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Daeschler SC, So KJW, Feinberg K, Manoraj M, Cheung J, Zhang J, Mirmoeini K, Santerre JP, Gordon T, Borschel GH. A functional tacrolimus-releasing nerve wrap for enhancing nerve regeneration following surgical nerve repair. Neural Regen Res 2025; 20:291-304. [PMID: 38767493 PMCID: PMC11246136 DOI: 10.4103/nrr.nrr-d-22-01198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/15/2024] [Indexed: 05/22/2024] Open
Abstract
JOURNAL/nrgr/04.03/01300535-202501000-00036/figure1/v/2024-05-14T021156Z/r/image-tiff Axonal regeneration following surgical nerve repair is slow and often incomplete, resulting in poor functional recovery which sometimes contributes to lifelong disability. Currently, there are no FDA-approved therapies available to promote nerve regeneration. Tacrolimus accelerates axonal regeneration, but systemic side effects presently outweigh its potential benefits for peripheral nerve surgery. The authors describe herein a biodegradable polyurethane-based drug delivery system for the sustained local release of tacrolimus at the nerve repair site, with suitable properties for scalable production and clinical application, aiming to promote nerve regeneration and functional recovery with minimal systemic drug exposure. Tacrolimus is encapsulated into co-axially electrospun polycarbonate-urethane nanofibers to generate an implantable nerve wrap that releases therapeutic doses of bioactive tacrolimus over 31 days. Size and drug loading are adjustable for applications in small and large caliber nerves, and the wrap degrades within 120 days into biocompatible byproducts. Tacrolimus released from the nerve wrap promotes axon elongation in vitro and accelerates nerve regeneration and functional recovery in preclinical nerve repair models while off-target systemic drug exposure is reduced by 80% compared with systemic delivery. Given its surgical suitability and preclinical efficacy and safety, this system may provide a readily translatable approach to support axonal regeneration and recovery in patients undergoing nerve surgery.
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Affiliation(s)
- Simeon C Daeschler
- SickKids Research Institute, Neuroscience and Mental Health Program, Toronto, ON, Canada
| | - Katelyn J W So
- SickKids Research Institute, Neuroscience and Mental Health Program, Toronto, ON, Canada
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Konstantin Feinberg
- SickKids Research Institute, Neuroscience and Mental Health Program, Toronto, ON, Canada
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Marina Manoraj
- SickKids Research Institute, Neuroscience and Mental Health Program, Toronto, ON, Canada
| | - Jenny Cheung
- SickKids Research Institute, Neuroscience and Mental Health Program, Toronto, ON, Canada
| | - Jennifer Zhang
- SickKids Research Institute, Neuroscience and Mental Health Program, Toronto, ON, Canada
- Division of Plastic and Reconstructive Surgery, the Hospital for Sick Children, Toronto, ON, Canada
| | - Kaveh Mirmoeini
- SickKids Research Institute, Neuroscience and Mental Health Program, Toronto, ON, Canada
| | - J Paul Santerre
- Translational Biology and Engineering Program, Ted Rogers Centre for Heart Research, Institute of Biomedical Engineering, Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - Tessa Gordon
- SickKids Research Institute, Neuroscience and Mental Health Program, Toronto, ON, Canada
- Division of Plastic and Reconstructive Surgery, the Hospital for Sick Children, Toronto, ON, Canada
| | - Gregory H Borschel
- SickKids Research Institute, Neuroscience and Mental Health Program, Toronto, ON, Canada
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- Indiana University School of Medicine, Indianapolis, IN, USA
- Division of Plastic and Reconstructive Surgery, the Hospital for Sick Children, Toronto, ON, Canada
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Hendry JM, Head LK. Alternative Nerve Coaptations: End-To-Side and Beyond. Hand Clin 2024; 40:369-377. [PMID: 38972681 DOI: 10.1016/j.hcl.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
Modern end-to-side (ETS) nerve transfers have undergone several permutations since the early 1990's. Preclinical data have revealed important mechanisms and patterns of donor axon outgrowth into the recipient nerves and target reinnervation. The versatility of ETS nerve transfers can also potentially address several processes that limit functional recovery after nerve injury by babysitting motor end-plates and/or supporting the regenerative environment within the denervated nerve. Further clinical and basic science work is required to clarify the ideal clinical indications, contraindications, and mechanisms of action for these techniques in order to maximize their potential as reconstructive options.
