously, in this situation, there is none, but you just like the maintaining the normal trajectory of pull. And then the cascade. I rarely cut the proximal, rarely. I don't think there's anything wrong with it. I can't think of one. Right, and then we would do another weave or roll it around or something like that. What's that? We were just saying that these transfers, even though they're tetraplegic here, they're perfect for the machete injuries. Yeah, oh, that's a good point. That's a huge point. So even though they're applicable for spinal cord injury, I use them a lot with the same principles. I've done them in Volkman's. It'd be another really good one if you think about it for Volkman's. If you need to get pinch and you need to get grasp because you lost your volar compartment, it's certainly easier than a free muscle and less of a hit, and it works. Yeah, and then let me think what else. That's it. Release is really hard because release is... The way we get release, if we decide to get release, and I really don't do it much anymore because Jim House does it, is the only way your EDC, I talked about this before, extends your IP if you block your MCP. So you have to do something to keep your MCP joint in flexion, like a Zancoli, right? So like a volar plate advancement or an FDS around itself that's a passive tenodesis, and then transfer something to your EDC so they get this. So the EDC will extend the IP joint. It's your classic Bouvier test. That's the only way the EDC extends the IP joint is to block the MPs. And in some kids who we've been desperate to get some opening, we've actually fused their MP joints in just a little bit of flexion with an Accutrack screw, right, and then transferred to their EDC. The problem with that, it really narrows their web space in between the fingers. But these are desperate cases. They'll take any opening because they have a little bit of grasp. What else we want to talk about? What else we got? I don't know. Can you do that Volkman release? Oh, the Volkman release? So how are you going to go across there getting that balance on each one of those profundi? He did it. Nick did it. You may have been walking up. So we set it with an in-mass suture from the get-go. So first thing we do, and we set the index a little bit tighter, Murph, because if any finger comes down early, we want it to be the index lateral pinch, right, opposite of how we come down. And we just set it right away. I actually really like doing it. If you saw me first open it, right, I say don't touch. You know what I mean? Because don't touch the tendons. They're where they should be. And then I take the index and pull a smidge and then just go across and then go back. And it's always right. If you start messing with them and trying to get your own tension, you're not as good as God gave the tension. So you might as well just pull the index a little bit tighter and come right across. That's why that one quick dissection is really a good thing to do because it gets you right in the right plane as long as you're deep to the median nerve. It's bad to include the median nerve in your tendon transfer. Another safety tip. Another safety tip. Yeah, I saw earlier for that biceps and triceps, I think you're using the ulnar nerve as a fulcrum. I did? Oh, no. Just went underneath that. I will say one thing that I think is always interesting in these dissections is when you look at the ECRL, ECRB distally, they're tubular, big tendons, and then you go approximately and they're laying right next to one another and you say, boy, it's sometimes hard to tell A from B. And you'd expect them to be sitting like this and kissing, but they're really like this. And you see very nicely here when you harvested the L, the B was literally deep to it. It wasn't next to it. It was deep to it. And that's an important thing to remember when you're in that. Yeah, and the other thing you noticed is I didn't have the angle, but Emily had the angle. I think that's the other thing about surgery that's important. Sometimes you're just on the wrong side of the table, whether you're assisting or helping. And I honestly couldn't see it. You saw it from your other side when I went through. That's just good teamwork because I really was having trouble finding it. And then that's it. Oh, you know what we can do? We can look at the pronator real quick. Let's just see that. So we're now in blah. Here's the sensory nerve. Here's sensory nerve here. Yeah, exactly. So pull that back. Oh, my God, we got everything in the way. Pull that back. I'm going to pull it. And look at that. Voila. Aha, take that. When you harvest your pronator, do you always take it extended with a little strip of periosteum? Always. Yes. The answer is yes. I'm sorry. The answer is yes. Although I will tell you that for wrist now, I prefer FDS instead of pronator, which has been a change in the last five years or so. Wrist extension. Yeah, wrist