1
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Pamuk Ç. Digital nerve injury: to repair or not? Ir J Med Sci 2023; 192:2235-2241. [PMID: 36596984 DOI: 10.1007/s11845-022-03268-4] [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: 12/20/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND There are very few studies comparing patients with and without repair after digital nerve injury. It is still controversial whether digital nerve repair is necessary. AIMS The aim of this study was to evaluate the long-term clinical outcomes of patients with unilateral isolated digital nerve injury who underwent surgical repair and those who did not. METHODS Seventy-four patients with unilateral digital nerve injury were included in the study. Of these, the patients who underwent surgical repair were determined as group A (n = 42), the patients without repair as group B (n = 32), and the groups were divided into subgroups according to injury levels. Results were evaluated with a minimum follow-up of 24 months. RESULTS When the S2PD results were evaluated overall, it was found that those who had digital nerve repair (group A) had significantly better outcomes compared to those without repair (group B) (p = 0.012). When the subgroups were evaluated according to the injury localization, no significant difference was observed at the distal levels, while it was observed that the patients who underwent repair in the proximal levels showed significantly better results (p = 0.003, p = 0.012). CONCLUSION In this study, it was seen that there was no difference between the results of repair and non-repair of unilateral nerve injuries distal to the middle level of the middle phalanx, but repair is required in injuries proximal to this level.
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Affiliation(s)
- Çağdaş Pamuk
- Orthopedics and Traumatology Department, Private Silivri Anadolu Hospital, Istanbul, Turkey.
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2
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Frostadottir D, Chemnitz A, Johansson OT LJ, Holst J, Dahlin LB. Evaluation of Processed Nerve Allograft in Peripheral Nerve Surgery: A Systematic Review and Critical Appraisal. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5088. [PMID: 37383478 PMCID: PMC10299771 DOI: 10.1097/gox.0000000000005088] [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: 03/20/2023] [Accepted: 05/05/2023] [Indexed: 06/30/2023]
Abstract
Peripheral nerve injuries cause substantial problems when not treated properly. A specific problem is reconstruction of nerve defects, which can be treated in different ways. This study aimed to systematically review whether processed nerve allograft (PNA) is justified in reconstruction of a nerve defect in patients after posttraumatic or iatrogenic peripheral nerve injury and to compare PNA with other established methods. Methods A systematic review with a focused question, PICO (patient, intervention, comparison, outcome) and constraints, was performed. A structured literature search, including several databases, was done to evaluate the existing evidence for outcomes and postoperative complications related to PNA. The certainty of evidence was classified according to Grading of Recommendations, Assessment, Development and Evaluations. Results No conclusions, concerning differences in outcome of nerve reconstruction using PNA compared with the use of nerve autograft or conduits, could be drawn. The level of certainty for all evaluated outcomes was very low (⊕◯◯◯). Most published studies lack a control group to patients treated with PNA; being only descriptive, making it difficult to compare PNA with established methods without substantial risk of bias. For studies including a control group, the scientific evidence was of very low certainty, due to a low number of included patients, and large, undefined loss of patients during follow-up, rendering a high risk of bias. Finally, the authors often had financial disclosures. Conclusion Properly conducted randomized controlled trial studies on the use of PNA in reconstruction of peripheral nerve injuries are needed to establish recommendations in clinical practice.
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Affiliation(s)
- Drifa Frostadottir
- From the Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Translational Medicine—Hand Surgery, Lund University, Malmö, Sweden
| | - Anette Chemnitz
- From the Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
| | | | - Jan Holst
- Department of Vascular Disease, Skåne University Hospital, Malmö, Sweden
- Department of Research and Education, HTA syd, Skåne University Hospital, Lund, Sweden
| | - Lars B. Dahlin
- From the Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Translational Medicine—Hand Surgery, Lund University, Malmö, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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3
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Acott TR. Digital Nerve Reconstruction. Orthop Clin North Am 2022; 53:187-195. [PMID: 35365263 DOI: 10.1016/j.ocl.2021.12.003] [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: 02/02/2023]
Abstract
Tension-free primary digital nerve repair may be unachievable in the presence of a nerve defect and require digital nerve reconstruction. Multiple techniques are available for reconstruction of a digital nerve defect using conduits, autograft, and allograft. Multiple comparison studies exist in the literature, suggesting similar results with autograft and allograft reconstruction, with several comparison studies suggesting inferior outcomes with conduit repair.
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Affiliation(s)
- Thomas R Acott
- The CORE Institute, 18444 North 25th Avenue, Suite. 210, Phoenix, AZ 85023, USA.
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4
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Bianchi S, Mauler F. Ultrasound Appearance of In Vitro Nerve Allografts and Conduits for Peripheral Nerve Reconstruction. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:763-771. [PMID: 34037265 DOI: 10.1002/jum.15757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/04/2021] [Accepted: 05/09/2021] [Indexed: 06/12/2023]
Abstract
Ultrasound enables the accurate assessment of traumatic disorders of small peripheral nerves of extremities. Human nerve allografts and nerve conduits are increasingly used for the surgical treatment of nerve trauma but ultrasound reports on this field are scarce in the radiological literature. We present the macroscopic and in vitro ultrasound appearance of human allografts, and synthetic and biological conduits. In addition, we describe the ultrasound findings in some patients operated upon using the same devices. The in vitro ultrasound appearance correlated well with the macroscopic appearance of the devices. Awareness of their appearance in vitro can help sonologists when examining postsurgical patients.