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Affiliation(s)
- J Michael Hendry
- Division of Plastic and Reconstructive Surgery, Queen's University, Kingston, Ontario K7L 5G2, Canada; Centre for Neuroscience Studies, Queens University, 18 Stuart Street, Kingston, Ontario, K7L3N6, Canada
| | - Linden K Head
- Division of Plastic and Reconstructive Surgery, Queen's University, Kingston, Ontario K7L 5G2, Canada.
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McMorrow LA, Czarnecki P, Reid AJ, Tos P. Current perspectives on peripheral nerve repair and management of the nerve gap. J Hand Surg Eur Vol 2024; 49:698-711. [PMID: 38603601 DOI: 10.1177/17531934241242002] [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: 04/13/2024]
Abstract
From the first surgical repair of a nerve in the 6th century, progress in the field of peripheral nerve surgery has marched on; at first slowly but today at great pace. Whether performing primary neurorrhaphy or managing multiple large nerve defects, the modern nerve surgeon has an extensive range of tools, techniques and choices available to them. Continuous innovation in surgical equipment and technique has enabled the maturation of autografting as a gold standard for reconstruction and welcomed the era of nerve transfer techniques all while bioengineers have continued to add to our armamentarium with implantable devices, such as conduits and acellular allografts. We provide the reader a concise and up-to-date summary of the techniques available to them, and the evidence base for their use when managing nerve transection including current use and applicability of nerve transfer procedures.
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Affiliation(s)
- Liam A McMorrow
- Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Piotr Czarnecki
- Department of Traumatology, Orthopaedics and Hand Surgery, Poznań University of Medical Sciences, Poznań, Poland
| | - Adam J Reid
- Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Pierluigi Tos
- Azienda Socio Sanitaria Territoriale Gaetano Pini, Milan, Italy
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Li CW, Huang RW, Lin CH, Hsu CC, Lin YT, Chen HC, Tang YB, Chen SH. Supercharge end-to-side nerve transfer from anterior interosseous nerve to augment intrinsic recovery in high ulnar nerve injuries of varying magnitudes. Asian J Surg 2024:S1015-9584(24)00569-4. [PMID: 38599967 DOI: 10.1016/j.asjsur.2024.03.142] [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: 10/17/2023] [Revised: 02/21/2024] [Accepted: 03/22/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND High ulnar nerve injuries result in intrinsic muscle weakness and are inconvenient for patients. Moreover, conventional surgical techniques often fail to achieve satisfactory motor recovery. A potential reconstructive solution in the form of the supercharge end-to-side (SETS) anterior interosseous nerve (AIN) transfer method has emerged. Therefore, this study aims to compare surgical outcomes of patients with transected and in-continuity high ulnar nerve lesions following SETS AIN transfer. METHODS Between June 2015 and May 2023, patients with high ulnar palsy in the form of transection injuries or lesion-in-continuity were recruited. The assessment encompassed several objective results, including grip strength, key pinch strength, compound muscle action potential, sensory nerve action potential, and two-point discrimination tests. The muscle power of finger abduction and adduction was also recorded. Additionally, subjective questionnaires were utilized to collect data on patient-reported outcomes. Overall, the patients were followed up for up to 2 years. RESULTS Patients with transected high ulnar nerve lesions exhibited worse baseline performance than those with lesion-in-continuity, including motor and sensory functions. However, they experienced greater motor improvement but less sensory recovery, resulting in comparable final motor outcomes in both groups. In contrast, the transection group showed worse sensory outcomes. CONCLUSIONS Our findings suggest that SETS AIN transfer benefits patients with high ulnar nerve palsy, regardless of the lesion type. Nonetheless, improvements may be more pronounced in patients with transected lesions.