extension. So I take two FDS. I bring them back in the form. I go through the interosseous membrane just proximal to the PQ. Then I shuttle it up to either the tendons or I go around the third metacarpal, and one around, one around, and back to each other. It's a better transfer. For isolated radial nerve. That's a lot of FDS you're giving up there, no? Two FDSs for wrist extension? You got to think about giving up that FDS. I don't have anything. Plus it's a ton of excursion. You're giving 88 to get 40, 30? You're giving what? 88 millimeters of excursion. Oh, yeah. It works great, though. It's so synergistic. I think that's the difference. But if you have two FDS, what it does, it does probably weaken your grip a little bit, of course, but it gives you better balance. I've had some of my pronator transfers. Yeah, exactly. They make a fist and they go like that, like, urgh. And I don't think it's my transfer. I think it's just you're asking one muscle to do a whole heck of a lot. You're going to resist FDS, FTP. It's just a lot to ask out of it. Do you take the middle and ring finger FDSs? Yeah. And you wrap it around the third? Yeah, so in the kids, in an adult I would just put it in the tendon. In the kids, you can just go one way and the other way and then pigstick it back to itself and then go side to side like you go. You know what I'm saying? So if this is going around, if this is the third metacarpal, let's say the thumb is the third metacarpal, so one tendon goes like this, around like that. I pigstick it through itself, right, so that's one. And then the other one is going the other way, right? So the other one, this one went, the other one's going this way, right? And then I pigstick it to itself and then I just sew it like that. So it just pulls straight up, right? Yeah, it's good. I will say, having harvested the pronator a bunch of times, I do feel like that periosteal extension turns into a bunch of nothingness by the time you have it elevated, and it's really disappointing. It certainly is in children, I think, little kids. I can see why we probably use the supplements, because there's really very little work with it. And we've done a lot of these radial nerve transfers in kids, in the ER, and a lot of them have failed, I think, because the tissue's just terrible. The pronator's inadequate. Even with the bony extension, et cetera. Try FDS, you're not going to go back. Yeah, we definitely have done that, yeah. Yeah, for sure. Sound check. Okay, so again, this incision starts above the elbow. Because the ulnar moves anterior, you're going to have to get rid of the musculoskeptin anyway. It's not like it's truly transposed, but it moves with the entire heads of the FCU, and it can get kinked up here. So you've got to get rid of that. So we'll make this a small incision. Endoscopic. I hate minimally invasive surgery anyway. So let me just feel where I am. Here's the ulna down here. And again, what we'll do again, just to ease, so people can see more, we'll just de-skin this a little bit. Thank you. That case you showed earlier, those are always heart-rendering cases. I was trying to avoid a couple of centimeter incision and... Which ones? The Volkman's, you know, sort of casting too tight cases. Oh, my gosh. Manipulating too much cases. They are heart-rendering. We've all done it, taken off a cast and seen it. They've cubinited somebody, molded it. Then you have to deal with the wound. Pediatric elbows, it's a frightening subfield. Yeah. I seriously tell my fellows, it should scare you, because so much is unknown. So much you can't see, too, that's another big problem. I don't really do it, but I get the impression, I think I'd just open everything. You should be. So here's your ulnar nerve. Beauty is the most aggressive surgeon in town. Everything's open. I'll just keep coming this way a little bit more. This cadaver's got the weirdest thing here. What is that? I don't know. A suture, maybe? Here's your ulnar vessels. Okay, so now we've got the skin opened up. So the first thing we do, I'm going to put this down a second, is look for scissors. So here's your ulnar nerve here, right? Open up this intermuscular septum, and then we usually have to get rid of this edge, because this edge will become a problem as this all moves anteriorly, right? Now, I think one of the hard things is just making sure you don't knock off the collateral, right? So here's your epicondyle here. Give me another knife, please. Thank you. Oh, that's our other incision. It scared the hell out of me. Oh, no, it's just another bursa. That's the other incision. Yeah, I was still on the other cadaver, actually. All right? Can I have a sponge again? Get rid of some of this stuff. Okay. So let's do this. I'm going to put this down. Let's open up this ulnar nerve this direction. Em, can you do that? I can't reach. Just come that way. Yeah, open that whole thing up. Good. Perfect. Okay, good. Let's