Experimental comparison of muscle contractility after three methods of reinnervation

Clinically Available Low Intensity Ultrasound Devices do not Promote Axonal Regeneration After Peripheral Nerve Surgery-A Preclinical Investigation of an FDA-Approved Device

The slow axonal regeneration and consecutive delayed muscle reinnervation cause persistent functional deficits following peripheral nerve injury, even following sufficient surgical nerve reconstruction. Preclinically, adjunct ultrasound therapy has shown to significantly accelerate nerve regeneration and thereby improve muscle function compared to nerve reconstruction alone. However, although FDA-approved and clinically well-tested ultrasound devices for other conditions such as delayed-healing fractures are available, they have not been investigated for peripheral nerve injury yet. Aiming to provide a fast clinical translation, we evaluated EXOGEN (Bioventus LLC, Durham, USA), a clinical device for low-intensity ultrasound therapy in various treatment intervals following peripheral nerve surgery. Sixty rats, randomized to five groups of twelve animals each, underwent median nerve transection and primary epineural nerve reconstruction. Post-surgically the ultrasound therapy (duration: 2 min, frequency: 1.5 MHz, pulsed SATA-intensity: 30 mW/cm², repetition-rate: 1.0 kHz, duty-cycle: 20%) was applied either weekly, 3 times a week or daily. A daily sham-therapy and a control-group served as references. Functional muscle testing, electrodiagnostics and histological analyses were used to evaluate nerve regeneration. The post-surgically absent grip strength recovered in all groups and increased from week four on without any significant differences among groups. The weekly treated animals showed significantly reduced target muscle atrophy compared to sham-treated animals (p = 0.042), however, with no significant differences to three-times-a-week-, daily treated and control animals. The number of myelinated axons distal to the lesion site increased significantly in all groups (p < 0.001) without significant difference among groups (p > 0.05). A full recovery of distal latency was achieved in all groups and muscle function and CMAP recurred with insignificant differences among groups. In conclusion, the clinically available FDA-approved ultrasound device did not promote the axonal regeneration following nerve injury in comparison to control and sham groups. This is in contrast to a conclusive preclinical evidence base and likely due to the insufficient ultrasound-intensity of 30 mW/cm². We recommend the clinical investigation of 200–300 mW/cm².

Characteristics of tetanic force produced by the sternomastoid muscle of the rat

The sternomastoid (SM) muscle plays an important role in supporting breathing. It also has unique anatomical advantages that allow its wide use in head and neck tissue reconstruction and muscle reinnervation. However, little is known about its contractile properties. The experiments were run on rats and designed to determine in vivo the relationship between muscle force (active muscle contraction to electrical stimulation) with passive tension (passive force changing muscle length) and two parameters (intensity and frequency) of electrical stimulation. The threshold current for initiating noticeable muscle contraction was 0.03 mA. Maximal muscle force (0.94 N) was produced by using moderate muscle length/tension (28 mm/0.08 N), 0.2 mA stimulation current, and 150 Hz stimulation frequency. These data are important not only to better understand the contractile properties of the rat SM muscle, but also to provide normative values which are critical to reliably assess the extent of functional recovery following muscle reinnervation.

Preliminary investigation of a polyethylene glycol hydrogel "nerve glue"

Background

Polyethylene glycol (PEG) hydrogel is a biocompatible semi-adherent gel like substance that can potentially augment nerve repair much like a fibrin sealant. Potential advantages of this substance include fast preparation and set up time, as well as adhesion inhibiting properties. The purpose of this study was to perform an initial evaluation of PEG hydrogel in this application.

Methods

The sciatic nerves of 29 rats were transected and repaired using two 10-0 nylon sutures and either PEG hydrogel or fibrin glue. After 10 weeks, contraction forces of the reinnervated muscles were evaluated and histological assessment of scar tissue performed.

Results

Muscle strength testing revealed the average ratio of experimental to control sides for the fibrin glue group was 0.75 and for the PEG hydrogel group was 0.72 (no significant difference). Longitudinal sections through the nerve repair site showed no significant difference in nerve diameter but did demonstrate a significant reduction in scar thickness in the PEG hydrogel group (p < 0.01).

