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Christy M, Dy CJ. Optimizing Outcomes in Revision Peripheral Nerve Surgery of the Upper Extremity. Clin Plast Surg 2024; 51:459-472. [PMID: 39216933 DOI: 10.1016/j.cps.2024.02.012] [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] [Indexed: 09/04/2024]
Abstract
Peripheral nerve surgeries for compressive neuropathy in the upper extremity are generally successful. However, cases that either fail or have complications requiring revision surgery are challenging. During revision consideration, surgeons should perform a comprehensive preoperative workup to understand the etiology of the patient's symptoms and categorize symptoms as persistent, recurrent, or new in relation to the index procedure. Revision surgery often requires an open, extensile approach with additional procedures to optimize outcomes. Even with proper workup and treatment, clinical outcomes of revision surgeries are inferior compared to primary surgeries and patients should be well informed prior to undergoing such procedures.
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Affiliation(s)
- Michele Christy
- Department of Orthopaedic Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8233, St Louis, MO 63110, USA
| | - Christopher J Dy
- Department of Orthopaedic Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8233, St Louis, MO 63110, USA.
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Burahee AS, Duraku LS, Bosman R, Shirley C, van der Oest MJW, Zuidam MJ, Power DM. Porcine submucosal extracellular matrix wrapping of the ulnar nerve in revision cubital tunnel surgery. J Plast Reconstr Aesthet Surg 2024; 98:176-183. [PMID: 39270614 DOI: 10.1016/j.bjps.2024.08.072] [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: 04/13/2024] [Revised: 06/26/2024] [Accepted: 08/20/2024] [Indexed: 09/15/2024]
Abstract
The wrapping technique aims to protect the nerve when the nerve bed is compromised or more commonly to prevent the recurrence of scar tethering following neurolysis. A wrap provides a physical barrier to scar and helps restore the paraneurial gliding layer. This study aimed to evaluate the results of the AxoGuard® nerve protector, a porcine-derived submucosal extracellular matrix (PECM), used as an adjunct in persistent or recurrent cubital tunnel syndrome (CuTS). This retrospective cohort study evaluated patients diagnosed, between 2012 and 2020, with neuropathic pain who underwent revision surgery. Patients were categorised into Group A (revision surgery only) and Group B (revision surgery and adjunctive PECM nerve wrapping). Disease severity was scored at the baseline and six months post-operatively using the McGowan classification. A linear regression model was used to assess the effect of wrapping the ulnar nerve on the clinical outcome at six months. Fifty-nine nerves were treated; among them, adjunctive PECM wrapping was used in 32 nerves. Disease severity at baseline was similar between the groups. After adjusting for differences in baseline characteristics, participants in Group B improved with a significant difference of 0.43 McGowan points over Group A (95% CI (0.01-0.86), p = 0.049). There were no implant-related complications. Group B improved with excellent or good outcomes in 84.4% patients at the final follow-up. Persistent or recurrent CuTS were associated with neuropathic pain and significant nerve scar tether. The use of PECM appears to lead to improved clinical symptoms, possibly by reducing adhesions and encouraging physiological glide. LEVEL OF EVIDENCE: Level III evidence.
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Affiliation(s)
- Abdus S Burahee
- Department Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2TH, United Kingdom; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Liron S Duraku
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Romy Bosman
- Department Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2TH, United Kingdom; Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Colin Shirley
- Department Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2TH, United Kingdom
| | - Mark J W van der Oest
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Michiel J Zuidam
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dominic M Power
- Department Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham B15 2TH, United Kingdom.
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Mayrhofer-Schmid M, Aman M, Panayi AC, Raasveld FV, Kneser U, Eberlin KR, Harhaus L, Böcker A. Fibrin Glue Coating Limits Scar Tissue Formation around Peripheral Nerves. Int J Mol Sci 2024; 25:3687. [PMID: 38612497 PMCID: PMC11011750 DOI: 10.3390/ijms25073687] [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: 02/25/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Scar tissue formation presents a significant barrier to peripheral nerve recovery in clinical practice. While different experimental methods have been described, there is no clinically available gold standard for its prevention. This study aims to determine the potential of fibrin glue (FG) to limit scarring around peripheral nerves. Thirty rats were divided into three groups: glutaraldehyde-induced sciatic nerve injury treated with FG (GA + FG), sciatic nerve injury with no treatment (GA), and no sciatic nerve injury (Sham). Neural regeneration was assessed with weekly measurements of the visual static sciatic index as a parameter for sciatic nerve function across a 12-week period. After 12 weeks, qualitative and quantitative histological analysis of scar tissue formation was performed. Furthermore, histomorphometric analysis and wet muscle weight analysis were performed after the postoperative observation period. The GA + FG group showed a faster functional recovery (6 versus 9 weeks) compared to the GA group. The FG-treated group showed significantly lower perineural scar tissue formation and significantly higher fiber density, myelin thickness, axon thickness, and myelinated fiber thickness than the GA group. A significantly higher wet muscle weight ratio of the tibialis anterior muscle was found in the GA + FG group compared to the GA group. Our results suggest that applying FG to injured nerves is a promising scar tissue prevention strategy associated with improved regeneration both at the microscopic and at the functional level. Our results can serve as a platform for innovation in the field of perineural regeneration with immense clinical potential.
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Affiliation(s)
- Maximilian Mayrhofer-Schmid
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, 69120 Heidelberg, Germany
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Martin Aman
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Adriana C. Panayi
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Floris V. Raasveld
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02215, USA
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Erasmus University, 3015 GD Rotterdam, The Netherlands
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Kyle R. Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Leila Harhaus
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, 69120 Heidelberg, Germany
- Department of Hand Surgery, Peripheral Nerve Surgery and Rehabilitation, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen, Germany
| | - Arne Böcker
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, 69120 Heidelberg, Germany
- Department of Hand Surgery, Peripheral Nerve Surgery and Rehabilitation, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen, Germany
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Bengur FB, Komatsu C, Fedor CN, Loder S, Baker JS, Totwani A, Irgebay Z, Nerone WV, Solari MG, Marra KG. Biodegradable Nerve Guide with Glial Cell Line-Derived Neurotrophic Factor Improves Recovery After Facial Nerve Injury in Rats. Facial Plast Surg Aesthet Med 2023; 25:478-486. [PMID: 36877591 PMCID: PMC10664574 DOI: 10.1089/fpsam.2022.0346] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
Background: Bioengineered nerve guides with glial cell line-derived neurotrophic factor (GDNF) support recovery after facial nerve injury by acting as regenerative scaffolds. Objective: To compare functional, electrophysiological, and histological outcomes after repair of rat facial nerve transection in control, empty nerve guide, and nerve guide with GDNF conditions. Methods: Rats underwent transection and primary repair of the buccal branch of the facial nerve and were divided into (1) transection and repair only, (2) transection and repair augmented with empty guide, (3) transection and repair augmented with GDNF-guide groups. Weekly measurements of the whisking movements were recorded. At 12 weeks, compound muscle action potentials (CMAPs) at the whisker pad were assessed, and samples were collected for histomorphometric analysis. Results: Rats in GDNF-guide group displayed the earliest peak in normalized whisking amplitude. CMAPs were significantly higher after GDNF-guide placement. Mean fiber surface area of the target muscle, axonal count of the injured branch, and the number of Schwann cells were highest with GDNF guides. Conclusion: The biodegradable nerve guide containing double-walled GDNF microspheres enhanced recovery after facial nerve transection and primary repair.