see. So here's the ulnar nerve here. So here's your other head of your... here's your FCU. So knife back to me. So now we're going to start... lifting up this off of the ulna. Still fascia. And I like to do this with a bipolar so it doesn't bleed. We don't have to worry about that today, but you don't want it to bleed. So I'm just trying to find the border of the all of this. It's like it's raining in here. That's what we need. Yep, I'm coming. Which way is that going? The other way. I think. Hold this for a second. There we go. Right? And what I'm doing is just to get me in the right spot. I might as well get in the right spot where I'm not going to do anything bad. And that's the ulna. I finally found it. The ulna's just way down here. So now I'm going to cut these. I'm going to start cutting these muscles off of the ulna a little bit. Put your rake down here for me. Pull that up even more deeper right there. There you go. Perfect. Now let me just get this thing going. And it's a big hit. We just started the fight. Come down here one more. So you put a hemovac in these things. Have you ever had to go back and get it after a hematoma? I guess they're in a cast, huh? So, yeah, I usually put a hemovac. Is that what you said when I come to you? Yeah. Yeah, I'm sure there must be a fair amount of bleeding. Yeah, they can bleed a lot. But you've never had to re-operate on them if you're looking to evacuate a hematoma or anything like that? No, because I always use a hemovac, I think. So this is our ulna. So this is our ulna we're seeing now. We're just trying to get in the right plane. This muscle needs to come up. This down here is all bipolar. And I guess it's a little bit because of the kids. You know, you don't want to just be frying their periosteum. No, I'm just, you know, using it as like a knife. Yeah, pulling and cutting. Right? Because now we're in a good plane down here. So this is all ulna. Everyone see it? Right? So now we're going to start marching over. And I'm going to have to come back here, which is the hardest part, I think. And down here, I just want to see where I am. I should be right on IO. I'm in a second. Still more muscle. Come up here a second. Yep. Yep. Let me see the other end of this a second. That's it. Just hold like that until I get oriented. Gosh, I'm not used to such a big arm. Mm-hmm. Come in here a second, will you? Makes for some more stories. Ha, ha, ha. What's up? Okay, so let's come up here again. Now let's try and find... Is it bad? Okay, come over here a second. Yeah, let's go find the end. So let's... You know the median nerve and stuff's gonna be right in here, right? Okay. Okay. So there's a couple ways to do this. One is to come here, which is sometimes harder. Or two is to come this way. And then we're gonna lift this off. So there's median nerve right in here. You see it, Nick? You probably got it better. Is that it right there? So if you can slide this way with something, then we can take all this off. You want that or a hemostat? I'm gonna take off this one head of the FCU right now. Yeah, exactly right. Yep, exactly. So this is the owner head of the FCU that I'm taking off here. Want to take it off? Where the hell are you? Okay, good. You on bone? I think so. Wait here a second. I got it. Perfect. That's an ortho move. I'm gonna go to the mallet. So you think you're on top of collateral? I should be. Because I'm a little distal. The blue string. Okay. I need a cent or something, too. So pull that like that. And pull this like that. Okay. There's owner nerve right there, right? Yep. It's way up there. We're fine. Now I'm just gonna come through here where that flea went. And this is where I take my time, at least my first take of my time, to make sure that I'm... Yeah, I don't want to take off collateral. I'm getting close to it. Okay, where are you there? I feel like that's tubercle. Okay, another knife. How big do you want it? Ten or fifteen? Fifteen would be fine. It's like an optic cord right there. Mm-hmm. Yep. Mm-hmm. I see it. Yep. So now I'm just making sure that I'm also deep to ulnar nerve, right? Here we go. I'm moving the wrong arm. Should be right here. Yeah. Mm-hmm. Yeah. Is the quality character of the tissue still the same? Yeah. It's obvious. It's more chickeny. It's harder. So this is your collateral here. Okay. Right? Because this is, what? Yeah. Yeah, see it? Because this is brachialis. Mm-hmm. Agreed? Yep. So we're almost gotten the wrong plane, but now we're getting the right plane. That's brachialis fibers coming down. Agreed? Mm-hmm. Yeah. It's a little outer branch. Yep. Okay, so now we're getting somewhere. We're going to need a bigger bow. Let's take off this here next. Where's median nerve? Did you see it? Yeah, it's deep. Okay, you got it? Let's see on the left side. Yes, there it is. You good with it? Mm-hmm. Let me tell you, it looks like the arm's never going to move after this, but it does. Yeah. It's