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Xu H, Chen G, Yuan Y, Zhou S, Wo Y, Wang W. Development of a Semifascicle Graft Technique to Bridge Peripheral Nerve Defect: A Case Report and Animal Study. Ann Plast Surg 2023; 91:578-584. [PMID: 37823623 DOI: 10.1097/sap.0000000000003650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Autologous nerve grafting, the criterion standard for bridging peripheral nerves, can cause complications at the donor site. We investigated a novel approach to reconstruct the nerve gap with a split cross-sectional unmatched semifascicle autograft, which was harvested from the distal part of the injured nerve. METHODS A patient diagnosed with left-sided frontal branch facial nerve dissection underwent nerve bridging emergency surgery using a semifascicle nerve graft. A sciatic nerve model was used to validate the feasibility and mechanism of this method. Male Sprague-Dawley rats (n = 36) were randomized into (A) intact fascicle, (B) semifascicle, and (C) semifascicle + conduit groups and further subdivided into 4- and 8-week groups for histological analysis of the neurotissue area, fibers, and Schwann cells. The 8-week groups underwent weekly pain and temperature tests; the wet weight of the gastrocnemius muscle was measured after euthanasia. RESULTS The frontalis of the patient's injured side exhibited movement at 2 months postsurgery and recovered a symmetrical appearance at 13 months. Group A exhibited more neurotissue areas and fibers than groups B and C at week 4; group B had more neurotissue than group C. Group A had greater neurotissue areas than groups B and C at week 8; groups B and C exhibited no differences. The groups displayed no differences regarding nerve fiber, pain, and temperature analysis at week 8. Muscle wet weight of groups A and B exhibited no differences and was higher than that of group C. CONCLUSION We demonstrated the clinical translational value of semifascicle nerve grafts; the injured site was both the donor and recipient, thereby avoiding donor site damage and associated complications.
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Affiliation(s)
- Heng Xu
- From the Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Gang Chen
- From the Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Ye Yuan
- Department of Orthopedics, Beijing Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing
| | - Sizheng Zhou
- From the Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
| | - Yan Wo
- Department of Anatomy and Physiology, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wenjin Wang
- From the Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai
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2
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Truong AY, Chinta M, Chen Y, Black GG, Valerio IL, Gfrerer L. Targeted Nipple Reinnervation in Gender-affirming Mastectomy Using Autologous Nerve Graft. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5203. [PMID: 38152711 PMCID: PMC10752481 DOI: 10.1097/gox.0000000000005203] [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: 01/18/2023] [Accepted: 06/29/2023] [Indexed: 12/29/2023]
Abstract
Our team recently described targeted nipple reinnervation (TNR) during female-to-male gender-affirming mastectomy with free nipple grafting using either direct nerve coaptation or nerve allograft. The goals of TNR are to improve sensation (including erogenous sensation) and prevent numbness, paresthesias, chronic pain, and phantom sensation. Here, we describe our modified technique, which has evolved to use autologous intercostal nerve branches as donor nerves for reinnervation if direct nerve coaptation cannot be achieved. During TNR, the T3-T5 sensory branches are preserved and coapted to the repositioned nipple-areolar complex (NAC). In patients with donor nerves that were not adequate in length to allow for direct coaptation, autologous intercostal nerve branches were not used for coaptation (branches present along the chest wall that would otherwise be lost) or one of the T3-T5 branches were harvested. An end-to-end nerve repair between the autograft and donor nerves was done, and the donor nerve/autograft complex was coapted to the NAC. Targeted muscle reinnervation was performed after autograft harvest to prevent neuroma formation. TNR with intercostal nerve autograft is technically feasible in female-to-male gender-affirming mastectomy with free nipple grafting when direct coaptation is not possible. Chest reinnervation using autologous intercostal nerve branches as donor nerves is another option for reinnervation when the nerves are too short for direct coaptation. Because the collection of long-term data is ongoing, the effectiveness of NAC reinnervation using our technique will be described in a future publication.
