Sural nerve grafts for delayed repair of divided posterior interosseos nerves

Sural nerve grafts were used in three patients to bridge gaps measuring 2 1/2 to 4 1/2 cm in previously transected but not repaired posterior interosseous nerves. The grafts were done at 4, 5, and 7 months after injury. Extension was weaker in all three than on the uninjured side, but the range of motion was complete, with the exception of a slight lag of index finger extension and partial return of extension of the extensor carpi ulnaris in the same patient. All three patients recovered full function of the involved hand 1 year after grafting. The properties of the posterior interosseous nerve (pure motor and short distance to the muscle) contribute to good results with nerve grafts in delayed nerve repairs. We believe that these results are better than tendon transfers, at least in young patients.

Treatment of skin and median nerve defects with peroneal neurofasciocutaneous flap

A large neurofasciocutaneous flap that consisted of a peroneal flap and a segment of sural nerve was used in the simultaneous reconstruction of a large soft tissue and nerve defect caused by a crushing injury of the distal forearm. A 10 x 15 cm peroneal flap, including a 10 cm segment of sural nerve, was successfully transferred to an 8 x 12 cm skin defect, reconstructing a 5 cm defect of the median nerve. Two years after repair, the opponens pollicis muscle showed good contraction, although palmar abduction of the thumb remained poor. Static two-point discrimination was 20 mm on the pulp surface of both thumb and index finger and 15 mm on the middle finger.

Duchenne-Erb palsy. Experience with direct surgery

Between 1973 and 1984, 31 direct explorations of traumatic Duchenne-Erb palsy (C5 and C6) were performed in two hospitals. Simple neurolysis was performed in 12 cases, in which C5 and C6 were found to be in continuity; the operation resulted in useful motor function in nine of the 12 cases. A cause-and-effect relationship of neurolysis to the recovery of function was difficult to prove. In five cases where only one root was completely damaged, four nerve graftings produced useful motor results but the function of one graft was not demonstrable when the other root was in continuity. In 14 cases of complete lesions of both C5 and C6 treated by nerve grafting, there were seven functional motor results that were attributable to the grafts. Both the overall results and the result of elbow flexion were statistically correlated with the number of grafts used to repair the corresponding nerve structure (p less than 0.01). Favorable results were not obtained when the graft had been delayed for more than nine months. All of the patients who had nerve grafts within five months had favorable results.

An alternative to the classical nerve graft for the management of the short nerve gap

Reconstruction of a short nerve gap by a nerve graft produces donor-site scarring, loss of donor nerve function, and neuroma formation. This study compared the regeneration achieved after 1 year in 16 monkeys across a 3-cm upper arm ulnar nerve gap with a bioabsorbable polyglycolic acid nerve conduit with the regeneration achieved with a classical interfascicular interpositional sural nerve graft. The results demonstrated electrophysiologic and histologic evidence of neural regeneration across the gaps in all experimental groups. The bioabsorbable nerve conduit groups and the sural nerve graft group had mean fiber diameters, amplitudes, and conduction velocities each significantly less than those of normal control ulnar nerves. There was, however, no significant difference between any of the experimental groups. Electromyography demonstrated recovery of 19 of the 28 (68 percent) intrinsic muscles studied. These results demonstrate that the primate peripheral nerve can regenerate across short nerve gaps when guided by an appropriate nerve conduit, suggesting that a single-stage biodegradable polyglycolic acid conduit may be used as an alternative to a short interfascicular nerve graft.

Wandering nerve graft technique for management of the recalcitrant painful neuroma in the hand: a case report

A new technique for the management of the painful neuroma following ray amputation of the index finger is reported. The rationale behind this operative procedure, which is based on both clinical and experimental work, is outlined. The patients' follow-up to 4 years postoperatively is presented.