just taking off everything. Yeah, just taking off everything. That's exactly right. Am I okay? Yeah. People always talk about submusculars and looking out for the medial colon, and I'm like, People always talk about submusculars and looking out for the medial collateral, but I think you really have to go out of your way to take it out. Mm-hmm. We were talking about the medial condyle fracture and the difference between a thrower having one and a dramatic one. Mm-hmm. I think it's the one the thrower gets that's really involved in the collateral because it's steeped to it. Mm-hmm. And, you know, Sean, I just really studied long ago Good. Okay, so now let's just take this off. Yeah, take that off. At all. Right. Although, you know, post-elbow, post-medial epicondylectomy instability has been described. We've got to check that piece to achieve that. They have bad medial epicondylectomy. And they have medial condylectomy. Yeah. So you can see how the nerve has to come up. That's why you have to get it up there so it can come up. Mm-hmm. Okay. Okay, so let's go back down here. So we think that this is here. This is... What is this? I don't think that is brachialis. It's coming from here. I mean, brachialis. Brachialis is going to be over here. See it? Mm-hmm. It's just the owner head of the pronate. This is where it's going to be. Where's brachialis? Over here, Nick? Mm-hmm, yeah. See it right there? Yeah, that's the patch over the top. Yeah, I don't think that's it. It's just flexing. Yeah, me too. Cool. Right, me too. This is definitely where you need somebody on the other side of the table looking out for you. Mm-hmm. So there's collateral. Is that more of it? Take that. That shouldn't be collateral, should it? No, collateral is here. Yeah. It's going the wrong direction. Yeah, I agree. Collateral is down here. Collateral should be going the other way, yeah. It should be brachialis. Yeah, exactly. Scott, was there a series of these in JBJS recently, like I'd say in the last year, from France? I don't know. I think so. I can't get the end of that here. Still muscle. This is a humongous arm. It's great. Oh, we're getting close to tiger country. You can feel it. When your sphincter tone gets great enough, it's easy when you stop. Yeah, I'd say you're smack in the middle of tiger country right now. Yeah, we're getting close. But we're still not there. We're still at way too much muscle. Turn that way. That's it. Just like that. Uh-huh. Nice. It's a blow for freedom. Yeah. Now we're coming over here and I see his membrane. Here, you see it? Okay, so there's membrane, right? Yep. And now we're just coming over the membrane nice and slow. We're staying away from tiger country for now. Because if I can, here's what I'm thinking, if I can get here and hook the other side of the radius, then well, I'll get way much, I'll get much better exposure. The only thing I'm looking out for right now is the AIN, that's right, which is going to be right in the middle here. I think I just got a glimpse of. We should only see our PQ fibers going the other way. There's AIN. See? So you got to find AIN, which is right. And there's pronators, that makes sense. These aren't, I don't think these are pronators. I think there's still stuff on this side of pronator. I think pronator is going to be deeper. All right, so now that's that. Is that good? Okay, so there, see, there it is. They're going into the, see it right there? Mm-hmm. So this is not, this is other stuff. This is the weirdest instrument. No. So can you see that, can you guys see the antenorossi's vessel right there? That's good, there it is. So remember I told you distally, you go above the antenorossi's? So here we're distally and we're above the antenorossi's, right? And then we should be just about on the radius and the FPL right there. Hold that pretty hard. See that? That's our grade field, right? So now we're, now we can, now we're safer here at least. And because we're, that's radius, you see? So I'm going to hook radius. See I have one of those reverses? So now I'm on the radial side of the radius. See that? Now we'll start taking this off. This is going to be FPL that we're taking off here, see it? So that's FPL off, right? So now we just, we just got to connect that to that, right? And while I'm doing this, I'm doing this too, by the way. Yeah, to keep tension on it. Yeah, to make sure I know what I'm doing and what's going on. So now I'm still, I'm still deep to the Army, Navy, to the AIN. See it? Okay, hold that. Oh, that's, that is fantastic. This is probably, I don't know what this is. We should be getting up towards some FDS stuff. Yeah, FDS origin should be part of that. Yeah, right here. And this is what's hard to get because you're all the way on the other side of the... Yeah, you know, it's okay to take a mental break. Nick? Yeah, either go big or you go home, back to Seattle. And again, this is really, oh, here we