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Catapano J, Wong CR, Sarkhosh T, Stefaniuk S, Dengler J. Optimal Technique for Cutting Peripheral Nerves in Nerve Transfer Surgery: A Survey of Peripheral Nerve Surgeons. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6162. [PMID: 39281093 PMCID: PMC11398831 DOI: 10.1097/gox.0000000000006162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 07/24/2024] [Indexed: 09/18/2024]
Abstract
Background Nerve transfer procedures are performed in patients with proximal nerve injuries to optimize their potential for functional recovery. The study aimed to determine the preferred surgical technique and tool used by peripheral nerve surgeons to transect nerves in nerve transfers. Methods All current members of the American Society of Peripheral Nerve were invited to complete a cross-sectional 10-question survey. Data on practice demographics, nerve-cutting instruments/techniques used, and their belief on whether this impacted patient outcomes were collected. Results A total of 49 American Society of Peripheral Nerve members participated in the study, the majority of whom were over 10 years into practice (n = 30/49; 61%). The most common response was a scalpel blade (n = 26/49; 53%), with the remaining 47% using iris scissors, micro-serrated scissors, a razor blade, specialized nerve microscissors, or a specialized nerve-cutting device. The number of years in practice (P = 0.0271) and the percentage of practice that involves treating patients with peripheral nerve injuries (P = 0.0054) is significantly associated with the belief that crushing the donor nerves during transection may result in worse outcomes following nerve transfer. Only the latter is significantly associated with this belief in recipient nerves (P = 0.0214). Conclusions Our findings demonstrate that peripheral nerve surgeons believe that the technique used to transect nerves before coaptation influences outcomes after nerve transfer. Further ex vivo studies are necessary to investigate how different cutting techniques influence nerve morphology and scarring at the coaptation site to optimize outcomes after peripheral nerve surgery.
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Affiliation(s)
- Joseph Catapano
- From the Division of Plastic and Reconstructive Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
- Division of Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Chloe R Wong
- Division of Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Tara Sarkhosh
- Division of Plastic and Reconstructive Surgery, Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Stephanie Stefaniuk
- Division of Plastic and Reconstructive Surgery, Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jana Dengler
- Division of Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Plastic and Reconstructive Surgery, Tory Trauma Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Camuzard O, Lu JCY, Abbadi SE, Chang TNJ, Chuang DCC. The Impact of Exercise on Motor Recovery after Long Nerve Grafting-Experimental Rat Study. J Reconstr Microsurg 2023; 39:508-516. [PMID: 36693393 DOI: 10.1055/s-0043-1761207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Long nerve grafting often results in unsatisfactory functional outcomes. In this study we aim to investigate the effect of swimming exercise on nerve regeneration and functional outcomes after long nerve grafting. METHODS A reversed long nerve graft was interposed between C6 and the musculocutaneous nerve in 40 rats. The rats were divided into four groups with 10 in each based on different postoperative swimming regimes for rehabilitation: group A, continuous exercise; group B, early exercise; group C, late exercise; and group D, no exercise (control group). A grooming test was assessed at 4, 8, 12, and 16 weeks postoperatively. Biceps muscle compound action potential (MCAP), muscle tetanic contraction force (MTCF), and muscle weights were assessed after 16 weeks. Histomorphometric analyses of the musculocutaneous nerves were performed to examine nerve regeneration. RESULTS The grooming test showed all groups except group D demonstrated a trend of progressive improvement over the whole course of 16 weeks. Biceps MCAP, MTCF, and muscle weights all showed significant better results in the exercise group in comparison to the group D at 16 weeks, which is especially true in groups A and B. Nerve analysis at 16 weeks, however, showed no significant differences between the exercise groups and the control group. CONCLUSIONS Swimming after long nerve grafting can significantly improve muscle functional behavior and volume. The effect is less evident on nerve regeneration. Continuous exercise and early exercise after surgery show more optimal outcomes than late or no exercise. Having a good habit with exercise in the early period is thought as the main reason. Further studies are needed to determine the optimal exercise regimen.