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Affiliation(s)
| | - Flavien Mauler
- Division of Plastic Surgery and Hand Surgery, Kantonsspital Aarau, Aarau, Switzerland
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5
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Kaplan B, Levenberg S. The Role of Biomaterials in Peripheral Nerve and Spinal Cord Injury: A Review. Int J Mol Sci 2022; 23:ijms23031244. [PMID: 35163168 PMCID: PMC8835501 DOI: 10.3390/ijms23031244] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 12/18/2022] Open
Abstract
Peripheral nerve and spinal cord injuries are potentially devastating traumatic conditions with major consequences for patients’ lives. Severe cases of these conditions are currently incurable. In both the peripheral nerves and the spinal cord, disruption and degeneration of axons is the main cause of neurological deficits. Biomaterials offer experimental solutions to improve these conditions. They can be engineered as scaffolds that mimic the nerve tissue extracellular matrix and, upon implantation, encourage axonal regeneration. Furthermore, biomaterial scaffolds can be designed to deliver therapeutic agents to the lesion site. This article presents the principles and recent advances in the use of biomaterials for axonal regeneration and nervous system repair.
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Affiliation(s)
- Ben Kaplan
- Faculty of Biomedical Engineering, Technion-Israel Institute of Technology, Haifa 3200003, Israel;
- Bruce Rapaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3525433, Israel
| | - Shulamit Levenberg
- Faculty of Biomedical Engineering, Technion-Israel Institute of Technology, Haifa 3200003, Israel;
- Correspondence:
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6
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Braga Silva J, Leal BLM, Magnus GA, de Souza Stanham V, Mattiello R, Wolff CG. Comparison of nerve conduits and nerve graft in digital nerve regeneration: A systematic review and meta-analysis. HAND SURGERY & REHABILITATION 2021; 40:715-721. [PMID: 34425267 DOI: 10.1016/j.hansur.2021.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/28/2021] [Accepted: 08/06/2021] [Indexed: 11/16/2022]
Abstract
The goal of this systematic review and meta-analysis was to compare nerve conduits and nerve graft for peripheral nerve regeneration. This type of lesion frequently causes disability due to pain, paresthesia and motor deficit. On the PICO process, "P" corresponded to patients with peripheral digital nerve lesions of any age, gender or ethnicity, "I" to interventions with nerve conduits or nerve graft, "C" to the control group with no treatment, placebo or receiving other treatment, and "O" to outcome assessment of nerve regeneration. Initial search found in 3859 studies, including 2001 duplicates. The remaining 1858 studies were selected by title and/or abstract; 1798 articles were excluded, leaving 60 articles for full-text review. Thirty-nine of these 60 reports were excluded as not meeting our inclusion criteria, and 21 articles were ultimately included in the systematic review. For patients older than 40 years, there was a greater mean improvement on S2PD and M2PD tests with grafting, which seemed to be the better surgical technique, positively impacting prognosis. On the M2PD test, there was significantly greater improvement in 11-17.99 mm defects with grafting (P < 0.001); this finding should guide surgical strategy in peripheral nerve regeneration, to ensure better outcomes.
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Affiliation(s)
- J Braga Silva
- Service of Hand Surgery and Reconstructive Microsurgery, São Lucas Hospital, Centro Clinico PUCRS, Av. Ipiranga, 6690, Suite 216, Porto Alegre, RS 90610-000, Brazil; School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga, 6681 - Partenon, Porto Alegre, RS 90619-900, Brazil.
| | - B L M Leal
- School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga, 6681 - Partenon, Porto Alegre, RS 90619-900, Brazil
| | - G A Magnus
- School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga, 6681 - Partenon, Porto Alegre, RS 90619-900, Brazil
| | - V de Souza Stanham
- School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga, 6681 - Partenon, Porto Alegre, RS 90619-900, Brazil
| | - R Mattiello
- School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga, 6681 - Partenon, Porto Alegre, RS 90619-900, Brazil
| | - C G Wolff
- School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga, 6681 - Partenon, Porto Alegre, RS 90619-900, Brazil
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Kasper M, Deister C, Beck F, Schmidt CE. Bench-to-Bedside Lessons Learned: Commercialization of an Acellular Nerve Graft. Adv Healthc Mater 2020; 9:e2000174. [PMID: 32583574 DOI: 10.1002/adhm.202000174] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/11/2020] [Indexed: 12/19/2022]
Abstract
Peripheral nerve injury can result in debilitating outcomes including loss of function and neuropathic pain. Although nerve repair research and therapeutic development are widely studied, translation of these ideas into clinical interventions has not occurred at the same rate. At the turn of this century, approaches to peripheral nerve repair have included microsurgical techniques, hollow conduits, and autologous nerve grafts. These methods provide satisfactory results; however, they possess numerous limitations that can prevent effective surgical treatment. Commercialization of Avance, a processed nerve allograft, sought to address limitations of earlier approaches by providing an off-the-shelf alternative to hollow conduits while maintaining many proregenerative properties of autologous grafts. Since its launch in 2007, Avance has changed the landscape of the nerve repair market and is used to treat tens of thousands of patients. Although Avance has become an important addition to surgeon and patient clinical options, the product's journey from bench to bedside took over 20 years with many research and commercialization challenges. This article reviews the events that have brought a processed nerve allograft from the laboratory bench to the patient bedside. Additionally, this review provides a perspective on lessons and considerations that can assist in translation of future medical products.