go. So now we're just about to get deep to the AIN. You see it? I see it. Let me see this. I got you. Deep to the AIA? Yeah, AI both. Yeah, so this has to go. Right. And then this, right here again. We're just about to get deep to it. See it? I don't have it yet. Two hours. I try, I try and get this done under, under tourniquet too. Why are you saying we've been here too long? Okay, so now here's interosseous membrane, right? Here's collateral. Here's this. We just got to get the rid of the rest of this stuff and make this connection. I don't see my brachialis yet. And you have to get over the biceps too, which we will. That's something. Okay. Yeah, that's really good. You get a sense or something there. See it? Right where that, mm-hmm, something I don't want to just go crazy through. Yeah, we usually do. Usually when I'm done. That's a good question. Not when I start, because if anything is going to be stimulatable, I want to know about it. But our guys use a lot, they do a lot of ultrasound guided blocks in our kids. So I'm having, I'm getting there. I'm just stuck trying to find the right plane where the brachioradialis, but I'm going to find it. Oh, yay. I think I killed the scissors. Okay, one second. It's looking like something different. See it? But I think it's FDS arch. Don't you? Because it's not, it's certainly not. Oh, that was another good move. Okay. It's just, I don't know, it seems pretty immediate, but I think it is. I'm being a little bit of a baby here, but I'm just about to get into trouble. See that? I don't know why. That's that sphincter tone feeling you have. You know, there's too much fat. Did you see when I was coming? I was coming up this way, there was too much fat. We were deep to the artery, and there's something big that we would like to try and leave, or at least coagulate. Oh, you know what it is? I think it's that connection between the post-urinalysis artery and the anterior ulcerous artery. Yeah. Mm-hmm. Okay, so now that proximal fenestration. Let's come back up here. So this now, collateral here should be on brachialis. There should be nothing here, right? Okay, there's brachialis. Is that a flood warning from the Higgins house? There we go. So now median artery and brachial artery are up, median artery and brachial artery are up. This is that little periphery. We'll cut this little tendon here. Okay, so now the last, not the last part, but the other point that's a pain in the ass is here. So let's figure out how to do this. We can go under or over. It looks like we need to go under, but we got to just connect these two dots. Let me move you up here, Nick. Okay, got that? That's it. So now this is just to get stripped off here, and we got to work in this window. It looks like we want to be, where's brachialis? Yeah, we want to be down here a little bit. Where's radius? Right here. I should see biceps in a second. So when you do this in kids that have had a bulk membrane, what kind of function do they get? It depends on the muscle status. If the muscle is good, they have some other, the more superficial stuff, it's okay. They do great, right? Yeah, they do great, actually. So now I'm on the radial side of the, yeah, one more reverse. Yeah, and then this is brachialis coming down. Biceps should be right here. I just haven't seen it yet, right? I just can't get, I don't want to get rid of that, because that's it. And then you just play around this, when it goes front to back. Yeah, you know, that's what we're looking for, actually. That's exactly right. Let me see. Hold that just not too hard. It's got to be right here. I just don't see it. But I think that's it. I mean, that's released, right? I mean, all else we have to do, right? What's that? Fingers are still pretty good. So let's just go over it again. So this came off. Ulnar nerve we'd have to make less tension on it. Just do that, right? There's ulnar nerve over there. Medial nerve is right here, right? Brachialis is right next to it. This is brachialis coming down. There's your ante-neurosis here into your pronator. There's it going to the back. There's your neurosis membrane. Here's your collateral, and here's your naked ulna. But we're on the radial side of the radius, which is key, right? And then you would just see, sometimes you have to do a little bit more of this, but I don't know because it isn't in the vulcans. But that's your release. And then you want to, and you can see, you'll come out. Oh, it's very extended. And look at the distance even in this non-vulcans that we got. And sometimes it'll end up being down here. But you don't want to put it back. That'd be a bad idea. Heels down. But the last one we did a couple weeks ago put out about like 80 cc's. I mean, a fair amount. Yeah, it's a really good shot. Well, that's a great landmark to Azure coming over. Remember, we thought the first thing was in brachialis. We were wrong. You just have to find that, because then you