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Affiliation(s)
- Olivier Camuzard
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang-Gung University, Taipei, Taiwan
- Department of Plastic and Reconstructive Surgery, Hôpital Pasteur 2, CHU de Nice, Université Côte d'Azur, Nice, France
| | - Johnny Chuieng-Yi Lu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang-Gung University, Taipei, Taiwan
| | - Sam El Abbadi
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang-Gung University, Taipei, Taiwan
| | - Tommy Nai-Jen Chang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang-Gung University, Taipei, Taiwan
| | - David Chwei-Chin Chuang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang-Gung University, Taipei, Taiwan
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Saltzman EB, Krishnan K, Winston MJ, Das De S, Lee SK, Wolfe SW. A Cadaveric Study on the Utility of the Levator Scapulae Motor Nerve as a Donor for Brachial Plexus Reconstruction. J Hand Surg Am 2021; 46:812.e1-812.e5. [PMID: 33487489 DOI: 10.1016/j.jhsa.2020.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 09/30/2020] [Accepted: 11/23/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of the study was to evaluate the utility of the levator scapulae motor nerve (LSN) as a donor nerve for brachial plexus nerve transfer. We hypothesized that the LSN could be transferred to the suprascapular nerve (SSN) or long thoracic nerve (LTN) with a reliable tension-free coaptation and appropriate donor-to-recipient axon count ratio. METHODS Twelve brachial plexus dissections were performed on 6 adult cadavers, bilaterally. We identified the LSN, spinal accessory nerve (SAN), SSN, and LTN. Each nerve was prepared for transfer and nerve redundancies were calculated. Cross-sections of each nerve were examined histologically, and axons counted. We transferred the LSN to target first the SSN and then the LTN, in a tension-free coaptation. For reference, we transferred the distal SAN to target the SSN and LTN and compared transfer parameters. RESULTS Three cadavers demonstrated 2 LSN branches supplying the levator scapulae. The axon count ratio of donor-to-recipient nerve was 1:4.0 (LSN:SSN) and 1:2.1 (LSN:LTN) for a single LSN branch and 1:3.0 (LSN:SSN) and 1:1.6 (LSN:LTN) when 2 LSN branches were available. Comparatively, the axon count ratio of donor-to-recipient nerve was 1:2.5 and 1:1.3 for the SAN to the SSN and the LTN, respectively. The mean redundancy from the LSN to the SSN and the LTN was 1.7 cm (SD, 3.1 cm) and 2.9 cm (SD, 2.8 cm), and the redundancy from the SAN to the SSN and the LTN was 4.5 (SD, 0.7 cm) and 0.75 cm (SD, 1.0 cm). CONCLUSIONS These data support the use of the LSN as a potential donor for direct nerve transfer to the SSN and LTN, given its adequate redundancy and size match. CLINICAL RELEVANCE The LSN should be considered as an alternative nerve donor source for brachial plexus reconstruction, especially in 5-level injuries with scarce donor nerves. If used in lieu of the SAN during primary nerve reconstruction, trapezius tendon transfer for improved external rotation would be enabled.
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Affiliation(s)
- Eliana B Saltzman
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery
| | - Karthik Krishnan
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery; Weill Medical College of Cornell University, New York, NY
| | - Mark J Winston
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery
| | - Soumen Das De
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery
| | - Steve K Lee
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery; Weill Medical College of Cornell University, New York, NY
| | - Scott W Wolfe
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery; Weill Medical College of Cornell University, New York, NY.
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Qian T, Qian K, Xu T, Shi J, Ma T, Song Z, Xu C, Li L. Efficacy evaluation of personalized coaptation in neurotization for motor deficit after peripheral nerve injury: A systematic review and meta-analysis. Brain Behav 2020; 10:e01582. [PMID: 32129004 PMCID: PMC7177589 DOI: 10.1002/brb3.1582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/10/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Peripheral neurotization, recently as a promising approach, has taken effect in recovering motor function after damage to a peripheral nerve root. Neural anastomosis comprised of nerve conduit and neurorrhaphy participates in the nerve reconstruction. Current literature lacks evidence supporting an individualized coaptation for rescue of locomotor loss in rat subjects with paraplegia secondary to peripheral nerve injury (PNI). METHODS This meta-analysis intends to qualify the specificity of gap-specific coaptation in treating a paralyzed limb following PNI. We used a highly sensitive search strategy to identify all published studies in multiple databases up to 1 May 2019. All identified trials were systematically evaluated using specific inclusion and exclusion criteria. Cochrane methodology was also applied to the results of this study. RESULTS Twelve studies, including 349 rat subjects, met eligibility criteria. For a medium nerve defect (0.5-3.0 cm), nerve conduit was more likely than neurorrhaphy to precipitate axon regeneration and improve motor outcome of the hemiplegic limb (OR = 3.61, 95% CI = 1.80, 7.26, p < .0003) at 3-month follow-up, whereas neurorrhaphy might take its place in promoting limb motor function in a small nerve gap (<0.5 cm) (OR = 0.48, 95% CI = 0.22, 1.07, p < .007). For a small nerve defect, nerve conduit still demonstrated visible effectiveness in recovery of limb motion albeit poorer than neurorrhaphy (OR = 1.50, 95% CI = 0.92, 2.47, p < .05). CONCLUSION Selective neurotization facilitates motor regeneration after nerve transection, and advisable choice of neural coaptation can maximize functional outcome on an individual basis.