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Affiliation(s)
- Albert Y. Truong
- From Division of Plastic and Reconstructive Surgery, New York-Presbyterian/Weill Cornell Medicine. New York, N.Y
- Division of Plastic and Reconstructive Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, N.Y
| | - Malini Chinta
- From Division of Plastic and Reconstructive Surgery, New York-Presbyterian/Weill Cornell Medicine. New York, N.Y
- Division of Plastic and Reconstructive Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, N.Y
| | - Yunchan Chen
- From Division of Plastic and Reconstructive Surgery, New York-Presbyterian/Weill Cornell Medicine. New York, N.Y
| | - Grant G. Black
- From Division of Plastic and Reconstructive Surgery, New York-Presbyterian/Weill Cornell Medicine. New York, N.Y
| | - Ian L. Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Lisa Gfrerer
- From Division of Plastic and Reconstructive Surgery, New York-Presbyterian/Weill Cornell Medicine. New York, N.Y
- Division of Plastic and Reconstructive Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, N.Y
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Jerome JTJ, Matsui C. Distal Nerve Transfers in Hand and Forearm for Traumatic Brachial Plexus and Peripheral Nerve Injuries: A Narrative Review. Indian J Orthop 2023; 57:1347-1358. [PMID: 37609024 PMCID: PMC10441932 DOI: 10.1007/s43465-023-00965-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/25/2023] [Indexed: 08/24/2023]
Abstract
Background Various studies published good outcomes in brachial plexus injuries using nerve transfers for shoulder and elbow functions. However, little is known about the outcome of the distal nerve transfers in the forearm and hand. Targeting the nerve distally produces an early return of function in brachial plexus and peripheral nerve injuries (BPPNI). Therefore, researchers have focused on nerve transfers from the motor branches of the ulnar, median, and radial nerve. Similarly, sensory reinnervation is also obtained by potential donor transfers in the forearm and hand. There have been various attempts by surgeons to target the muscle and promote early reinnervation by different nerve transfers. Conclusions The distal nerve transfers in the forearm and hand are promising when performed early. It effectively restores hand and forearm functions and may be considered a better option than tendon transfer, which has a one-tendon-one function. This narrative review article discusses the different distal nerve transfers for various presentations of BPNNI.
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Affiliation(s)
- J. Terrence Jose Jerome
- Department of Orthopedics, Hand, and Reconstructive Microsurgery, Olympia Hospital & Research Centre, 47, 47A Puthur High Road, Puthur, Trichy, Tamilnadu 620017 India
| | - Chihiro Matsui
- Department of Orthopedics, Hand, and Reconstructive Microsurgery, Olympia Hospital & Research Centre, 47, 47A Puthur High Road, Puthur, Trichy, Tamilnadu 620017 India
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, 113-8431 Japan
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Chuieng-Yi Lu J, An-Jou Lin J, Lee CH, Nai-Jen Chang T, Chwei-Chin Chuang D. Phrenic Nerve as an Alternative Donor for Nerve Transfer to Restore Shoulder Abduction in Severe Multiple Root Injuries of the Adult Brachial Plexus. J Hand Surg Am 2023; 48:954.e1-954.e10. [PMID: 35610117 DOI: 10.1016/j.jhsa.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/26/2022] [Accepted: 03/09/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Nerve transfer is the gold standard to restore shoulder abduction in acute brachial plexus injuries. The aim of this study was to compare the phrenic nerve (Ph) to the spinal accessory nerve (XI) as the donor nerve for this purpose. METHODS A retrospective chart review was performed on 136 patients with acute brachial plexus injuries who received a nerve transfer of the shoulder with either the Ph (94 patients) or XI (42 patients). Each group was divided into 3 subgroups based on the recipient nerve. The maximum degree of shoulder abduction was recorded after 2 years of postoperative follow-up. A generalized estimating equation model was performed to examine the variables affecting shoulder abduction over time. RESULTS The maximum degrees of shoulder abduction achieved were 61.9° ± 38.7° in patients with Ph and 51.1° ± 37.3° in patients with XI. More than M3 shoulder abduction was achieved by 67% of patients with Ph versus 59% of patients with XI. The regression analysis showed that the age at the time of surgery correlated more with the functional outcome over time than the choice of donor nerve. CONCLUSIONS In multiple root brachial plexus injuries, the Ph exhibited similar outcomes to the XI for shoulder abduction. Our routine exploration of the supraclavicular plexus exposes the Ph conveniently for nerve transfer. The phrenic nerve should be considered as an alternative when the XI is not available or is reserved for secondary reconstruction. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Johnny Chuieng-Yi Lu
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Linkou, Taiwan
| | - Jennifer An-Jou Lin
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Linkou, Taiwan
| | - Che-Hsiung Lee
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Linkou, Taiwan
| | - Tommy Nai-Jen Chang
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Linkou, Taiwan
| | - David Chwei-Chin Chuang
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Linkou, Taiwan.