Conclusion

Though further study is necessary to fully evaluate, PEG hydrogel results in less scar tissue formation and equivalent muscle recovery as fibrin sealant when applied as a nerve glue in a rodent sciatic nerve repair model.

Denervated Muscle Fibers Explain the Deficit in Specific Force following Reinnervation of the Rat Extensor Digitorum Longus Muscle

The authors tested the hypothesis that, after denervation and reinnervation of skeletal muscle, observed deficits in specific force can be completely attributed to the presence of denervated muscle fibers. The peroneal nerve innervating the extensor digitorum longus muscle in rats was sectioned and the distal stump was coapted to the proximal stump, allowing either a large number of motor axons (nonreduced, n = 12) or a drastically reduced number of axons access to the distal nerve stump (drastically reduced, n = 18). A control group of rats underwent exposure of the peroneal nerve, without transection, followed by wound closure (control, n = 9). Four months after the operation, the maximum tetanic isometric force (Fo) of the extensor digitorum longus muscle was measured in situ and the specific force (sFo) was calculated. Cross-sections of the muscles were labeled for neural cell adhesion molecule (NCAM) protein to distinguish between innervated and denervated muscle fibers. Compared with extensor digitorum longus muscles from rats in the control (295 +/- 11 kN/m2) and nonreduced (276 +/- 12 kN/m2) groups, sFo of the extensor digitorum longus muscles from animals in the drastically reduced group was decreased (227 +/- 15 kN/m2, p < 0.05). The percentage of denervated muscle fibers in the extensor digitorum longus muscles from animals in the drastically reduced group (18 +/- 3 percent) was significantly higher than in the control (3 +/- 1 percent) group, but not compared with the nonreduced (9 +/- 2 percent) group. After exclusion of the denervated fibers, sFo did not differ between extensor digitorum longus muscles from animals in the drastically reduced (270 +/- 20 kN/m2), nonreduced (301 +/- 13 kN/m2), or control (303 +/- 10 kN/m2) groups. The authors conclude that, under circumstances of denervation and rapid reinnervation, the decrease in sFo of muscle can be attributed to the presence of denervated muscle fibers.

Superficial or deep implantation of motor nerve after denervation: an experimental study--superficial or deep implantation of motor nerve

Neurorraphy, conventional nerve grafting technique, and artificial nerve conduits are not enough for repair in severe injuries of peripheral nerves, especially when there is separation of motor nerve from muscle tissue. In these nerve injuries, reinnervation is indicated for neurotization. The distal end of a peripheral nerve is divided into fascicles and implanted into the aneural zone of target muscle tissue. It is not known how deeply fascicles should be implanted into muscle tissue. A comparative study of superficial and deep implantation of separated motor nerve into muscle tissue is presented in the gastrocnemius muscle of rabbits. In this experimental study, 30 white New Zealand rabbits were used and divided into 3 groups of 10 rabbits each. In the first group (controls, group I), only surgical exposure of the gastrocnemius muscle and motor nerve (tibial nerve) was done without any injury to nerves. In the superficial implantation group (group II), tibial nerves were separated and divided into their own fascicles. These fascicles were implanted superficially into the lateral head of gastrocnemius muscle-aneural zone. In the deep implantation group (group III), the tibial nerves were separated and divided into their own fascicles. These fascicles were implanted around the center of the muscle mass, into the lateral head of the gastrocnemius muscle-aneural zone. Six months later, histopathological changes and functional recovery of the gastrocnemius muscle were investigated. Both experimental groups had less muscular weight than in the control group. It was found that functional recovery was achieved in both experimental groups, and was better in the superficial implantation group than the deep implantation group. EMG recordings revealed that polyphasic and late potentials were frequently seen in both experimental groups. Degeneration and regeneration of myofibrils were observed in both experimental groups. New motor end-plates were formed in a scattered manner in both experimental groups. However, they were more dense in the superficial implantation group than the deep implantation group. It was concluded that superficial implantation has a more powerful contractile capacity than that of deep implantation. We believe that this might arise from the high activity of glycolytic enzymes in peripheral muscle fibers of gastrocnemius muscle, decrease in insufficient intramuscular guidance apparatus, and intramuscular microneuroma formation at the insufficient neuromuscular junction since the motor nerve had less route to muscle fibers.