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Affiliation(s)
- TengDa Qian
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Department of Neurosurgery, Jintan Hospital affiliated to Jiangsu University, Jintan, China
| | - Kai Qian
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - TuoYe Xu
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Shi
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Tao Ma
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Department of Neurosurgery, Changzhou first people's Hospital, Suzhou University, Changzhou, China
| | - ZeWu Song
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - ChengMing Xu
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - LiXin Li
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Nepomuceno AC, de Faria JC, Politani EL, Silva EG, Salomone R, Longo MV, Lima W, Salles AG, Gemperli R. Convergent end-to-end neurorrhaphy: An alternative technique for dual innervation of the gastrocnemius muscle in rats. Microsurgery 2019; 39:535-542. [PMID: 30706529 DOI: 10.1002/micr.30433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 12/29/2018] [Accepted: 01/11/2019] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Muscle contraction generated by electrical impulses simultaneously originating from two different neural sources may be an interesting treatment alternative for long term facial palsy. An experimental model was designed to compare single and dual innervation of the gastrocnemius muscle (GM) in rats. METHODS Fifty adult Wistar rats underwent transection of their right peroneal nerve and were divided into five groups (n = 10): control (C), tibial nerve section (TS), tibial nerve primary end-to-end neurorrhaphy (PEE), tibial nerve primary repair associated with end-to-side peroneal-to-tibial nerve transfer (PRES), and tibial nerve repair by convergent end-to-end (CEE) neurorrhaphy between the proximal stumps of the tibial and peroneal nerves to the distal stump of the tibial nerve. The outcomes were assessed 12 weeks after the experiment by walking track, electromyography, GM mass index, and histomorphometric analysis of the distal tibial nerve. RESULTS The functional recovery of the PRES (-33.77 ± 24.13) and CEE (-42.15 ± 31.14) groups was greater (P < 0.003) than the PEE group (-80.26 ± 17.20). The CEE group (18.35 ± 7.84) showed greater amplitude (P = 0.006) than the PEE group (8.2 ± 4.64). There was no difference in the muscle mass index among the reinnervation groups (P > 0.705). Histologic analysis revealed greater (P < 0.002) axonal density in the CEE group (126.70 ± 15.01) compared to PEE (99.70 ± 12.82) and PRES (92.00 ± 19.17) groups. CONCLUSIONS The dual innervation techniques showed earlier and greater functional recovery of the GM than did the single innervation technique. The CEE group showed a 40% higher number of regenerated axons in the distal tibial nerve stump.
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Affiliation(s)
- André C Nepomuceno
- Plastic Surgery Department, Hospital das Clínicas, University of São Paulo, São Paulo, São Paulo, Brazil
| | - José C de Faria
- Plastic Surgery Department, Hospital das Clínicas, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Elisa L Politani
- Plastic Surgery Department, Hospital das Clínicas, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Eduardo G Silva
- Plastic Surgery Department, Hospital das Clínicas, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Raquel Salomone
- Plastic Surgery Department, Hospital das Clínicas, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Marco V Longo
- Plastic Surgery Department, Hospital das Clínicas, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Washington Lima
- Plastic Surgery Department, Hospital das Clínicas, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Alessandra G Salles
- Plastic Surgery Department, Hospital das Clínicas, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Rolf Gemperli
- Plastic Surgery Department, Hospital das Clínicas, University of São Paulo, São Paulo, São Paulo, Brazil
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Novel Model of Somatosensory Nerve Transfer in the Rat. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018. [PMID: 29737497 DOI: 10.1007/5584_2018_209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Nerve transfer (neurotization) is a reconstructive procedure in which the distal denervated nerve is joined with a proximal healthy nerve of a less significant function. Neurotization models described to date are limited to avulsed roots or pure motor nerve transfers, neglecting the clinically significant mixed nerve transfer. Our aim was to determine whether femoral-to-sciatic nerve transfer could be a feasible model of mixed nerve transfer. Three Sprague Dawley rats were subjected to unilateral femoral-to-sciatic nerve transfer. After 50 days, functional recovery was evaluated with a prick test. At the same time, axonal tracers were injected into each sciatic nerve distally to the lesion site, to determine nerve fibers' regeneration. In the prick test, the rats retracted their hind limbs after stimulation, although the reaction was moderately weaker on the operated side. Seven days after injection of axonal tracers, dyes were visualized by confocal microscopy in the spinal cord. Innervation of the recipient nerve originated from higher segments of the spinal cord than that on the untreated side. The results imply that the femoral nerve axons, ingrown into the damaged sciatic nerve, reinnervate distal targets with a functional outcome.
