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Upper Extremity Tendon Transfer with Secondary Mitrofanoff and Malone Procedure: A Pathway to Independence in the High Spinal Cord Injured Patient
Bic Cung, MD1, Scott Kozin, MD2, Andrew Kirsch, ND3, Jonathan Roth, M.D.4, Gregory E. Dean, M.D.5.
1Temple University, Phildelphia, PA, USA, 2Shriners Hospital, Philadelphia, PA, USA, 3Emory University, Atlanta, GA, USA, 4Temple University, Philadelphia, PA, USA, 5Temple University, Voorhees, PA, USA.

BACKGROUND:: In select spinal cord injury patients with poor upper extremities function tendon transfer surgery to improve manual dexterity has allowed them to achieve independent catheterization status following continent urinary diversion. We review our experience with Mitrofanoff appendicovesicostomy and the Malone procedure in this select demographic.
METHOD:: We performed a retrospective chart review of patients who underwent Mitrofanoff vesicostomy for bladder management (with or without bladder augmentation and antegrade catheterizable enema). All patients had thorough clinical and radiographic evaluation prior to surgery. All patients underwent successful tendon transfer surgery with demonstrable improved pinch-grasp function and assessed for ability to perform self-CIC prior to urinary diversion. Peri-operative and post-operative evaluation were performed, including assessment of complications and of ability to self-catheterize stoma independently.
RESULTS: A total of eight patients (3 males, 5 females) with mean age 18 (range 15 - 21) underwent urinary diversion after tendon transfer from 2005 to 2013. Five patients (63%) had combined Mitrofanoff vesicostomy and Malone antegrade catheterizable enema (MACE) procedure while three (37%) had Mitrofanoff appendicovesicostomy alone. Peri-operative complications include one patient (13%) with bowel anastomotic leak requiring laparotomy and primary repair of leak. Seven of eight patients (87%) have demonstrated the ability to perform CIC independently. The remaining patient (13%) was able to independently catheterize but awaits revision for a stomal stenosis. Median follow up time was 5 years (range 1 - 9).
CONCLUSIONS: Patients with limited hand mobility, not considered traditional candidates for Mitrofanoff and Malone reconstruction may be considered for these procedures, following upper extremity tendon transfer. This team approach can result in independence for a patient group previously not considered candidates for this reconstruction. Continent catheterizable urinary diversion as well as the Malone procedure following tendon transfer surgery provides a valuable option for patients with high spinal cord injuries and can permit the acquisition of independent catheterization status.

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