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Hernández-Gil J, Chow CY, Chatras H, de Souza França PD, Samuels ZV, Cornejo M, King GF, Lewis JS, Reiner T, Gonzales J. Development and Validation of Nerve-Targeted Bacteriochlorin Sensors. J Am Chem Soc 2023; 145:14276-14287. [PMID: 37339504 DOI: 10.1021/jacs.3c02520] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
We report an innovative approach to producing bacteriochlorins (bacs) via formal cycloaddition by subjecting a porphyrin to a trimolecular reaction. Bacs are near-infrared probes with the intrinsic ability to serve in multimodal imaging. However, despite their ability to fluoresce and chelate metal ions, existing bacs have thus offered limited ability to label biomolecules for target specificity or have lacked chemical purity, limiting their use in bio-imaging. In this work, bacs allowed a precise and controlled appending of clickable linkers, lending the porphyrinoids substantially more chemical stability, clickability, and solubility, rendering them more suitable for preclinical investigation. Our bac probes enable the targeted use of biomolecules in fluorescence imaging and Cerenkov luminescence for guided intraoperative imaging. Bacs' capacity for chelation provides opportunities for use in non-invasive positron emission tomography/computed tomography. Herein, we report the labeling of bacs with Hs1a, a (NaV1.7)-sodium-channel-binding peptide derived from the Chinese tarantula Cyriopagopus schmidti to yield Bac-Hs1a and radiolabeled Hs1a, which shuttles our bac sensor(s) to mouse nerves. In vivo, the bac sensor allowed us to observe high signal-to-background ratios in the nerves of animals injected with fluorescent Bac-Hs1a and radiolabeled Hs1a in all imaging modes. This study demonstrates that Bac-Hs1a and [64Cu]Cu-Bac-Hs1a accumulate in peripheral nerves, providing contrast and utility in the preclinical space. For the chemistry and bio-imaging fields, this study represents an exciting starting point for the modular manipulation of bacs, their development and use as probes for diagnosis, and their deployment as formidable multiplex nerve-imaging agents for use in routine imaging experiments.
