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Isaacs JE, Drinane JJ. Nerve Allografts: Current Utility and Future Directions. Hand Clin 2024; 40:357-367. [PMID: 38972680 DOI: 10.1016/j.hcl.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
Processed nerve allograft is a widely accepted tool for reconstructing peripheral nerve defects. Repair parameters that need to be considered include gap length, nerve diameter, nerve type (motor, sensory, or mixed), and the soft tissue envelope. Although the use of processed nerve allograft must be considered based on each unique clinical scenario, a rough algorithm can be formed based on the available animal and clinical literature. This article critically reviews the current surgical algorithm, defines the role of processed nerve allograft compared with nerve autograft, and discusses how this role may change in the future.
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Affiliation(s)
- Jonathan E Isaacs
- Division of Hand Surgery, Department of Orthopedic Surgery, Virginia Commonwealth University Health System, 1200 East Broad Street, Richmond, VA, USA.
| | - James J Drinane
- Division of Hand Surgery, Department of Orthopedic Surgery, Virginia Commonwealth University Health System, 1200 East Broad Street, Richmond, VA, USA
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2
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Wu RT, Chuieng-Yi Lu J. Nerve Autograft: Preservation of a Lost Art. Hand Clin 2024; 40:347-356. [PMID: 38972679 DOI: 10.1016/j.hcl.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
Nerve autografts involve the transplantation of a segment of the patient's own nerve to bridge a nerve gap. Autografts provide biological compatibility, support for axonal regeneration, and the ability to provide an anatomic scaffold for regrowth that other modalities may not match. Disadvantages of the autograft include donor site morbidity and the extra operative time needed to harvest the graft. Nevertheless, nerve autografts such as the sural nerve remain the gold standard in reconstructing nerve gaps, but a multitude of factors need to be favorable in order to garner reliable, consistent outcomes.
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Affiliation(s)
- Robin T Wu
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Standford, CA 94305, USA
| | - Johnny Chuieng-Yi Lu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing Street, Guishan District, Taoyuan City, 333 Taiwan; Chang Gung University, Taoyuan, Taiwan.
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Bedar M, Pulos NA, Shin AY. Dynamic Seeding versus Microinjection of Adipose-Derived Mesenchymal Stem Cells to Acellular Nerve Allograft Reconstructions. Plast Reconstr Surg 2024; 154:114e-125e. [PMID: 37537724 PMCID: PMC10838349 DOI: 10.1097/prs.0000000000010970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
BACKGROUND Functional recovery after acellular nerve allograft (ANA) reconstruction remains inferior to that after autologous nerve grafting, but improved outcomes have been demonstrated with the addition of adipose-derived mesenchymal stem cells (MSCs). Controversy exists regarding the optimal cell-delivery method to enhance ANA reconstructions. The authors investigated the functional recovery of ANAs after dynamic seeding versus microinjection of MSCs. METHODS Forty Lewis rats underwent reconstruction of a 10-mm sciatic nerve defect. Animals were divided into 4 groups: reversed autograft, ANA alone, dynamically seeded ANA, or ANA injected with MSCs. During the survival period, ultrasound measurements of the tibialis anterior muscle cross-sectional area were performed. At 12 weeks, functional recovery was evaluated using measurements of ankle contracture, compound muscle action potential, maximum isometric tetanic force, muscle mass, histomorphometry, and immunofluorescence. RESULTS The dynamic seeding and microinjection groups demonstrated higher cross-sectional tibialis anterior muscle area recovery than autografts and ANAs alone at week 8 and weeks 4 and 8, respectively. The ankle contracture and compound muscle action potential amplitude recovery were superior in autografts and both seeding methods compared with ANAs alone. The microinjection group demonstrated significantly higher isometric tetanic force, muscle mass, and number of axons compared with ANAs alone. Both seeding methods showed higher CD34 densities compared with ANAs alone. No significant differences between dynamic seeding and microinjection were observed in functional or histologic outcomes. CONCLUSIONS The addition of MSCs to ANAs demonstrated earlier motor regeneration compared with autografts and ANAs alone. Both seeding methods improved functional outcomes in the rat sciatic nerve defect model.
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Affiliation(s)
- Meiwand Bedar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Plastic Surgery, Nijmegen, The Netherlands
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Leis A, Smetana BS, Strohl AB, Styron JF. Comparative Effectiveness Systematic Review and Meta-analysis of Peripheral Nerve Repair Using Direct Repair and Connector-assisted Repair. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5927. [PMID: 38983950 PMCID: PMC11233104 DOI: 10.1097/gox.0000000000005927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/01/2024] [Indexed: 07/11/2024]
Abstract
Background This clinical literature systematic review and meta-analysis were performed to assess differences in outcomes between nerves repaired with direct repair (DR) and connector-assisted repair (CAR). Methods A systematic literature review for DR and CAR was performed. Studies from 1980 through August 2023 were included if DR or CAR repairs were performed in upper extremities with nerve gaps less than 5 mm and reported sensory Medical Research Council Classification (MRCC) outcomes or equivalent. Comparative analyses were planned for meaningful recovery (MR) rate (at both S3 and S3+ or better), postsurgical neuroma, cold intolerance, altered sensation, pain, and revision rate. Results There were significant differences in MR rates for CAR and DR. At the MRCC S3 threshold, 96.1% of CAR and 81.3% of DR achieved MR (P < 0.0001). At the MRCC S3+ threshold, 87.1% of CAR and 54.2% of DR achieved this higher threshold of MR (P < 0.0001). There were no differences in neuroma rate or pain scores in our dataset. Altered sensation (dysesthesia, paresthesia, hyperesthesia, or hypersensitivity) was not discussed in any CAR studies, so no analysis could be performed. The revision rate for both procedures was 0%. The proportion of patients with cold intolerance was 46.2% in the DR studies, which was significantly higher than the 10.7% of patients in the CAR group. Conclusions Significantly more patients achieved sensory MR and fewer had cold intolerance when the CAR technique, instead of the DR technique, was performed to repair peripheral nerve injuries.
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Affiliation(s)
- Amber Leis
- From UCI Health, Orange, Calif
- Indiana Hand to Shoulder Center, Indianapolis, Ind
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Silverstein ML, Momeni A. Restoring Sensation through Abdominal Flap Neurotization in Breast Reconstruction. J Clin Med 2024; 13:3826. [PMID: 38999392 PMCID: PMC11242435 DOI: 10.3390/jcm13133826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 07/14/2024] Open
Abstract
Breast sensation plays a significant role in the safety and quality of life of women who undergo mastectomy and reconstruction. In 1992, Slezak et al. introduced the concept of abdominal flap neurotization to improve sensation of the reconstructed breast. Over the next 30 years, numerous studies iterated on Slezak's technique, suggesting technical modifications and new methodologies for assessing sensory recovery. Despite evidence that reinnervation increases patient satisfaction following autologous breast reconstruction, abdominal flap neurotization remains a rarely performed procedure. In this article, we review the evolution of flap neurotization in breast reconstruction and describe our approach to facilitating sensory recovery of the breast while limiting donor site morbidity.
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Affiliation(s)
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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6
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Lam TC, Leung YY. Innovations in Peripheral Nerve Regeneration. Bioengineering (Basel) 2024; 11:444. [PMID: 38790310 PMCID: PMC11118957 DOI: 10.3390/bioengineering11050444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/14/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
The field of peripheral nerve regeneration is a dynamic and rapidly evolving area of research that continues to captivate the attention of neuroscientists worldwide. The quest for effective treatments and therapies to enhance the healing of peripheral nerves has gained significant momentum in recent years, as evidenced by the substantial increase in publications dedicated to this field. This surge in interest reflects the growing recognition of the importance of peripheral nerve recovery and the urgent need to develop innovative strategies to address nerve injuries. In this context, this article aims to contribute to the existing knowledge by providing a comprehensive review that encompasses both biomaterial and clinical perspectives. By exploring the utilization of nerve guidance conduits and pharmacotherapy, this article seeks to shed light on the remarkable advancements made in the field of peripheral nerve regeneration. Nerve guidance conduits, which act as artificial channels to guide regenerating nerves, have shown promising results in facilitating nerve regrowth and functional recovery. Additionally, pharmacotherapy approaches have emerged as potential avenues for promoting nerve regeneration, with various therapeutic agents being investigated for their neuroprotective and regenerative properties. The pursuit of advancing the field of peripheral nerve regeneration necessitates persistent investment in research and development. Continued exploration of innovative treatments, coupled with a deeper understanding of the intricate processes involved in nerve regeneration, holds the promise of unlocking the complete potential of these groundbreaking interventions. By fostering collaboration among scientists, clinicians, and industry partners, we can accelerate progress in this field, bringing us closer to the realization of transformative therapies that restore function and quality of life for individuals affected by peripheral nerve injuries.
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Affiliation(s)
| | - Yiu Yan Leung
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong, China;
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Peled AW, Peled ZM. Sensate immediate breast reconstruction. Gland Surg 2024; 13:552-560. [PMID: 38720669 PMCID: PMC11074667 DOI: 10.21037/gs-23-416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/18/2024] [Indexed: 05/12/2024]
Abstract
As breast cancer therapies and associated oncologic outcomes continue to improve, greater attention has been placed on quality-of-life issues after breast cancer and breast cancer risk-reducing treatments. The loss of sensation that typically occurs after mastectomy can have significant negative psychological, sexual, and functional impact on patients after surgery. Further, injury of nerves not only leads to numbness, but can also cause chronic neuropathic pain, which can be very debilitating to affected patients. In order to minimize these impacts, there is expanding uptake of surgical approaches that preserve nerves at the time of mastectomy and reconstruct injured nerves either during mastectomy or during delayed reconstruction. These advances have been facilitated by anatomic studies investigating different variants of intercostal anatomy and better understanding the course of the nerves innervating the mastectomy skin and nipple-areolar complex (NAC). With improved knowledge of the intercostal nerve anatomy, surgeons are able to carefully preserve nerves at the time of mastectomy, thus improving sensory outcomes. Additionally, nerve reconstruction techniques have advanced, particularly with newer nerve allograft technologies, which allows for nerve reconstruction to be done both at the time of mastectomy, as well as in a delayed fashion. The focus of this article is to describe the current state of sensory preservation and immediate reinnervation at the time of mastectomy and the advances that have allowed for these new approaches.
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Affiliation(s)
- Anne Warren Peled
- Sutter Health California Pacific Medical Center, San Francisco, CA, USA
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Aujla J, Tong JY, Curragh D, Caplash Y, Chehade M, Tumuluri K, Au A, Low N, Avisar I, Sagiv O, Barequet I, Ben Simon G, Selva D. Corneal Neurotization for Neurotrophic Keratopathy: A Multicentre Experience. Ophthalmic Plast Reconstr Surg 2024:00002341-990000000-00376. [PMID: 38624152 DOI: 10.1097/iop.0000000000002684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
PURPOSE Corneal neurotization is an emerging technique that offers potential for visual rehabilitation in neurotrophic keratopathy. This study reports on a multicenter experience and outcomes for both direct and indirect methods of corneal neurotization. METHODS Retrospective case series. Sixteen patients with neurotrophic keratopathy who underwent corneal neurotization across 5 centers in Australia and Israel were identified for inclusion. Corneal neurotization was performed via direct neurotization from the ipsilateral or contralateral supraorbital/supratrochlear nerve or by the use of an interpositional sural nerve graft. Change in corneal sensitivity (measured in millimeters by the Cochet-Bonnet aesthesiometer), visual acuity, and corneal health. RESULTS Over a mean follow-up period of 31.3 months (range: 3 months-8 years), mean corneal sensitivity improved from 3.6 mm (range: 0-25 mm) to 25.3 mm (range: 0-57 mm). Visual acuity improved on average from 20/380 to 20/260. Twelve of 16 patients (75.0%) improved in at least 2 out of the 3 main outcome measures. Nine patients (56.3%) showed an improvement in visual acuity; 13 (81.3%) showed an improvement in average corneal sensitivity; and 11 (68.8%) showed an improvement in corneal health. There were no intraoperative or postoperative complications. CONCLUSIONS Corneal neurotization is an emerging surgical treatment option for the management of neurotrophic keratopathy. With appropriate case selection, outcomes are favorable and complication rates are low, for a condition that is otherwise challenging to manage. Patients with severe neurotrophic keratopathy should be considered for this surgical treatment option.