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Affiliation(s)
- Chun-Wei Li
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Keelung, Chang Gung University, College of Medicine, Keelung, Taiwan (No. 222, Maijin Rd, Anle District, Keelung City, 204, Taiwan
| | - Ren-Wen Huang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan (No. 5, Fuxing St, Guishan District, Taoyuan City, 333, Taiwan
| | - Cheng-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan (No. 5, Fuxing St, Guishan District, Taoyuan City, 333, Taiwan
| | - Chung-Chen Hsu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan (No. 5, Fuxing St, Guishan District, Taoyuan City, 333, Taiwan
| | - Yu-Te Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan (No. 5, Fuxing St, Guishan District, Taoyuan City, 333, Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan (No. 2, Yude Rd, North District, Taichung City, 404327, Taiwan
| | - Yueh-Bih Tang
- Department of Plastic Surgery, National Taiwan University Hospital, Taipei, Taiwan (No. 7, Chung Shan S. Rd, Zhongzheng District, Taipei City, 100225, Taiwan; Department of Cosmetic Surgery, Far Eastern Memorial Hospital, Taipei, Taiwan (No. 21, Section 2, Nanya S. Rd, Banqiao District, New Taipei City, 220, Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan (No. 5, Fuxing St, Guishan District, Taoyuan City, 333, Taiwan; Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan (No. 1, Section 1, Ren'ai Rd, Zhongzheng District, Taipei City, 100, Taiwan.
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Lo IN, Yin CY, Huang HK, Huang YC, Wang JP. Outcomes of radiocarpal pinning to facilitate nerve repair in wrist-level ulnar nerve injuries with defect. J Chin Med Assoc 2023; 86:981-984. [PMID: 37729606 DOI: 10.1097/jcma.0000000000001000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND The ideal scenario for ulnar nerve repair is primary end-to-end neurorrhaphy in a tension-free environment. However, this could be complicated by soft tissue loss, scarring, and neuroma formation in a delayed injury, creating a nerve defect. With a wrist-level nerve defect, a flexion position can help shorten the nerve gap; however, maintaining the position can be challenging intraoperatively and postoperatively. METHODS Previously, we proposed our method of using a 1.6-mm K wire for radius-lunate-capitate pinning of the wrist in flexion to minimize the nerve gap, thereby facilitating neuroma excision and end-to-end neurorrhaphy in delayed ulnar nerve injury. In this study, we elaborate our method and present our case series. RESULTS From October 2018 to July 2020, five patients (mean age: 48.2 years; mean delay from injury to surgery: 84.6 days; mean follow-up: 17.5 months) were retrospectively reviewed. The mean flexion fixation angle was 52°, and the K wire was removed at an average of 5.1 weeks postoperatively. All patients were followed up for a minimum of 12 months. All patients achieved M4 and S3 or S3+ neurologically (according to the criteria of the Nerve Injuries Committee of the British Medical Research Council). The mean disabilities arm, shoulder, and hand score was 14.1. The mean grasp and pinch strengths were, respectively, 76.8% and 63.6% of the contralateral hand. All wrist range of motion returned to normal within 12 weeks. No complications were noted intraoperatively or postoperatively. CONCLUSION Our study showed that radiocarpal pinning of the wrist in flexion was safe and convenient to minimize the nerve gap and to facilitate end-to-end neurorrhaphy in limited-sized wrist-level ulnar nerve defects.
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Affiliation(s)
- I-Ning Lo
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital Taitung Branch, Taitung, Taiwan, ROC
| | - Cheng-Yu Yin
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hui-Kuang Huang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopaedics, Chiayi Christian Hospital, Chiayi, Taiwan, ROC
- Chung Hwa University of Medical Technology, Tainan, Taiwan, ROC
| | - Yi-Chao Huang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Jung-Pan Wang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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Chen X, Guo J, Zhou Y, Lao J, Zhao X, Rui J. Modified contralateral C7 transfer to restore ulnar nerve function without sacrificing median nerve recovery: an experimental study. J Hand Surg Eur Vol 2023; 48:731-737. [PMID: 37203387 DOI: 10.1177/17531934231170103] [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: 05/20/2023]
Abstract
Contralateral C7 (cC7) transfer is a technique used in patients with total brachial plexus avulsion. An ulnar nerve graft (UNG) is usually used, as intrinsic function is not expected to be restored due to length of reinnervation required. In this study, we attempted to improve intrinsic function recovery by preserving the deep branch of the ulnar nerve (dbUN) and reanimating it with the anterior interosseous nerve (AIN) after cC7 transfer. Fifty-four rats were divided into the following three groups: Group A, traditional cC7 transfer to the median nerve with a UNG; Group B, cC7 transfer preserving and repairing the dbUN with the terminal branch of the AIN; Group C, same as Group B; however, the dbUN was coapted after 1 month with the AIN. At 3, 6 and 9 months postoperatively, the results of electrodiagnostic and histomorphometric examinations of the interosseous muscle were significantly better in Groups B and C, without affecting AIN recovery. In conclusion, the modified cC7 transfer technique can potentially improve intrinsic function recovery without affecting median nerve recovery.