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Affiliation(s)
- Javier Hernández-Gil
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, United States
- Biomedical MRI/MoSAIC, Department of Imaging and Pathology, Katholieke Universiteit Leuven, Herestraat 49, B3000 Leuven, Belgium
- Instituto de Tecnología Química, Universitat Politècnica de València, Consejo Superior de Investigaciones Científicas, Valencia E-46022, Spain
| | - Chun Yuen Chow
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, Queensland 4072, Australia
- Australian Research Council Centre of Excellence for Innovations in Peptide and Protein Research, The University of Queensland, St Lucia, Queensland 4072, Australia
| | - Hugo Chatras
- Department of Chemistry, Cleveland State University, 2153 Euclid Avenue, Cleveland, Ohio 44115, United States
| | - Paula Demétrio de Souza França
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, United States
- Department of Otorhinolaryngology and Head and Neck Surgery, Federal University of São Paulo, São Paulo, SP 04020-041, Brazil
| | - Zachary V Samuels
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, United States
| | - Mike Cornejo
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, United States
| | - Glenn F King
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, Queensland 4072, Australia
- Australian Research Council Centre of Excellence for Innovations in Peptide and Protein Research, The University of Queensland, St Lucia, Queensland 4072, Australia
| | - Jason S Lewis
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, United States
- Department of Pharmacology, Weill-Cornell Medical College, New York, New York 10065, United States
- Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, New York 10065, United States
- Department of Radiology, Weill Cornell Medical College, 1300 York Avenue, New York, New York 10065, United States
| | - Thomas Reiner
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, United States
- Department of Pharmacology, Weill-Cornell Medical College, New York, New York 10065, United States
- Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, New York 10065, United States
- Department of Radiology, Weill Cornell Medical College, 1300 York Avenue, New York, New York 10065, United States
| | - Junior Gonzales
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York 10065, United States
- Department of Chemistry, Cleveland State University, 2153 Euclid Avenue, Cleveland, Ohio 44115, United States
- Center for Gene Regulation in Health and Disease, 2153 Euclid Avenue, Cleveland, Ohio 44115, United States
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Megerle K. Kommentar zu "Combined Reconstruction of the Ulnar Nerve after its wide Resection by Nerve Grafting at the Site of the Resection and distal Transfer of the Anterior Interosseus Nerve to the deep Branch of the Ulnar Nerve". HANDCHIR MIKROCHIR P 2023; 55:85-86. [PMID: 36796376 DOI: 10.1055/a-1984-8485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Affiliation(s)
- Kai Megerle
- Zentrum für Handchirurgie, Mikrochirurgie und Plastische Chirurgie, Schön Klinik München Harlaching, München, Germany
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7
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Li Y, Chen Z, Zhou J, Guan Y, Xing J, Niu Z, Zhang B, Zeng Q, Pei X, Wang Y, Peng J, Xu W, Yue W, Han Y. Combining chitin biological conduits with injectable adipose tissue-derived decellularised matrix hydrogels loaded with adipose-derived mesenchymal stem cells for the repair of peripheral nerve defects in rats. Colloids Surf A Physicochem Eng Asp 2022. [DOI: 10.1016/j.colsurfa.2022.130743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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8
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Brogan DM, Dy CJ, Rioux-Forker D, Wever J, Leversedge FJ. Influences of Repair Site Tension and Conduit Splinting on Peripheral Nerve Reconstruction. Hand (N Y) 2022; 17:1048-1054. [PMID: 33356577 PMCID: PMC9608270 DOI: 10.1177/1558944720974117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We investigated the use of a conduit splinting technique to mitigate tension at the coaptation site of a rodent nerve defect model to determine the optimal reconstruction method for segmental nerve defects. METHODS A rat sciatic nerve segmental defect model was created by excising 5mm of the sciatic nerve unilaterally. Four groups of 10 rats were each reconstructed using 1 of 4 techniques: primary repair, repair with conduit splinting, reverse isograft with conduit splinting, and reverse isograft without splinting. Functional outcomes were assessed at 6 weeks by measurement of Sciatic Functional Index (SFI), and sciatic nerves were harvested at the nonsurvival surgery. Histomorphologic measurements were reported as a value normalized to the average measurements of the control side. The primary outcomes were assessment of nerve continuity and the proportion of nerve fibers in the regenerating nerve compared with the uninjured side. RESULTS The number of repair site rupture rates was lower when a conduit splint was used-less than half of the primary repairs under tension remained intact at 6 weeks. No difference was seen in axon number, size, and density between primary repairs and those augmented by conduit splints, but worse functional outcomes and more debris were present compared with the intact primary repairs. CONCLUSIONS Nerve conduit splinting reduced rupture rates, particularly for nerve repairs associated with a segmental defect. No significant difference was seen in the number of axons among techniques. Primary nerve repair under tension that did not rupture demonstrated superior SFI.