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Affiliation(s)
| | - Jessica Y Tong
- South Australian Institute of Ophthalmology
- Department of Plastic and Reconstructive Surgery, Royal Adelaide Hospital, Adelaide
| | | | - Yugesh Caplash
- Department of Plastic and Reconstructive Surgery, Royal Adelaide Hospital, Adelaide
| | | | - Krishna Tumuluri
- Save Sight Institute, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney
| | - Alicia Au
- Monash Health Clayton, VIC, Australia
| | | | | | - Oded Sagiv
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel
- Section of Ophthalmology, Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, U.S.A
| | - Irit Barequet
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel
| | - Guy Ben Simon
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel
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Redolfi Riva E, Özkan M, Contreras E, Pawar S, Zinno C, Escarda-Castro E, Kim J, Wieringa P, Stellacci F, Micera S, Navarro X. Beyond the limiting gap length: peripheral nerve regeneration through implantable nerve guidance conduits. Biomater Sci 2024; 12:1371-1404. [PMID: 38363090 DOI: 10.1039/d3bm01163a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Peripheral nerve damage results in the loss of sensorimotor and autonomic functions, which is a significant burden to patients. Furthermore, nerve injuries greater than the limiting gap length require surgical repair. Although autografts are the preferred clinical choice, their usage is impeded by their limited availability, dimensional mismatch, and the sacrifice of another functional donor nerve. Accordingly, nerve guidance conduits, which are tubular scaffolds engineered to provide a biomimetic environment for nerve regeneration, have emerged as alternatives to autografts. Consequently, a few nerve guidance conduits have received clinical approval for the repair of short-mid nerve gaps but failed to regenerate limiting gap damage, which represents the bottleneck of this technology. Thus, it is still necessary to optimize the morphology and constituent materials of conduits. This review summarizes the recent advances in nerve conduit technology. Several manufacturing techniques and conduit designs are discussed, with emphasis on the structural improvement of simple hollow tubes, additive manufacturing techniques, and decellularized grafts. The main objective of this review is to provide a critical overview of nerve guidance conduit technology to support regeneration in long nerve defects, promote future developments, and speed up its clinical translation as a reliable alternative to autografts.
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Affiliation(s)
- Eugenio Redolfi Riva
- The Biorobotic Institute, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127 Pisa, Italy.
- Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127 Pisa, Italy
| | - Melis Özkan
- Institute of Materials, école Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
- Bertarelli Foundation Chair in Translational Neural Engineering, Center for Neuroprosthetics and Institute of Bioengineering, école Polytechnique Federale de Lausanne, Lausanne, Switzerland
| | - Estefania Contreras
- Integral Service for Laboratory Animals (SIAL), Faculty of Veterinary, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Department of Cell Biology, Physiology and Immunology, Institute of Neurosciences, Universitat Autònoma de Barcelona (UAB), 08193 Bellaterra, Spain.
| | - Sujeet Pawar
- Institute of Materials, école Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Ciro Zinno
- The Biorobotic Institute, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127 Pisa, Italy.
- Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127 Pisa, Italy
| | - Enrique Escarda-Castro
- Complex Tissue Regeneration Department, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, The Netherlands
| | - Jaehyeon Kim
- Complex Tissue Regeneration Department, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, The Netherlands
| | - Paul Wieringa
- Complex Tissue Regeneration Department, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, Maastricht, The Netherlands
| | - Francesco Stellacci
- Institute of Materials, école Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
- Institute of Materials, Department of Bioengineering and Global Health Institute, École Polytechnique Fédérale de Lausanne (EPFL), Station 12, CH-1015 Lausanne, Switzerland
| | - Silvestro Micera
- The Biorobotic Institute, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127 Pisa, Italy.
- Department of Excellence in Robotics & AI, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127 Pisa, Italy
- Bertarelli Foundation Chair in Translational Neural Engineering, Center for Neuroprosthetics and Institute of Bioengineering, école Polytechnique Federale de Lausanne, Lausanne, Switzerland
| | - Xavier Navarro
- Department of Cell Biology, Physiology and Immunology, Institute of Neurosciences, Universitat Autònoma de Barcelona (UAB), 08193 Bellaterra, Spain.
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), 28031 Madrid, Spain
- Institute Guttmann Foundation, Hospital of Neurorehabilitation, Badalona, Spain
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Broeren BO, Hundepool CA, Kumas AH, Duraku LS, Walbeehm ET, Hooijmans CR, Power DM, Zuidam JM, De Jong T. The effectiveness of acellular nerve allografts compared to autografts in animal models: A systematic review and meta-analysis. PLoS One 2024; 19:e0279324. [PMID: 38295088 PMCID: PMC10829984 DOI: 10.1371/journal.pone.0279324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 05/07/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Treatment of nerve injuries proves to be a worldwide clinical challenge. Acellular nerve allografts are suggested to be a promising alternative for bridging a nerve gap to the current gold standard, an autologous nerve graft. OBJECTIVE To systematically review the efficacy of the acellular nerve allograft, its difference from the gold standard (the nerve autograft) and to discuss its possible indications. MATERIAL AND METHODS PubMed, Embase and Web of Science were systematically searched until the 4th of January 2022. Original peer reviewed paper that presented 1) distinctive data; 2) a clear comparison between not immunologically processed acellular allografts and autologous nerve transfers; 3) was performed in laboratory animals of all species and sex. Meta analyses and subgroup analyses (for graft length and species) were conducted for muscle weight, sciatic function index, ankle angle, nerve conduction velocity, axon count diameter, tetanic contraction and amplitude using a Random effects model. Subgroup analyses were conducted on graft length and species. RESULTS Fifty articles were included in this review and all were included in the meta-analyses. An acellular allograft resulted in a significantly lower muscle weight, sciatic function index, ankle angle, nerve conduction velocity, axon count and smaller diameter, tetanic contraction compared to an autologous nerve graft. No difference was found in amplitude between acellular allografts and autologous nerve transfers. Post hoc subgroup analyses of graft length showed a significant reduced muscle weight in long grafts versus small and medium length grafts. All included studies showed a large variance in methodological design. CONCLUSION Our review shows that the included studies, investigating the use of acellular allografts, showed a large variance in methodological design and are as a consequence difficult to compare. Nevertheless, our results indicate that treating a nerve gap with an allograft results in an inferior nerve recovery compared to an autograft in seven out of eight outcomes assessed in experimental animals. In addition, based on our preliminary post hoc subgroup analyses we suggest that when an allograft is being used an allograft in short and medium (0-1cm, > 1-2cm) nerve gaps is preferred over an allograft in long (> 2cm) nerve gaps.
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Affiliation(s)
- Berend O. Broeren
- Department of Plastic & Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Caroline A. Hundepool
- Department of Plastic & Reconstructive Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Ali H. Kumas
- Department of Plastic & Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Liron S. Duraku
- Department of Plastic, Reconstructive & Hand Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Erik T. Walbeehm
- Department of Plastic, Reconstructive & Hand Surgery, Haga Hospital and Xpert Clinic, Den Haag, The Netherlands
| | - Carlijn R. Hooijmans
- Department for Health Evidence Unit SYRCLE, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Anesthesiology, Pain and Palliative Care (Meta Research Team), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Dominic M. Power
- Department of Hand & Peripheral Nerve Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - J. Michiel Zuidam
- Department of Plastic & Reconstructive Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Tim De Jong
- Department of Plastic & Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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Ansaripour A, Thompson A, Styron JF, Javanbakht M. Cost-effectiveness analysis of Avance ® allograft for the treatment of peripheral nerve injuries in the USA. J Comp Eff Res 2024; 13:e230113. [PMID: 38031842 PMCID: PMC10842286 DOI: 10.57264/cer-2023-0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
Aim: Peripheral nerve injury (PNI) is a debilitating condition with significant associated morbidity, and which places a substantial socioeconomic burden on healthcare systems worldwide. Recently, allograft has emerged as a viable surgical alternative to autograft for the treatment of PNI. This study evaluated the cost effectiveness of allograft (Avance® Nerve Graft) compared with autograft for the peripheral nerve repair, from a US payer perspective. Methods: A Markov cohort model was developed to consider the treatment pathways followed by a patient population undergoing a single transected nerve repair with either allograft, or autograft. The marginal difference in meaningful recovery (MR) (effectiveness), and costs, between the two groups were estimated over a lifetime horizon. Deterministic and probabilistic sensitivity analyses (PSA) were performed to consider the uncertainty surrounding the base-case input parameter values and their effect on the overall incremental cost-effectiveness ratio (ICER). Results: The base-case analysis indicates that there is a small difference in the average probability of MR between the two groups (75.15% vs 70.46%; +4.69% with allograft). Allograft also results in cost savings ($12,677 vs $14,023; -$-1346 with allograft) compared with autograft. Deterministic sensitivity analysis shows that the costs of the initial surgical procedures are the main drivers of incremental cost, but that the intervention is likely to be cost saving compared with autograft regardless of the parameter variations made. Conclusion: The use of allograft with the Avance Nerve Graft has the potential to be a cost-effective alternative to autograft for the surgical treatment of PNI in the USA.
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Affiliation(s)
- Amir Ansaripour
- Optimax Access Ltd., Hofplein, Rotterdam, 3032AC, The Netherlands
| | | | | | - Mehdi Javanbakht
- Optimax Access Ltd, Kenneth Dibben House, Enterprise Rd, Chilworth, Southampton Science Park, Southampton, SO16 7NS, UK
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12
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Zheng S, Wei H, Cheng H, Qi Y, Gu Y, Ma X, Sun J, Ye F, Guo F, Cheng C. Advances in nerve guidance conduits for peripheral nerve repair and regeneration. AMERICAN JOURNAL OF STEM CELLS 2023; 12:112-123. [PMID: 38213640 PMCID: PMC10776341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 11/02/2023] [Indexed: 01/13/2024]
Abstract
Peripheral nerve injury (PNI) can cause partial or total motor and sensory nerve function, leading to physical disability and nerve pain that severely affects patients' quality of life. Autologous nerve transplantation is currently the clinically recognized gold standard, but due to its inherent limitations, researchers have been searching for alternative treatments. Nerve guidance conduits (NGCs) have attracted much attention as a favorable alternative to promote the repair and regeneration of damaged peripheral nerves. In this review, we provide an overview of the anatomy of peripheral nerves, peripheral nerve injury and repair, and current treatment methods. Importantly, different design strategies of NGCs used for the treatment of PNI and their applications in PNI repair are highlighted. Finally, an outlook on the future development and challenges of NGCs is presented.
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Affiliation(s)
- Shasha Zheng
- Department of Otolaryngology Head and Neck Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Jiangsu Provincial Key Medical Discipline (Laboratory)Nanjing 210003, Jiangsu, China
| | - Hao Wei
- Department of Otolaryngology Head and Neck Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Jiangsu Provincial Key Medical Discipline (Laboratory)Nanjing 210003, Jiangsu, China
| | - Hong Cheng
- Department of Otolaryngology Head and Neck Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Jiangsu Provincial Key Medical Discipline (Laboratory)Nanjing 210003, Jiangsu, China
| | - Yanru Qi
- Department of Otolaryngology Head and Neck Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Jiangsu Provincial Key Medical Discipline (Laboratory)Nanjing 210003, Jiangsu, China
| | - Yajun Gu
- Department of Otolaryngology Head and Neck Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Jiangsu Provincial Key Medical Discipline (Laboratory)Nanjing 210003, Jiangsu, China
| | - Xiaofeng Ma
- Department of Otolaryngology Head and Neck Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Jiangsu Provincial Key Medical Discipline (Laboratory)Nanjing 210003, Jiangsu, China
| | - Jiaqiang Sun
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of ChinaHefei 230001, Anhui, China
| | - Fanglei Ye
- Department of Otology, The First Affiliated Hospital of Zhengzhou UniversityZhengzhou 450000, Henan, China
| | - Fangfang Guo
- Department of Plastic and Reconstruction Surgery, Zhongda Hospital, Southeast UniversityNanjing 210009, Jiangsu, China
| | - Cheng Cheng
- Department of Otolaryngology Head and Neck Surgery, Affiliated Drum Tower Hospital of Nanjing University Medical School, Jiangsu Provincial Key Medical Discipline (Laboratory)Nanjing 210003, Jiangsu, China
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Bedar M, Saffari TM, Mathot F, Shin AY. Functional outcomes of nerve allografts augmented with mesenchymal stem cells and surgical angiogenesis in a rat sciatic nerve defect model. J Plast Reconstr Aesthet Surg 2023; 87:329-338. [PMID: 37925923 PMCID: PMC10842349 DOI: 10.1016/j.bjps.2023.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/22/2023] [Accepted: 10/07/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Motor function recovery following acellular nerve allograft (ANA) repair remains inferior to autologous nerve reconstruction. We investigated the functional recovery of ANAs after combined mesenchymal stem cell (MSC) delivery and surgical angiogenesis in a rat sciatic nerve defect model. METHODS In 100 Lewis rats, unilateral sciatic nerve defects were reconstructed with (I) autografts, (II) ANAs, (III) ANAs wrapped with a superficial inferior epigastric artery fascial (SIEF) flap, combined with either (IV) undifferentiated MSCs or (V) Schwann cell-like differentiated MSCs. The tibialis anterior muscle area was evaluated during the survival period using ultrasonography. Functional recovery, histomorphometry, and immunofluorescence were assessed at 12 and 16 weeks. RESULTS At 12 weeks, the addition of surgical angiogenesis and MSCs improved ankle contractures. The SIEF flap also significantly improved compound muscle action potential (CMAP) outcomes compared with ANAs. Autografts outperformed all groups in muscle force and weight. At 16 weeks, ankle contractures of ANAs remained inferior to autografts and SIEF, whereas the CMAP amplitude was comparable between groups. The muscle force of autografts remained superior to all other groups, and the muscle weight of ANAs remained inferior to autografts. No differences were found in histomorphometry outcomes between SIEF groups and ANAs. Vascularity, determined by CD34 staining, was significantly higher in SIEF groups compared with ANAs. CONCLUSIONS The combination of surgical angiogenesis and MSCs did not result in a synergistic improvement in functional outcomes. In a short nerve gap model, the adipofascial flap may provide sufficient MSCs to ANAs without additional ex vivo MSC seeding.