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Affiliation(s)
- Fuat Baris Bengur
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Chiaki Komatsu
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Caroline Nadia Fedor
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shawn Loder
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jocelyn S. Baker
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Aanchal Totwani
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Zhazira Irgebay
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - W. Vincent Nerone
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mario G. Solari
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kacey G. Marra
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Mayrhofer-Schmid M, Klemm TT, Aman M, Kneser U, Eberlin KR, Harhaus L, Boecker AH. Shielding the Nerve: A Systematic Review of Nerve Wrapping to Prevent Adhesions in the Rat Sciatic Nerve Model. J Pers Med 2023; 13:1431. [PMID: 37888042 PMCID: PMC10607771 DOI: 10.3390/jpm13101431] [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: 09/04/2023] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Peripheral nerve pathology is frequently encountered in clinical practice among peripheral nerve and extremity surgeons. One major factor limiting nerve regeneration and possibly leading to revision surgeries is the development of traumatic or postoperative adhesions and scarring around nerves. In experimental models, different materials have been studied to limit scar tissue formation when wrapped around nerves. METHODS A systematic review of studies describing nerve-wrapping materials in a non-transectional rat sciatic nerve model was performed following the PRISMA guidelines. Literature describing nerve-wrapping methods for the prevention of peripheral nerve scarring in rat sciatic nerve models was identified using PubMed and Web of Science, scanned for relevance and analyzed. RESULTS A total of 15 original articles describing 23 different materials or material combinations for nerve wrapping were included. The heterogeneity of the methods used did not allow a meta-analysis, thus, a systematic review was performed. Out of 28 intervention groups, 21 demonstrated a preventive effect on scar tissue formation in at least one qualitative or quantitative assessment method. CONCLUSIONS The analyzed literature describes a variety of materials from different origins to limit peripheral nerve scarring and adhesions. Thus, a scar-preventive effect by wrapping peripheral nerves as adhesion prophylaxis seems likely. However, a quantitative comparison of the studies to identify the optimal material or technique is not possible with the diversity of used models and study designs. Therefore, further research needs to be performed to identify the optimal nerve wraps to be used routinely in clinical practice.
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Affiliation(s)
- Maximilian Mayrhofer-Schmid
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Tess T. Klemm
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Martin Aman
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Kyle R. Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Leila Harhaus
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
- Department of Hand Surgery, Peripheral Nerve Surgery and Rehabilitation, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen, Germany
| | - Arne H. Boecker
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
- Department of Hand Surgery, Peripheral Nerve Surgery and Rehabilitation, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen, Germany
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Aman M, Mayrhofer-Schmid M, Schwarz D, Bendszus M, Daeschler SC, Klemm T, Kneser U, Harhaus L, Boecker AH. Avoiding scar tissue formation of peripheral nerves with the help of an acellular collagen matrix. PLoS One 2023; 18:e0289677. [PMID: 37540691 PMCID: PMC10403074 DOI: 10.1371/journal.pone.0289677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/24/2023] [Indexed: 08/06/2023] Open
Abstract
INTRODUCTION Extensive scar tissue formation after peripheral nerve injury or surgery is a common problem. To avoid perineural scarring, implanting a mechanical barrier protecting the nerve from inflammation processes in the perineural environment has shown promising results for functional recovery. This study investigates the potential of an acellular collagen-elastin matrix wrapped around a peripheral nerve after induction of scar tissue formation. MATERIALS AND METHODS In the present study, 30 Lewis rats were separated into three groups and sciatic nerve scarring was induced with 2.5% glutaraldehyde (GA-CM) or 2.5% glutaraldehyde with a supplemental FDA-approved acellular collagen-elastin matrix application (GA+CM). Additionally, a sham group was included for control. Nerve regeneration was assessed by functional analysis using the Visual Statisc Sciatic Index (SSI) and MR neurography during the 12-week regeneration period. Histological and histomorphometry analysis were performed to evaluate the degree of postoperative scar tissue formation. RESULTS Histological analysis showed an extensive scar tissue formation for GA-CM. Connective tissue ratio was significantly (p < 0.009) reduced for GA+CM (1.347 ± 0.017) compared to GA-CM (1.518 ± 0.057). Similarly, compared to GA+CM, MR-Neurography revealed extensive scar tissue formation for GA-CM with a direct connection between nerve and paraneural environment. Distal to the injury site, quantitative analysis presented significantly higher axon density (p = 0.0145), thicker axon diameter (p = 0.0002) and thicker myelinated fiber thickness (p = 0.0008) for GA+CM compared to GA-CM. Evaluation of functional recovery revealed a significantly faster regeneration for GA+CM. CONCLUSION The supplemental application of an acellular collagen-elastin matrix showed beneficial effects in histological, radiological, and functional analysis. Therefore, applying a collagen-elastin matrix around the nerve after peripheral nerve injury or surgery may have beneficial effects on preventing scar tissue formation in the long run. This represents a feasible approach to avoid scar tissue formation in peripheral nerve surgery.
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Affiliation(s)
- Martin Aman
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Maximilian Mayrhofer-Schmid
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Daniel Schwarz
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Simeon C Daeschler
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Tess Klemm
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Hand- and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 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, 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, Department of Hand- and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
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Saffari TM, Moore AM, Schmucker RW. Compression Neuropathies: Revisions and Managing Expectations. Hand Clin 2023; 39:389-401. [PMID: 37453766 DOI: 10.1016/j.hcl.2023.02.009] [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: 07/18/2023]
Abstract
Most compression neuropathies can be reliably treated with surgical decompression; however, in approximately 25% of the cases, this release fails, requiring revision surgery. Defining the correct diagnosis after a failed nerve decompression (ie, persistent, recurrent, or new symptoms) is of the utmost importance and guides toward the optimal treatment. This article describes the clinical categorization of secondary carpal tunnel syndrome and cubital tunnel syndrome, intraoperative principles of revision surgery and treatment options that are currently available.
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Affiliation(s)
- Tiam M Saffari
- Department of Plastic and Reconstructive Surgery, The Ohio State University Columbus, OH, USA
| | - Amy M Moore
- Department of Plastic and Reconstructive Surgery, The Ohio State University Columbus, OH, USA
| | - Ryan W Schmucker
- Department of Plastic and Reconstructive Surgery, The Ohio State University Columbus, OH, USA.
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Ence AK, DeGeorge BR. Management of Failed Carpal and Cubital Tunnel Release: An Evidence-Based Guide to Success. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023; 5:510-518. [PMID: 37521553 PMCID: PMC10382932 DOI: 10.1016/j.jhsg.2023.05.008] [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: 03/09/2022] [Accepted: 05/11/2023] [Indexed: 08/01/2023] Open
Abstract
Carpal tunnel and cubital tunnel syndromes are the most common compressive neuropathies of the upper extremity with surgical treatment having high success rates for both conditions. Although uncommon, persistent or recurrent carpal and cubital tunnel syndrome presents a challenge for patients and providers. Diagnosis of persistence versus recurrence of the pathology is key in establishing an appropriate treatment plan to provide the best possible patient outcomes. After an established diagnosis, a wide array of treatment options exist which varies based on previous procedures performed. This review discusses relevant anatomy, etiology, and clinical presentations of persistent and recurrent carpal and cubital tunnel syndromes. The range of treatment options is presented based on history and diagnostic findings. Treatment options span from revision of nerve decompression to the use of soft tissue rearrangement procedures. Some specific treatment options discussed include simple revision nerve decompression, external neurolysis, soft tissue rearrangement, such as the hypothenar fat flap or various transposition techniques, and the use of nerve wraps. Included is an evidence-based management guide for diagnosis and treatment of persistent versus recurrent carpal and cubital tunnel syndromes.