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Affiliation(s)
- Xi Chen
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, P. R. China
- NHC Key Laboratory of Hand Reconstruction (Fudan University), Shanghai, P. R. China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, P. R. China
| | - Jinding Guo
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, P. R. China
- NHC Key Laboratory of Hand Reconstruction (Fudan University), Shanghai, P. R. China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, P. R. China
| | - Yingjie Zhou
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, P. R. China
- NHC Key Laboratory of Hand Reconstruction (Fudan University), Shanghai, P. R. China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, P. R. China
| | - Jie Lao
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, P. R. China
- NHC Key Laboratory of Hand Reconstruction (Fudan University), Shanghai, P. R. China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, P. R. China
| | - Xin Zhao
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, P. R. China
- NHC Key Laboratory of Hand Reconstruction (Fudan University), Shanghai, P. R. China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, P. R. China
| | - Jing Rui
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, P. R. China
- NHC Key Laboratory of Hand Reconstruction (Fudan University), Shanghai, P. R. China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, P. R. China
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Czarnecki P, Huber J, Szymankiewicz-Szukała A, Górecki M, Romanowski L. End-to-Side vs. Free Graft Nerve Reconstruction-Experimental Study on Rats. Int J Mol Sci 2023; 24:10428. [PMID: 37445608 DOI: 10.3390/ijms241310428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/11/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
The long history of regeneration nerve research indicates many clinical problems with surgical reconstruction to be resolved. One of the promising surgical techniques in specific clinical conditions is end-to-side neurorrhaphy (ETS), described and then repeated with different efficiency in the 1990s of the twentieth century. There are no reliable data on the quality of recipient nerve regeneration, possible donor nerve damage, and epineural window technique necessary to be performed. This research attempts to evaluate the possible regeneration after end-to-side neurorrhaphy, its quality, potential donor nerve damage, and the influence of epineural windows on regeneration efficiency. Forty-five female Wistar rats were divided into three equal groups, and various surgical technics were applied: A-ETS without epineural window, B-ETS with epineural window, and C-free graft reconstruction. The right peroneal nerve was operated on, and the tibial nerve was selected as a donor. After 24 weeks, the regeneration was evaluated by (1) footprint analysis every two weeks with PFI (peroneal nerve function index), TFI (tibial nerve function index), and SFI (sciatic nerve function index) calculations; (2) the amplitude and latency measurements of motor evoked potentials parameters recorded on both sides of the peroneal and tibial nerves when electroneurography with direct sciatic nerve electrical stimulation and indirect magnetic stimulation were applied; (3) histomorphometry with digital conversion of a transverse semithin nerve section, with axon count, fibers diameter, and calculation of axon area with a semiautomated method were performed. There was no statistically significant difference between the groups investigated in all the parameters. The functional indexes stabilized after eight weeks (PFI) and six weeks (TFI and SFI) and were positively time related. The lower amplitude of tibial nerve potential in groups A and B was proven compared to the non-operated side. Neurophysiological parameters of the peroneal nerve did not differ significantly. Histomorphometry revealed significantly lower diameter and area of axons in operated peroneal nerves compared to non-operated nerves. The axon count was at a normal level in every group. Tibial nerve parameters did not differ from non-operated values. Regeneration of the peroneal nerve after ETS was ascertained to be at the same level as in the case of free graft reconstruction. Peroneal nerves after ETS and free graft reconstruction were ascertained to have a lower diameter and area than non-operated ones. The technique of an epineural window does not influence the regeneration result of the peroneal nerve. The tibial nerve motor evoked potentials were characterized by lower amplitudes in ETS groups, which could indicate axonal impairment.