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Affiliation(s)
- Meiwand Bedar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA; Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Plastic Surgery, Nijmegen, the Netherlands
| | - Tiam M Saffari
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA; Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Plastic Surgery, Nijmegen, the Netherlands
| | - Femke Mathot
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA; Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Plastic Surgery, Nijmegen, the Netherlands
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
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14
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Contreras E, Traserra S, Bolívar S, Nieto-Nicolau N, Jaramillo J, Forés J, Jose-Cunilleras E, Moll X, García F, Delgado-Martínez I, Fariñas O, López-Chicón P, Vilarrodona A, Udina E, Navarro X. Decellularized Graft for Repairing Severe Peripheral Nerve Injuries in Sheep. Neurosurgery 2023; 93:1296-1304. [PMID: 37319401 DOI: 10.1227/neu.0000000000002572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 04/26/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Peripheral nerve injuries resulting in a nerve defect require surgical repair. The gold standard of autograft (AG) has several limitations, and therefore, new alternatives must be developed. The main objective of this study was to assess nerve regeneration through a long gap nerve injury (50 mm) in the peroneal nerve of sheep with a decellularized nerve allograft (DCA). METHODS A 5-cm long nerve gap was made in the peroneal nerve of sheep and repaired using an AG or using a DCA. Functional tests were performed once a month and electrophysiology and echography evaluations at 6.5 and 9 months postsurgery. Nerve grafts were harvested at 9 months for immunohistochemical and morphological analyses. RESULTS The decellularization protocol completely eliminated the cells while preserving the extracellular matrix of the nerve. No significant differences were observed in functional tests of locomotion and pain response. Reinnervation of the tibialis anterior muscles occurred in all animals, with some delay in the DCA group compared with the AG group. Histology showed a preserved fascicular structure in both AG and DCA; however, the number of axons distal to the nerve graft was higher in AG than in DCA. CONCLUSION The decellularized graft assayed supported effective axonal regeneration when used to repair a 5-cm long gap in the sheep. As expected, a delay in functional recovery was observed compared with the AG because of the lack of Schwann cells.
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Affiliation(s)
- Estefanía Contreras
- Department of Cell Biology, Physiology and Immunology, Institute of Neuroscience, Universitat Autònoma de Barcelona, Bellaterra , Spain
- Integral Service for Laboratory Animals (SIAL), Faculty of Veterinary, Universitat Autònoma de Barcelona, Bellaterra , Spain
| | - Sara Traserra
- Department of Cell Biology, Physiology and Immunology, Institute of Neuroscience, Universitat Autònoma de Barcelona, Bellaterra , Spain
- Integral Service for Laboratory Animals (SIAL), Faculty of Veterinary, Universitat Autònoma de Barcelona, Bellaterra , Spain
| | - Sara Bolívar
- Department of Cell Biology, Physiology and Immunology, Institute of Neuroscience, Universitat Autònoma de Barcelona, Bellaterra , Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas, Instituto de Salud Carlos III, Bellaterra , Spain
| | | | - Jessica Jaramillo
- Department of Cell Biology, Physiology and Immunology, Institute of Neuroscience, Universitat Autònoma de Barcelona, Bellaterra , Spain
| | - Joaquim Forés
- Department of Cell Biology, Physiology and Immunology, Institute of Neuroscience, Universitat Autònoma de Barcelona, Bellaterra , Spain
- Hand and Peripheral Nerve Unit, Hospital Clínic i Provincial, Universitat de Barcelona, Barcelona , Spain
| | - Eduard Jose-Cunilleras
- Department of Animal Medicine and Surgery, Universitat Autònoma de Barcelona, Bellaterra , Spain
| | - Xavier Moll
- Department of Animal Medicine and Surgery, Universitat Autònoma de Barcelona, Bellaterra , Spain
| | - Félix García
- Department of Animal Medicine and Surgery, Universitat Autònoma de Barcelona, Bellaterra , Spain
| | - Ignacio Delgado-Martínez
- Department of Cell Biology, Physiology and Immunology, Institute of Neuroscience, Universitat Autònoma de Barcelona, Bellaterra , Spain
| | - Oscar Fariñas
- Barcelona Tissue Bank, Banc de Sang i Teixits, Barcelona , Spain
- Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona , Spain
| | - Patrícia López-Chicón
- Barcelona Tissue Bank, Banc de Sang i Teixits, Barcelona , Spain
- Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona , Spain
| | - Anna Vilarrodona
- Barcelona Tissue Bank, Banc de Sang i Teixits, Barcelona , Spain
- Vall Hebron Institute of Research (VHIR), Barcelona , Spain
| | - Esther Udina
- Department of Cell Biology, Physiology and Immunology, Institute of Neuroscience, Universitat Autònoma de Barcelona, Bellaterra , Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas, Instituto de Salud Carlos III, Bellaterra , Spain
| | - Xavier Navarro
- Department of Cell Biology, Physiology and Immunology, Institute of Neuroscience, Universitat Autònoma de Barcelona, Bellaterra , Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas, Instituto de Salud Carlos III, Bellaterra , Spain
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15
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Mercer DM, Nguyen HM, Curtis W, Heifner JJ, Chafey DH. Consideration for Limb Salvage in Place of Amputation in Complex Tibial Fracture With Neurovascular Injury: A Case Report. THE IOWA ORTHOPAEDIC JOURNAL 2023; 43:20-24. [PMID: 38213861 PMCID: PMC10777692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
High-energy tibial fractures often present with associated soft tissue injuries, including neuro-vascular damage, complicating the treatment decision. A 33-year-old male presented with Gustilo Anderson type IIIA fracture of the left distal tibia and fibula with associated closed calcaneus fracture and tibial nerve transection. Amputation was discussed, but the decision was made for limb salvage with nerve allograft. The patient displayed satisfactory functional recovery at 29 months postoperatively without need for major revision, grafting, arthrodesis, or amputation. This case report provides an example of successful limb salvage utilizing tibial nerve allograft in a complex high-energy lower extremity injury. Level of Evidence: IV.
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Affiliation(s)
- Deana M. Mercer
- Department of Orthopaedics & Rehabilitation, University of New Mexico, Albuquerque, New Mexico, USA
| | - Hoang M. Nguyen
- Department of Orthopaedics & Rehabilitation, University of New Mexico, Albuquerque, New Mexico, USA
| | - William Curtis
- Department of Orthopaedics & Rehabilitation, University of New Mexico, Albuquerque, New Mexico, USA
| | | | - David H. Chafey
- Department of Orthopaedics & Rehabilitation, University of New Mexico, Albuquerque, New Mexico, USA
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16
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Tan RES, Jeyaratnam S, Lim AYT. Updates in peripheral nerve surgery of the upper extremity: diagnosis and treatment options. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:391. [PMID: 37970602 PMCID: PMC10632574 DOI: 10.21037/atm-23-1500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 08/11/2023] [Indexed: 11/17/2023]
Abstract
The loss of function resulting from peripheral nerve injuries confers a significant burden to the patient and society. The treatment of peripheral nerve injuries requires an accurate diagnosis and formulation of a functional reconstructive plan. Advances in peripheral nerve imaging complement electrodiagnostic studies, and provide us with detailed information regarding the status of nerve injury, repair, and regeneration in order to prognosticate recovery and determine the need for surgical intervention. When direct nerve repair is not possible, the methods for bridging a nerve gap are the nerve autograft, allograft and conduit. While current research supports the use of conduits and nerve allografts for shorter nerve gaps, the nerve autograft still remains the gold standard for bridging a nerve gap. When direct nerve repair or nerve grafting fails, or is anticipated to be insufficient, nerve transfers are an alternative for reconstruction. Knowledge of axonal counts, upper limb innervation patterns, location and clustering of upper limb peripheral nerves allows for the design of new nerve transfers. The options of nerve transfers for radial, ulnar and median nerve injuries are outlined, as well as their outcomes. Nerve transfers are an attractive option for restoring motor and sensory function while minimizing donor site morbidity. However, one must consider their limitations, and preserve donor sites for secondary tendon transfer options. This article presents the latest information regarding the imaging of peripheral nerves, methods to bridge a nerve gap, and nerve transfers to aid the peripheral nerve surgeon in choosing a reconstructive plan.
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Affiliation(s)
| | | | - Aymeric Y. T. Lim
- Department of Hand and Reconstructive Microsurgery, National University Health System, Singapore, Singapore
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17
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Zimmermann KS, Aman M, Harhaus L, Boecker AH. Improving outcomes in traumatic peripheral nerve injuries to the upper extremity. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03751-3. [PMID: 37864051 DOI: 10.1007/s00590-023-03751-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/25/2023] [Indexed: 10/22/2023]
Abstract
Peripheral nerve lesions of the upper extremity are common and are associated with devastating limitations for the patient. Rapid and accurate diagnosis of the lesion by electroneurography, neurosonography, or even MR neurography is important for treatment planning. There are different therapeutic approaches, which may show individual differences depending on the injured nerve. If a primary nerve repair is not possible, several strategies exist to bridge the gap. These may include autologous nerve grafts, bioartificial nerve conduits, or acellular nerve allografts. Tendon and nerve transfers are also of major importance in the treatment of nerve lesions in particular with long regeneration distances. As a secondary reconstruction, in addition to tendon transfers, there is also the option for free functional muscle transfer. In amputations, the prevention of neuroma is of great importance, for which different strategies exist, such as target muscle reinnervation, regenerative peripheral nerve interface, or neurotized flaps. In this article, we give an overview of the latest methods for the therapy of peripheral nerve lesions.
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Affiliation(s)
- Kim S Zimmermann
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Martin Aman
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Leila Harhaus
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
- Department of Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Arne H Boecker
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany.
- Department of Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany.
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18
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Isaacs J, Nydick JA, Means KR, Merrell GA, Ilyas A, Levin LS. A Multicenter Prospective Randomized Comparison of Conduits Versus Decellularized Nerve Allograft for Digital Nerve Repairs. J Hand Surg Am 2023; 48:904-913. [PMID: 37530686 DOI: 10.1016/j.jhsa.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 05/06/2023] [Accepted: 05/24/2023] [Indexed: 08/03/2023]
Abstract
PURPOSE While there are advantages and disadvantages to both processed nerve allografts (PNA) and conduits, a large, well-controlled prospective study is needed to compare the efficacy and to delineate how each of these repair tools can be best applied to digital nerve injuries. We hypothesized that PNA digital nerve repairs would achieve superior functional recovery for longer length gaps compared with conduit-based repairs. METHODS Patients (aged 18-69 years) presenting with suspected acute or subacute (less than 24 weeks old) digital nerve injuries were recruited to prticipate at 20 medical centers across the United States. After stratification to short (5-14 mm) and long (15-25 mm) gap subgroups, the patients were randomized (1:1) to repair with either a commercially available PNA or collagen conduit. Baseline and outcomes assessments were obtained either before or immediately after surgery and planned at 3-, 6-, 9-, and 12-months after surgery. All assessors and patients were blinded to the treatment arm. RESULTS In total, 220 patients were enrolled, and 183 patients completed an acceptable last evaluable visit (at least 6 months and not more than 15 months postrepair). At last follow-up, for the short gap repair groups, average static two-point discrimination was 7.3 ± 2.8 mm for PNA and 7.5 ± 3.1 mm for conduit repairs. For the long gap group, average static two-point discrimination was significantly lower at 6.1 ± 3.3 mm for PNA compared with 7.5 ± 2.4 mm for conduit repairs. Normal sensation (American Society for Surgery of the Hand scale) was achieved in 40% of PNA long gap repairs, which was significantly more than the 18% observed in long conduit patients. Long gap conduits had more clinical failures (lack of protective sensation) than short gap conduits. CONCLUSIONS Although supporting similar levels of nerve regeneration for short gap length digital nerve repairs, PNA was clinically superior to conduits for long gap reconstructions. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.
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Affiliation(s)
- Jonathan Isaacs
- Virginia Commonwealth University Medical Center, Richmond, VA.
| | | | | | | | | | - L Scott Levin
- University of Pennsylvania, Penn Medicine, Philadelphia, PA
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19
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Kaplan J, Lee ZH, Grome L, Yao CMKL, Mericli AF, Roubaud MS, Largo RD, Garvey PB. Sensory Outcomes for Inferior Alveolar Nerve Reconstruction with Allograft following Free Fibula Mandible Reconstruction. Plast Reconstr Surg 2023; 152:499e-506e. [PMID: 36780351 DOI: 10.1097/prs.0000000000010286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
BACKGROUND As patient survival with head and neck cancer has improved, treatment goals have had to evolve to focus on improving quality of life. Traditionally, patients who have undergone mandibulectomy are left with an insensate chin and lower lip secondary to resection of the inferior alveolar nerve (IAN). The purpose of this study was to critically evaluate the authors' initial experience using processed nerve allografts (PNA) for IAN reconstruction following oncologic mandibulectomy and reconstruction with free fibula osteocutaneous flaps and to assess their patients' sensory outcomes. METHODS The authors performed a retrospective review of the first 32 patients who underwent immediate IAN reconstruction with PNA at the time of oncologic mandibulectomy and mandible reconstruction with free fibula osteocutaneous flaps at The University of Texas M. D. Anderson Cancer Center over a 1-year period. Semmes-Weinstein filament sensory testing was conducted at multiple surgical follow-up appointments to evaluate the quality of sensory recovery. RESULTS Thirteen of the 32 patients underwent postoperative Semmes-Weinstein filament testing. All 13 patients demonstrated partial return of sensation. At a mean follow-up of 8.33 months, the average level of sensation was 60.93% that of the unaffected side of the lower lip. CONCLUSIONS Patients were consistently afforded improvement in lower lip sensation using PNA-based IAN grafting as an adjunct to free fibula-based mandible reconstruction. The procedure adds no additional surgical morbidity and has shown consistent positive results.