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9
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Nerve Injuries in Total Knee Arthroplasty. Orthop Clin North Am 2022; 53:123-127. [PMID: 35365256 DOI: 10.1016/j.ocl.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Nerve injury is one of the potential complications of total knee arthroplasty. The extent of the injury includes motor and sensory dysfunction, either temporary or permanent. Although the consequences of nerve injury may be dramatic, the probability of occurrence during the course of primary knee arthroplasty is low, around 0.12% to 0.4%. Local dressing removal and knee flexion are imperative, and the initial investigations include ultrasound or MRI and nerve conduction studies. The extent of recovery depends on the type and severity of the initial nerve palsy; however, most patients are expected to have at least a partial recovery.
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10
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Baradaran A, El-Hawary H, Efanov JI, Xu L. Peripheral Nerve Healing: So Near and Yet So Far. Semin Plast Surg 2021; 35:204-210. [PMID: 34526869 DOI: 10.1055/s-0041-1731630] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Peripheral nerve injuries represent a considerable portion of chronic disability that especially affects the younger population. Prerequisites of proper peripheral nerve injury treatment include in-depth knowledge of the anatomy, pathophysiology, and options in surgical reconstruction. Our greater appreciation of nerve healing mechanisms and the development of different microsurgical techniques have significantly refined the outcomes in treatment for the past four decades. This work reviews the peripheral nerve regeneration process after an injury, provides an overview of various coaptation methods, and compares other available treatments such as autologous nerve graft, acellular nerve allograft, and synthetic nerve conduits. Furthermore, the formation of neuromas as well as their latest treatment options are discussed.
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Affiliation(s)
- Aslan Baradaran
- Division of Plastic and Reconstructive Surgery, Montreal General Hospital, McGill University, Montreal, Quebec, Canada
| | - Hassan El-Hawary
- Division of Plastic and Reconstructive Surgery, Montreal General Hospital, McGill University, Montreal, Quebec, Canada
| | - Johnny Ionut Efanov
- Division of Plastic and Reconstructive Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Liqin Xu
- Division of Plastic and Reconstructive Surgery, Montreal General Hospital, McGill University, Montreal, Quebec, Canada
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11
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Braga Silva J, Busnello CV, Becker AS, Moriguchi CA, de Melo RO, Waichel VB. End-to-side neurorrhaphy in peripheral nerves: Does it work? HAND SURGERY & REHABILITATION 2021; 41:2-6. [PMID: 34464758 DOI: 10.1016/j.hansur.2021.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/05/2021] [Accepted: 08/21/2021] [Indexed: 11/15/2022]
Abstract
Acute peripheral nerve injuries are common and can cause physical disabilities with sensory and functional sequelae; they therefore require surgery. The aim of this study was to conduct a systematic review to assess the clinical applicability of end-to-side neurorrhaphy in peripheral nerve reconstruction, based on available evidence. We carried out a systematic review of the literature using MEDLINE/PubMed, EMBASE, Cochrane Library, Web of Science, Scielo and Scopus through March 16, 2021. Most of the selected studies were qualitative and employed nonrandomized groups of patients, without standardized scales for assessing outcomes, which made statistical analysis difficult. Efficacy varied from 24% to 81%. Factors for better outcome included the type of injury, type of injured nerve (sensory, motor or mixed), presence of an epineural window, topography, injury extension <1.3 cm, and intervention within 2 weeks of injury. Clinical studies so far lack scientific evidence on end-to-side neurorrhaphy in peripheral nerve lesions.
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Affiliation(s)
- J Braga Silva
- Service of Hand Surgery and Reconstructive Microsurgery, São Lucas Hospital, Centro Clinico PUCRS, Av. Ipiranga 6690, Suite 216, 90610-000 Porto Alegre, Rio Grande do Sul, Brazil.
| | - C V Busnello
- School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga 6690, 90610-000 Porto Alegre, Rio Grande do Sul, Brazil.
| | - A S Becker
- School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga 6690, 90610-000 Porto Alegre, Rio Grande do Sul, Brazil.
| | - C A Moriguchi
- School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga 6690, 90610-000 Porto Alegre, Rio Grande do Sul, Brazil.
| | - R O de Melo
- School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga 6690, 90610-000 Porto Alegre, Rio Grande do Sul, Brazil.
| | - V B Waichel
- School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Av. Ipiranga 6690, 90610-000 Porto Alegre, Rio Grande do Sul, Brazil.