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Affiliation(s)
- Andrew K. Ence
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Brent R. DeGeorge
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
- Department of Plastic Surgery, University of Virginia, Charlottesville, VA
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Zhan Y, Zhou Z, Chen M, Gong X. Photothermal Treatment of Polydopamine Nanoparticles@Hyaluronic Acid Methacryloyl Hydrogel Against Peripheral Nerve Adhesion in a Rat Model of Sciatic Nerve. Int J Nanomedicine 2023; 18:2777-2793. [PMID: 37250473 PMCID: PMC10224687 DOI: 10.2147/ijn.s410092] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/06/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose Peripheral nerve adhesion occurs following injury and surgery. Functional impairment leading by peripheral nerve adhesion remains challenging for surgeons. Local tissue overexpression of heat shock protein (HSP) 72 can reduce the occurrence of adhesion. This study aims to develop a photothermal material polydopamine nanoparticles@Hyaluronic acid methacryloyl hydrogel (PDA NPs@HAMA) and evaluate their efficacy for preventing peripheral nerve adhesion in a rat sciatic nerve adhesion model. Materials and Methods PDA NPs@HAMA was prepared and characterized. The safety of PDA NPs@HAMA was evaluated. Seventy-two rats were randomly assigned to one of the following four groups: the control group; the hyaluronic acid (HA) group; the polydopamine nanoparticles (PDA) group and the PDA NPs@HAMA group (n = 18 per group). Six weeks after surgery, the scar formation was evaluated by adhesion scores and biomechanical and histological examinations. Nerve function was assessed with electrophysiological examination, sensorimotor analysis and gastrocnemius muscle weight measurements. Results There were significant differences in the score on nerve adhesion between the groups (p < 0.001). Multiple comparisons indicated that the score was significantly lower in the PDA NPs@HAMA group (95% CI: 0.83, 1.42) compared with the control group (95% CI: 1.86, 2.64; p = 0.001). Motor nerve conduction velocity and muscle compound potential of the PDA NPs@HAMA group were higher than the control group's. According to immunohistochemical analysis, the PDA NPs@HAMA group expressed more HSP72, less α-smooth muscle actin (α-SMA), and had fewer inflammatory reactions than the control group. Conclusion In this study, a new type of photo-cured material with a photothermic effect was designed and synthesized-PDA NPs@HAMA. The photothermic effect of PDA NPs@HAMA protected the nerve from adhesion to preserve the nerve function in the rat sciatic nerve adhesion model. This effectively prevented adhesion-related damage.
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Affiliation(s)
- Yongxin Zhan
- Department of Hand and Podiatric Surgery, Orthopedics Center, The First Hospital of Jilin University, Changchun, 130021, People’s Republic of China
- Jilin Province Key Laboratory on Tissue Repair, Reconstruction and Regeneration, The First Hospital of Jilin University, Changchun, 130021, People’s Republic of China
| | - Zekun Zhou
- Department of Hand and Podiatric Surgery, Orthopedics Center, The First Hospital of Jilin University, Changchun, 130021, People’s Republic of China
- Jilin Province Key Laboratory on Tissue Repair, Reconstruction and Regeneration, The First Hospital of Jilin University, Changchun, 130021, People’s Republic of China
| | - Miao Chen
- Department of Hand and Podiatric Surgery, Orthopedics Center, The First Hospital of Jilin University, Changchun, 130021, People’s Republic of China
- Jilin Province Key Laboratory on Tissue Repair, Reconstruction and Regeneration, The First Hospital of Jilin University, Changchun, 130021, People’s Republic of China
| | - Xu Gong
- Department of Hand and Podiatric Surgery, Orthopedics Center, The First Hospital of Jilin University, Changchun, 130021, People’s Republic of China
- Jilin Province Key Laboratory on Tissue Repair, Reconstruction and Regeneration, The First Hospital of Jilin University, Changchun, 130021, People’s Republic of China
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Jammeh ML, Yang A, Abuirqeba AA, Ohman JW, Thompson RW. Reoperative Brachial Plexus Neurolysis After Previous Anatomically Complete Supraclavicular Decompression for Neurogenic Thoracic Outlet Syndrome: A 10-Year Single-Center Case Series. Oper Neurosurg (Hagerstown) 2022; 23:125-132. [PMID: 35838452 PMCID: PMC9287103 DOI: 10.1227/ons.0000000000000252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 02/16/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Optimal management of recurrent neurogenic thoracic outlet syndrome (NTOS) remains a considerable challenge. OBJECTIVE To assess the safety and effectiveness of reoperative brachial plexus neurolysis in patients with recurrent NTOS. METHODS From 2009 to 2019, 85 patients underwent reoperative supraclavicular brachial plexus neurolysis for recurrent NTOS after a previous anatomically complete supraclavicular decompression. Data from a prospectively maintained database were analyzed retrospectively. RESULTS The mean patient age at reoperation was 36.9 ± 1.3 (range 15-64) years, 75% were female, and the interval after previous primary operation was 2.5 ± 0.2 years. Intervening injury had precipitated recurrent NTOS in 14 patients (16%), and the mean Disability of the Arm, Shoulder, and Hand (QuickDASH) score before reoperation was 65.2 ± 2.6, reflecting substantial disability. Operative findings consisted of dense fibrous scar tissue surrounding/encasing the brachial plexus. Compared with the previous primary operations, reoperations had a shorter operative time (198 ± 4 vs 161 ± 5 minutes, P < .01) and hospital stay (4.4 ± 0.2 vs 3.6 ± 0.1 days, P < .01), but there were no significant differences in the frequency of prolonged hospitalization (7.1% vs 4.7%), early reoperation (3.5% vs 1.2%), or 30-day hospital readmission (8.2% vs 7.1%). During a median follow-up of 4.8 years, QuickDASH scores improved by 23.3 ± 2.6 (34.2% ± 3.6%; P < .01) and patient-rated outcomes were excellent in 24%, good in 42%, fair in 26%, and poor in 8%. CONCLUSION Reoperative supraclavicular brachial plexus neurolysis is technically challenging but safe and effective treatment for recurrent NTOS, with significant improvements in symptoms and function. Diminishing perineural scar tissue development and avoiding secondary injury would likely decrease the need for reoperations.
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Affiliation(s)
- Momodou L. Jammeh
- The Center for Thoracic Outlet Syndrome and the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Section of Vascular Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Alexander Yang
- The Center for Thoracic Outlet Syndrome and the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Division of Neurosurgery, Department of Surgery, Creighton University, Omaha, Nebraska, USA
| | - Ahmmad A. Abuirqeba
- The Center for Thoracic Outlet Syndrome and the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Section of Vascular Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - J. Westley Ohman
- The Center for Thoracic Outlet Syndrome and the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Section of Vascular Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Robert W. Thompson
- The Center for Thoracic Outlet Syndrome and the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA;,Section of Vascular Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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11
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Nicolas CF, Corvi JJ, Zheng Y, Park KH, Akelina Y, Engemann A, Strauch RJ. Resorbable Nerve Wraps: Can They Be Overtightened? J Reconstr Microsurg 2022; 38:694-702. [PMID: 35292952 DOI: 10.1055/s-0042-1744274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Nerve wrapping has been advocated to minimize scarring and adhesion following neurorrhaphy or neurolysis. A wrap should provide an enclosure that is snug enough to protect and support the affected nerve without strangulating the nerve. The degree to which resorbable wraps should be ": tightened" around the nerve is largely subjective with scant literature on the subject. The purpose of this study was to evaluate the effects of tightly fitting resorbable nerve wraps around intact rat sciatic nerves. METHODS Twenty-four Sprague-Dawley rats underwent exposure and circumferential measurement of the right sciatic nerve. Porcine-derived extracellular matrix (ECM) wraps were trimmed and sutured to enclose the nerve with a tight (same as that of the nerve, n = 8) or loose (2.5x that of the nerve, n = 8) circumference. Sham-surgery control animals (n = 8) had no wrap treatment. Functional outcome was recorded biweekly by sciatic functional index (SFI) with walking track analysis and electrical stimulation. Animals were sacrificed at 12 weeks for histologic analyses. RESULTS No withdrawal response could be evoked in the tight-wrap group until week 9, while significant improvement in SFI first occurred between weeks 5 and 7. By week 12, the tight-wrap group required 60% more current compared with baseline stimulation to produce a withdrawal response. They recovered 81% of SFI baseline values but also demonstrated significantly greater intraneural collagen content (p < 0.001) and lower axon density (p < 0.05) than in the loose-wrap and sham groups. The loose-wrap group had comparable functional and histologic outcomes to the sham control group. CONCLUSION Resorbable ECM nerve wraps applied tightly around intact rat sciatic nerves caused significant functional impairment and histological changes characteristic of acute nerve compression. Significant but incomplete functional recovery was achieved by the tight-wrap group after 12 weeks, but such recovery may not apply in humans.