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Affiliation(s)
- Jordan Kaplan
- From the Division of Plastic Surgery, Baylor College of Medicine
| | - Z-Hye Lee
- Department of Plastic and Reconstructive Surgery, The University of Texas M. D. Anderson Cancer Center
| | - Luke Grome
- From the Division of Plastic Surgery, Baylor College of Medicine
| | | | - Alexander F Mericli
- Department of Plastic and Reconstructive Surgery, The University of Texas M. D. Anderson Cancer Center
| | - Margaret S Roubaud
- Department of Plastic and Reconstructive Surgery, The University of Texas M. D. Anderson Cancer Center
| | - Rene D Largo
- Department of Plastic and Reconstructive Surgery, The University of Texas M. D. Anderson Cancer Center
| | - Patrick B Garvey
- Department of Plastic and Reconstructive Surgery, The University of Texas M. D. Anderson Cancer Center
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20
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Hsu MW, Chen SH, Tseng WL, Hung KS, Chung TC, Lin SC, Koo J, Hsueh YY. Physical processing for decellularized nerve xenograft in peripheral nerve regeneration. Front Bioeng Biotechnol 2023; 11:1217067. [PMID: 37324430 PMCID: PMC10267830 DOI: 10.3389/fbioe.2023.1217067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/23/2023] [Indexed: 06/17/2023] Open
Abstract
In severe or complex cases of peripheral nerve injuries, autologous nerve grafts are the gold standard yielding promising results, but limited availability and donor site morbidity are some of its disadvantages. Although biological or synthetic substitutes are commonly used, clinical outcomes are inconsistent. Biomimetic alternatives derived from allogenic or xenogenic sources offer an attractive off-the-shelf supply, and the key to successful peripheral nerve regeneration focuses on an effective decellularization process. In addition to chemical and enzymatic decellularization protocols, physical processes might offer identical efficiency. In this comprehensive minireview, we summarize recent advances in the physical methods for decellularized nerve xenograft, focusing on the effects of cellular debris clearance and stability of the native architecture of a xenograft. Furthermore, we compare and summarize the advantages and disadvantages, indicating the future challenges and opportunities in developing multidisciplinary processes for decellularized nerve xenograft.
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Affiliation(s)
- Ming-Wei Hsu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Szu-Han Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Center of Cell Therapy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- International Research Center for Wound Repair and Regeneration, National Cheng Kung University, Tainan, Taiwan
| | - Wan-Ling Tseng
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan
| | - Kuo-Shu Hung
- Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tzu-Chun Chung
- Department of Orthopedic Surgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Sheng-Che Lin
- Division of Plastic Surgery, Department of Surgery, An-Nan Hospital, China Medical University, Tainan, Taiwan
| | - Jahyun Koo
- School of Biomedical Engineering, Korea University, Seoul, Republic of Korea
| | - Yuan-Yu Hsueh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Center of Cell Therapy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- International Research Center for Wound Repair and Regeneration, National Cheng Kung University, Tainan, Taiwan
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21
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O'Neill RC, Spiegel AJ. Modern Approaches to Breast Neurotization. Clin Plast Surg 2023; 50:347-355. [PMID: 36813412 DOI: 10.1016/j.cps.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Absent or diminished breast sensation is a persistent problem for many postmastectomy patients. Breast neurotization is an opportunity to improve sensory outcomes, which are poor and unpredictable if left to chance. Several techniques for autologous and implant reconstruction have been described with successful clinical and patient-reported outcomes. Neurotization is a safe procedure with minimal risk for morbidity and it presents a fantastic avenue for future research.
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Affiliation(s)
- Rebecca C O'Neill
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
| | - Aldona J Spiegel
- Institute for Reconstructive Surgery, Houston Methodist Hospital, 6560 Fannin Street #2200, Houston, TX 77030, USA.
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22
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Itoh M, Itou J, Imai S, Okazaki K, Iwasaki K. A survey on the usage of decellularized tissues in orthopaedic clinical trials. Bone Joint Res 2023; 12:179-188. [PMID: 37051813 PMCID: PMC10032226 DOI: 10.1302/2046-3758.123.bjr-2022-0383.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
Orthopaedic surgery requires grafts with sufficient mechanical strength. For this purpose, decellularized tissue is an available option that lacks the complications of autologous tissue. However, it is not widely used in orthopaedic surgeries. This study investigated clinical trials of the use of decellularized tissue grafts in orthopaedic surgery. Using the ClinicalTrials.gov (CTG) and the International Clinical Trials Registry Platform (ICTRP) databases, we comprehensively surveyed clinical trials of decellularized tissue use in orthopaedic surgeries registered before 1 September 2022. We evaluated the clinical results, tissue processing methods, and commercial availability of the identified products using academic literature databases and manufacturers' websites. We initially identified 4,402 clinical trials, 27 of which were eligible for inclusion and analysis, including nine shoulder surgery trials, eight knee surgery trials, two ankle surgery trials, two hand surgery trials, and six peripheral nerve graft trials. Nine of the trials were completed. We identified only one product that will be commercially available for use in knee surgery with significant mechanical load resistance. Peracetic acid and gamma irradiation were frequently used for sterilization. Despite the demand for decellularized tissue, few decellularized tissue products are currently commercially available, particularly for the knee joint. To be viable in orthopaedic surgery, decellularized tissue must exhibit biocompatibility and mechanical strength, and these requirements are challenging for the clinical application of decellularized tissue. However, the variety of available decellularized products has recently increased. Therefore, decellularized grafts may become a promising option in orthopaedic surgery.
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Affiliation(s)
- Masafumi Itoh
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
- Institute for Medical Regulatory Science, Comprehensive Research Organization, Waseda University, Tokyo, Japan
- Tokyo Women's Medical University - Waseda University Joint Graduate School, Waseda University, Tokyo, Japan
| | - Junya Itou
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
- Tokyo Women's Medical University - Waseda University Joint Graduate School, Waseda University, Tokyo, Japan
| | - Shinya Imai
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
| | - Ken Okazaki
- Department of Orthopaedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
| | - Kiyotaka Iwasaki
- Institute for Medical Regulatory Science, Comprehensive Research Organization, Waseda University, Tokyo, Japan
- Tokyo Women's Medical University - Waseda University Joint Graduate School, Waseda University, Tokyo, Japan
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
- Department of Mordern Mechanical Engineering, School of Creative Science and Engineering, Waseda University, Tokyo, Japan
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23
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Peters BR, Wood MD, Hunter DA, Mackinnon SE. Acellular Nerve Allografts in Major Peripheral Nerve Repairs: An Analysis of Cases Presenting With Limited Recovery. Hand (N Y) 2023; 18:236-243. [PMID: 33880944 PMCID: PMC10035101 DOI: 10.1177/15589447211003175] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Acellular nerve allografts have been used successfully and with increasing frequency to reconstruct nerve injuries. As their use has been expanded to treat longer gap, larger diameter nerve injuries, some failed cases have been reported. We present the histomorphometry of 5 such cases illustrating these limitations and review the current literature of acellular nerve allografts. METHODS Between 2014 and 2019, 5 patients with iatrogenic nerve injuries to the median or ulnar nerve reconstructed with an AxoGen AVANCE nerve allograft at an outside hospital were treated in our center with allograft excision and alternative reconstruction. These patients had no clinical or electrophysiological evidence of recovery, and allograft specimens at the time of surgery were sent for histomorphological examination. RESULTS Three patients with a median and 2 with ulnar nerve injury were included. Histology demonstrated myelinated axons present in all proximal native nerve specimens. In 2 cases, axons failed to regenerate into the allograft and in 3 cases, axonal regeneration diminished or terminated within the allograft. CONCLUSIONS The reported cases demonstrate the importance of evaluating the length and the function of nerves undergoing acellular nerve allograft repair. In long length, large-diameter nerves, the use of acellular nerve allografts should be carefully considered.
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Affiliation(s)
- Blair R. Peters
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Oregon Health & Science Univeristy, Portland, OR, USA
| | - Matthew D. Wood
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel A. Hunter
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Susan E. Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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24
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Update on Upper Limb Neuroma Management. J Craniofac Surg 2023; 34:1140-1143. [PMID: 36728490 DOI: 10.1097/scs.0000000000009164] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/04/2022] [Indexed: 02/03/2023] Open
Abstract
Painful terminal neuromas in the upper limb due to nerve injury are common. Neuroma symptoms include a sharp and burning sensation, cold intolerance, dysesthesia, pain, numbness, and paresthesia. These symptoms could have a negative impact on the functional ability of the patient and quality of life. In addition, Prostheses use might be abandoned by amputees due to neuroma-induced pain. Many clinicians face challenges while managing neuromas. Contemporary "active" methods like regenerative peripheral nerve interface (RPNI), targeted muscle reinnervation (TMR), and processed nerve allograft repair (PNA) are replacing the conventional "passive" approaches such as excision, transposition, and implantation techniques. RPNI involves inducing axonal sprouting by transplanting the free end of a peripheral nerve into a free muscle graft. TMR includes reassigning the role of the peripheral nerve by the transfer of the distal end of a pure sensory or a mixed peripheral nerve to a motor nerve of a nearby muscle segment. To give the peripheral nerve a pathway to re-innervate its target tissue, PNA entails implanting a sterile extracellular matrix prepared from decellularized and regenerated human nerve tissue with preserved epineurium and fascicles. Of these, RPNI and TMR appear to hold a promising treatment for nerve-ending neuromas and prevent their relapse. In contrast, PNA may reduce neuroma pain and allow meaningful nerve repair. The aim of this article is to provide an overview of the newer approaches of TMR, RPNI, and PNA and discuss their implications, surgical techniques, and reported consequences.
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Repair of Long Nerve Defects with a New Decellularized Nerve Graft in Rats and in Sheep. Cells 2022; 11:cells11244074. [PMID: 36552838 PMCID: PMC9777287 DOI: 10.3390/cells11244074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/30/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
Decellularized nerve allografts (DC) are an alternative to autografts (AG) for repairing severe peripheral nerve injuries. We have assessed a new DC provided by VERIGRAFT. The decellularization procedure completely removed cellularity while preserving the extracellular matrix. We first assessed the DC in a 15 mm gap in the sciatic nerve of rats, showing slightly delayed but effective regeneration. Then, we assayed the DC in a 70 mm gap in the peroneal nerve of sheep compared with AG. Evaluation of nerve regeneration and functional recovery was performed by clinical, electrophysiology and ultrasound tests. No significant differences were found in functional recovery between groups of sheep. Histology showed a preserved fascicular structure in the AG while in the DC grafts regenerated axons were grouped in small units. In conclusion, the DC was permissive for axonal regeneration and allowed to repair a 70 mm long gap in the sheep nerve.