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12
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Bamba R, Loewenstein SN, Adkinson JM. Donor site morbidity after sural nerve grafting: A systematic review. J Plast Reconstr Aesthet Surg 2021; 74:3055-3060. [PMID: 33985927 DOI: 10.1016/j.bjps.2021.03.096] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 12/31/2020] [Accepted: 03/13/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Understanding the morbidity of sural nerve harvest is important when counselling patients regarding nerve grafts. Existing data consist of small studies with varying degrees of follow-up and a wide range of reported donor site outcomes. The objective of this study was to systematically review the literature and pool the current data for postoperative outcomes after sural nerve graft harvest. METHODS A systematic review of literature was conducted to identify studies that examined donor site outcomes of sural nerve graft harvests. RESULTS Five-hundred and fourteen studies were identified through a literature search, and nine studies met inclusion criteria. There were 240 patients who underwent sural nerve grafts. The most common methods for sensory evaluation were patient survey (44.4%) and Semmes-Weinstein evaluation (33.3%). Five studies reported surface areas of sensory loss, and this generally decreased over time after sural nerve grafting. Overall, 87.2% of patients (n = 190) reported sensory loss, 25.6% (n = 42) of patients reported pain, 22.2% (n = 28) of patients reported cold sensitivity, and 10% (n = 20) of patients reported functional impairment at follow-up. When the proximal sural nerve was spared during harvest, the extent of sensory loss and pain were less than harvest at the popliteal fossa (87.4% vs 95.7%, p = 0.0407 and 9.1% vs 35.5%, p = 0.0004, respectively). CONCLUSIONS In this study, we present the extent of sensory loss and rates of pain, cold sensitivity, and functional impairment after sural nerve harvest. These data should be discussed prior to surgery in order for patients and surgeons to make an informed decision.
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Affiliation(s)
- Ravinder Bamba
- Division of Plastic Surgery, Department of Surgery, Indiana University, 545 Barnhill Drive, Emerson Hall 232, Indianapolis, IN 46202, United States
| | - Scott N Loewenstein
- Division of Plastic Surgery, Department of Surgery, Indiana University, 545 Barnhill Drive, Emerson Hall 232, Indianapolis, IN 46202, United States
| | - Joshua M Adkinson
- Division of Plastic Surgery, Department of Surgery, Indiana University, 545 Barnhill Drive, Emerson Hall 232, Indianapolis, IN 46202, United States.
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13
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Lu CY, Santosa KB, Jablonka-Shariff A, Vannucci B, Fuchs A, Turnbull I, Pan D, Wood MD, Snyder-Warwick AK. Macrophage-Derived Vascular Endothelial Growth Factor-A Is Integral to Neuromuscular Junction Reinnervation after Nerve Injury. J Neurosci 2020; 40:9602-9616. [PMID: 33158964 PMCID: PMC7726545 DOI: 10.1523/jneurosci.1736-20.2020] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/20/2020] [Accepted: 10/22/2020] [Indexed: 01/13/2023] Open
Abstract
Functional recovery in the end target muscle is a determinant of outcome after peripheral nerve injury. The neuromuscular junction (NMJ) provides the interface between nerve and muscle and includes non-myelinating terminal Schwann cells (tSCs). After nerve injury, tSCs extend cytoplasmic processes between NMJs to guide axon growth and NMJ reinnervation. The mechanisms related to NMJ reinnervation are not known. We used multiple mouse models to investigate the mechanisms of NMJ reinnervation in both sexes, specifically whether macrophage-derived vascular endothelial growth factor-A (Vegf-A) is crucial to establishing NMJ reinnervation at the end target muscle. Both macrophage number and Vegf-A expression increased