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Affiliation(s)
- Piotr Czarnecki
- Department of Traumatology, Orthopaedics and Hand Surgery, Poznań University of Medical Sciences, 61-545 Poznań, Poland
| | - Juliusz Huber
- Department of Pathophysiology of Locomotor Organs, Poznań University of Medical Sciences, 61-545 Poznań, Poland
| | | | - Michał Górecki
- Department of Traumatology, Orthopaedics and Hand Surgery, Poznań University of Medical Sciences, 61-545 Poznań, Poland
| | - Leszek Romanowski
- Department of Traumatology, Orthopaedics and Hand Surgery, Poznań University of Medical Sciences, 61-545 Poznań, Poland
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Pathiyil RK, Alzahrani S, Midha R. Reverse End-to-Side Transfer to Ulnar Motor Nerve: Evidence From Preclinical and Clinical Studies. Neurosurgery 2023; 92:667-679. [PMID: 36757319 DOI: 10.1227/neu.0000000000002325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/26/2022] [Indexed: 02/10/2023] Open
Abstract
The disappointing outcomes of conventional nerve repair or grafting procedures for proximal ulnar nerve injuries have led the scientific community to search for better alternatives. The pronator quadratus branch of the anterior interosseous nerve has been transferred to the distal ulnar motor branch in a reverse end-to-side fashion with encouraging results. This transfer is now becoming commonly used as an adjunct to cubital tunnel decompression in patients with compressive ulnar neuropathy, underscoring the need for this knowledge transfer to the neurosurgical community. However, the mechanism of recovery after these transfers is not understood completely. We have reviewed the existing preclinical and clinical literature relevant to this transfer to summarize the current level of understanding of the underlying mechanisms, define the indications for performing this transfer in the clinic, and identify the complications and best practices with respect to the operative technique. We have also attempted to identify the major deficiencies in our current level of understanding of the recovery process to propose directions for future research.
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Affiliation(s)
- Rajesh Krishna Pathiyil
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Gross JN, Dawson SE, Wu GJ, Loewenstein S, Borschel GH, Adkinson JM. Outcomes after Anterior Interosseous Nerve to Ulnar Motor Nerve Transfer. J Brachial Plex Peripher Nerve Inj 2023; 18:e1-e5. [PMID: 36644673 PMCID: PMC9833888 DOI: 10.1055/s-0042-1760097] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 09/07/2022] [Indexed: 01/13/2023] Open
Abstract
Background Ulnar nerve lesions proximal to the elbow can result in loss of intrinsic muscle function of the hand. The anterior interosseous nerve (AIN) to deep motor branch of the ulnar nerve (DBUN) transfer has been demonstrated to provide intrinsic muscle reinnervation, thereby preventing clawing and improving pinch and grip strength. The purpose of this study was to evaluate the efficacy of the AIN to DBUN transfer in restoring intrinsic muscle function for patients with traumatic ulnar nerve lesions. Methods We performed a prospective, multi-institutional study of outcomes following AIN to DBUN transfer for high ulnar nerve injuries. Twelve patients were identified, nine of which were enrolled in the study. The mean time from injury to surgery was 15 weeks. Results At final follow-up (mean postoperative follow-up 18 months + 15.5), clawing was observed in all nine patients with metacarpophalangeal joint hyperextension of the ring finger averaging 8.9 degrees (+ 10.8) and small finger averaging 14.6 degrees (+ 12.5). Grip strength of the affected hand was 27% of the unaffected extremity. Pinch strength of the affected hand was 29% of the unaffected extremity. None of our patients experienced claw prevention after either end-to-end ( n = 4) or end-to-side ( n = 5) AIN to DBUN transfer. Conclusion We conclude that, in traumatic high ulnar nerve injuries, the AIN to DBUN transfer does not provide adequate intrinsic muscle reinnervation to prevent clawing and normalize grip and pinch strength.
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Affiliation(s)
- Jeffrey N. Gross
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Steven E. Dawson
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Gerald J. Wu
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Scott Loewenstein
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Gregory H. Borschel
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Joshua M. Adkinson
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, United States,Address for correspondence Joshua M. Adkinson, MD Indiana University Department of SurgeryDivision of Plastic Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis, IN 46202United States
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Abstract
PURPOSE OF REVIEW To review advances in the diagnostic evaluation and management of traumatic peripheral nerve injuries. RECENT FINDINGS Serial multimodal assessment of peripheral nerve injuries facilitates assessment of spontaneous axonal regeneration and selection of appropriate patients for early surgical intervention. Novel surgical and rehabilitative approaches have been developed to complement established strategies, particularly in the area of nerve grafting, targeted rehabilitation strategies and interventions to promote nerve regeneration. However, several management challenges remain, including incomplete reinnervation, traumatic neuroma development, maladaptive central remodeling and management of fatigue, which compromise functional recovery. SUMMARY Innovative approaches to the assessment and treatment of peripheral nerve injuries hold promise in improving the degree of functional recovery; however, this remains a complex and evolving area.