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Yonezawa H, Yamamoto N, Hayashi K, Takeuchi A, Miwa S, Igarashi K, Morinaga S, Asano Y, Saito S, Tada K, Nojima T, Tsuchiya H. Do Liquid Nitrogen-treated Tumor-bearing Nerve Grafts Have the Capacity to Regenerate, and Do They Pose a Risk of Local Recurrence? A Study in Rats. Clin Orthop Relat Res 2022; 480:2442-2455. [PMID: 35976198 PMCID: PMC10540061 DOI: 10.1097/corr.0000000000002336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 07/01/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Under most circumstances, the resection of soft tissue sarcomas of the extremities can be limb-sparing, function-preserving oncologic resections with adequate margins. However, en bloc resection may require resection of the major peripheral nerves, causing poor function in the extremities. Although liquid nitrogen treatment has been used to sterilize malignant bone tumors, its use in the preparation of nerve grafts has, to our knowledge, not been reported. Hence, this study aimed to investigate the tumor recurrence and function after peripheral nerve reconstruction using liquid nitrogen-treated tumor-bearing nerves in a rat model. QUESTIONS/PURPOSES (1) Do liquid nitrogen-treated frozen autografts have regeneration capabilities? (2) Do liquid nitrogen-treated tumor-bearing nerves cause any local recurrences in vivo in a rat model? METHODS Experiment 1: Twelve-week-old female Wistar rats, each weighing 250 g to 300 g, were used. A 10-mm-long section of the right sciatic nerve was excised; the prepared nerve grafts were bridge-grafted through end-to-end suturing. The rats were grouped as follows: an autograft group, which underwent placement of a resected sciatic nerve after it was sutured in the reverse orientation, and a frozen autograft group, which underwent bridging of the nerve gap using a frozen autograft. The autograft was frozen in liquid nitrogen, thawed at room temperature, and then thawed in distilled water before application. The third group was a resection group in which the nerve gap was not reconstructed. Twenty-four rats were included in each group, and six rats per group were evaluated at 4, 12, 24, and 48 weeks postoperatively. To assess nerve regeneration after reconstruction using the frozen nerve graft in the nontumor rat model, we evaluated the sciatic functional index, tibialis anterior muscle wet weight ratio, electrophysiologic parameters (amplitude and latency), muscle fiber size (determined with Masson trichrome staining), lower limb muscle volume, and immunohistochemical findings (though neurofilament staining and S100 protein produced solely and uniformly by Schwann cells associated with axons). Lower limb muscle volume was calculated via CT before surgery (0 weeks) and at 4, 8, 12, 16, 20, 24, 32, 40, and 48 weeks after surgery. Experiment 2: Ten-week-old female nude rats (F344/NJcl-rnu/rnu rats), each weighing 100 g to 150 g, were injected with HT1080 (human fibrosarcoma) cells near the bilateral sciatic nerves. Two weeks after injection, the tumor grew to a 10-mm-diameter mass involving the sciatic nerves. Subsequently, the tumor was resected with the sciatic nerves, and tumor-bearing sciatic nerves were obtained. After liquid nitrogen treatment, the frozen tumor-bearing nerve graft was trimmed to a 5-mm-long tissue and implanted into another F344/NJcl-rnu/rnu rat, in which a 5-mm-long section of the sciatic nerve was resected to create a nerve gap. Experiment 2 was performed with 12 rats; six rats were evaluated at 24 and 48 weeks postoperatively. To assess nerve regeneration and tumor recurrence after nerve reconstruction using frozen tumor-bearing nerve grafts obtained from the nude rat with human fibrosarcoma involving the sciatic nerve, the sciatic nerve's function and histologic findings were evaluated in the same way as in Experiment 1. RESULTS Experiment 1: The lower limb muscle volume decreased once at 4 weeks in the autograft and frozen autograft groups and gradually increased thereafter. The tibialis anterior muscle wet weight ratio, sciatic functional index, muscle fiber size, and electrophysiologic evaluation showed higher nerve regeneration potential in the autograft and frozen autograft groups than in the resection group. The median S100-positive areas (interquartile range [IQR]) in the autograft group were larger than those in the frozen autograft group at 12 weeks (0.83 [IQR 0.78 to 0.88] versus 0.57 [IQR 0.53 to 0.61], difference of medians 0.26; p = 0.04) and at 48 weeks (0.86 [IQR 0.83 to 0.99] versus 0.74 [IQR 0.69 to 0.81], difference of median 0.12; p = 0.03). Experiment 2: Lower limb muscle volume decreased at 4 weeks and gradually increased thereafter. The median muscle fiber size increased from 0.89 (IQR 0.75 to 0.90) at 24 weeks to 1.20 (IQR 1.08 to 1.34) at 48 weeks (difference of median 0.31; p< 0.01). The median amplitude increased from 0.60 (IQR 0.56 to 0.67) at 24 weeks to 0.81 (IQR 0.76 to 0.90) at 48 weeks (difference of median 0.21; p < 0.01). Despite tumor involvement and freezing treatment, tumor-bearing frozen grafts demonstrated nerve regeneration activity, with no local recurrence observed at 48 weeks postoperatively in nude rats. CONCLUSION Tumor-bearing frozen nerve grafts demonstrated nerve regeneration activity, and there was no tumor recurrence in rats in vivo. CLINICAL RELEVANCE A frozen nerve autograft has a similar regenerative potential to that of a nerve autograft. Although the findings in a rat model do not guarantee efficacy in humans, if they are substantiated by large-animal models, clinical trials will be needed to evaluate the efficacy of tumor-bearing frozen nerve grafts in humans.
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Affiliation(s)
- Hirotaka Yonezawa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Norio Yamamoto
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Katsuhiro Hayashi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Akihiko Takeuchi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Shinji Miwa
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Kentaro Igarashi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Sei Morinaga
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Yohei Asano
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Shiro Saito
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Kaoru Tada
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
| | - Takayuki Nojima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
- Department of Diagnostic Pathology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa, Japan
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Yu T, Ao Q, Ao T, Ahmad MA, Wang A, Xu Y, Zhang Z, Zhou Q. Preparation and assessment of an optimized multichannel acellular nerve allograft for peripheral nerve regeneration. Bioeng Transl Med 2022. [DOI: 10.1002/btm2.10435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Tianhao Yu
- The VIP Department, School and Hospital of Stomatology China Medical University, Liaoning Provincial Key Laboratory of Oral Diseases Shenyang China
| | - Qiang Ao
- Department of Developmental Cell Biology, Key Laboratory of Medical Cell Biology, Ministry of Education China Medical University Shenyang China
- NMPA Key Laboratory for Quality Research and Control of Tissue Regenerative Biomaterial, Institute of Regulatory Science for Medical Device, National Engineering Research Center for Biomaterials Sichuan University Chengdu Sichuan China
| | - Tianrang Ao
- Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | | | - Aijun Wang
- Department of Neurological Surgery University of California Davis Sacramento California USA
| | - Yingxi Xu
- Department of Clinical Nutrition Shengjing Hospital of China Medical University Shenyang China
| | - Zhongti Zhang
- The VIP Department, School and Hospital of Stomatology China Medical University, Liaoning Provincial Key Laboratory of Oral Diseases Shenyang China
| | - Qing Zhou
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology China Medical University, Liaoning Provincial Key Laboratory of Oral Diseases Shenyang China
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Muscle-in-Vein Conduits for the Treatment of Symptomatic Neuroma of Sensory Digital Nerves. J Pers Med 2022; 12:jpm12091514. [PMID: 36143300 PMCID: PMC9503054 DOI: 10.3390/jpm12091514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/07/2022] [Accepted: 09/13/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Considering the debilitating burden of neuroma resulting in a significant loss of function and excruciating pain, the use of muscle-in-vein conduits (MVCs) for the reconstruction of painful neuroma of sensory nerves of the fingers was assessed. Methods: We retrospectively analyzed 10 patients who underwent secondary digital nerve repair by MVCs. The recovery of sensibility was evaluated by static and moving two-point discrimination (2PDs, 2PDm) and Semmes-Weinstein monofilament testing (SWM). The minimum follow-up was set 12 months after the operation. Results: The median period between trauma and nerve repair was 13.4 weeks (IQR 53.5). After neuroma resection, defects ranged from 10–35 mm (mean 17.7 mm, SD 0.75). The successful recovery of sensibility was achieved in 90% of patients after a median follow-up of 27.0 months (IQR 31.00). The mean 2PDs and 2PDm was 8.1 mm (SD 3.52) and 5.2 mm (SD 2.27), respectively. Assessment by SWM resulted in a mean value of 3.54 (SD 0.69). Reduction in pain was achieved among all patients; eight patients reported the complete relief of neuropathic pain. There was no recurrence of neuroma in any patient. Conclusions: Muscle-in-vein conduits provide an effective treatment for painful neuroma of digital nerves, resulting in satisfactory restoration of sensory function and relief of pain.
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Vallejo FA, Diaz A, Errante EL, Smartz T, Khan A, Silvera R, Brooks AE, Lee YS, Burks SS, Levi AD. Systematic review of the therapeutic use of Schwann cells in the repair of peripheral nerve injuries: Advancements from animal studies to clinical trials. Front Cell Neurosci 2022; 16:929593. [PMID: 35966198 PMCID: PMC9372346 DOI: 10.3389/fncel.2022.929593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/05/2022] [Indexed: 11/26/2022] Open
Abstract
Objective To systematically evaluate the literature on the therapeutic use of Schwann cells (SC) in the repair of peripheral nerve injuries. Methods The Cochrane Library and PubMed databases were searched using terms [(“peripheral nerve injury” AND “Schwann cell” AND “regeneration”) OR (“peripheral nerve injuries”)]. Studies published from 2008 to 2022 were eligible for inclusion in the present study. Only studies presenting data from in-vivo investigations utilizing SCs in the repair of peripheral nerve injuries qualified for review. Studies attempting repair of a gap of ≥10 mm were included. Lastly, studies needed to have some measure of quantifiable regenerative outcome data such as histomorphometry, immunohistochemical, electrophysiology, or other functional outcomes. Results A search of the PubMed and Cochrane databases revealed 328 studies. After screening using the abstracts and methods, 17 studies were found to meet our inclusion criteria. Good SC adherence and survival in conduit tubes across various studies was observed. Improvement in morphological and functional outcomes with the use of SCs in long gap peripheral nerve injuries was observed in nearly all studies. Conclusion Based on contemporary literature, SCs have demonstrated clear potential in the repair of peripheral nerve injury in animal studies. It has yet to be determined which nerve conduit or graft will prove superior for delivery and retention of SCs for nerve regeneration. Recent developments in isolation and culturing techniques will enable further translational utilization of SCs in future clinical trials.
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Affiliation(s)
- Frederic A. Vallejo
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Anthony Diaz
- Department of Neurosurgery, University of Connecticut, Farmington, CT, United States
| | - Emily L. Errante
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Taylor Smartz
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Aisha Khan
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, United States
- Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Risset Silvera
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, United States
- Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Adriana E. Brooks
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, United States
- Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Yee-Shuan Lee
- Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Stephen Shelby Burks
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, United States
- Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Allan D. Levi
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, United States
- Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
- *Correspondence: Allan D. Levi
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Pu JJ, Hakim SG, Melville JC, Su YX. Current Trends in the Reconstruction and Rehabilitation of Jaw following Ablative Surgery. Cancers (Basel) 2022; 14:cancers14143308. [PMID: 35884369 PMCID: PMC9320033 DOI: 10.3390/cancers14143308] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/18/2022] [Accepted: 06/21/2022] [Indexed: 12/04/2022] Open
Abstract
Simple Summary The Maxilla and mandible provide skeletal support for of the middle and lower third of our faces, allowing for the normal functioning of breathing, chewing, swallowing, and speech. The ablative surgery of jaws in the past often led to serious disfigurement and disruption in form and function. However, with recent strides made in computer-assisted surgery and patient-specific implants, the individual functional reconstruction of the jaw is evolving rapidly and the prompt rehabilitation of both the masticatory function and aesthetics after jaw resection has been made possible. In the present review, the recent advancements in jaw reconstruction technology and future perspectives will be discussed. Abstract The reconstruction and rehabilitation of jaws following ablative surgery have been transformed in recent years by the development of computer-assisted surgery and virtual surgical planning. In this narrative literature review, we aim to discuss the current state-of-the-art jaw reconstruction, and to preview the potential future developments. The application of patient-specific implants and the “jaw-in-a-day technique” have made the fast restoration of jaws’ function and aesthetics possible. The improved efficiency of primary reconstructive surgery allows for the rehabilitation of neurosensory function following ablative surgery. Currently, a great deal of research has been conducted on augmented/mixed reality, artificial intelligence, virtual surgical planning for soft tissue reconstruction, and the rehabilitation of the stomatognathic system. This will lead to an even more exciting future for the functional reconstruction and rehabilitation of the jaw following ablative surgery.
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Affiliation(s)
- Jane J. Pu
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong;
| | - Samer G. Hakim
- Department Oral and Maxillofacial Surgery, University Hospital of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany;
| | - James C. Melville
- Department of Oral and Maxillofacial Surgery, University of Texas Health Science Center at Houston, Houston, TX 77030, USA;
| | - Yu-Xiong Su
- Division of Oral and Maxillofacial Surgery, Faculty of Dentistry, The University of Hong Kong, Hong Kong;
- Correspondence:
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Abstract
BACKGROUND Acellular nerve allograft (ANA) occupies an increasingly prominent role in the treatment of peripheral nerve reconstruction. There is demonstrable efficacy; however, some grafts fail to support axonal regrowth and the reasons for this are unclear. This study examines the ANA experience in a specialized peripheral nerve surgery department to discuss the clinical and histological findings in failed cases. METHOD Failed ANA grafts were identified from a prospective database using Medical Research Council Classification (MRCC) S3 and M3 as thresholds for success. Cases in which ANA grafting was indicated for nerve related pain and dysesthesia but where no subjective improvement in symptoms occurred were also included. Patients requiring revision surgery after ANA grafting were also considered failures. Cases were then examined in conjunction with a literature review to identify possible mechanisms of failure, including detailed histological analysis in 2 cases. RESULTS Eight failed procedures were identified from a database of 99 separate allograft records on 74 patients. This included procedures for 2 tibial nerves, 2 superficial radial nerves, 2 median nerves, 1 digital nerve and a lateral cord brachial plexus injury (male/female, 5:3; age range, 24-54 years). Allograft length range 25 to 120 mm. One postoperative infection was identified. Histological findings in 2 cases included adequate vascularization of allograft material without subsequent axonal regeneration, a reduction of large myelinated fibers proximal to a tibial nerve allograft in the setting of a chronic injury, and a preference for small rather than large fiber regeneration. CONCLUSIONS This article reports instances of ANA graft failure in a variety of contexts, for which the primary reasons for failure remain unclear. The etiology is likely to be multifactorial with both patient, graft and surgeon factors contributing to failure. Further clinical and histological analysis of ANA failures will improve our understanding of the mechanisms of graft failure.