Comparison of regeneration across a vascularized versus conventional nerve graft: case report

A histological and functional comparison of regeneration across a vascularized and conventional nerve graft was carried out in a clinical case. The two branches of the medial antebrachial cutaneous nerve were used to neurotize the median nerve at the wrist. The superficial branch of the radial nerve (vascularized nerve graft) and a conventional sural nerve graft were used as the interposition grafts between the two branches of the medial antebrachial cutaneous nerve and the median nerve. This nerve grafting procedure was carried out in two stages. The proximal neurorrhaphy was carried out 7 months prior to the distal nerve repair. Biopsies were taken from the distal portions of the vascularized radial sensory nerve and the conventional sural nerve at the time of the second procedure. Histological evaluation demonstrated superior regeneration across the vascularized nerve graft. Subjectively, the patient described better sensory recovery in the territory innervated by the vascularized nerve graft. Sensory testing in the two territories demonstrated better sensibility in the territory innervated by the vascularized nerve graft.

A reliable technique of free vascularized sural nerve grafting and preliminary results of clinical applications

A technique of harvesting a free vascularized sural nerve graft based on either the cutaneous branch of the peroneal artery or the muscular perforating branch of the posterior tibial artery is described. Anatomic dissections with dye injection studies confirmed the reliability of this blood supply to a 25 cm long segment of the sural nerve. The sural nerve can be sectioned into as many as four segments while safely maintaining each segment's vascularity through intact fascia. A skin monitor can be elevated with the nerve to monitor vascular patency. The free vascularized sural nerve was used to reconstruct 16 nerve defects in the upper extremity. All 13 skin monitors elevated have survived. Early follow-up (range, 2 to 31 months) has shown encouraging clinical recovery. Although our preliminary results are difficult to compare with other series, this technique appears promising in clinical circumstances when interfascicular nerve grafting is indicated but the recipient bed is heavily scarred and poorly vascularized.

Nerve sharing by an interpositional sural nerve graft between the great auricular and inferior alveolar nerve to restore lower lip sensation

A case of bilateral nerve sharing via an autogenous sural nerve graft interposed between the ipsilateral great auricular nerve and the inferior alveolar nerve was used to restore sensation to the lower lip. To our knowledge this is the first report of successful nerve sharing between a sensory branch of the cervical plexus and the inferior alveolar nerve.

Facial nerve grafts: effects of postoperative irradiation

Six patients with cancers arising in the parotid region were treated with surgery and postoperative irradiation. All cases had extensive resections with sacrifice of the seventh nerve and primary autogenous cable graft repair. Four of the six patients had good to excellent dynamic function at 18 months; the fifth case had fair mimetic function with ability to close the eye and protect the cornea, and the final case failed to demonstrate any function at one year, but was found to have recurrent tumor at the skull base.

Free autologous nerve grafting--comparison of suture materials

The inferior alveolar nerve was reconstructed by grafting the sural nerve in 16 rabbits. Suturing was performed using the non-absorbable suture material Ethilon and absorbable Vicryl. The postoperative results were evaluated by measuring the following parameters: electrical stimulus threshold, conduction velocity, area of myelin sheaths, area of nerve fibres, number of nerve fibres, histogram of the diameter of nerve fibres. All these values are discussed, to give an idea of the healing process and to examine the influence of absorbable suture material.

Arterialized venous free sural nerve grafting

Since August 1980, a new technique of nerve grafting has been developed in our clinic. A free sural nerve graft, with its attached small saphenous vein arterialized, was used for repairing long segments of nerve defects. Experimental studies of this kind of nerve graft have proved the merits of this new technique. The same favorable results were then obtained in 14 patients, with 2 grafts failing because of vascular thrombosis. We have the impression that the shorter the time interval between the injury and the surgical repair, the better the result. In 2 patients with motor nerve injury, the motor function was well recovered when the operation was performed within 6 months after the injury, whereas none was recovered in those cases with an interval longer than 2 years.

Autogenous sural nerve grafts: a harvesting technique

Sural nerve grafts have applicability in many facets of reconstructive surgery. A harvesting technique is described which utilizes a tendon stripper introduced through a single distal incision. This method provides adequate length of autogenous graft material without significant difficulty or morbidity.

Severe injuries of the radial nerve treated by sural nerve grafting

We present six cases of severe injuries of the radial nerve in the arm. These were all treated by autogenous nerve grafting over distances of between 7 and 14 cm up to 26 months after the injury. We describe our results and discuss the place of nerve grafting in the management of these injuries.