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Affiliation(s)
- Mary Kasper
- J. Crayton Pruitt Family Department of Biomedical EngineeringUniversity of Florida Gainesville FL 32611 USA
| | | | | | - Christine E. Schmidt
- J. Crayton Pruitt Family Department of Biomedical EngineeringUniversity of Florida Gainesville FL 32611 USA
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8
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Usami S, Kawahara S, Inami K. Additional advancement after elevation of a neurovascular advancement flap with interposition of an artificial nerve conduit. J Plast Reconstr Aesthet Surg 2019; 72:1418-1433. [PMID: 31000359 DOI: 10.1016/j.bjps.2019.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 03/24/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Satoshi Usami
- Department of Hand Surgery, Tokyo Hand Surgery & Sports Medicine Institute, Takatsuki Orthopaedic Hospital, 360 Takatsukicho, Hachioji, Tokyo, Japan.
| | - Sanshiro Kawahara
- Department of Hand Surgery, Tokyo Hand Surgery & Sports Medicine Institute, Takatsuki Orthopaedic Hospital, 360 Takatsukicho, Hachioji, Tokyo, Japan
| | - Kohei Inami
- Department of Hand Surgery, Tokyo Hand Surgery & Sports Medicine Institute, Takatsuki Orthopaedic Hospital, 360 Takatsukicho, Hachioji, Tokyo, Japan
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9
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Rbia N, Bulstra LF, Saffari TM, Hovius SER, Shin AY. Collagen Nerve Conduits and Processed Nerve Allografts for the Reconstruction of Digital Nerve Gaps: A Single-Institution Case Series and Review of the Literature. World Neurosurg 2019; 127:e1176-e1184. [PMID: 31003028 DOI: 10.1016/j.wneu.2019.04.087] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE A single-institution case series is reported and a review of the literature on the outcomes of digital nerve gap reconstruction with the NeuraGen type 1 collagen nerve conduit (Integra Life Sciences, Plainsboro New Jersey, USA) and the Avance Nerve Graft (Axogen Inc., Alachua, Florida, USA) is presented. METHODS Thirty-seven patients were included with a minimal follow-up of 12 months. Primary outcome was postoperative sensory recovery measured by static 2-point discrimination test or the Semmes-Weinstein monofilament test. Secondary outcome measurements were perioperative or postoperative complications. Final outcome data were stratified to grade results as excellent, good, or poor. RESULTS The mean nerve gap length was 14 ± 4.9 mm for the collagen conduits versus 18.4 ± 9.3 for nerve allografts. After 12 months, outcomes were graded as excellent sensory recovery in 48% of the collagen conduit repairs and 39% of the nerve allografts (P = 0.608), good in 26% of the conduits and 55% of the allografts (P = 0.074), and poor in 26% of the conduits versus 6% of the allografts (P = 0.091). One neuroma and 1 infection were reported. Graft rejection or extrusion was not observed. CONCLUSIONS Nerve conduits and processed nerve allografts offer convenient off-the-shelf options for digital nerve gap repair. Both techniques offer effective means of reconstructing a digital nerve gap <2.5 cm at a minimum of 12 months of follow-up. Future prospective randomized large sample size studies comparing nerve conduits with allografts are needed to perform subgroup analyses and to define their exact role in digital nerve injuries.
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Affiliation(s)
- Nadia Rbia
- Department of Orthopedic Surgery, Division of Hand and Microvascular Surgery, Mayo Clinic, Minnesota, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Liselotte F Bulstra
- Department of Orthopedic Surgery, Division of Hand and Microvascular Surgery, Mayo Clinic, Minnesota, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Tiam M Saffari
- Department of Orthopedic Surgery, Division of Hand and Microvascular Surgery, Mayo Clinic, Minnesota, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Steven E R Hovius
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Division of Hand and Microvascular Surgery, Mayo Clinic, Minnesota, USA.
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10
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A clinical multi‐center registry study on digital nerve repair using a biodegradable nerve conduit of PGA with external and internal collagen scaffolding. Microsurgery 2018; 39:395-399. [DOI: 10.1002/micr.30417] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 11/20/2018] [Accepted: 11/27/2018] [Indexed: 01/23/2023]
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11
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Rebowe R, Rogers A, Yang X, Kundu SC, Smith TL, Li Z. Nerve Repair with Nerve Conduits: Problems, Solutions, and Future Directions. J Hand Microsurg 2018; 10:61-65. [PMID: 30154617 DOI: 10.1055/s-0038-1626687] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 01/02/2018] [Indexed: 01/09/2023] Open
Abstract
Nerve conduits are becoming increasingly popular for the repair of peripheral nerve injuries. Their ease of application and lack of donor site morbidity make them an attractive option for nerve repair in many situations. Today, there are many different conduits to choose in different sizes and materials, giving the reconstructive surgeon many options for any given clinical problem. However, to properly utilize these unique reconstructive tools, the peripheral nerve surgeon must be familiar not only with their standard indications but also with their functional limitations. In this review, the authors identify the common applications of nerve conduits, expected results, and shortcomings of current techniques. Furthermore, future directions for nerve conduit use are identified.