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Rui J, Xu YL, Zhao X, Li JF, Gu YD, Lao J. Phrenic and intercostal nerves with rhythmic discharge can promote early nerve regeneration after brachial plexus repair in rats. Neural Regen Res 2018; 13:862-868. [PMID: 29863017 PMCID: PMC5998610 DOI: 10.4103/1673-5374.232482] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Exogenous discharge can positively promote nerve repair. We, therefore, hypothesized that endogenous discharges may have similar effects. The phrenic nerve and intercostal nerve, controlled by the respiratory center, can emit regular nerve impulses; therefore these endogenous automatically discharging nerves might promote nerve regeneration. Action potential discharge patterns were examined in the diaphragm, external intercostal and latissimus dorsi muscles of rats. The phrenic and intercostal nerves showed rhythmic clusters of discharge, which were consistent with breathing frequency. From the first to the third intercostal nerves, spontaneous discharge amplitude was gradually increased. There was no obvious rhythmic discharge in the thoracodorsal nerve. Four animal groups were performed in rats as the musculocutaneous nerve cut and repaired was bland control. The other three groups were followed by a side-to-side anastomosis with the phrenic nerve, intercostal nerve and thoracodorsal nerve. Compound muscle action potentials in the biceps muscle innervated by the musculocutaneous nerve were recorded with electrodes. The tetanic forces of ipsilateral and contralateral biceps muscles were detected by a force displacement transducer. Wet muscle weight recovery rate was measured and pathological changes were observed using hematoxylin-eosin staining. The number of nerve fibers was observed using toluidine blue staining and changes in nerve ultrastructure were observed using transmission electron microscopy. The compound muscle action potential amplitude was significantly higher at 1 month after surgery in phrenic and intercostal nerve groups compared with the thoracodorsal nerve and blank control groups. The recovery rate of tetanic tension and wet weight of the right biceps were significantly lower at 2 months after surgery in the phrenic nerve, intercostal nerve, and thoracodorsal nerve groups compared with the negative control group. The number of myelinated axons distal to the coaptation site of the musculocutaneous nerve at 1 month after surgery was significantly higher in phrenic and intercostal nerve groups than in thoracodorsal nerve and negative control groups. These results indicate that endogenous autonomic discharge from phrenic and intercostal nerves can promote nerve regeneration in early stages after brachial plexus injury.
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Affiliation(s)
- Jing Rui
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China
| | - Ya-Li Xu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Zhao
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Ji-Feng Li
- Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Yu-Dong Gu
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China
| | - Jie Lao
- Department of Hand Surgery, Huashan Hospital, Fudan University; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
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McGrath AM, Lu JCY, Chang TNJ, Fang F, Chuang DCC. Proximal versus Distal Nerve Transfer for Biceps Reinnervation-A Comparative Study in a Rat's Brachial Plexus Injury Model. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 4:e1130. [PMID: 28293499 PMCID: PMC5222644 DOI: 10.1097/gox.0000000000001130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 09/20/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND The exact role of proximal and distal nerve transfers in reconstruction strategies of brachial plexus injury remains controversial. We compared proximal with distal nerve reconstruction strategies in a rat model of brachial plexus injury. METHODS In rats, the C6 spinal nerve with a nerve graft (proximal nerve transfer model, n = 30, group A) and 50% of ulnar nerve (distal nerve transfer model, n = 30, group B) were used as the donor nerves. The targets were the musculocutaneous nerve and the biceps muscle. Outcomes were recorded at 4, 8, 12, and 16 weeks postoperatively. Outcome parameters included grooming test, biceps muscle weight, compound muscle action potentials, tetanic contraction force, and axonal morphology of the donor and target nerves. RESULTS The axonal morphology of the 2 donor nerves revealed no significant difference. Time interval analysis in the proximal nerve transfer group showed peak axon counts at 12 weeks and a trend of improvement in all functional and physiologic parameters across all time points with statistically significant differences for grooming test, biceps compound action potentials, tetanic muscle contraction force, and muscle weight at 16 weeks. In contrast, in the distal nerve transfer group, the only statistically significant difference was observed between the 4 and 8 week time points, followed by a plateau from 8 to 16 weeks. CONCLUSIONS Outcomes of proximal nerve transfers are ultimately superior to distal nerve transfers in our experimental model. Possible explanations for the superior results include a reduced need for cortical adaptation and higher proportions of motor units in the proximal nerve transfers.