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Curran MWT, Olson JL, Morhart MJ, Wu SSZ, Midha R, Berger MJ, Chan KM. Reverse End-to-Side Nerve Transfer for Severe Ulnar Nerve Injury: A Western Canadian Multicentre Prospective Nonrandomized Cohort Study. Neurosurgery 2022; 91:856-862. [PMID: 36170167 DOI: 10.1227/neu.0000000000002143] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/12/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Reverse end-to-side (RETS) nerve transfer has become increasingly popular in patients with severe high ulnar nerve injury, but the reported outcomes have been inconsistent. OBJECTIVE To evaluate the "babysitting effect," we compared outcomes after anterior interosseous nerve RETS transfer with nerve decompression alone. To evaluate the source of regenerating axons, a group with end-to-end (ETE) transfer was used for comparisons. METHODS Electrophysiology measures were used to quantify the regeneration of anterior interosseous nerve (AIN) and ulnar nerve fibers while functional recovery was evaluated using key pinch and Semmes-Weinstein monofilaments. The subjects were followed postsurgically for 3 years. RESULTS Sixty-two subjects (RETS = 25, ETE = 16, and decompression = 21) from 4 centers in Western Canada were enrolled. All subjects with severe ulnar nerve injury had nerve compression at the elbow except 10 in the ETE group had nerve laceration or traction injury. Postsurgically, no reinnervation from the AIN to the abductor digiti minimi muscles was seen in any of the RETS subjects. Although there was no significant improvement in compound muscle action potentials amplitudes and pressure detection thresholds in the decompression and RETS group, key pinch strength significantly improved in the RETS group ( P < .05). CONCLUSION The results from published clinical trials are conflicting in part because crossover regeneration from the donor nerve has never been measured. Unlike those with ETE nerve transfers, we found that there was no crossover regeneration in the RETS group. The extent of reinnervation was also no different from decompression surgery alone. Based on these findings, the justifications for this surgical technique need to be carefully re-evaluated.
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Affiliation(s)
- Matthew W T Curran
- Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jaret L Olson
- Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michael J Morhart
- Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Simon S Z Wu
- Department of Medicine, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Raj Midha
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Berger
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada
| | - K Ming Chan
- Department of Medicine, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Thakkar M, Rose A, King W, Engelman K, Bednarz B. Anterior Interosseous Nerve to Ulnar Nerve Transfer: A systematic review. JPRAS Open 2022; 32:195-210. [PMID: 35498818 PMCID: PMC9043848 DOI: 10.1016/j.jpra.2022.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 02/27/2022] [Indexed: 11/27/2022] Open
Abstract
Background Objectives Methods Results Conclusion
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Robinson LR, Binhammer P. Role of electrodiagnosis in nerve transfers for focal neuropathies and brachial plexopathies. Muscle Nerve 2021; 65:137-146. [PMID: 34331718 DOI: 10.1002/mus.27376] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 07/13/2021] [Accepted: 07/18/2021] [Indexed: 12/16/2022]
Abstract
Over the past 2 decades, the surgical treatment of brachial plexus and peripheral nerve injuries has advanced considerably. Nerve transfers have become an important surgical tool in addition to nerve repair and grafting. Electrodiagnosis has traditionally played a role in the diagnosis and localization of peripheral nervous system injuries, but a different approach is needed for surgical decision-making and monitoring recovery. When patients have complete or severe injuries they should be referred to surgical colleagues early after injury, as outcomes are best when nerve transfers are performed within the first 3 to 6 mo after onset. Patients with minimal recovery of voluntary activity are particularly challenging, and the presence of a few motor unit action potentials in these individuals should be interpreted on the basis of timing and evidence of ongoing reinnervation. Evaluation of potential recipient and donor muscles, as well as redundant muscles, for nerve transfers requires an individualized approach to optimize the chances of a successful surgical intervention. Anomalous innervation takes on new importance in these patients. Communication between surgeons and electrodiagnostic medicine specialists (EMSs) is best facilitated by a joint collaborative clinic. Ongoing monitoring of recovery post-operatively is critical to allow for decision making for continued surgical and rehabilitation treatments. Different electrodiagnostic findings are expected with resolution of neurapraxia, distal axon sprouting, and axonal regrowth. As new surgical techniques become available, EMSs will play an important role in the assessment and treatment of these patients with severe nerve injuries.
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Affiliation(s)
- Lawrence R Robinson
- Physical Medicine & Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Paul Binhammer
- Plastic & Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada
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