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Affiliation(s)
- Ryan Rebowe
- Department of Orthopaedics, Wake Forest Baptist Medical Center, Winston Salem, North Carolina, United States
| | - Ashley Rogers
- Department of Orthopaedics, Wake Forest Baptist Medical Center, Winston Salem, North Carolina, United States
| | - Xuebin Yang
- Department of Oral Biology, University of Leeds, Leeds, United Kingdom
| | - S C Kundu
- Department of Biotechnology, Indian Institute of Technology, Kharagpur, West Bengal, India
| | - Thomas L Smith
- Department of Orthopaedics, Wake Forest Baptist Medical Center, Winston Salem, North Carolina, United States
| | - Zhongyu Li
- Department of Orthopaedics, Wake Forest Baptist Medical Center, Winston Salem, North Carolina, United States
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12
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Huber JL, Maier C, Mainka T, Mannil L, Vollert J, Homann HH. Recovery of mechanical detection thresholds after direct digital nerve repair versus conduit implantation. J Hand Surg Eur Vol 2017; 42:720-730. [PMID: 28395576 DOI: 10.1177/1753193417699777] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED The purpose of this study was to assess sensory and functional nerve recovery after digital nerve injury in patients with an end-to-end suture (S) or with implantation of a collagen conduit (C) to bridge a nerve gap. Fifteen S and 11 C with a follow-up of 6-36 months and 28 healthy control participants were enrolled. Methods of assessments were quantitative sensory testing, the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), range of motion and the painDetect questionnaire. After both procedures, sensory profiles showed largely recovered function of C and Aδ fibres but severe loss of Aβ-fibre function leading to increased mechanical detection thresholds. There was only minimal allodynia. Severe pain was absent. Patients with conduits reported more functional impairment, especially in work performance, which correlated with the assessed loss of Aß-fibre function. LEVEL OF EVIDENCE III.
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Affiliation(s)
- J L Huber
- 1 Department of Pain Management, BG-University Hospital Bergmannsheil, Bochum, Germany
| | - C Maier
- 1 Department of Pain Management, BG-University Hospital Bergmannsheil, Bochum, Germany
| | - T Mainka
- 1 Department of Pain Management, BG-University Hospital Bergmannsheil, Bochum, Germany.,3 Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - L Mannil
- 2 Department of Plastic Surgery and Hand Surgery, Burn Center, BG Trauma Center Duisburg, Duisburg, Germany.,4 Division of Plastic and Hand Surgery, University Hospital Zurich, Switzerland
| | - J Vollert
- 1 Department of Pain Management, BG-University Hospital Bergmannsheil, Bochum, Germany
| | - H-H Homann
- 2 Department of Plastic Surgery and Hand Surgery, Burn Center, BG Trauma Center Duisburg, Duisburg, Germany
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13
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Mackenzie SJ, Yi JL, Singla A, Russell TM, Osterhout DJ, Calancie B. Cauda equina repair in the rat: Part 3. Axonal regeneration across Schwann cell-Seeded collagen foam. Muscle Nerve 2017; 57:E78-E84. [PMID: 28746726 DOI: 10.1002/mus.25751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 07/12/2017] [Accepted: 07/23/2017] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Treatments for patients with cauda equina injury are limited. METHODS In this study, we first used retrograde labeling to determine the relative contributions of cauda equina motor neurons to intrinsic and extrinsic rat tail muscles. Next, we transected cauda equina ventral roots and proceeded to bridge the proximal and distal stumps with either a type I collagen scaffold coated in laminin (CL) or a collagen-laminin scaffold that was also seeded with Schwann cells (CLSC). Regeneration was assessed by way of serial retrograde labeling. RESULTS After accounting for the axonal contributions to intrinsic vs. extrinsic tail muscles, we noted a higher degree of double labeling in the CLSC group (58.0 ± 39.6%) as compared with the CL group (27.8 ± 16.0%; P = 0.02), but not the control group (33.5 ± 18.2%; P = 0.10). DISCUSSION Our findings demonstrate the feasibility of using CLSCs in cauda equina injury repair. Muscle Nerve 57: E78-E84, 2018.