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Affiliation(s)
- Aleksandra M McGrath
- Department of Hand and Plastic Surgery, Norrland's University Hospital, Umeå, Sweden; Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden; and Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei-Linkou, Taiwan
| | - Johnny Chuieng-Yi Lu
- Department of Hand and Plastic Surgery, Norrland's University Hospital, Umeå, Sweden; Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden; and Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei-Linkou, Taiwan
| | - Tommy Naj-Jen Chang
- Department of Hand and Plastic Surgery, Norrland's University Hospital, Umeå, Sweden; Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden; and Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei-Linkou, Taiwan
| | - Frank Fang
- Department of Hand and Plastic Surgery, Norrland's University Hospital, Umeå, Sweden; Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden; and Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei-Linkou, Taiwan
| | - David Chwei-Chin Chuang
- Department of Hand and Plastic Surgery, Norrland's University Hospital, Umeå, Sweden; Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden; and Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei-Linkou, Taiwan
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Tzou CH, Lu CYJ, Chang TNJ, Chuang DCC. Can an injured nerve be used as a donor nerve for distal nerve transfer?-An experimental study in rats. Microsurgery 2017; 37:647-654. [PMID: 28207955 DOI: 10.1002/micr.30153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 12/01/2016] [Accepted: 12/16/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND Distal nerve transfer has proven efficacy. The purpose of this study was to investigate if an injured nerve can be used as a donor nerve for transfer, and to determine the threshold of injury. MATERIALS AND METHODS Rat's left ulnar-nerves in the axilla with different degrees of injury were selected as the donor nerves for transfer, and the musculocutaneous-nerves the target nerves for being re-innervated. Six rats each served as positive and negative controls: Group A, intact ulnar-nerve transfer; and Group E, the ulnar-nerve was cut but no transfer. Ten rats each were assigned to Group B to Group D with 25%, 50%, and 75% transected ulnar-nerve, respectively and all were transferred to the musculocutaneous-nerve. After a 12-week recovery period, outcomes were evaluated. RESULTS Biceps muscle weight measurements showed all experimental groups-D 0.28 ± 0.02 g/72%, C 0.28 ± 0.03 g/73%, B 0.29 ± 0.04 g/74%, and A 0.29 ± 0.04 g/80%-were lighter than group H 0.36 ± 0.04 g, which were all statistically significant (P < 0.001). Muscle tetanus contraction force measurements were the lowest in group D35 ± 8.6 g/69%. Groups C and B measured 41 ± 8.5 g/75% and 40 ± 2.2 g/77% and group A 41 ± 9.4 g/95%, respectively. Group H showed muscle contraction force of 52 ± 7.2 g, which was statistically significant when compared to experimental groups (P < 0.05-0.001). EMG measurements of the biceps muscles showed: group D was 3.6 ± 0.7 mV/69%, group C was 3.6 ± 0.6 mV/75%, and group B was 4.2 mV ± 0.7/81%. Group H was5.1 ± 0.7 mV and statistically significant different when compared with experimental groups (P < 0.05-0.001).Axon counts of healthy ulnar-nerve (Group H) were 1849 ± 362. Axon counts of the injured ulnar-nerve were in group B 1447 ± 579/78%, group C 1051 ± 367/57% and group D 567 ± 230/31%. CONCLUSION The donor nerve should be healthy in order to provide optimal result. A big nerve (e.g., ulnar nerve) but injured with at least 75% axon spared is still potentially effective for transfer. In contrast, a small nerve (e.g., intercostal nerve) once injured with 75%axon spared would be considered a suboptimal donor nerve.