Effects of nerve growth factor on the neurotization of denervated muscles

Studies on surgical repair techniques of the peripheral nerve are still trying to improve the outcome. There are many studies on the effects of various neurotrophic factors on the transected peripheral nerve. Muscular neurotization, which is the direct implantation of the nerve to the target denervated skeletal muscle, is one of the techniques used when the primary repair of the peripheral nerves is not possible. The effects of nerve growth factor (NGF), which is one of the primary neurotrophic factors, on the reinnervation of denervated muscles by neurotization is investigated in this experimental study. The denervated soleus muscle was neurotized via peroneal nerve implantation (group 1), and NGF was administered to the neurotized muscle (group 2). All animals were evaluated at weeks 8, 10, and 12 using electromyography. Muscle contractility, muscle weight, and histological morphometric tests were performed at week 12. The experimental groups were compared with each other and normal control values. Electromyographically, group 2 (direct nerve implantation + NGF) demonstrated better reinnervation in all evaluations. The study of muscle weight showed that the muscle mass was 75% of the normal soleus muscle in group 1 and was 85% of the normal side in group 2 at the end of week 12. In group 1, the twitch force was 56% of the normal soleus muscle and was 71% in group 2. Tetanic force was 53% of the normal soleus muscle in group 1 and 68% in group 2. Histological morphometric studies revealed that there was a decrease in the density of the motor end plates in group 1, but there was no statistically significant difference between the normal soleus muscles and the NGF applied to group 2. The positive effects of NGF on the neurotization of denervated muscles seen in this study suggest that it may be useful for treating some difficult reconstructions caused by denervation.

Qualitative and quantitative changes in acetylcholine receptor distribution at the neuromuscular junction following free muscle transfer

The qualitative and quantitative changes in acetylcholine receptor distribution were studied in the gracilis muscle of the Wistar rat following free neurovascular transfer. Even at 30 weeks after transfer, the morphology of the neuromuscular junction failed to return to the presurgical state. The number of acetylcholine receptors at the reinnervated neuromuscular junction also remained lower than the control. The persistent weakness following free neurovascular muscle transfer may be attributed to these qualitative and quantitative changes at the neuromuscular junction.

The effect of two episodes of denervation and reinnervation on skeletal muscle contractile function

Sensory or motor "baby-sitting" has been proposed as a clinical strategy to preserve muscle integrity if motion-specific axons must regenerate over a long distance to reach denervated target muscles. Denervated muscles are innervated temporarily by using axons from nearby sensory or motor nerves. After motion specific motor axons have reached the target, the baby-sitter nerve is severed and motion-specific axons are directed to the target. Although this strategy minimizes denervation time, the requisite second episode of denervation and reinnervation might be deleterious to muscle contractile function. This study was designed to test the hypothesis that two sequential episodes of skeletal muscle denervation and reinnervation result in greater force and power deficits than a single peripheral nerve injury and repair. Adult Lewis rats underwent either transection and epineurial repair or sham exposure of the left peroneal nerve. After a 4-month recovery period, the contractile properties of the extensor digitorum longus muscle of the sham exposure group (control, n = 9) and one of the nerve division and repair groups (repair group 1, n = 9) were evaluated with measurements of the maximum tetanic isometric force, peak power, and maximal sustained power. A third group of rats underwent a second cycle of nerve division and repair (repair group 2, n = 9) at this same time point. Four months postoperatively, contractile properties of the extensor digitorum longus muscles were evaluated. Maximum tetanic isometric force and peak power were significantly reduced in repair group 2 rats as compared with repair group 1 and control rats. Maximal sustained power was not significantly different between the groups. These data support our working hypothesis that skeletal muscle contractile function is adversely affected by two cycles of denervation and reinnervation as compared with a single episode of nerve division and repair.