know you're right. This is, this is, coronoid's going to be right here. What's that? You mean this way? Oh, I see what you're saying. You're saying that coronoid's up here? Yeah. What is it? What am I feeling there? What is that? Yeah, I'm feeling the biceps too. I said, why can't I see the tendon? Now I'm getting mad. It's probably just the bursa. Isn't there always a little bursa? Aha. See it? Yeah, a little bursa was around there. There it is. It's your path home. Yeah. What if here's the biceps? It just had this bursa stuff on top. Yeah. Yeah. So you're right. This is, then the coronoid's going to be up here. Yeah. Good. Fabulous. What do you think? Anything else? That was amazing. Thank you so much. Anytime. Did you ask for the Ghani flap? Yeah, I asked for the Ghani flap. So the Ghani flap, that's the last portion there. All right, so your Ghani flap, whatever you want. So the Ghani flap, again, is just, so the way, let's just talk about flaps in a second. The old Buck-Grampko flap was kind of like, just kind of like that, right? That's all it really was. And then Abdul Ghani just made it like this, just somewhat like that, right? And brought it down like that, right? Maybe not that wide. Not that wide, but like that wide, right? And the difference is, when you raise it, let me have a knife one side, just real quick. When you raise the flap, you got to do it sharply, right? And you just want to get down to the tendon right there and into here. And then we're going to bring it down like so. And then the same thing over here, you're going to go back. And such a little change he did. And you don't have to make it this big all the time, but you got to make it so that this last random part is less random. Does that make sense? And then you just come down to the tendon and lift it up, keeping some of the fat with it, obviously, right? And it's a pretty quick elevation. What's that? Yeah, exactly. That's exactly right. So this just comes up like that. You want to leave some of your parotene on, obviously. And then just keep going back. I do sometimes put suture in here so I don't shear it, just like you're doing a radial forearm flap. And then the cool thing about this, and relax. So therefore, this is what comes into the part, you see it? You see the difference? So this whole thing is going to be inset into your contracted web space, right? And then you can try and close some of this, and you may need a little bit of a pinch graph up in here. But that's the only modification. I'll send the article to Jim, he can send it to you. I use it all the time anymore. And so it's such an ingenious thing. It can go really vulnar, Murph. It can go really vulnar. So I can't even open this up. Not really. That's a good question. Not really. But you've got to bring this skin down. You've got to open the fascia on the dorsum of the first DI and on the vulnar aspect of the adductor. Pretend it's a princeps and bring it in. We use it a lot in arthrogrypotic thumbs too now, or in aperts hands. Aperts is a great reason to use it. Abdul Ghani, G-H-A-N-I. I'll send it to Jim. It's really good. You don't end up with much, Mike. It's really, if you think about it, this will just close, right? Sometimes a little bit back here. That's it. And in a kid, honestly, you can mobilize it and usually not need any graft on it. But it's better than that, what was that thing called we looked at? They didn't call it a stiletto. What did you call it? Yeah. Was it journal club? Yeah. What did they call it? Was it a Kaplan flap? Dorsal first web space. Dorsal first web space. Is that what they called it? Yeah. It's really good. The only thing it does do, the one thing it does do that you have to just be willing to accept, is you can't do much other stuff. Like you can't say, I'm going to then separate the long finger. I'm always afraid that I've just disrupted this entire blood supply here. I'm not going to go. Oh, you're right. Right. Pulling skin in different directions. At the same time. So my aperts kids now, I'll try and do this and maybe try and separate the fifth, because the fifth's pretty safe. Yeah, right. Far away. Yeah. But these are not safe. You have to come back. But you can also just come back in a kid and just cut through it if you have to eventually. Sure. But look at it. It's a great flap to rotate. Look at that thing. Yeah. And the key is making that wide radial portion. Yep. Yep. Interesting. Yeah. Well, this is virtual wood. He just calls it the dorsal transposition flap. Yeah. Is that what they called it in the article? Yeah. All right. Anything else? I think that's loads, Scott. You've done gone above and beyond. Thank you so much. My pleasure. All right.

tendon transfers

tetraplegia

C5-C6 level injury

surgery principles

hand function hierarchy

biceps transfer

triceps transfer

elbow extension

brachioradialis muscle

lateral pinch

grasp

proper excursion

ulnar nerve release procedure