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Affiliation(s)
- Chieh-Han Tzou
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Chuieng-Yi Johnny Lu
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tommy Nai-Jen Chang
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - David Chwei-Chin Chuang
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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10
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Gordon T, Borschel GH. The use of the rat as a model for studying peripheral nerve regeneration and sprouting after complete and partial nerve injuries. Exp Neurol 2017; 287:331-347. [DOI: 10.1016/j.expneurol.2016.01.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 01/14/2016] [Accepted: 01/15/2016] [Indexed: 02/06/2023]
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11
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Schenck TL, Lin S, Stewart JK, Koban KC, Aichler M, Rezaeian F, Giunta RE. Sensory reanimation of the hand by transfer of the superficial branch of the radial nerve to the median and ulnar nerve. Brain Behav 2016; 6:e00578. [PMID: 28032001 PMCID: PMC5166995 DOI: 10.1002/brb3.578] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 07/17/2016] [Accepted: 08/10/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND It remains a surgical challenge to treat high-grade nerve injuries of the upper extremity. Extra-anatomic reconstructions through the transfer of peripheral nerves have gained clinical importance over the past decades. This contribution outlines the anatomic and histomorphometric basis for the transfer of the superficial branch of the radial nerve (SBRN) to the median nerve (MN) and the superficial branch of the ulnar nerve (SBUN). METHODS The SBRN, MN, and SBUN were identified in 15 specimens and the nerve transfer performed. A favorable site for coaptation was chosen and its location described using relevant anatomical landmarks. Histomorphometric characteristics of donor and target were compared to evaluate the chances of a clinical success. RESULTS A suitable location for dissecting the SBRN was identified prior to its first bifurcation. Coaptations were possible near the pronator quadratus muscle, approximately 22 cm distal to the lateral epicondyle of the humerus. The MN and SBUN had to be dissected interfasciculary over 82 ± 5.7 mm and 49 ± 5.5 mm, respectively. Histomorphometric analysis revealed sufficient donor-to-recipient axon ratios for both transfers and identified the SBRN as a suitable donor with high axon density. CONCLUSION Our anatomic and histomorphometric results indicate that the SBRN is a suitable donor for the MN and SBUN at wrist level. The measurements show feasibility of this procedure and shall help in planning this sensory nerve transfer. High axon density in the SBRN identifies it or its branches an ideal candidate for sensory reanimation of fingers and thumbs.
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Affiliation(s)
- Thilo L Schenck
- Hand Surgery, Plastic Surgery and Aesthetic Surgery Ludwig-Maximilians-University Munich Munich Germany
| | - Shenyu Lin
- Hand Surgery, Plastic Surgery and Aesthetic Surgery Ludwig-Maximilians-University Munich Munich Germany
| | - Jessica K Stewart
- Department of Obstetrics and Gynecology University Hospital rechts der Isar Technical University Munich Munich Germany
| | - Konstantin C Koban
- Hand Surgery, Plastic Surgery and Aesthetic Surgery Ludwig-Maximilians-University Munich Munich Germany
| | - Michaela Aichler
- Research Unit Analytical Pathology Helmholtzzentrum München German Research Center for Environmental Health Munich Germany
| | - Farid Rezaeian
- Department of Plastic Surgery and Hand Surgery University Hospital Zurich Zurich Switzerland
| | - Riccardo E Giunta
- Hand Surgery, Plastic Surgery and Aesthetic Surgery Ludwig-Maximilians-University Munich Munich Germany
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Restoration of ulnar nerve motor function by pronator quadratus motor branch: an anatomical study. Acta Neurochir (Wien) 2016; 158:755-759. [PMID: 26860598 DOI: 10.1007/s00701-016-2728-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 01/27/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The traditional surgical approach to repair of brachial plexus lesions involves use of whole segment ulnar nerve graft for contralateral seventh cervical (cC7) nerve root transfer, which sabotages the possibility of ulnar nerve recovery. We assessed the anatomical feasibility of a new approach that involves preservation of the motor branch of ulnar nerve (MBUN), for a later stage repair using the recovered pronator quadratus motor branch (PQMB), subsequent to the cC7 transfer procedure. METHODS Twenty-seven adult cadaver arms and one side of fresh adult cadaver were used in this study. The anterior interosseous nerve and its PQMB, as well as the motor and sensory branches of the ulnar nerve were dissected. The distances from the end of PQMB to the mid-point of a line joining the radial styloid and ulnar styloid, as well as to the point of divergence of the ulnar nerve, were measured. The MBUN was dissected from distal to proximal and the maximum length was measured. The diameter and number of axons of the nerve branches were also recorded. RESULTS The distance from the end of the PQMB to the midpoint of the radial styloid and ulnar styloid was 6.04 ± 0.52 cm, and that to the point of divergence of the ulnar nerve was 8.02 ± 0.63 cm. The maximum length of the MBUN after its dissociation was 9.70 ± 1.38 cm. The mean diameters of axons of the MBUN and PQMB were 0.09 ± 0.02 cm and 0.05 ± 0.01 cm, respectively. The corresponding mean numbers of axons were 2913 ± 624 and 757 ± 183, respectively. CONCLUSIONS The results indicate that the PQMB is suitable for transferring to the MBUN without nerve graft. This anatomical study paves the way for further testing of this new procedure after cC7 transfer in clinical settings.