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Affiliation(s)
- Celine F Nicolas
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - John J Corvi
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - YuanDian Zheng
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Katherine H Park
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yelena Akelina
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | | | - Robert J Strauch
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
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12
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Revision of Carpal Tunnel Surgery. J Clin Med 2022; 11:jcm11051386. [PMID: 35268477 PMCID: PMC8911490 DOI: 10.3390/jcm11051386] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/08/2022] [Accepted: 02/24/2022] [Indexed: 12/14/2022] Open
Abstract
Carpal tunnel release is one of the most commonly performed upper extremity procedures. The majority of patients experience significant improvement or resolution of their symptoms. However, a small but important subset of patients will experience the failure of their initial surgery. These patients can be grouped into persistent, recurrent, and new symptom categories. The approach to these patients starts with a thorough clinical examination and is supplemented with electrodiagnostic studies. The step-wise surgical management of revision carpal tunnel surgery consists of the proximal exploration of the median nerve, Guyon’s release with neurolysis, the rerelease of the transverse retinaculum, evaluation of the nerve injury, treatment of secondary sites of compression, and potential ancillary procedures. The approach and management of failed carpal tunnel release are reviewed in this article.
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13
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Shin YH, Yun HW, Park SY, Choi SJ, Park IS, Min BH, Kim JK. Effect of glutaraldehyde-crosslinked cartilage acellular matrix film on anti-adhesion and nerve regeneration in a rat sciatic nerve injury model. J Tissue Eng Regen Med 2021; 15:1023-1036. [PMID: 34591344 DOI: 10.1002/term.3249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 09/01/2021] [Indexed: 01/16/2023]
Abstract
Decellularized extra-cellular matrix (ECM) has been studied as an alternative to anti-adhesive biomaterials and cartilage acellular matrix (CAM) has been shown to inhibit postoperative adhesion in several organs. This study aimed to evaluate the suitability of glutaraldehyde (GA) crosslinked CAM-films as anti-adhesion barriers for peripheral nerve injury. The films were successfully fabricated and showed improved physical properties such as mechanical strength, swelling ratio, and lengthened degradation period while maintaining the microstructure and chemical composition after GA crosslinking. In the in vitro study of CAM-film, the dsDNA content met the recommended limit of decellularization and more than 70% of the major ECM components were preserved after decellularization. The adhesion and proliferation of seeded human umbilical vein endothelial cells and fibroblasts were significantly lower in CAM-film than in control, but similar with Seprafilm. However, the CAM-film extract did not show cytotoxicity. In the in vivo study, the peri-neural fibrosis was thicker, adhesion score higher, and peri-neural collagen fibers more abundant in the control group than in the CAM-film group. The total number of myelinated axons was significantly higher in the CAM-film group than in the control group. The inflammatory marker decreased with time in the CAM-film group compared to that in the control group, whereas the nerve regenerative marker expression was maintained. Moreover, the ankle angles at contracture and toe-off were higher in the CAM film-treated rats than in the control rats. GA-crosslinked CAM films may be used during peripheral nerve surgery to prevent peri-neural adhesion and enhance nerve functional recovery.
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Affiliation(s)
- Young Ho Shin
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee-Woong Yun
- Cell Therapy Center, Ajou Medical Center, Suwon, Korea
- Department of Orthopedic Surgery, School of Medicine, Ajou University, Suwon, Korea
| | - Suk Young Park
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Soon Jin Choi
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Su Park
- Cell Therapy Center, Ajou Medical Center, Suwon, Korea
| | - Byoung-Hyun Min
- Cell Therapy Center, Ajou Medical Center, Suwon, Korea
- Department of Orthopedic Surgery, School of Medicine, Ajou University, Suwon, Korea
| | - Jae Kwang Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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14
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Burahee AS, Sanders AD, Power DM. The management of failed cubital tunnel decompression. EFORT Open Rev 2021; 6:735-742. [PMID: 34667644 PMCID: PMC8489475 DOI: 10.1302/2058-5241.6.200135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Cubital tunnel decompression is a commonly performed operation with a much higher failure rate than carpal tunnel release. Failed cubital tunnel release generally occurs due to an inadequate decompression in the primary procedure, new symptoms due to an iatrogenic cause, or development of new areas of nerve irritation. Our preferred technique for failed release is revision circumferential neurolysis with medial epicondylectomy, as this eliminates strain, removes the risk of subluxation, and avoids the creation of secondary compression points. Adjuvant techniques including supercharging end-to-side nerve transfer and nerve wrapping show promise in improving the results of revision surgery. Limited quality research exists in this subject, compounded by the lack of consensus on diagnostic criteria, classification, and outcome assessment.
Cite this article: EFORT Open Rev 2021;6:735-742. DOI: 10.1302/2058-5241.6.200135
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Affiliation(s)
- Abdus S Burahee
- The Peripheral Nerve Injury Service, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew D Sanders
- The Peripheral Nerve Injury Service, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Dominic M Power
- The Peripheral Nerve Injury Service, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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15
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Hanwright PJ, Rath JB, von Guionneau N, Slavin B, Pinni S, Zlotolow D, Shores J, Dellon AL, Tuffaha SH. The Effects of a Porcine Extracellular Matrix Nerve Wrap as an Adjunct to Primary Epineurial Repair. J Hand Surg Am 2021; 46:813.e1-813.e8. [PMID: 33563483 DOI: 10.1016/j.jhsa.2020.11.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 09/22/2020] [Accepted: 11/27/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Outcomes after end-to-end epineural suture repair remain poor. Nerve wraps have been advocated to improve regeneration across repair sites by potentially reducing axonal escape and scar ingrowth; however, limited evidence currently exists to support their use. METHODS Forty Lewis rats underwent median nerve division and immediate repair. Half were repaired with epineural suturing alone, and the others underwent epineural suture repair with the addition of a nerve wrap. Motor recovery was measured using weekly grip strength and nerve conduction testing for 15 weeks. Histomorphometric analyses were performed to assess intraneural collagen deposition, cellular infiltration, and axonal organization at the repair site, as well as axonal regeneration and neuromuscular junction reinnervation distal to the repair site. RESULTS The wrapped group demonstrated significantly less intraneural collagen deposition at 5 weeks. Axonal histomorphometry, cellular infiltration, neuromuscular junction reinnervation, and functional recovery did not differ between groups. CONCLUSIONS Nerve wraps reduced collagen deposition within the coaptation; however, no differences were observed in axonal regeneration, neuromuscular junction reinnervation, or functional recovery. CLINICAL RELEVANCE These findings suggest that extracellular matrix nerve wraps can attenuate scar deposition at the repair site. Any benefits that may exist with regards to axonal regeneration and functional recovery were not detected in our model.
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Affiliation(s)
- Philip J Hanwright
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jennifer B Rath
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Nicholas von Guionneau
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Benjamin Slavin
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Sai Pinni
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Dan Zlotolow
- Department of Orthopedic Surgery, Shriners Hospital for Children-Philadelphia, Philadelphia, PA
| | - Jaimie Shores
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - A Lee Dellon
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Sami H Tuffaha
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD.