A specific force deficit exists in skeletal muscle after partial denervation

Skeletal muscle demonstrates a specific force deficit after repair of injured peripheral nerves, microneurovascular muscle transfer, and normal aging. Because atrophy cannot account for deficits in specific force, other, unknown, mechanisms are responsible for the resulting muscle contractile dysfunction under these circumstances. We tested the hypothesis that a subpopulation of denervated fibers is partially or completely responsible for the specific force deficit after partial denervation of the rat extensor digitorum longus muscle (EDL). Adult Fisher rats underwent either sham exposure or partial transection of 80% of the cross-sectional area of the left deep peroneal nerve. After a 2-week recovery period, maximum isometric force (F(0)) was measured in situ and maximum specific force (sF(0)) was calculated for EDL from both control (n = 8) and partial denervation (n = 7) groups. Innervated fiber cross-sectional area (CSA(inn)) was measured directly from whole EDL cross sections after immunohistochemical labeling for neural cell adhesion molecule (NCAM), a marker of muscle fiber denervation. A corrected specific force value (sF(0-inn)) was calculated by normalizing F(0) to CSA(inn). Partial skeletal muscle denervation resulted in significant reductions in muscle mass, F(0), and sF(0). The percentage of muscle fibers expressing NCAM in the extrajunctional sarcolemma increased from 1.0 +/- 0.8% in control to 49 +/- 15% in partially denervated EDL muscles. A 62.7% deficit in EDL specific force was observed after partial denervation. Denervated muscle fibers accounted for 59.3% of this deficit, but sF(0-inn) still differed significantly between control and partially denervated muscles, with a 25.5% difference between groups. In partially denervated muscles, the specific force deficit is partially but not fully explained by a subpopulation of noncontractile, denervated fibers.

Skeletal muscle reinnervation by reduced axonal numbers results in whole muscle force deficits

Patients sustaining a peripheral nerve injury will frequently experience residual muscle weakness after muscle reinnervation, even if the nerve repair is performed under optimal circumstances to allow rapid muscle reinnervation. The mechanisms responsible for this contractile dysfunction remain unclear. It is hypothesized that after peripheral nerve injury and repair, a reduced number of axons are available for skeletal muscle reinnervation that results in whole muscle force and specific force deficits. A rat model of peroneal nerve injury and repair was designed so that the number of axons available for reinnervation could be systematically reduced. In adult rats, the peroneal nerve to the extensor digitorum longus muscle was either left intact (sham group, n = 8) or divided and repaired with either 50 percent (R50 group, n = 7) or 100 percent (R100 group, n = 8) of the axons in the proximal stump included in the repair. Four months after surgery, maximal tetanic isometric force was measured and specific force was calculated for each animal. Mean tetanic isometric force for extensor digitorum longus muscles from R50 rats (2765.7 +/- 767.6 mN) was significantly lower than sham (4082.8 +/- 196.5 mN) and R100 (3729.0 +/-370.2 mN) rats (p < 0.003). Mean specific force calculations revealed significant deficits in both the R100 (242.1 +/- 30 kN/m2) and R50 (190.6 +/- 51.8 kN/m2) rats compared with the sham animals (295.9 +/- 14 kN/m2) (p < 0.0005). These data support our hypothesis that after peripheral nerve injury and repair, reinnervation of skeletal muscle by a reduced number of axons results in a reduction in tetanic isometric force and specific force. The greater relative reduction in specific force compared with absolute force production after partial nerve repair may indicate that a population of residual denervated muscle fibers is responsible for this deficit.