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Bergmeister KD, Aman M, Riedl O, Manzano-Szalai K, Sporer ME, Salminger S, Aszmann OC. Experimental nerve transfer model in the rat forelimb. Eur Surg 2016; 48:334-341. [PMID: 28058042 PMCID: PMC5167219 DOI: 10.1007/s10353-016-0386-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 01/13/2016] [Indexed: 11/30/2022]
Abstract
Background Nerve transfers are a powerful tool in extremity reconstruction, but the neurophysiological effects have not been adequately investigated. As 81 % of nerve injuries and most nerve transfers occur in the upper extremity with its own neurophysiological properties, the standard rat hindlimb model may not be optimal in this paradigm. Here we present an experimental rat forelimb model to investigate nerve transfers. Methods In ten male Sprague-Dawley rats, the ulnar nerve was transferred to the motor branch of long head of the biceps. Sham surgery was performed in five animals (exposure/closure). After 12 weeks of regeneration, muscle force and Bertelli test were performed and evaluated. Results The nerve transfer successfully reinnervated the long head of the biceps in all animals, as indicated by muscle force and behavioral outcome. No aberrant reinnervation occurred from the original motor source. Muscle force was 2,68 N ± 0.35 for the nerve transfer group and 2,85 N ± 0.39 for the sham group, which was not statically different (p = 0.436). The procedure led to minor functional deficits due to the loss of ulnar nerve function; this, however, could not be quantified with any of the presented measures. Conclusion The above-described rat model demonstrated a constant anatomy, suitable for nerve transfers that are accessible to standard neuromuscular analyses and behavioral testing. This model allows the study of both neurophysiologic properties and cognitive motor function after nerve transfers in the upper extremity.
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Affiliation(s)
- K D Bergmeister
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria ; Division of Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - M Aman
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - O Riedl
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria ; Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - K Manzano-Szalai
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - M E Sporer
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - S Salminger
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria ; Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - O C Aszmann
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria ; Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
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Sukegawa K, Suzuki T, Ogawa Y, Kobayashi T, Matsuura Y, Kuniyoshi K. A Cadaver Study of Median-to-Radial Nerve Transfer for Radial Nerve Injuries. J Hand Surg Am 2016; 41:20-6. [PMID: 26710730 DOI: 10.1016/j.jhsa.2015.10.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 10/15/2015] [Accepted: 10/15/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the anatomic feasibility of a median-to-radial nerve transfer in cadaver limbs and to quantify the number of axons present in the cut ends of the involved donor and recipient nerves. METHODS Ten fresh frozen cadaveric upper limbs were dissected. We investigated whether the flexor carpi radialis (FCR) branch/flexor digitorum superficialis (FDS) branch (donor nerve) reached the posterior interosseous nerve (PIN)/extensor carpi radialis brevis (ECRB) branch (recipient nerve) without tension. We also investigated the length of the transected supinator fascia for FCR-posterior interosseous nerve transfer and the FDS-ECRB positional relationship using the epicondyle line and the midline of the forearm as axes. The findings were used for these 2 types of nerve transfer with evaluation closer to the target muscles. The distance between the point at which the FDS and ECRB branches met and the point at which the ECRB branch entered the muscle was measured. After nerve coaptation, the axon number was determined by histological evaluation. RESULTS In all limbs, the FCR and FDS branches reached the PIN and the ECRB branch without tension. The transected supinator fascia was 17 (3-25) mm long. The point at which the FDS branch reached the ECRB branch [corrected] was 48 (23-65) mm distal to the epicondyle line and approximately 23 (18-27) mm radial to the midline of the forearm. The distance between the point at which the FDS and ECRB branches met and the point at which the ECRB branch entered the muscle was 27 (17-40) mm. The mean axon numbers were FCR, 1501 (932-3022); PIN, 5162 (4325-7732); FDS, 885 (558-962); and ECRB, 548 (433-723). CONCLUSIONS The FCR branch could be transferred to the PIN [corrected] and the FDS to the ECRB branch in all limbs without tension. CLINICAL RELEVANCE We provide anatomical and histological information for median-to-radial nerve transfer.