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Affiliation(s)
- Calum Thomson
- From the Department of Peripheral Nerve Surgery, Queen Elizabeth Hospital
| | | | - Ute Pohl
- Department of Cellular Pathology
| | - Dominic M Power
- The Birmingham Peripheral Nerve Injury Service, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Closing the Gap: Bridging Peripheral Sensory Nerve Defects with a Chitosan-Based Conduit a Randomized Prospective Clinical Trial. J Pers Med 2022; 12:jpm12060900. [PMID: 35743685 PMCID: PMC9224872 DOI: 10.3390/jpm12060900] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/20/2022] [Accepted: 05/24/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: If tensionless nerve coaptation is not possible, bridging the resulting peripheral nerve defect with an autologous nerve graft is still the current gold standard. The concept of conduits as an alternative with different materials and architectures, such as autologous vein conduits or bioartificial nerve conduits, could not replace the nerve graft until today. Chitosan, as a relatively new biomaterial, has recently demonstrated exceptional biocompatibility and material stability with neural lineage cells. The purpose of this prospective randomized clinical experiment was to determine the efficacy of chitosan-based nerve conduits in regenerating sensory nerves in the hand. Materials and methods: Forty-seven patients with peripheral nerve defects up to 26 mm distal to the carpal tunnel were randomized to receive either a chitosan conduit or an autologous nerve graft with the latter serving as the control group. Fifteen patients from the conduit group and seven patients from the control group were available for a 12-month follow-up examination. The primary outcome parameter was tactile gnosis measured with two-point discrimination. The secondary outcome parameters were Semmens Weinstein Monofilament Testing, self-assessed pain, and patient satisfaction. Results: Significant improvement (in static two-point discrimination) was observed six months after trauma (10.7 ± 1.2 mm; p < 0.05) for chitosan-based nerve conduits, but no further improvement was observed after 12 months of regeneration (10.9 ± 1.3 mm). After six months and twelve months, the autologous nerve graft demonstrated comparable results to the nerve conduit, with a static two-point discrimination of 11.0 ± 2.0 mm and 7.9 ± 1.1 mm. Semmes Weinstein Filament Testing in the nerve conduit group showed a continuous improvement over the regeneration period by reaching from 3.1 ± 0.3 after three months up to 3.7 ± 0.4 after twelve months. Autologous nerve grafts presented similar results: 3.3 ± 0.4 after three months and 3.7 ± 0.5 after twelve months. Patient satisfaction and self-reported pain levels were similar between the chitosan nerve conduit and nerve graft groups. One patient required revision surgery due to complications associated with the chitosan nerve tube. Conclusion: Chitosan-based nerve conduits are safe and suitable for bridging nerve lesions up to 26 mm in the hand. Tactile gnosis improved significantly during the early regeneration period, and functional outcomes were similar to those obtained with an autologous nerve graft. Thus, chitosan appears to be a sufficient substitute for autologous nerve grafts in the treatment of small nerve defects in the hand.
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Pedroza-Montoya FE, Tamez-Mata YA, Simental-Mendía M, Soto-Domínguez A, García-Pérez MM, Said-Fernández S, Montes-de-Oca-Luna R, González-Flores JR, Martínez-Rodríguez HG, Vilchez-Cavazos F. Repair of ovine peripheral nerve injuries with xenogeneic human acellular sciatic nerves prerecellularized with allogeneic Schwann-like cells—an innovative and promising approach. Regen Ther 2022; 19:131-143. [PMID: 35229011 PMCID: PMC8850753 DOI: 10.1016/j.reth.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/11/2022] [Accepted: 01/27/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction The iatrogenic effects of repairing peripheral nerve injuries (PNIs) with autografts (AGTs) encouraged the present study to involve a new approach consisting of grafting xenogeneic prerecellularized allogeneic cells instead of AGTs. Methods We compared sheep's AGT regenerative and functional capacity with decellularized human nerves prerecellularized with allogeneic Schwann-like cell xenografts (onwards called xenografts). Mesenchymal stem cells were isolated from ovine adipose tissue and induced in vitro to differentiate into Schwann-like cells (SLCs). Xenografts were grafted in ovine sciatic nerves. Left sciatic nerves (20 mm) were excised from 10 sheep. Then, five sheep were grafted with 20 mm xenografts, and five were reimplanted with their nerve segment rotated 180° (AGT). Results All sheep treated with xenografts or AGT progressively recovered the strength, movement, and coordination of their intervened limb, which was still partial when the study was finished at sixth month postsurgery. At this time, numerous intrafascicular axons were observed in the distal and proximal graft extremes of both xenografts or AGTs, and submaximal nerve electrical conduction was observed. The xenografts and AGT-affected muscles appeared partially stunted. Conclusions Xenografts and AGT were equally efficacious in starting PNI repair and justified further studies using longer observation times. The hallmarks from this study are that human xenogeneic acellular scaffolds were recellularized with allogenic SCL and were not rejected by the nonhuman receptors but were also as functional as AGT within a relatively short time postsurgery. Thus, this innovative approach promises to be more practical and accessible than AGT or allogenic allografts and safer than AGT for PNI repair.
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Liodaki E, Kisch T, Mailänder P, Stang F. [Use of acellular allogeneic nerve transplants for nerve defects of the hand : Experience from a German hand surgery center]. Unfallchirurg 2022; 125:892-896. [PMID: 35166880 DOI: 10.1007/s00113-022-01143-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 11/26/2022]
Abstract
Peripheral nerve injuries are often encountered in traumatological care. The aim of this manuscript is to provide initial data, experiences and performance reports from Germany in the implantation of acellular human nerve transplants in peripheral sensory nerve defects of the hand and to put these data in the context of a comprehensive review of the literature. Of the patients 4 (7 digital nerves) were examined 6 months postoperatively and 5 patients (6 digital nerves) were examined 1 year after the operation (3 were also at the 6‑month examination). All patients had a clinical improvement after nerve reconstruction (≥ S3 according to the classification of sensory recovery of the Medical Research Council modified by Mackinnon and Dellon). Disadvantages of our clinical study are the small number of patients, the inhomogeneity (primary and secondary nerve reconstruction) and the lack of comparison with other nerve reconstruction methods.
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Affiliation(s)
- Eirini Liodaki
- Klinik für Plastische Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Deutschland.
| | - Tobias Kisch
- Klinik für Plastische Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Deutschland
| | - Peter Mailänder
- Klinik für Plastische Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Deutschland
| | - Felix Stang
- Klinik für Plastische Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Deutschland
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Tamez-Mata Y, Pedroza-Montoya FE, Martínez-Rodríguez HG, García-Pérez MM, Ríos-Cantú AA, González-Flores JR, Soto-Domínguez A, Montes-de-Oca-Luna R, Simental-Mendía M, Peña-Martínez VM, Vílchez-Cavazos F. Nerve gaps repaired with acellular nerve allografts recellularized with Schwann-like cells: Preclinical trial. J Plast Reconstr Aesthet Surg 2022; 75:296-306. [PMID: 34257032 DOI: 10.1016/j.bjps.2021.05.066] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 05/03/2021] [Accepted: 05/27/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Acellular nerve allografts (ANA) recellularized with mesenchymal stem cells (MSC) or Schwann cells (SC) are, at present, a therapeutic option for peripheral nerve injuries (PNI). This study aimed to evaluate the regenerative and functional capacity of a recellularized allograft (RA) compared with autograft nerve reconstruction in PNI. METHODS Fourteen ovines were randomly included in two groups (n=7). A peroneal nerve gap 30 mm in length was excised, and nerve repair was performed by the transplantation of either an autograft or a recellularized allograft with SC-like cells. Evaluations included a histomorphological analysis of the ANA, MSC pre differentiated into SC-like cells, at one year follow-up functional limb recovery (support and gait), and nerve regeneration using neurophysiological tests and histomorphometric analysis. All evaluations were compared with the contralateral hindlimb as the control. RESULTS The nerve allograft was successfully decellularized and more than 70% of MSC were pre differentiated into SC-like cells. Functional assessment in both treated groups improved similarly over time (p <0.05). Neurophysiological results (latency, amplitude, and conduction velocity) also improved in both treated groups at twelve months. Histological results demonstrated a less organized arrangement of nerve fibers (p <0.05) with an active remyelination process (p <0.05) in both treated groups compared with controls at twelve months. CONCLUSIONS ANA recellularized with SC-like cells proved to be a successful treatment for nerve gaps. Motor recovery and nerve regeneration were satisfactorily achieved in both graft groups compared with their contralateral nontreated nerves. This approach could be useful for the clinical therapy of PNI.
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Affiliation(s)
- Y Tamez-Mata
- Traumatology and Orthopedics, Bone and Tissue Bank Division, Universidad Autonoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González"
| | - F E Pedroza-Montoya
- Biochemistry and Molecular Medicine Department, Cell Therapy Division, Universidad Autonoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González"
| | - H G Martínez-Rodríguez
- Biochemistry and Molecular Medicine Department, Cell Therapy Division, Universidad Autonoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González"
| | - M M García-Pérez
- Plastic Surgery Service, Universidad Autonoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González"
| | - A A Ríos-Cantú
- Plastic Surgery Service, Universidad Autonoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González"
| | - J R González-Flores
- Plastic Surgery Service, Universidad Autonoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González"
| | - A Soto-Domínguez
- Histology Department, Universidad Autonoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González"
| | - R Montes-de-Oca-Luna
- Histology Department, Universidad Autonoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González"
| | - M Simental-Mendía
- Traumatology and Orthopedics, Bone and Tissue Bank Division, Universidad Autonoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González"
| | - V M Peña-Martínez
- Traumatology and Orthopedics, Bone and Tissue Bank Division, Universidad Autonoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González"
| | - F Vílchez-Cavazos
- Traumatology and Orthopedics, Bone and Tissue Bank Division, Universidad Autonoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González".
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Dervan A, Franchi A, Almeida-Gonzalez FR, Dowling JK, Kwakyi OB, McCoy CE, O’Brien FJ, Hibbitts A. Biomaterial and Therapeutic Approaches for the Manipulation of Macrophage Phenotype in Peripheral and Central Nerve Repair. Pharmaceutics 2021; 13:2161. [PMID: 34959446 PMCID: PMC8706646 DOI: 10.3390/pharmaceutics13122161] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 12/18/2022] Open
Abstract
Injury to the peripheral or central nervous systems often results in extensive loss of motor and sensory function that can greatly diminish quality of life. In both cases, macrophage infiltration into the injury site plays an integral role in the host tissue inflammatory response. In particular, the temporally related transition of macrophage phenotype between the M1/M2 inflammatory/repair states is critical for successful tissue repair. In recent years, biomaterial implants have emerged as a novel approach to bridge lesion sites and provide a growth-inductive environment for regenerating axons. This has more recently seen these two areas of research increasingly intersecting in the creation of 'immune-modulatory' biomaterials. These synthetic or naturally derived materials are fabricated to drive macrophages towards a pro-repair phenotype. This review considers the macrophage-mediated inflammatory events that occur following nervous tissue injury and outlines the latest developments in biomaterial-based strategies to influence macrophage phenotype and enhance repair.
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Affiliation(s)
- Adrian Dervan
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland; (A.D.); (A.F.); (F.R.A.-G.); (F.J.O.)
- Trinity Centre for Bioengineering, Trinity College Dublin, D02 R590 Dublin, Ireland
- Advanced Materials and Bioengineering Research Centre (AMBER), Royal College of Surgeons in Ireland and Trinity College Dublin, D02 YN77 Dublin, Ireland
| | - Antonio Franchi
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland; (A.D.); (A.F.); (F.R.A.-G.); (F.J.O.)
- Trinity Centre for Bioengineering, Trinity College Dublin, D02 R590 Dublin, Ireland
| | - Francisco R. Almeida-Gonzalez
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland; (A.D.); (A.F.); (F.R.A.-G.); (F.J.O.)
- Trinity Centre for Bioengineering, Trinity College Dublin, D02 R590 Dublin, Ireland
- Advanced Materials and Bioengineering Research Centre (AMBER), Royal College of Surgeons in Ireland and Trinity College Dublin, D02 YN77 Dublin, Ireland
| | - Jennifer K. Dowling
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland; (J.K.D.); (O.B.K.); (C.E.M.)
- FutureNeuro SFI Research Centre, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
| | - Ohemaa B. Kwakyi
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland; (J.K.D.); (O.B.K.); (C.E.M.)
- School of Medicine, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
| | - Claire E. McCoy
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland; (J.K.D.); (O.B.K.); (C.E.M.)
- FutureNeuro SFI Research Centre, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
| | - Fergal J. O’Brien
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland; (A.D.); (A.F.); (F.R.A.-G.); (F.J.O.)
