=====ASSH 2020 Precourse=====
====Hari - bridging long nerve gaps====

  * nerve grafts - kids - good sensation, sometimes motor
  * running the nerve
  * combined nerve - do to both median and ulnar nerve
  * extensor only to MCPJ

====Safa: Composite flaps====
  * one or more flaps?
  * 3 flaps for thumb at base 
    * ALT -> fibula with spacer for CMCJ (floating) -> toe
  * simultaneous flap
    * alternatives to ALT -- RFF flap
    * multiple E2S used along radial artery
  * Radius bone defect
    * mutliple lattissimus plus fibula for radius
  * alternatives to fibula for length - 2nd toe / 2nd MC  and big toe

====Ko: Targeted Muscle Reinnervation====
  * TMR - neural signals still exists -> myoelectric
  * TMR nerve transfers
    * pain - neuroma better 58% to 4% - Souza CORR 2014
    * 23/26 patients (89%) able to wear prosthesis throughout the day
    * phantom limb pain is better - annals of surgery

=== Example transfer===
  * median to ain
  * ulnar to fcu
  * dsrbn to fds

===acute TMR=== 
  * pain control
  * first 2-3 weeks
  * ue and LE
  * can't have proximal nerve injury


====Raja: When to stop====
* basic hand function can be achieved -- we are only competing with prosthesis and transplantation
  * 'basic' hand - thumb and post

===things that made a difference===
  * radical deb
  * emergency micro
  * ? later surgery

===what is required===
  * skill levels 
  * time -- multi-staged procedures
  * resources 
    --> if one component is not available --> no more
 
===Site specific===
  * What is 'no more' in one centre, can become 'yes we can' in another center
 
  * yes to no conditions
    * infection 
      * reduced quality of outcome
      * increases cost
      * increases time frame of treatment
    
  * all components but say no
    * life at risk or more morbidity -- major replant sick at 5 days  (SpO2 100) -- muscle necrosis --> amputate
    *- polytrauma -- "triage"
 
 
  * e micro
  * secondary procedures

  * **low threshold for seeking help**