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16
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Brogan DM, Dy CJ, Lee TY, Rioux-Forker D, Wever J, Leversedge FJ. Histologic and Functional Outcomes of Conduit Wrapping for Peripheral Nerve Repair: Early Results in a Rat Model. J Reconstr Microsurg 2021; 37:559-565. [PMID: 33517567 DOI: 10.1055/s-0040-1722762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The concept of utilizing a nerve conduit for augmentation of a primary nerve repair has been advocated as a method to prevent neural scarring and decrease adhesions. Despite clinical use, little is known about the effects of a nerve conduit wrapped around a primary repair. To better understand this, we investigated the histologic and functional effects of use of a nerve conduit wrapped around a rat sciatic nerve repair without tension. METHODS Twenty Lewis' rats were divided into two groups of 10 rats each. In each group, unilateral sciatic nerve transection and repair were performed, with the opposite limb utilized as a matched control. In the first group, direct repair alone was performed; in the second group, this repair was augmented with a porcine submucosa conduit wrapped around the repair site. Sciatic functional index (SFI) was measured at 6 weeks with walking track analysis in both groups. Nonsurvival surgeries were then performed in all animals to harvest both the experimental and control nerves to measure histomorphometric parameters of recovery. Histomorphometric parameters assessed included total number of neurons, nerve fiber density, nerve fiber width, G-ratio, and percentage of debris. Unpaired t-test was used to compare outcomes between the two groups. RESULTS All nerves healed uneventfully but compared with direct repair; conduit usage was associated with greater histologic debris, decreased axonal density, worse G-ratio, and worse SFI. No significant differences were found in total axon count or gastrocnemius weight. CONCLUSION In the absence of segmental defects, conduit wrapping primary nerve repairs seem to be associated with worse functional and mixed histologic outcomes at 6 weeks, possibly due to debris from conduit resorption. While clinical implications are unclear, more basic science and clinical studies should be performed prior to widespread adoption of this practice.
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Affiliation(s)
- David M Brogan
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Christopher J Dy
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Tony Y Lee
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Dana Rioux-Forker
- Division of Plastic Surgery, University of Missouri, Columbia, Missouri
| | - Jason Wever
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
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17
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Dibbs RP, Ali K, Sarrami SM, Koshy JC. Revision Peripheral Nerve Surgery of the Upper Extremity. Semin Plast Surg 2021; 35:119-129. [PMID: 34121947 DOI: 10.1055/s-0041-1727290] [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: 10/21/2022]
Abstract
Peripheral nerve injuries of the upper extremity can result from a wide array of etiologies, with the two most common being compression neuropathy and traumatic injuries. These types of injuries are common and can be psychologically, functionally, and financially devastating to the patient. A detailed preoperative evaluation is imperative for appropriate management. Traumatic injuries can typically be treated with local burial techniques, targeted muscle reinnervation, and regenerative peripheral nerve interfaces. Median nerve compression is frequently managed with complete release of the antebrachial fascia/transverse carpal ligament and/or use of flap coverage such as the hypothenar fat pad flap and local muscle flaps. Ulnar nerve compression is commonly managed via submuscular transposition, subcutaneous transposition, neurolysis, and nerve wrapping. In this review, we discuss the preoperative evaluation, surgical techniques, and advantages and disadvantages of each treatment modality for patients with compressive and traumatic upper extremity nerve injuries.
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Affiliation(s)
- Rami P Dibbs
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
| | - Kausar Ali
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
| | - Shayan M Sarrami
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
| | - John C Koshy
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
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18
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Yoo MC, Chon J, Jung J, Kim SS, Bae S, Kim SH, Yeo SG. Potential Therapeutic Strategies and Substances for Facial Nerve Regeneration Based on Preclinical Studies. Int J Mol Sci 2021; 22:ijms22094926. [PMID: 34066483 PMCID: PMC8124575 DOI: 10.3390/ijms22094926] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/23/2021] [Accepted: 04/27/2021] [Indexed: 12/14/2022] Open
Abstract
Despite advances in microsurgical technology and an improved understanding of nerve regeneration, obtaining satisfactory results after facial nerve injury remains a difficult clinical problem. Among existing peripheral nerve regeneration studies, relatively few have focused on the facial nerve, particularly how experimental studies of the facial nerve using animal models play an essential role in understanding functional outcomes and how such studies can lead to improved axon regeneration after nerve injury. The purpose of this article is to review current perspectives on strategies for applying potential therapeutic methods for facial nerve regeneration. To this end, we searched Embase, PubMed, and the Cochrane library using keywords, and after applying exclusion criteria, obtained a total of 31 qualifying experimental studies. We then summarize the fundamental experimental studies on facial nerve regeneration, highlighting recent bioengineering studies employing various strategies for supporting facial nerve regeneration, including nerve conduits with stem cells, neurotrophic factors, and/or other therapeutics. Our summary of the methods and results of these previous reports reveal a common feature among studies, showing that various neurotrophic factors arising from injured nerves contribute to a microenvironment that plays an important role in functional recovery. In most cases, histological examinations showed that this microenvironmental influence increased axonal diameter as well as myelination thickness. Such an analysis of available research on facial nerve injury and regeneration represents the first step toward future therapeutic strategies.
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Affiliation(s)
- Myung Chul Yoo
- Department of Physical Medicine & Rehabilitation, College of Medicine, Kyung Hee University, Seoul 02447, Korea; (M.C.Y.); (J.C.)
| | - Jinmann Chon
- Department of Physical Medicine & Rehabilitation, College of Medicine, Kyung Hee University, Seoul 02447, Korea; (M.C.Y.); (J.C.)
| | - Junyang Jung
- Department of Anatomy and Neurobiology, College of Medicine, Kyung Hee University, Seoul 02447, Korea;
| | - Sung Su Kim
- Department of Biochemistry and Molecular Biology, School of Medicine, Kyung Hee University, Seoul 02447, Korea;
| | - Seonhwan Bae
- Department of Otorhinolaryngology, Head & Neck Surgery, College of Medicine, Kyung Hee University, Seoul 02447, Korea; (S.B.); (S.H.K.)
| | - Sang Hoon Kim
- Department of Otorhinolaryngology, Head & Neck Surgery, College of Medicine, Kyung Hee University, Seoul 02447, Korea; (S.B.); (S.H.K.)
| | - Seung Geun Yeo
- Department of Otorhinolaryngology, Head & Neck Surgery, College of Medicine, Kyung Hee University, Seoul 02447, Korea; (S.B.); (S.H.K.)