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Affiliation(s)
- Samuel J Mackenzie
- Department of Neuroscience, Upstate Medical University, Syracuse, New York, USA
| | - Juneyoung L Yi
- Department of Neurosurgery, Upstate Medical University, IHP 1213, 750 East Adams Street, Syracuse, New York, 13210, USA
| | - Amit Singla
- Department of Neurosurgery, Upstate Medical University, IHP 1213, 750 East Adams Street, Syracuse, New York, 13210, USA
| | - Thomas M Russell
- Department of Cell and Developmental Biology, Upstate Medical University, Syracuse, New York, USA
| | - Donna J Osterhout
- Department of Cell and Developmental Biology, Upstate Medical University, Syracuse, New York, USA
| | - Blair Calancie
- Department of Neurosurgery, Upstate Medical University, IHP 1213, 750 East Adams Street, Syracuse, New York, 13210, USA
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Rbia N, Shin AY. The Role of Nerve Graft Substitutes in Motor and Mixed Motor/Sensory Peripheral Nerve Injuries. J Hand Surg Am 2017; 42:367-377. [PMID: 28473159 DOI: 10.1016/j.jhsa.2017.02.017] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 02/22/2017] [Indexed: 02/02/2023]
Abstract
Alternatives to nerve autograft have been invented and approved for clinical use. The reported outcomes of these alternatives in mixed motor nerve repair in humans are scarce and marked by wide variabilities. The purpose of our Current Concepts review is to provide an evidence-based overview of the effectiveness of nerve conduits and allografts in motor and mixed sensory/motor nerve reconstruction. Nerve graft substitutes have good outcomes in mixed/motor nerves in gaps less than 6 mm and internal diameters between 3 and 7 mm. There is insufficient evidence for their use in larger-gap and -diameter nerves; the evidence remains that major segmental motor or mixed nerve injury is optimally treated with a cabled nerve autograft.
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Affiliation(s)
- Nadia Rbia
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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15
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Panagopoulos GN, Megaloikonomos PD, Mavrogenis AF. The Present and Future for Peripheral Nerve Regeneration. Orthopedics 2017; 40:e141-e156. [PMID: 27783836 DOI: 10.3928/01477447-20161019-01] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 08/23/2016] [Indexed: 02/03/2023]
Abstract
Peripheral nerve injury can have a potentially devastating impact on a patient's quality of life, resulting in severe disability with substantial social and personal cost. Refined microsurgical techniques, advances in peripheral nerve topography, and a better understanding of the pathophysiology and molecular basis of nerve injury have all led to a decisive leap forward in the field of translational neurophysiology. Nerve repair, nerve grafting, and nerve transfers have improved significantly with consistently better functional outcomes. Direct nerve repair with epineural microsutures is still the surgical treatment of choice when a tension-free coaptation in a well-vascularized bed can be achieved. In the presence of a significant gap (>2-3 cm) between the proximal and distal nerve stumps, primary end-to-end nerve repair often is not possible; in these cases, nerve grafting is the treatment of choice. Indications for nerve transfer include brachial plexus injuries, especially avulsion type, with long distance from target motor end plates, delayed presentation, segmental loss of nerve function, and broad zone of injury with dense scarring. Current experimental research in peripheral nerve regeneration aims to accelerate the process of regeneration using pharmacologic agents, bioengineering of sophisticated nerve conduits, pluripotent stem cells, and gene therapy. Several small molecules, peptides, hormones, neurotoxins, and growth factors have been studied to improve and accelerate nerve repair and regeneration by reducing neuronal death and promoting axonal outgrowth. Targeting specific steps in molecular pathways also allows for purposeful pharmacologic intervention, potentially leading to a better functional recovery after nerve injury. This article summarizes the principles of nerve repair and the current concepts of peripheral nerve regeneration research, as well as future perspectives. [Orthopedics. 2017; 40(1):e141-e156.].
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16
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Pinho AC, Fonseca AC, Serra AC, Santos JD, Coelho JFJ. Peripheral Nerve Regeneration: Current Status and New Strategies Using Polymeric Materials. Adv Healthc Mater 2016; 5:2732-2744. [PMID: 27600578 DOI: 10.1002/adhm.201600236] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Indexed: 12/16/2022]
Abstract
Experiments concerning peripheral nerve regeneration have been reported since the end of the 19th century. The need to implement an effective surgical procedure in terms of functional recovery has resulted in the appearance of several approaches to solve this problem. Nerve autograft was the first approach studied and is still considered the gold standard. Since autografts require donor harvesting, other strategies involving the use of natural materials have also been studied. Nevertheless, the results were not very encouraging and attention has moved towards the use of nerve conduits made from polymers, whose properties can be easily tailored and which allow the nerve conduit to be easily processed into a variety of shapes and forms. Some of these materials are already approved by the US Food and Drug Administration (FDA), as is presented here. Furthermore, polymers with conductive properties have very recently been subject to intensive study in this field, since it is believed that such properties have a positive influence in the regeneration of the new axons. This manuscript intends to give a global view of the mechanisms involved in peripheral nerve regeneration and the main strategies used to recover motor and sensorial function of injured nerves.