in end target muscles after nerve injury and repair. In mice with impaired recruitment of macrophages and monocytes (Ccr2-/- mice), the absence of CD68+ cells (macrophages) in the muscle resulted in diminished muscle function. Using a Vegf-receptor 2 (VegfR2) inhibitor (cabozantinib; CBZ) via oral gavage in wild-type (WT) mice resulted in reduced tSC cytoplasmic process extension and decreased NMJ reinnervation compared with saline controls. Mice with Vegf-A conditionally knocked out in macrophages (Vegf-Afl/fl; LysMCre mice) demonstrated a more prolonged detrimental effect on NMJ reinnervation and worse functional muscle recovery. Together, these results show that contributions of the immune system are integral for NMJ reinnervation and functional muscle recovery after nerve injury.SIGNIFICANCE STATEMENT This work demonstrates beneficial contributions of a macrophage-mediated response for neuromuscular junction (NMJ) reinnervation following nerve injury and repair. Macrophage recruitment occurred at the NMJ, distant from the nerve injury site, to support functional recovery at the muscle. We have shown hindered terminal Schwann cell (tSC) injury response and NMJ recovery with inhibition of: (1) macrophage recruitment after injury; (2) vascular endothelial growth factor receptor 2 (VegfR2) signaling; and (3) Vegf secretion from macrophages. We conclude that macrophage-derived Vegf is a key component of NMJ recovery after injury. Determining the mechanisms active at the end target muscle after motor nerve injury reveals new therapeutic targets that may translate to improve motor recovery following nerve injury.
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Affiliation(s)
- Chuieng-Yi Lu
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110-1093
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan City, Guishan District 33305, Taiwan
| | - Katherine B Santosa
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110-1093
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109-4217
| | - Albina Jablonka-Shariff
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110-1093
| | - Bianca Vannucci
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110-1093
| | - Anja Fuchs
- Division of General Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110-1093
| | - Isaiah Turnbull
- Division of General Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110-1093
| | - Deng Pan
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110-1093
| | - Matthew D Wood
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110-1093
| | - Alison K Snyder-Warwick
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110-1093
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Moucharafieh RC, Badra MI, Boulos KA, Mansour JI, Daher JC, Wardani HM, Nour HGAE, Sayde EG, Nehme AH. Nerve transfers in the upper extremity: A review. Injury 2020; 51:2804-2810. [PMID: 32448466 DOI: 10.1016/j.injury.2020.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 02/02/2023]
Abstract
Injury of the brachial plexus and peripheral nerve often result in significant upper extremity dysfunction and disability. Nerve transfers are replacing other techniques as the gold standard for brachial plexus and other proximal peripheral nerve injuries. These transfers require an intimate knowledge of nerve topography, a technically demanding Intraneural dissection and require extensive physical therapy for retraining. In this review, we present a summary of the most widely accepted nerve transfers in the upper extremity described in the current literature.
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Affiliation(s)
- Ramzi C Moucharafieh
- Department of Orthopedic Surgery and Traumatology, Saint Georges University Medical Center, Balamand University, P.O. Box 166378, Achrafieh, Beirut, 1100 2807, Lebanon; Department of Orthopedic Surgery and Traumatology, Clemenceau Medical Center Affiliated With Johns Hopkins International, Clemenceau Beirut, Lebanon.