- Correspondence: ; Tel.: +82-2-958-8980; Fax: +82-2-958-8470
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19
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Gao YB, Liu ZG, Lin GD, Guo Y, Chen L, Huang BT, Yin YB, Yang C, Sun LY, Rong YB, Chen S. Safety and efficacy of a nerve matrix membrane as a collagen nerve wrapping: a randomized, single-blind, multicenter clinical trial. Neural Regen Res 2021; 16:1652-1659. [PMID: 33433497 PMCID: PMC8323693 DOI: 10.4103/1673-5374.303040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A new nerve matrix membrane derived from decellularized porcine nerves has been shown to retain the major extracellular matrix components, and to be effective in preventing adhesion between the nerve anastomosis sites and the surrounding tissues in a rat sciatic nerve transection model, thereby enhancing regeneration of the nerve. The effectiveness of the membrane may be attributed to its various bioactive components. In this prospective, randomized, single-blind, parallel-controlled multicenter clinical trial, we compared the safety and efficacy of the new nerve matrix membrane with a previously approved bovine tendon-derived type I collagen nerve wrapping. A total of 120 patients with peripheral nerve injury were recruited from Beijing Jishuitan Hospital, The First Bethune Hospital of Jilin University, and Yantai Yuhuangding Hospital, China. The patients were randomly assigned to undergo end-to-end and tension-free neurorrhaphy with nerve matrix membrane (n = 60, 52 male, 8 female, mean age 41.34 years, experimental group) or tendon-derived collagen nerve wrapping (n = 60, 42 male, 18 female, mean age 40.17 years, control group). Patients were followed-up at 14 ± 5, 30 ± 7, 90 ± 10 and 180 ± 20 days after the operation. Safety evaluation included analyses of local and systemic reactions, related laboratory tests, and adverse reactions. Efficacy evaluation included a static 2-point discrimination test, a moving 2-point discrimination test, and a Semmes–Weinstein monofilament examination. Sensory nerve function was evaluated with the British Medical Research Council Scale and Semmes–Weinstein monofilament examination. The ratio (percentage) of patients with excellent to good results in sensory nerve recovery 180 ± 20 days after the treatment was used as the primary effectiveness index. The percentages of patients with excellent to good results in the experimental and control groups were 98.00% and 94.44%, respectively, with no significant difference between the two groups. There were no significant differences in the results of routine blood tests, liver and renal function tests, coagulation function tests, or immunoglobulin tests at 14 and 180 days postoperatively between the two groups. These findings suggest that the novel nerve matrix membrane is similar in efficacy to the commercially-available bovine-derived collagen membrane in the repair of peripheral nerve injury, and it may therefore serve as an alternative in the clinical setting. The clinical trial was approved by the Institutional Ethics Committee of Beijing Jishuitan Hospital, China (approval No. 20160902) on October 8, 2016, the Institutional Ethics Committee of the First Bethune Hospital of Jilin University, China (approval No. 160518-088) on December 14, 2016, and the Institutional Ethics Committee of Yantai Yuhuangding Hospital, China (approval No. 2016-10-01) on December 9, 2016. The clinical trial was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR2000033324) on May 28, 2020.
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Affiliation(s)
- Yong-Bin Gao
- Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Zhi-Gang Liu
- Department of Hand Surgery, The First Bethune Hospital of Jilin University, Changchun, Jilin Province, China
| | - Guo-Dong Lin
- Department of Hand and Foot Surgery, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Yang Guo
- Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Lei Chen
- Department of Hand Surgery, The First Bethune Hospital of Jilin University, Changchun, Jilin Province, China
| | - Bo-Tao Huang
- Department of Hand and Foot Surgery, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Yao-Bin Yin
- Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Chen Yang
- Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Li-Ying Sun
- Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Yan-Bo Rong
- Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Shanlin Chen
- Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing, China
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20
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Dong R, Liu C, Tian S, Bai J, Yu K, Liu L, Tian D. Electrospun polycaprolactone (PCL)-amnion nanofibrous membrane prevents adhesions and promotes nerve repair in a rat model of sciatic nerve compression. PLoS One 2020; 15:e0244301. [PMID: 33338083 PMCID: PMC7748280 DOI: 10.1371/journal.pone.0244301] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/03/2020] [Indexed: 11/19/2022] Open
Abstract
Adhesion and scarring after neural surgery are detrimental to nerve regeneration and functional recovery. Amniotic membranes have been used in tissue repair due to their immunogenicity and richness in cytokines. In this study, an electrospun polycaprolactone (PCL)-amnion nanofibrous membrane was prepared for the treatment of sciatic nerve compression in a rat model. The effects of the PCL-amnion nanofibrous membrane on the prevention of adhesion formation and nerve regeneration were evaluated using electrophysiology and histological analyses. Compared with the medical chitosan hydrogel dressing, the PCL-amnion nanofibrous membrane significantly reduced peripheral nerve adhesion and promoted the rapid recovery of nerve conduction. Moreover, the immunohistochemical analysis identified more Schwann cells and less pro-inflammatory M1 macrophages in the PCL-amnion group. Western blot and RT-PCR results showed that the expression levels of type-Ⅰ and Ⅲ collagen in the PCL-treated rats were half of those in the control group after 12 weeks, while the expression level of nerve growth factor was approximately 3.5 times that found in the rats treated with medical chitosan hydrogel. In summary, electrospun PCL-amnion nanofibrous membranes can effectively reduce adhesion after neural surgery and promote nerve repair and regeneration. The long-term retention in vivo and sustained release of cytokines make PCL-amnion a promising biomaterial for clinical application.
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Affiliation(s)
- Ruiyi Dong
- Department of Orthopedics, Cangzhou Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou, Hebei, China
| | - Chunjie Liu
- Department of Orthopedics, Tangshan Workers Hospital, Tangshan, Hebei, China
| | - Siyu Tian
- Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jiangbo Bai
- Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Kunlun Yu
- Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Lei Liu
- Department of Orthopedics, Changping District Hospital, Beijing, China
| | - Dehu Tian
- Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
- * E-mail:
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21
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Nicot C, Césari B, Saint-Cast Y, Raimbeau G, Rabarin F. Benefits of a collagen membrane for recurrent ulnar nerve entrapment at the elbow: A series of 40 cases. HAND SURGERY & REHABILITATION 2020; 40:145-149. [PMID: 33309790 DOI: 10.1016/j.hansur.2020.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/08/2020] [Accepted: 11/10/2020] [Indexed: 11/28/2022]
Abstract
The rate of failure or recurrence after ulnar nerve release at the elbow is up to 25%. Various biomaterials have been developed to protect nerves from postoperative adhesions. The aim of this study was to review a case series of 40 surgical revision procedures of the ulnar nerve at the elbow, protected by a collagen membrane (Cova™ ORTHO). Forty patients who had this revision surgery between January 2013 and December 2017 were reviewed: 34 were evaluated in person, 6 were evaluated over the phone. The operation consisted in release of the ulnar nerve, anterior subcutaneous transposition and nerve protection using a collagen membrane. We assessed the following parameters with an average follow-up of 4 years and 3 months: paresthesia, night awakening, quality of life (QuickDASH score) and neuropathic pain (DN4 questionnaire). The outcome was determined with the Gabel & Amadio score. The patients' satisfaction was evaluated. A significant decrease in paresthesia and night awakening was found (p < 0.05). The average Gabel & Amadio score improved from 4.4 to 6.7 with 5 excellent, 19 good, 9 fair, and 1 poor result. The average DN4 was 5/10 and the QuickDASH score was 40.1. Eighty percent of patients were satisfied or very satisfied with the outcome. Surgical revision of the ulnar nerve at the elbow remains a delicate operation without a gold standard. This case series found good or excellent results in 70% of patients. Surgical revision of the ulnar nerve with a collagen membrane is a reliable alternative among other possibilities for ulnar nerve release at the elbow.
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Affiliation(s)
- C Nicot
- CHU d'Angers, 4, rue Larrey, 49100 Angers, France.
| | - B Césari
- Centre de la Main, 47, rue de la Foucaudière, 49000 Trélazé, France.
| | - Y Saint-Cast
- Centre de la Main, 47, rue de la Foucaudière, 49000 Trélazé, France.
| | - G Raimbeau
- Centre de la Main, 47, rue de la Foucaudière, 49000 Trélazé, France.
| | - F Rabarin
- Centre de la Main, 47, rue de la Foucaudière, 49000 Trélazé, France.