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Affiliation(s)
- Ana C. Pinho
- CEMUC Department of Chemical Engineering; University of Coimbra; Rua Sílvio Lima-Pólo II 3030-790 Coimbra Portugal
| | - Ana C. Fonseca
- CEMUC Department of Chemical Engineering; University of Coimbra; Rua Sílvio Lima-Pólo II 3030-790 Coimbra Portugal
| | - Arménio C. Serra
- CEMUC Department of Chemical Engineering; University of Coimbra; Rua Sílvio Lima-Pólo II 3030-790 Coimbra Portugal
| | - José D. Santos
- CEMUC Department of Metallurgical and Materials Engineering; University of Porto; Rua Dr Roberto Frias 4200-465 Porto Portugal
| | - Jorge F. J. Coelho
- CEMUC Department of Chemical Engineering; University of Coimbra; Rua Sílvio Lima-Pólo II 3030-790 Coimbra Portugal
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17
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Oruç M, Ozer K, Çolak Ö, Kankaya Y, Koçer U. Does crossover innervation really affect the clinical outcome? A comparison of outcome between unilateral and bilateral digital nerve repair. Neural Regen Res 2016; 11:1499-1505. [PMID: 27857757 PMCID: PMC5090856 DOI: 10.4103/1673-5374.191226] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2016] [Indexed: 11/13/2022] Open
Abstract
Digital nerve injuries are the mostly detected nerve injury in the upper extremity. However, since the clinical phenomenon of crossover innervation at some degree from uninjured digital nerve to the injured side occurs after digital nerve injuries is sustained, one could argue that this concept might even result in the overestimation of the outcome of the digital nerve repair. With this knowledge in mind, this study aimed to present novel, pure, focused and valuable clinical data by comparing the outcomes of bilateral and unilateral digital nerve repair. A retrospective review of 28 fingers with unilateral or bilateral digital nerve repair using end-to-end technique in 19 patients within 2 years was performed. Weber's two-point discrimination, sharp/dull discrimination, warm/cold sensation and Visual Analog Scale scoring were measured at final 12-month follow ups in all patients. There was no significant difference in recovery of sensibility after unilateral and bilateral digital nerve repairs. Though there is crossover innervation microscopically, it is not important in the clinical evaluation period. According to clinical findings from this study, crossover innervations appear to be negligible in the estimation of outcomes of digital neurorrhaphy.
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Affiliation(s)
- Melike Oruç
- Ankara Training and Research Hospital, Plastic, Reconstructive and Aesthetic Surgery Clinic, Ankara, Turkey
| | - Kadri Ozer
- Aydin State Hospital, Plastic, Reconstructive and Aesthetic Surgery Clinic, Aydin, Turkey
| | - Özlem Çolak
- Istanbul Okmeydani Training and Research Hospital, Plastic, Reconstructive and Aesthetic Surgery Clinic, Istanbul, Turkey
| | - Yüksel Kankaya
- Ankara Training and Research Hospital, Plastic, Reconstructive and Aesthetic Surgery Clinic, Ankara, Turkey
| | - Uğur Koçer
- Ankara Training and Research Hospital, Plastic, Reconstructive and Aesthetic Surgery Clinic, Ankara, Turkey
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18
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Means KR, Rinker BD, Higgins JP, Payne SH, Merrell GA, Wilgis EFS. A Multicenter, Prospective, Randomized, Pilot Study of Outcomes for Digital Nerve Repair in the Hand Using Hollow Conduit Compared With Processed Allograft Nerve. Hand (N Y) 2016; 11:144-51. [PMID: 27390554 PMCID: PMC4920529 DOI: 10.1177/1558944715627233] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Current repair options for peripheral nerve injuries where tension-free gap closure is not possible include allograft, processed nerve allograft, and hollow tube conduit. Here we report on the outcomes from a multicenter prospective, randomized, patient- and evaluator-blinded, pilot study comparing processed nerve allograft and hollow conduit for digital nerve reconstructions in the hand. METHODS Across 4 centers, consented participants meeting inclusion criteria while not meeting exclusion criteria were randomized intraoperatively to either processed nerve allograft or hollow conduit. Standard sensory and safety assessments were conducted at baseline, 1, 3, 6, 9, and 12 months after reconstruction. The primary outcome was static 2-point discrimination (s2PD) testing. Participants and assessors were blinded to treatment. The contralateral digit served as the control. RESULTS We randomized 23 participants with 31 digital nerve injuries. Sixteen participants with 20 repairs had at least 6 months of follow-up while 12-month follow-up was available for 15 repairs. There were no significant differences in participant and baseline characteristics between treatment groups. The predominant nerve injury was laceration/sharp transection. The mean ± SD length of the nerve gap prior to repair was 12 ± 4 mm (5-20 mm) for both groups. The average s2PD for processed allograft was 5 ± 1 mm (n = 6) compared with 8 ± 5 mm (n = 9) for hollow conduits. The average moving 2PD for processed allograft was 5 ± 1 mm compared with 7 ± 5 mm for hollow conduits. All injuries randomized to processed nerve allograft returned some degree of s2PD as compared with 75% of the repairs in the conduit group. Two hollow conduits and one allograft were lost due to infection during the study. CONCLUSIONS In this pilot study, patients whose digital nerve reconstructions were performed with processed nerve allografts had significantly improved and more consistent functional sensory outcomes compared with hollow conduits.