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Affiliation(s)
- Koji Sukegawa
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan.
| | - Takane Suzuki
- Department of Bioenvironmental Medicine, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Yasufumi Ogawa
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Tomoko Kobayashi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Yusuke Matsuura
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Kazuki Kuniyoshi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
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Schenck TL, Stewart J, Lin S, Aichler M, Machens HG, Giunta RE. Anatomical and histomorphometric observations on the transfer of the anterior interosseous nerve to the deep branch of the ulnar nerve. J Hand Surg Eur Vol 2015; 40:591-6. [PMID: 25261412 DOI: 10.1177/1753193414551909] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This study focuses on the anatomical and histomorphometric features of the transfer of the anterior interosseous nerve to the deep motor branch of the ulnar nerve. The transfer was carried out in 15 cadaver specimens and is described using relevant anatomical landmarks. Nerve samples of donor and target nerves were histomorphometrically analysed and compared. The superficial and the deep ulnar branches had to be separated from each other for a length of 67 mm (SD 12; range 50-85) to reach the site of coaptation. We identified a suitable site for coaptation lying proximal to the pronator quadratus muscle, 202 mm (SD 15; range 185-230) distal to the medial epicondyle of the humerus. The features of the anterior interosseous nerve included a smaller nerve diameter, smaller cross-sectional area of fascicles, fewer fascicles and axons, but a similar axon density. The histomorphometric inferiority of the anterior interosseous nerve raises a question about whether it should be transferred only to selected parts of the deep motor branch of the ulnar nerve.Level III.
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Affiliation(s)
- T L Schenck
- Department of Plastic Surgery and Hand Surgery, University Hospital rechts der Isar, Technical University Munich, Germany
| | - J Stewart
- Hand Surgery, Plastic Surgery and Aesthetic Surgery, Ludwig Maximilians University Munich, Germany
| | - S Lin
- Hand Surgery, Plastic Surgery and Aesthetic Surgery, Ludwig Maximilians University Munich, Germany
| | - M Aichler
- Research Unit Analytical Pathology, Helmholtzzentrum München, German Research Center for Environmental Health, Munich, Germany
| | - H-G Machens
- Department of Plastic Surgery and Hand Surgery, University Hospital rechts der Isar, Technical University Munich, Germany
| | - R E Giunta
- Hand Surgery, Plastic Surgery and Aesthetic Surgery, Ludwig Maximilians University Munich, Germany
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Wu JX, Chen L, Ding F, Gu YD. A rat model study of atrophy of denervated musculature of the hand being faster than that of denervated muscles of the arm. J Muscle Res Cell Motil 2012; 34:15-22. [PMID: 23065138 DOI: 10.1007/s10974-012-9328-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Accepted: 10/03/2012] [Indexed: 12/30/2022]
Abstract
There are no biological marks to indicate if denervated muscle atrophy after nerve injury is irreversible. Clinically in obstetric brachial plexus palsy (OBPP), atrophy of denervated intrinsic musculature of the hand is much faster to irreversible than that of denervated muscles of the arm. 64 pup rats whose C5C6 had been divided and C7C8T1 avulsed, were divided equally into the reconstruction and control groups. The former had subgroups R1, R5, R10, R15 where the ulnar and musculocutaneous nerves were reconstructed one, five, ten and 15 weeks respectively after injury and efficacy was evaluated 12 weeks later. The latter had C1, C5, C10, C15 subgroups where denervated muscles of the two nerves were assessed one, five, ten and 15 weeks after injury. Results of average cross-sectional area of the muscle fiber for intrinsic musculature of the forepaw showed that the R5, R10, R15 subgroups were not statistically superior to the C5, C10, C15 ones, respectively, though R1 was; those for biceps indicated, however, that the R1, R5, R10 subgroups were better than the C1, C5, C10 ones, respectively, though R15 was not. In the reconstruction subgroups regenerative nerve fibers in each nerve were no less than 53 percent of those on the control side, while number of motor end plates was statistically less in subgroups with irreversible muscle atrophy. We conclude that rat model of OBPP is suitable for simulating clinical appearance of atrophy of denervated intrinsic musculature of the hand being faster than that of denervated muscles of the arm.
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Affiliation(s)
- Ji-xin Wu
- Department of Hand Surgery, Huashan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, China
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Keilhoff G, Fansa H. Mesenchymal stem cells for peripheral nerve regeneration--a real hope or just an empty promise? Exp Neurol 2011; 232:110-3. [PMID: 21945007 DOI: 10.1016/j.expneurol.2011.09.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 09/04/2011] [Indexed: 01/20/2023]
Affiliation(s)
- Gerburg Keilhoff
- Institute of Biochemistry and Cell Biology, University of Magdeburg, Magdeburg, Germany.
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