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Thakker A, Sharma SC, Hussain NM, Devani P, Lahiri A. Nerve wrapping for recurrent compression neuropathy: A systematic review. J Plast Reconstr Aesthet Surg 2020; 74:549-559. [PMID: 33268044 DOI: 10.1016/j.bjps.2020.10.085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 10/18/2020] [Accepted: 10/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The recurrence of symptoms following primary nerve compression surgery can occur in up to 25% of cases. Nerve wrapping can be utilised for revision surgery. An ideal barrier should minimise the chance of fibrosis, scarring and allow for adequate nerve gliding. This review evaluates the use of autologous or commercially available allograft and xenograft options as barriers against nerve scarring following revision surgery. METHODS PubMed, Ovid Embase and Cochrane databases were searched using the All Fields Index. Nine hundred titles underwent title screening with 11 studies being included in the final analysis. The risk of bias was assessed using the Methodological Index for Non-Randomised Studies (MINORS) tool. PRISMA guidelines were followed at all stages and the review was registered with PROSPERO (CRD 42020182818). RESULTS The 11 studies comprised of all case series. In total, 114 patients were included, with ages ranging from 28 to 90. Previously, the number of revision surgeries ranged from 0 to 5. Autologous veins were used in 6 studies, collagen in 3 studies and human amniotic membrane in 2 studies. Improvements in subjective and objective outcomes were seen with all wrap types. Pain was the most common residual symptom (46% of patients). The most common complication was pain at the donor site following vein harvest (19% of patients). CONCLUSION This is the first systematic review to summarise the outcomes of nerve wraps for revision compression neuropathy. While improvements in outcomes were reported, further comparative studies are needed to determine the best nerve wrap.
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Affiliation(s)
- Arjuna Thakker
- University Hospitals Of Leicester NHS Trust, Leicester LE1 5WW, United Kingdom.
| | | | | | - Pooja Devani
- University Hospitals Of Leicester NHS Trust, Leicester LE1 5WW, United Kingdom
| | - Anindya Lahiri
- Sandwell and West Birmingham NHS Trust, West Bromwich B71 4HJ, United Kingdom
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Fernandes CH, Santos JBGD, Schwartz-Fernandes F, Ostermann AL, Faloppa F. Fatores de insucesso do tratamento cirúrgico da síndrome do túnel do carpo: Quando e como revisar a cirurgia de descompressão do túnel do carpo. Rev Bras Ortop 2020; 57:718-725. [PMID: 36226206 PMCID: PMC9550358 DOI: 10.1055/s-0040-1713759] [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: 12/20/2019] [Accepted: 04/20/2020] [Indexed: 12/04/2022] Open
Abstract
Despite being a procedure widely used all over the world with high rates of symptom remission, surgical treatment of carpal tunnel syndrome may present unsatisfactory outcomes. Such outcomes may be manifested clinically by non-remission of symptoms, remission of symptoms with recurrence a time after surgery or appearance of different symptoms after surgery. Different factors are related to this unsuccessful surgical treatment of carpal tunnel syndrome. Prevention can be achieved through a thorough preoperative clinical evaluation of the patient. As such, the surgeon will be able to make differential or concomitant diagnoses, as well as determine factors related to patient dissatisfaction. Perioperative factors include the correct identification of anatomical structures for complete median nerve decompression. Numerous procedures have been described for managing postoperative factors. Among them, the most common is adhesion around the median nerve, which has been treated with relative success using different vascularized flaps or autologous or homologous tissue coverage. The approach to cases with unsuccessful surgical treatment of carpal tunnel syndrome is discussed in more detail in the text.
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Affiliation(s)
- Carlos Henrique Fernandes
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - João Baptista Gomes dos Santos
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | | | - A. Lee Ostermann
- Hand and Orthopaedic Surgery Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Flávio Faloppa
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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[Surgical treatment of carpal tunnel syndrome: open release of the flexor retinaculum and hypothenar fat flap for revision surgery]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2020; 32:219-235. [PMID: 32524170 DOI: 10.1007/s00064-020-00662-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/09/2020] [Accepted: 03/26/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Decompression of the median nerve by complete release of the flexor retinaculum and the distal antebrachial fascia. In the case of revision surgery providing of a scar-free covering of the median nerve, if necessary. INDICATIONS Carpal tunnel release is indicated for symptomatic patients with painful paraesthesia or neurological deficits after adequate diagnostic evaluation. The hypothenar fat flap is indicated in revision surgery if a sufficient nerve bed of the median nerve is needed and to restore nerve gliding. CONTRAINDICATIONS General operative limitations. The hypothenar fat flap is not indicated in revision surgery if median nerve irritation is not caused by surrounding scaring but other reasons like tendonitis. SURGICAL TECHNIQUE Proximal longitudinal incision of the palm. Subcutaneous dissection and incision of the palmar aponeurosis. Careful ulnar incision of the transverse carpal ligament. Considerate release of the distal and proximal parts of the retinaculum as well as the distal part of the antebrachial fascia. Exploration of the median nerve and palpation of the carpal tunnel and resection of compressive structures, if necessary. In case of revision surgery, if required, the hypothenar fat flap is raised. The fat flap is transposed without tension palmar to the median nerve and fixed to the radial side of the carpal tunnel. POSTOPERATIVE MANAGEMENT Early functional mobilization. Immobilization for a short period is optional. After revision surgery and hypothenar fat flap, splinting for one week is recommended.
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Zhu Y, Jin Z, Luo Y, Wang Y, Peng N, Peng J, Wang Y, Yu B, Lu C, Zhang S. Evaluation of the Crushed Sciatic Nerve and Denervated Muscle with Multimodality Ultrasound Techniques: An Animal Study. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:377-392. [PMID: 31699548 DOI: 10.1016/j.ultrasmedbio.2019.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 06/10/2023]
Abstract
This study was aimed at evaluating the value of multimodality ultrasound techniques in the detection of crushed sciatic nerve and denervated muscle in rabbits. Fifty healthy male New Zealand white rabbits were randomly divided into five groups (n = 10 in each group): four crushed injury groups at 1, 2, 4 and 8 wk post-sciatic nerve crushed injury, and a control group without crush injury. The crushed sciatic nerve and denervated muscle were measured with conventional ultrasound, shear wave elastography and contrast-enhanced ultrasonography, and the results were compared with the histopathological parameters. The inter- and intra-reader reliability of multimodality ultrasound was assessed with intra-class correlation coefficients. Our results revealed that the sciatic nerve thickened at 2 wk post-crushed injury (p < 0.01), but recovered to almost normal thickness at 8 wk post-injury. Stiffness of the crushed nerve gradually increased (p < 0.01), and intraneural blood volume decreased (area under the curve, peak intensity, time to peak, p < 0.01 each) over time. Histopathological evaluation revealed obvious collagen hyperplasia and poor regenerated microvascular and sparse axonal regeneration and remyelination. Compared with that of the control group, the elastic modulus of the denervated muscle significantly increased (p < 0.05), which may be related to the increased intramuscular collagen (p < 0.01) and decreased muscle fiber cross-sectional area (p < 0.01). There were no significant differences in contrast-enhanced ultrasonography parameters (area under the curve, peak intensity, time to peak) of the denervated muscle between the crush injury groups and the control group (p >0.05). All ultrasound results had excellent inter- and intra-reader consistency (intraclass correlation coefficient >0.80). In conclusion, multimodality ultrasound techniques could provide quantitative information on the morphologic changes, mechanical properties and blood perfusion of crushed nerve and denervated muscle, which may be of great importance in clinical practice.