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Affiliation(s)
- Kenneth R. Means
- Curtis National Hand Center, Baltimore, MD, USA,Kenneth R. Means Jr, The Curtis National Hand Center, Medstar Union Memorial Hospital, 3333 N. Calvert St. 200 JPB, Baltimore, MD 21218, USA.
| | - Brian D. Rinker
- University of Kentucky Division of Plastic Surgery, Lexington, KY, USA
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19
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Abstract
Manufactured conduits and allografts are viable alternatives to direct suture repair and nerve autograft. Manufactured tubes should have gaps less than 10 mm, and ideally should be considered as an aid to the coaptation. Processed nerve allograft has utility as a substitute for either conduit or autograft in sensory nerve repairs. There is also a growing body of evidence supporting their utility in major peripheral nerve repairs, gap repairs up to 70 mm in length, as an alternative source of tissue to bolster the diameter of a cable graft, and for the management of neuromas in non-reconstructable injuries.
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Affiliation(s)
- Bauback Safa
- The Buncke Clinic, 45 Castro Street #121, San Francisco, CA 94114, USA.
| | - Gregory Buncke
- The Buncke Clinic, 45 Castro Street #121, San Francisco, CA 94114, USA
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20
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Kaushik AP, Hammert WC. Options for digital nerve gap. J Hand Surg Am 2015; 40:141-4. [PMID: 25446411 DOI: 10.1016/j.jhsa.2014.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Accepted: 09/25/2014] [Indexed: 02/02/2023]
Affiliation(s)
- Anjan P Kaushik
- Department of Orthopaedics and Rehabilitation, Strong Memorial Hospital, University of Rochester, Rochester, NY
| | - Warren C Hammert
- Department of Orthopaedics and Rehabilitation, Strong Memorial Hospital, University of Rochester, Rochester, NY.
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21
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Riley DC, Bittner GD, Mikesh M, Cardwell NL, Pollins AC, Ghergherehchi CL, Bhupanapadu Sunkesula SR, Ha TN, Hall BTD, Poon AD, Pyarali M, Boyer RB, Mazal AT, Munoz N, Trevino RC, Schallert T, Thayer WP. Polyethylene glycol-fused allografts produce rapid behavioral recovery after ablation of sciatic nerve segments. J Neurosci Res 2014; 93:572-83. [PMID: 25425242 DOI: 10.1002/jnr.23514] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/19/2014] [Accepted: 10/09/2014] [Indexed: 11/08/2022]
Abstract
Restoration of neuronal functions by outgrowths regenerating at ∼1 mm/day from the proximal stumps of severed peripheral nerves takes many weeks or months, if it occurs at all, especially after ablation of nerve segments. Distal segments of severed axons typically degenerate in 1-3 days. This study shows that Wallerian degeneration can be prevented or retarded, and lost behavioral function can be restored, following ablation of 0.5-1-cm segments of rat sciatic nerves in host animals. This is achieved by using 0.8-1.1-cm microsutured donor allografts treated with bioengineered solutions varying in ionic and polyethylene glycol (PEG) concentrations (modified PEG-fusion procedure), being careful not to stretch any portion of donor or host sciatic nerves. The data show that PEG fusion permanently restores axonal continuity within minutes, as initially assessed by action potential conduction and intracellular diffusion of dye. Behavioral functions mediated by the sciatic nerve are largely restored within 2-4 weeks, as measured by the sciatic functional index. Increased restoration of sciatic behavioral functions after ablating 0.5-1-cm segments is associated with greater numbers of viable myelinated axons within and distal to PEG-fused allografts. Many such viable myelinated axons are almost certainly spared from Wallerian degeneration by PEG fusion. PEG fusion of donor allografts may produce a paradigm shift in the treatment of peripheral nerve injuries.
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Affiliation(s)
- D C Riley
- Department of Plastic Surgery, Vanderbilt School of Medicine, Nashville, Tennessee; Department of Neuroscience, University of Texas at Austin, Austin, Texas
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22
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Chen X, Yin Y, Zhang T, Zhao Y, Yang Y, Yu X, Wang H. Ultrasound imaging of chitosan nerve conduits that bridge sciatic nerve defects in rats. Neural Regen Res 2014; 9:1386-8. [PMID: 25221596 PMCID: PMC4160870 DOI: 10.4103/1673-5374.137592] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2014] [Indexed: 12/02/2022] Open
Affiliation(s)
- Xiaoyang Chen
- Department of Doppler Ultrasound, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Yifei Yin
- Department of Doppler Ultrasound, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Tingting Zhang
- Department of Doppler Ultrasound, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Yahong Zhao
- Jiangsu Key Laboratory of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China
| | - Yumin Yang
- Jiangsu Key Laboratory of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China
| | - Xiaomei Yu
- Department of Doppler Ultrasound, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Hongkui Wang
- School of Biology and Basic Medical Sciences, Soochow University, Suzhou, Jiangsu Province, China ; Jiangsu Key Laboratory of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China
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23
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Abstract
Nerve conduits and acellular nerve allograft offer efficient and convenient tools for overcoming unexpected gaps during nerve repair. Both techniques offer guidance for migrating Schwann cells and axonal regeneration though utilizing very different scaffolds. The substantially greater amount of animal and clinical data published on nerve conduits is marked by wide discrepancies in results that may be partly explained by a still poorly defined critical repair gap and diameter size. The available information on acellular allografts appears more consistently positive though this tool is also hampered by a longer but also limited critical length. This article reviews the current relative literature and examines pertinent parameters for application of both acellular allograft and nerve conduits in overcoming short nerve gaps.