- Trinity Centre for Bioengineering, Trinity College Dublin, D02 R590 Dublin, Ireland
- Advanced Materials and Bioengineering Research Centre (AMBER), Royal College of Surgeons in Ireland and Trinity College Dublin, D02 YN77 Dublin, Ireland
| | - Alan Hibbitts
- Tissue Engineering Research Group, Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland; (A.D.); (A.F.); (F.R.A.-G.); (F.J.O.)
- Trinity Centre for Bioengineering, Trinity College Dublin, D02 R590 Dublin, Ireland
- Advanced Materials and Bioengineering Research Centre (AMBER), Royal College of Surgeons in Ireland and Trinity College Dublin, D02 YN77 Dublin, Ireland
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Broeren BO, Duraku LS, Hundepool CA, Walbeehm ET, Zuidam JM, Hooijmans CR, De Jong T. Nerve recovery from treatment with a vascularized nerve graft compared to an autologous non-vascularized nerve graft in animal models: A systematic review and meta-analysis. PLoS One 2021; 16:e0252250. [PMID: 34855774 PMCID: PMC8638852 DOI: 10.1371/journal.pone.0252250] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 11/17/2021] [Indexed: 12/09/2022] Open
Abstract
Background Treatment of nerve injuries proves to be a worldwide clinical challenge. Vascularized nerve grafts are suggested to be a promising alternative for bridging a nerve gap to the current gold standard, an autologous non-vascularized nerve graft. However, there is no adequate clinical evidence for the beneficial effect of vascularized nerve grafts and they are still disputed in clinical practice. Objective To systematically review whether vascularized nerve grafts give a superior nerve recovery compared to non-vascularized nerve autografts regarding histological and electrophysiological outcomes in animal models. Material and methods PubMed and Embase were systematically searched. The inclusion criteria were as follows: 1) the study was an original full paper which presented unique data; 2) a clear comparison between a vascularized and a non-vascularized autologous nerve transfer was made; 3) the population study were animals of all genders and ages. A standardized mean difference and 95% confidence intervals for each comparison was calculated to estimate the overall effect. Subgroup analyses were conducted on graft length, species and time frames. Results Fourteen articles were included in this review and all were included in the meta-analyses. A vascularized nerve graft resulted in a significantly larger diameter, higher nerve conduction velocity and axonal count compared to an autologous non-vascularized nerve graft. However, during sensitivity analysis the effect on axonal count disappeared. No significant difference was observed in muscle weight. Conclusion Treating a nerve gap with a vascularized graft results in superior nerve recovery compared to non-vascularized nerve autografts in terms of axon count, diameter and nerve conduction velocity. No difference in muscle weight was seen. However, this conclusion needs to be taken with some caution due to the inherent limitations of this meta-analysis. We recommend future studies to be performed under conditions more closely resembling human circumstances and to use long nerve defects.
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Affiliation(s)
- Berend O. Broeren
- Department of Plastic & Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
- * E-mail:
| | - Liron S. Duraku
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Caroline A. Hundepool
- Department of Plastic & Reconstructive Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Erik T. Walbeehm
- Department of Plastic & Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J. Michiel Zuidam
- Department of Plastic & Reconstructive Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Carlijn R. Hooijmans
- Department for Health Evidence Unit SYRCLE, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Anesthesiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Tim De Jong
- Department of Plastic & Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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Huddleston HP, Kurtzman JS, Connors KM, Koehler SM. A Retrospective Case Series of Peripheral Mixed Nerve Reconstruction Failures Using Processed Nerve Allografts. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3983. [PMID: 35070612 PMCID: PMC8769133 DOI: 10.1097/gox.0000000000003983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Favorable rates of meaningful recovery (≥M3/S3) of processed nerve allografts (PNAs) for mixed and motor nerve injuries have been reported, but there are few reports of patients having complete PNA failure (M0/S0). The purpose of this study was to describe the outcomes, including rate of complete failures, in a case series of patients who underwent PNA for peripheral mixed nerve reconstructions. METHODS A retrospective review of outcomes between May 2018 to September 2020 was performed. Consecutive patients who underwent nerve reconstruction (>15 mm) with PNA for a peripheral mixed nerve injury of the upper or lower extremity were eligible. Those who returned to clinic for a 10-month postoperative visit were included in this study. The primary outcome was whether the patient was defined as having a complete failure (M0/S0). RESULTS A total of 22 patients underwent a PNA during the time period; 14 patients participated in follow-up and were included (average age: 34.7 years) with a mean follow-up of 11.9 months. The average gap length was 46.4 mm (range 15-110 mm). At their 10-month postoperative visit, no patients had any motor or sensory improvement; all patients were deemed as having complete failure. Four patients underwent or were planned for subsequent revision surgery. CONCLUSIONS In this study, we demonstrated a high number of complete failures, with all 14 included patients sustaining a complete failure (100% failure rate) at a minimum 10-month follow-up visit. Failure in this case series was not observed to affect one nerve type, location, or be related to preoperative injury size.
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Affiliation(s)
- Hailey P Huddleston
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, N.Y
| | - Joey S Kurtzman
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, N.Y
| | - Katherine M Connors
- Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, N.Y
| | - Steven M Koehler
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, N.Y
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Clinical Outcomes and Patient Satisfaction After Corneal Neurotization. Cornea 2021; 40:1377-1386. [PMID: 34633356 DOI: 10.1097/ico.0000000000002759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 03/10/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study was to assess clinical outcomes of corneal neurotization (CN) and determine patient perception of postoperative results. METHODS This was a retrospective study involving 29 eyes in 28 patients who underwent CN. Chart review data included demographic and clinical history; ophthalmic examination including visual acuity, ocular surface quality, and corneal sensation; surgical technique; and postoperative course. Subjective self-reported patient outcomes of surgical success were also assessed. Only eyes with at least 6 months of follow-up were included in the statistical analysis. RESULTS A total of 24 eyes and 23 patients were included in statistical analyses. The median postoperative follow-up time was 12.2 months (interquartile range 10.9-18.5 mo). Twenty-three eyes (92%) achieved improvement in ocular surface quality. Eleven of 13 (85%) demonstrated healing of persistent epithelial defects at their last follow-up. Patients gained a median of 2.3 cm in Cochet-Bonnet esthesiometry measurements of sensation. No significant difference was found between preoperative and postoperative visual acuity. All 17 patients who provided self-assessment of their surgical outcome indicated they would undergo CN again if given the choice. Most of the patients reported that the postoperative pain was tolerable, with a median pain score of 3.0 on a 10-point scale (interquartile range 0.0-4.0). Sixteen patients (94%) reported full or partial return of skin sensation along the donor nerve distribution. CONCLUSIONS CN provides improvement in corneal health and sensibility, with high patient satisfaction and minimal postoperative pain and morbidity.
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Parker BJ, Rhodes DI, O'Brien CM, Rodda AE, Cameron NR. Nerve guidance conduit development for primary treatment of peripheral nerve transection injuries: A commercial perspective. Acta Biomater 2021; 135:64-86. [PMID: 34492374 DOI: 10.1016/j.actbio.2021.08.052] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/19/2021] [Accepted: 08/30/2021] [Indexed: 12/17/2022]
Abstract
Commercial nerve guidance conduits (NGCs) for repair of peripheral nerve discontinuities are of little use in gaps larger than 30 mm, and for smaller gaps they often fail to compete with the autografts that they are designed to replace. While recent research to develop new technologies for use in NGCs has produced many advanced designs with seemingly positive functional outcomes in animal models, these advances have not been translated into viable clinical products. While there have been many detailed reviews of the technologies available for creating NGCs, none of these have focussed on the requirements of the commercialisation process which are vital to ensure the translation of a technology from bench to clinic. Consideration of the factors essential for commercial viability, including regulatory clearance, reimbursement processes, manufacturability and scale up, and quality management early in the design process is vital in giving new technologies the best chance at achieving real-world impact. Here we have attempted to summarise the major components to consider during the development of emerging NGC technologies as a guide for those looking to develop new technology in this domain. We also examine a selection of the latest academic developments from the viewpoint of clinical translation, and discuss areas where we believe further work would be most likely to bring new NGC technologies to the clinic. STATEMENT OF SIGNIFICANCE: NGCs for peripheral nerve repairs represent an adaptable foundation with potential to incorporate modifications to improve nerve regeneration outcomes. In this review we outline the regulatory processes that functionally distinct NGCs may need to address and explore new modifications and the complications that may need to be addressed during the translation process from bench to clinic.
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Affiliation(s)
- Bradyn J Parker
- Department of Materials Science and Engineering, Monash University, 22 Alliance Lane, Clayton, Victoria 3800, Australia; Commonwealth Scientific and Industrial Research Organisation (CSIRO) Manufacturing, Research Way, Clayton, Victoria 3168, Australia
| | - David I Rhodes
- Department of Materials Science and Engineering, Monash University, 22 Alliance Lane, Clayton, Victoria 3800, Australia; ReNerve Pty. Ltd., Brunswick East 3057, Australia
| | - Carmel M O'Brien
- Commonwealth Scientific and Industrial Research Organisation (CSIRO) Manufacturing, Research Way, Clayton, Victoria 3168, Australia; Australian Regenerative Medicine Institute, Science, Technology, Research and innovation Precinct (STRIP), Monash University, Wellington Road, Clayton, Victoria 3800, Australia
| | - Andrew E Rodda
- Department of Materials Science and Engineering, Monash University, 22 Alliance Lane, Clayton, Victoria 3800, Australia
| | - Neil R Cameron
- Department of Materials Science and Engineering, Monash University, 22 Alliance Lane, Clayton, Victoria 3800, Australia; School of Engineering, University of Warwick, Coventry CV4 7AL, United Kingdom.
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Clinical Outcomes of Symptomatic Neuroma Resection and Reconstruction with Processed Nerve Allograft. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3832. [PMID: 34616638 PMCID: PMC8489892 DOI: 10.1097/gox.0000000000003832] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 07/22/2021] [Indexed: 01/10/2023]
Abstract
Background: Neuromas causing sensory disturbance can substantially affect nerve function and quality of life. Historically, passive termination of the nerve end and proximal relocation to muscle or bone has been performed after neuroma resection, but this method does not allow for neurologic recovery or prevent recurrent neuromas. The use of processed nerve allografts (PNAs) for intercalary reconstruction of nerve defects following neuroma resection is reasonable for neuroma management, although reported outcomes are limited. The purpose of this study was to assess the outcomes of pain reduction and functional recovery following neuroma resection and intercalary nerve reconstruction using PNA. Methods: Data on outcomes of PNA use for peripheral nerve reconstruction were collected from a multicenter registry study. The registry database was queried for upper extremity nerve reconstruction with PNA after resection of symptomatic neuroma. Patients completing both pain and quantitative sensory assessments were included in the analysis. Improvement in pain-related symptoms was determined via patient self-reported outcomes and/or the visual analog scale. Meaningful sensory recovery was defined as a score of at least S3 on the Medical Research Council Classification scale. Results: Twenty-five repairs involving 21 patients were included in this study. The median interval from injury to reconstruction was 386 days, and the average nerve defect length was 31 mm. Pain improved in 80% of repairs. Meaningful sensory recovery was achieved in 88% of repairs. Conclusion: Neuroma resection and nerve reconstruction using PNA can reduce or eliminate chronic peripheral nerve pain and provide meaningful sensory recovery.
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Mead KC, Sgromolo NM, Krueger CA, Rhee PC. Comminuted Distal Radius Fracture with Concomitant Median Nerve Transection: A Case Report and Literature Review. JBJS Case Connect 2021; 11:01709767-202109000-00122. [PMID: 34559735 DOI: 10.2106/jbjs.cc.21.00273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 41-year-old woman sustained a distal radius fracture with concomitant median nerve transection. The wound was consistent with an inside-to-outside mechanism with noted metaphyseal bone loss at the level of the median nerve injury. The median nerve was not amenable to primary repair, and given concern for inability to define the zone of the injury, the patient underwent delayed reconstruction of the nerve. CONCLUSION A review of the literature highlights the rare incidence of this combined injury that can be undetected or misdiagnosed as an acute carpal tunnel syndrome or stretch injury to the median nerve.
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Affiliation(s)
- Kelly C Mead
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Nicole M Sgromolo
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Chad A Krueger
- Department of Orthopedic Surgery, Rothman Institute, Abington, Pennsylvania
| | - Peter C Rhee
- Department of Orthopaedic Surgery, Division of Hand and Microvascular Surgery, Mayo Clinic, Rochester, Minnesota.,Clinical Investigation Facility, Travis Air Force Base, Fairfield, California
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Roballo KCS, Gigley JP, Smith TA, Bittner GD, Bushman JS. Functional and immunological peculiarities of peripheral nerve allografts. Neural Regen Res 2021; 17:721-727. [PMID: 34472457 PMCID: PMC8530136 DOI: 10.4103/1673-5374.322445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
This review addresses the accumulating evidence that live (not decellularized) allogeneic peripheral nerves are functionally and immunologically peculiar in comparison with many other transplanted allogeneic tissues. This is relevant because live peripheral nerve allografts are very effective at promoting recovery after segmental peripheral nerve injury via axonal regeneration and axon fusion. Understanding the immunological peculiarities of peripheral nerve allografts may also be of interest to the field of transplantation in general. Three topics are addressed: The first discusses peripheral nerve injury and the potential utility of peripheral nerve allografts for bridging segmental peripheral nerve defects via axon fusion and axon regeneration. The second reviews evidence that peripheral nerve allografts elicit a more gradual and less severe host immune response allowing for prolonged survival and function of allogeneic peripheral nerve cells and structures. Lastly, potential mechanisms that may account for the immunological differences of peripheral nerve allografts are discussed.