The effect of muscle transplantation after unilateral partial facial paralysis on craniofacial growth and development: relationship between muscle and nerve histomorphometric findings

Muscle transplantation has become an indispensable tool to restore the smile in patients with long-standing or congenital facial paralysis. However, little is known of the effect of this surgical intervention on craniofacial growth and development or of the adaptation of the transplant to its recipient site under circumstances of growth. The present study investigates these phenomena in the rabbit model. Twelve-day-old New Zealand White rabbits were randomly assigned to three experimental groups. The control group was used to study normal craniofacial growth and development (n = 15). In the nerve ablation group, unilateral paralysis of the buccal branches of the facial nerve was surgically induced (n = 15). In the transplant group, the surgically induced unilateral paralysis of the buccal branches was immediately followed by a neuromuscular graft (n = 12). All animals were operated on at the age of 12 days, and follow-up evaluations were performed at the ages of 2 months and 6 months. Computerized dorsoventral roentgencephalometric and computed tomography investigations were performed at both ages. Nerve and muscle histomorphometric measurements were performed at the age of 6 months to relate the quality of nerve and muscle regeneration to the growth parameters. The roentgencephalometric measurements revealed that analogous disturbed parameters were present in the nerve ablation and the transplant groups. However, in the transplant group, an additional significant effect of time between 2 and 6 months was seen for some parameters. This resulted in significant differences between the nerve ablation and transplant groups at 6 months for these parameters. Computed tomography measurements showed no significant differences in maxillary or mandibular volume in the transplant group compared with the control or nerve ablation groups. However, a significantly diminished increase in bone volume existed in the transplant group for the time period between 2 and 6 months in comparison with the control and nerve ablation groups. Muscle histomorphometric findings revealed a significant change in muscle fiber composition in the graft compared with the normal latissimus dorsi muscle; this was due to a major decrease in type IIB fibers, with an increase in type I and type IIA fibers. Compared with the normal zygomaticoauricular muscle, the amount of type I fibers was significantly increased. No fiber atrophy was found. Macroscopically, the transplanted muscle failed to increase its length during growth. Nerve histomorphometric findings demonstrated a normal amount of nerve fibers; however, they had significantly decreased diameters and reduced myelin areas. The nerve histomorphometric parameters were related to the muscle histomorphometric findings, which in turn were related to craniofacial growth disturbances. These findings suggested that the main growth differences between the transplant group and the control group may have been due to altered nerve function influencing muscle function. Scar tissue formation and the development of more intense muscle activity later are suggested as the causes of the additional effect of time between 2 and 6 months for the several parameters in the transplant group. Reasons for the failure of complete conversion of the graft to a fast muscle and the failure of the transplant to elongate during growth are discussed.

Mechanical function of muscle reinnervated by end-to-side neurorrhaphy

End-to-side neurorrhaphy is a surgical technique for peripheral nerve reconstruction when end-to-end neurorrhaphy is not an option. To define the effectiveness of end-to-side neurorrhaphy as a method of nerve repair, the authors tested the null hypothesis: there is no difference in the mechanical function of skeletal muscle denervated and reinnervated by end-to-side versus end-to-end neurorrhaphy. Adult Lewis rats underwent either transection and end-to-end epineurial repair of the left peroneal nerve (n = 9) or end-to-side repair of the distal stump of the peroneal nerve to the side of the tibial nerve (n = 8). After a 6-month recovery period, isometric force (Fo) was measured, and specific force (sFo) was calculated for the extensor digitorum longus muscle of each animal. Immunohistochemical staining for neural cell adhesion molecule (NCAM) was performed to identify populations of denervated muscle fibers. The mean extensor digitorum longus muscle mass in the end-to-end group (195 +/- 32 g) was significantly greater than that of the end-to-side group (146 +/- 55 g) (p < 0.05). A significantly greater percentage of denervated fibers was identified in the extensor digitorum longus muscles of animals in the end-to-side group (9.4 +/- 3.2 percent) than in those in the end-to-end group (3.8 +/- 1.0 percent) (p < 0.05). Despite a lower muscle mass and a higher percentage of denervated fibers, neither Fo nor sFo was significantly different in the two groups. These data support the null hypothesis that, under appropriate circumstances, there is no difference in the recovery of whole muscle force and specific force production in muscles reinnervated by end-to-side versus end-to-end neurorrhaphy.