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24
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Slutsky DJ. The management of digital nerve injuries. J Hand Surg Am 2014; 39:1208-15. [PMID: 24862117 DOI: 10.1016/j.jhsa.2013.12.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 12/04/2013] [Accepted: 12/06/2013] [Indexed: 02/02/2023]
Abstract
A tension-free coaptation is a key factor for the successful outcome of any nerve repair. A variety of host factors influence the outcome of digital nerve repair more than the type of repair per se. Although autologous graft remains the reference standard for reconstruction of any critical digital nerve defect, allografts and conduits have assumed an increasing role.
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25
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Abstract
SUMMARY Peripheral nerve injury is a significant problem affecting greater that 1 million people around the world each year and poses major challenges to the plastic and reconstructive surgeon. When primary nerve repair is not possible, several options for management of the nerve gap include a nerve autograft, nerve conduit, and acellular nerve allograft. For extensive and proximal nerve injuries, cellular nerve allografts and nerve transfers may be considered. This article reviews the indications and outcomes for each option, as in many cases more than one option may be acceptable.
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26
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Boeckstyns MEH, Sørensen AI, Viñeta JF, Rosén B, Navarro X, Archibald SJ, Valss-Solé J, Moldovan M, Krarup C. Collagen conduit versus microsurgical neurorrhaphy: 2-year follow-up of a prospective, blinded clinical and electrophysiological multicenter randomized, controlled trial. J Hand Surg Am 2013; 38:2405-11. [PMID: 24200027 DOI: 10.1016/j.jhsa.2013.09.038] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 09/24/2013] [Accepted: 09/26/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare repair of acute lacerations of mixed sensory-motor nerves in humans using a collagen tube versus conventional repair. METHODS In a prospective randomized trial, we repaired the ulnar or the median nerve with a collagen nerve conduit or with conventional microsurgical techniques. We enrolled 43 patients with 44 nerve lacerations. We performed electrophysiological tests and hand function using a standardized clinical evaluation instrument, the Rosen scoring system, after 12 and 24 months. RESULTS Operation time using the collagen conduit was significantly shorter than for conventional neurorrhaphy. There were no complications in terms of infection, extrusion of the conduit, or other local adverse reaction. Thirty-one patients with 32 nerve lesions, repaired with collagen conduits or direct suture, attended the 24-month follow-up. There was no difference between sensory function, discomfort, or total Rosen scores. Motor scores were significantly better for the direct suture group after 12 months, but after 24 months, there were no differences between the treatment groups. There was a general further recovery of both motor and sensory conduction parameters at 24 months compared with 12 months. There were no statistically significant differences in amplitudes, latencies, or conduction velocities between the groups. CONCLUSIONS Use of a collagen conduit produced recovery of sensory and motor functions that were equivalent to direct suture 24 months after repair when the nerve gap inside the tube was 6 mm or less, and the collagen conduit proved to be safe for these nerve lacerations in the forearm. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Affiliation(s)
- Michel E H Boeckstyns
- Clinic of Hand Surgery, Gentofte Hospital, University of Copenhagen; Section of Hand Surgery, Rigshospitalet, University of Copenhagen; Department of Clinical Neurophysiology, The Neuroscience Center, Rigshospitalet, University of Copenhagen; Institute of Neuroscience and Pharmacology, University of Copenhagen, Denmark; Department of Orthopedic Surgery, Hospital Clínic, University of Barcelona; Department of Cell Biology, Physiology, and Immunology, and Institute of Neurosciences, Universitat Autònoma de Barcelona; Institute of Biomedical Investigations August Pi i Sunyer, Barcelona, Spain; Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden; Integra LifeSciences, Plainsboro, New Jersey.
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27
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Lohmeyer JA. Re: 'recovery of two-point discrimination function after digital nerve repair in the hand using resorbable FDA- and CE-approved nerve conduits' by M.F. Meek and J.H. Coert. J Plast Reconstr Aesthet Surg. 2013 Oct;66(10):1307-15. J Plast Reconstr Aesthet Surg 2013; 67:281-2. [PMID: 24094616 DOI: 10.1016/j.bjps.2013.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 08/22/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Jörn A Lohmeyer
- Agaplesion Diakonieklinikum Hamburg, Dept. of Plastic Surgery, Hohe Weide 17, 20259 Hamburg, Germany.
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28
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Abstract
Evaluation of outcomes after peripheral nerve surgeries include several assessment methods that reflect different aspects of recovery, including reinnervation, tactile gnosis, integrated sensory and motor function, pain and discomfort, and neurophysiologic and patient-reported outcomes. This review lists measurements addressing these aspects as well as the advantages and disadvantages of each tool. Because of complexities of neurophysiology, assessment remains a difficult process, which requires researchers to focus on measurements best relevant to specific conditions and research questions.
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Affiliation(s)
- Yirong Wang
- Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing
| | - Malay Sunitha
- Clinical Research Coordinator, Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System; Ann Arbor, MI
| | - Kevin C. Chung
- Professor of Surgery, Section of Plastic Surgery, Assistant Dean for Faculty Affairs, The University of Michigan Medical School
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