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Affiliation(s)
| | - Jason P Gigley
- Department of Molecular Biology, University of Wyoming, Laramie, WY, USA
| | - Tyler A Smith
- Department of Molecular Biosciences, University of Texas at Austin, Austin, TX, USA
| | - George D Bittner
- Department of Neuroscience, University of Texas at Austin, Austin, TX, USA
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M Pothmann CE, Besmens IS, Rothenfluh E, Guidi M, Calcagni M, Frueh FS. [Neuropathic Pain - Differential Diagnosis and Treatment from the Hand Surgeon's Perspective]. PRAXIS 2021; 110:673-680. [PMID: 34521273 DOI: 10.1024/1661-8157/a003734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Neuropathic Pain - Differential Diagnosis and Treatment from the Hand Surgeon's Perspective Abstract. Neuropathic pain of the wrist and hand can be caused by a multitude of pathologies, such as trauma, iatrogenic damage, local peripheral nerve compression, nerve tumors and systemic diseases. Neuropathic pain can lead to chronification and disability, severely affecting the patients' quality of life and the ability to work. A precise diagnosis is the key to an adequate therapy with satisfactory functional results. An interdisciplinary and multimodal approach is a prerequisite when treating neuropathic pain. This review article provides an insight into the diagnosis and therapy of pathologies associated with neuropathic pain of the wrist and hand.
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Affiliation(s)
- Carina E M Pothmann
- Klinik für Plastische Chirurgie und Handchirurgie, Universitätsspital Zürich, Zürich
| | - Inga S Besmens
- Klinik für Plastische Chirurgie und Handchirurgie, Universitätsspital Zürich, Zürich
| | - Esin Rothenfluh
- Klinik für Plastische Chirurgie und Handchirurgie, Universitätsspital Zürich, Zürich
| | - Marco Guidi
- Klinik für Plastische Chirurgie und Handchirurgie, Universitätsspital Zürich, Zürich
| | - Maurizio Calcagni
- Klinik für Plastische Chirurgie und Handchirurgie, Universitätsspital Zürich, Zürich
| | - Florian S Frueh
- Klinik für Plastische Chirurgie und Handchirurgie, Universitätsspital Zürich, Zürich
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Kim DH, Shin SH, Lee MK, Lee JJ, Kim JK, Chung YG. Effectiveness and Biocompatibility of Decellularized Nerve Graft Using an In Vivo Rat Sciatic Nerve Model. Tissue Eng Regen Med 2021; 18:797-805. [PMID: 34386942 DOI: 10.1007/s13770-021-00353-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/04/2021] [Accepted: 05/10/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Decellularized nerve allografting is one of promising treatment options for nerve defect. As an effort to develop more efficient nerve graft, recently we have developed a new decellularization method for nerve allograft. The aim of this study was to evaluate the effectiveness and biocompatibility of nerve graft decellularized by our newly developed method. METHODS Forty-eight inbred male Lewis rats were divided into two groups, Group I (autograft group, n = 25), Group II (decellularized isograft group, n = 23). Decellularized nerve grafts were prepared with our newly developed methods using amphoteric detergent and nuclease treatment. Serum cytokine level measurements at 0, 2, and 4 weeks and histologic evaluation for inflammatory cell infiltration at 6 and 16 weeks after nerve graft. RESULTS There was no significant difference in mean maximum isometric tetanic force and weight of tibialis anterior muscle or ankle angle at toe-off phase between two groups at 6 and 16 weeks survival time points (p > 0.05). There was no inflammatory cell infiltration in either group and histomorphometric assessments of 6- and 16-week specimens of the isograft group did not differ from those in the autograft group with regard to number of fascicle, cross sectional area, fascicle area ratio, and number of regenerated nerve cells. CONCLUSION Based on inflammatory reaction, axonal regeneration, and functional outcomes, our newly developed decellularized nerve grafts were fairly biocompatible and had comparable effectiveness to autografts for nerve regeneration, which suggested it would be suitable for nerve reconstruction as an alternative to autograft.
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Affiliation(s)
- Dong Hyun Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Banpo-daero 222, Seocho-gu, Seoul, 06591, Korea
| | - Seung-Han Shin
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Banpo-daero 222, Seocho-gu, Seoul, 06591, Korea
| | - Myeong-Kyu Lee
- Department of Research and Development, Korea Public Tissue Bank, 37 Sagimakgol-ro 62beon-gil, Jungwon-gu, Seongnam-si, Gyeonggi-do, 13211, Korea
| | - Jae-Jin Lee
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Banpo-daero 222, Seocho-gu, Seoul, 06591, Korea
| | - Jae Kwang Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Korea
| | - Yang-Guk Chung
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Banpo-daero 222, Seocho-gu, Seoul, 06591, Korea.
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Zucal I, Mihic-Probst D, Pignet AL, Calcagni M, Giovanoli P, Frueh FS. Intraneural fibrosis and loss of microvascular architecture - Key findings investigating failed human nerve allografts. Ann Anat 2021; 239:151810. [PMID: 34324996 DOI: 10.1016/j.aanat.2021.151810] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Processed nerve allografts are increasingly used in clinical nerve reconstruction with promising results. However, allograft failure has been reported, leading to chronic pain and persistent loss of function. In the present work, we performed a histological and immunohistochemical analysis of two failed allograft reconstructions of a sensory human nerve one year after primary surgery. METHODS Two patients with a superficial radial nerve injury underwent nerve reconstruction with processed nerve allografts. The clinical follow-up was complicated by severe neuropathic pain and absent sensory reinnervation. Consequently, the failed allografts were excised with subsequent histological and immunohistochemical examinations. For that purpose, the collagen content and neurofilament network as well as the blood and lymphatic vasculature were analysed in the center of the specimens. RESULTS Histology revealed increased fibrosis, fatty degeneration, and disorganised proliferation of nerve fibres. Moreover, the microvascular network within the allografts was characterised by increased numbers of microvessels, whereas no difference was found concerning the lymphatic vasculature. CONCLUSION The herein presented histological and immunohistochemical findings indicate that the failure of human allografts is associated with loss of the physiological microvascular architecture. Future studies elucidating the complex interplay of angiogenesis, lymphangiogenesis and axonal regeneration are required to better understand the mechanisms of human allograft failure.
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Affiliation(s)
- Isabel Zucal
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Daniela Mihic-Probst
- Department of Pathology and Molecular Pathology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Anna-Lisa Pignet
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Maurizio Calcagni
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Florian S Frueh
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
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Holland JDR, Webster G, Rooney P, Wilshaw SP, Jennings LM, Berry HE. Effects of Chemical and Radiation Sterilisation on the Biological and Biomechanical Properties of Decellularised Porcine Peripheral Nerves. Front Bioeng Biotechnol 2021; 9:660453. [PMID: 34150728 PMCID: PMC8209421 DOI: 10.3389/fbioe.2021.660453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/10/2021] [Indexed: 11/18/2022] Open
Abstract
There is a clinical need for novel graft materials for the repair of peripheral nerve defects. A decellularisation process has been developed for porcine peripheral nerves, yielding a material with potentially significant advantages over other devices currently being used clinically (such as autografts and nerve guidance conduits). Grafts derived from xenogeneic tissues should undergo sterilisation prior to clinical use. It has been reported that sterilisation methods may adversely affect the properties of decellularised tissues, and therefore potentially negatively impact on the ability to promote tissue regeneration. In this study, decellularised nerves were produced and sterilised by treatment with 0.1% (v/v) PAA, gamma radiation (25-28 kGy) or E Beam (33-37 kGy). The effect of sterilisation on the decellularised nerves was determined by cytotoxicity testing, histological staining, hydroxyproline assays, uniaxial tensile testing, antibody labelling for collagen type IV, laminin and fibronectin in the basal lamina, and differential scanning calorimetry. This study concluded that decellularised nerves retained biocompatibility following sterilisation. However, sterilisation affected the mechanical properties (PAA, gamma radiation), endoneurial structure and basement membrane composition (PAA) of decellularised nerves. No such alterations were observed following E Beam treatment, suggesting that this method may be preferable for the sterilisation of decellularised porcine peripheral nerves.
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Affiliation(s)
- James D. R. Holland
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, United Kingdom
- School of Mechanical Engineering, Faculty of Engineering, University of Leeds, Leeds, United Kingdom
| | - Georgina Webster
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, United Kingdom
- School of Mechanical Engineering, Faculty of Engineering, University of Leeds, Leeds, United Kingdom
| | - Paul Rooney
- National Health Service Blood and Transplant (NHSBT) Tissue and Eye Services, Liverpool, United Kingdom
| | - Stacy-Paul Wilshaw
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, United Kingdom
- School of Pharmacy and Medical Sciences, Faculty of Life Sciences, University of Bradford, Bradford, United Kingdom
| | - Louise M. Jennings
- School of Mechanical Engineering, Faculty of Engineering, University of Leeds, Leeds, United Kingdom
| | - Helen E. Berry
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, United Kingdom
- School of Mechanical Engineering, Faculty of Engineering, University of Leeds, Leeds, United Kingdom
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48
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Curran MWT, Chan KM, Morhart MJ, Olson JL. Brachial Plexus Reconstruction Using Long Nerve Grafts as Spare Parts From an Amputated Limb: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00068. [PMID: 33983907 DOI: 10.2106/jbjs.cc.20.00739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE The reconstruction of large nerve gaps remains a reconstructive challenge. Here, we present a case report of brachial plexus reconstruction using nerve grafts harvested as spare parts from an amputated limb. It also allowed us to use motor nerve grafts to reconstruct defects in the posterior cord and musculocutaneous nerve. The patient recovered good shoulder and elbow function at 2.5 years with evidence of innervation distally on electromyography. CONCLUSION Spare part surgery should always be kept in a surgeons' reconstructive algorithm. Reconstruction of large nerve gaps can be achieved with autologous nerve grafts in certain circumstances.
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Affiliation(s)
- Matthew W T Curran
- Division of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - K Ming Chan
- Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, Alberta, Canada
| | - Michael J Morhart
- Division of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jaret L Olson
- Division of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada
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49
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Jacobson LA, Wood MD, Mackinnon SE. Editorial Commentary of "Nerve Reconstruction Using Processed Nerve Allograft in the US Military". Mil Med 2021; 186:148-151. [PMID: 33433561 DOI: 10.1093/milmed/usaa497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/08/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lauren A Jacobson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Matthew D Wood
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
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50
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Saffari TM, Chan K, Saffari S, Zuo KJ, McGovern RM, Reid JM, Borschel GH, Shin AY. Combined local delivery of tacrolimus and stem cells in hydrogel for enhancing peripheral nerve regeneration. Biotechnol Bioeng 2021; 118:2804-2814. [PMID: 33913523 DOI: 10.1002/bit.27799] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 12/19/2022]
Abstract
The application of scaffold-based stem cell transplantation to enhance peripheral nerve regeneration has great potential. Recently, the neuroregenerative potential of tacrolimus (a U.S. Food and Drug Administration-approved immunosuppressant) has been explored. In this study, a fibrin gel-based drug delivery system for sustained and localized tacrolimus release was combined with rat adipose-derived mesenchymal stem cells (MSC) to investigate cell viability in vitro. Tacrolimus was encapsulated in poly(lactic-co-glycolic) acid (PLGA) microspheres and suspended in fibrin hydrogel, using concentrations of 0.01 and 100 ng/ml. Drug release over time was measured. MSCs were cultured in drug-released media collected at various days to mimic systemic exposure. MSCs were combined with (i) hydrogel only, (ii) empty PLGA microspheres in the hydrogel, (iii) 0.01, and (iv) 100 ng/ml of tacrolimus PLGA microspheres in the hydrogel. Stem cell presence and viability were evaluated. A sustained release of 100 ng/ml tacrolimus microspheres was observed for up to 35 days. Stem cell presence was confirmed and cell viability was observed up to 7 days, with no significant differences between groups. This study suggests that combined delivery of 100 ng/ml tacrolimus and MSCs in fibrin hydrogel does not result in cytotoxic effects and could be used to enhance peripheral nerve regeneration.
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Affiliation(s)
- Tiam M Saffari
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Katelyn Chan
- Division of Plastic and Reconstructive Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Engineering, Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Sara Saffari
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Kevin J Zuo
- Division of Plastic and Reconstructive Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Neurosciences and Mental Health, SickKids Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Renee M McGovern
- Division of Oncology Research, Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Joel M Reid
- Division of Oncology Research, Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Gregory H Borschel
- Division of Plastic and Reconstructive Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Plastic Surgery, Riley Hospital for Children, Indiana University, Indianapolis, Indiana, USA
| | - Alexander Y Shin
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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