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Affiliation(s)
- Yaqiong Zhu
- Medical College of Nankai University, Tianjin, China; Departments of Ultrasound, Chinese PLA General Hospital, Beijing, China; Beijing Key Laboratory of Chronic Heart Failure Precision Medicine, Chinese PLA General Hospital, Beijing, China
| | - Zhuang Jin
- Departments of Ultrasound, Chinese PLA General Hospital, Beijing, China; General hospital of Northern Theater Command, Shenyang, Liaoning province, China
| | - Yukun Luo
- Departments of Ultrasound, Chinese PLA General Hospital, Beijing, China.
| | - Yuexiang Wang
- Departments of Ultrasound, Chinese PLA General Hospital, Beijing, China.
| | - Nan Peng
- Department of Geriatric Rehabilitation, Chinese PLA General Hospital, Beijing, China
| | - Jiang Peng
- Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China; Key Lab of Musculoskeletal Trauma & War Injuries, Chinese PLA General Hospital, Beijing, China
| | - Yu Wang
- Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China; Key Lab of Musculoskeletal Trauma & War Injuries, Chinese PLA General Hospital, Beijing, China
| | - Bo Yu
- Departments of Ultrasound, Chinese PLA General Hospital, Beijing, China
| | - Changfeng Lu
- Beijing Key Lab of Regenerative Medicine in Orthopedics, Chinese PLA General Hospital, Beijing, China; Key Lab of Musculoskeletal Trauma & War Injuries, Chinese PLA General Hospital, Beijing, China
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Uemura T, Takamatsu K, Okada M, Yokoi T, Onode E, Miyashima Y, Konishi S, Nakamura H. A case series of seven patients with recurrent median nerve neuropathy treated by the revision surgery of median nerve neurolysis and wrapping with radial artery perforator adipose flap. J Plast Reconstr Aesthet Surg 2019; 73:453-459. [PMID: 31757685 DOI: 10.1016/j.bjps.2019.09.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/09/2019] [Accepted: 09/28/2019] [Indexed: 11/19/2022]
Abstract
Adhesion neuropathy of the median nerve with persistent pain can be a challenging problem. Currently, coverage of the median nerve with a well-vascularized soft tissue is deemed necessary after secondary neurolysis. Herein, we reviewed the outcomes of seven patients with a persistent median nerve neuropathy after a primary open carpal tunnel release or a median nerve repair, treated with neurolysis and median nerve wrapping with radial artery perforator adipose flaps. During the revision surgery, after a careful and complete neurolysis of the scarred median nerve, the distally based radial artery perforator adipose flap without its fascia was raised and rotated to wrap the median nerve. The mean size of the perforator flap was 1146 mm2, which was enough to wrap the median nerve in all patients. At 26 months postsurgery, both the visual analog scale score for pain with tingling, and the patient-reported outcome measures improved. There was no recurrence of the median nerve adhesion neuropathy and no major complications were noted. Tinel's sign at the palmar wrist completely disappeared in four patients and was relieved in three patients. The median distal motor latency becomes recordable, and closer to a normal compound motor action potential postoperatively in all patients. Secondary neurolysis and median nerve wrapping with a radial artery perforator adipose flap, which was modified to be softer and thinner than the radial artery perforator adipofascial flap, was a successful treatment for the recurrent median nerve neuropathy in terms of both pain relief and restoration of the hand function.
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Affiliation(s)
- Takuya Uemura
- Department of Orthopaedic Surgery, Osaka General Hospital of West Japan Railway Company, 1-2-22 Matsuzakicho, Abeno-ku, Osaka 545-0053, Japan; Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan.
| | - Kiyohito Takamatsu
- Department of Orthopaedic Surgery, Yodogawa Christian Hospital, 1-7-50 Kunijima, Higashiyodogawa-ku, Osaka 533-0024, Japan
| | - Mitsuhiro Okada
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Takuya Yokoi
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Ema Onode
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
| | - Yusuke Miyashima
- Department of Orthopaedic Surgery, Osaka General Hospital of West Japan Railway Company, 1-2-22 Matsuzakicho, Abeno-ku, Osaka 545-0053, Japan
| | - Sadahiko Konishi
- Department of Orthopaedic Surgery, Osaka General Hospital of West Japan Railway Company, 1-2-22 Matsuzakicho, Abeno-ku, Osaka 545-0053, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan
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27
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Zhang D, Earp BE, Blazar P. Evaluation and Management of Unsuccessful Carpal Tunnel Release. J Hand Surg Am 2019; 44:779-786. [PMID: 31300226 DOI: 10.1016/j.jhsa.2019.05.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/20/2019] [Accepted: 05/27/2019] [Indexed: 02/02/2023]
Abstract
Carpal tunnel release (CTR) is a routine and effective surgical treatment for carpal tunnel syndrome. Dissatisfied patients after CTR are uncommon but present diagnostic and therapeutic challenges. This article discusses the most common reasons for unsuccessful CTR, the appropriate ensuing workup, and current evidence regarding revision surgery. The authors' preferred treatment algorithm for the surgical management of the unsuccessful CTR is presented.
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Affiliation(s)
- Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Brandon E Earp
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Philip Blazar
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
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28
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Zeng W, Osterman M, Stern PJ. Inflammatory Reactions to Xenogenic Nerve Wraps: A Report of Three Cases. JBJS Case Connect 2019; 9:e0302. [PMID: 31343998 DOI: 10.2106/jbjs.cc.18.00302] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
CASE Recurrent carpal tunnel syndrome is a challenging problem. Nerve wraps have been introduced as a barrier to prevent scar traction neuritis for use during revision carpal tunnel surgery. We present 3 cases of inflammatory responses to bovine collagen and porcine subintestinal mucosal nerve wraps in patients undergoing revision carpal tunnel surgery. No patient had evidence of infection, and pathology revealed acute and chronic inflammation. All 3 patients responded favorably following wrap removal. CONCLUSIONS We recommend caution with the routine use of nerve wraps in the setting of revision carpal tunnel surgery.
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Affiliation(s)
- Wenjing Zeng
- TriHealth Hand Surgery Specialists, Cincinnati, Ohio
| | | | - Peter J Stern
- Department of Orthopedics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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29
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Liu H, Huang H, Bi W, Tan X, Li R, Wen W, Song W, Zhang Y, Zhang F, Hu M. Effect of chitosan combined with hyaluronate on promoting the recovery of postoperative facial nerve regeneration and function in rabbits. Exp Ther Med 2018; 16:739-745. [PMID: 30116328 PMCID: PMC6090212 DOI: 10.3892/etm.2018.6238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 03/29/2018] [Indexed: 12/19/2022] Open
Abstract
To determine better solutions for postoperative nerve functional recovery, the effects of chitosan and hyaluronate on perineural scar formation and neural function recovery were investigated in 40 rabbits. Rabbits were randomized into 4 groups: A (chitosan), B (chitosan + hyaluronate), C (hyaluronate) and D (control). The rabbits underwent the same parotidectomy surgery, but different materials were used to cover the operated nerves. By evaluating specific indicators, including vibrissae motion tests, neural electrophysiological examinations and extraneural examinations, it was revealed that the amplitude of vibrissae motion of all groups had increased 6 weeks after surgery. The recovery of Group B was superior compared with all other groups at 4 and 12 weeks post-surgery; however no significant differences were detected. Group B exhibited a great number of nerve fibers, thicker myelin sheath and greater nerve conduction velocity. In summary, the use of a chitosan conduit combined with sodium hyaluronate gel may prevent perineural scar formation in facial nerves and promote nerve functional recovery.
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Affiliation(s)
- Huawei Liu
- Department of Stomatology, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Haitao Huang
- Department of Stomatology, The 1st Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China
| | - Wenting Bi
- Department of Stomatology, Beijing First Hospital of Integrated Chinese and Western Medicine, Beijing 100026, P.R. China
| | - Xinying Tan
- Department of Stomatology, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Runxin Li
- Department of Stomatology, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Weisheng Wen
- Department of Stomatology, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China
| | - Wenling Song
- Department of Quality Control, Beijing Yierkang Bioengineering Development Center, Beijing 102600, P.R. China
| | - Yanhua Zhang
- Department of Quality Control, Beijing Yierkang Bioengineering Development Center, Beijing 102600, P.R. China
| | - Feng Zhang
- Department of Quality Control, Beijing Yierkang Bioengineering Development Center, Beijing 102600, P.R. China
| | - Min Hu
- Department of Stomatology, Chinese People's Liberation Army General Hospital, Beijing 100853, P.R. China
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