| | - Mohammad I Badra
- Department of Orthopedic Surgery and Traumatology, Clemenceau Medical Center Affiliated With Johns Hopkins International, Clemenceau Beirut, Lebanon
| | - Karl A Boulos
- Department of Orthopedic Surgery, Lebanese American University Medical Center Rizk hospital, Achrafieh, Beirut, Lebanon
| | - Jad I Mansour
- Department of Orthopedic Surgery, Lebanese American University Medical Center Rizk hospital, Achrafieh, Beirut, Lebanon
| | - Jimmy C Daher
- Department of Orthopedic Surgery, Lebanese American University Medical Center Rizk hospital, Achrafieh, Beirut, Lebanon
| | - Hassan M Wardani
- Department of Orthopedic Surgery and Traumatology, Clemenceau Medical Center Affiliated With Johns Hopkins International, Clemenceau Beirut, Lebanon
| | - Hicham G Abd El Nour
- Department of Orthopedic Surgery and Traumatology, Saint Georges University Medical Center, Balamand University, P.O. Box 166378, Achrafieh, Beirut, 1100 2807, Lebanon
| | - Elias G Sayde
- Department of Orthopedic Surgery and Traumatology, Saint Georges University Medical Center, Balamand University, P.O. Box 166378, Achrafieh, Beirut, 1100 2807, Lebanon
| | - Alexandre H Nehme
- Department of Orthopedic Surgery and Traumatology, Saint Georges University Medical Center, Balamand University, P.O. Box 166378, Achrafieh, Beirut, 1100 2807, Lebanon
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Lu JQ, Tarnopolsky MA. Mitochondrial neuropathy and neurogenic features in mitochondrial myopathy. Mitochondrion 2020; 56:52-61. [PMID: 33220502 DOI: 10.1016/j.mito.2020.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/25/2020] [Accepted: 11/02/2020] [Indexed: 01/21/2023]
Abstract
Mitochondrial diseases (MIDs) involve multiple organs including peripheral nerves and skeletal muscle. Mitochondrial neuropathy (MN) and mitochondrial myopathy (MM) are commonly associated and linked at the neuromuscular junction (NMJ). Herein we review MN in connection with neurogenic features of MM, and pathological evidence for the involvement of the peripheral nerve and NMJ in MID patients traditionally assumed to have predominantly MM. MN is not uncommon, but still likely under-reported, and muscle biopsies of MM commonly exhibit neurogenic features. Pathological examination remains the gold standard to assess the nerve and muscle changes in patients with MIDs. Ultrastructural studies by electron microscopy are often necessary to fully characterize the pathology of mitochondrial cytopathy in MN and MM.
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Affiliation(s)
- Jian-Qiang Lu
- Department of Pathology and Molecular Medicine/Neuropathology, McMaster University, Hamilton, Ontario, Canada.
| | - Mark A Tarnopolsky
- Department of Medicine/Neurology, McMaster University, Hamilton, Ontario, Canada; Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Gordon T. Peripheral Nerve Regeneration and Muscle Reinnervation. Int J Mol Sci 2020; 21:ijms21228652. [PMID: 33212795 PMCID: PMC7697710 DOI: 10.3390/ijms21228652] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 12/24/2022] Open
Abstract
Injured peripheral nerves but not central nerves have the capacity to regenerate and reinnervate their target organs. After the two most severe peripheral nerve injuries of six types, crush and transection injuries, nerve fibers distal to the injury site undergo Wallerian degeneration. The denervated Schwann cells (SCs) proliferate, elongate and line the endoneurial tubes to guide and support regenerating axons. The axons emerge from the stump of the viable nerve attached to the neuronal soma. The SCs downregulate myelin-associated genes and concurrently, upregulate growth-associated genes that include neurotrophic factors as do the injured neurons. However, the gene expression is transient and progressively fails to support axon regeneration within the SC-containing endoneurial tubes. Moreover, despite some preference of regenerating motor and sensory axons to “find” their appropriate pathways, the axons fail to enter their original endoneurial tubes and to reinnervate original target organs, obstacles to functional recovery that confront nerve surgeons. Several surgical manipulations in clinical use, including nerve and tendon transfers, the potential for brief low-frequency electrical stimulation proximal to nerve repair, and local FK506 application to accelerate axon outgrowth, are encouraging as is the continuing research to elucidate the molecular basis of nerve regeneration.
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Affiliation(s)
- Tessa Gordon
- Department of Surgery, University of Toronto, Division of Plastic Reconstructive Surgery, 06.9706 Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
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Abstract
Microsurgical tissue transfer may provide reconstructive option for extensive loss of tissues due to upper extremity trauma or tumor resection. This article reviews the authors' experience in using microsurgical tissue transfers for reconstruction of upper extremity trauma.
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Affiliation(s)
- Chao Chen
- Department of Hand and Foot Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan 250021, Shandong, China
| | - Zeng Tao Wang
- Department of Hand and Foot Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan 250021, Shandong, China; Department of Hand and Foot Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China.
| | - Li Wen Hao
- Department of Hand and Foot Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan 250021, Shandong, China
| | - Lin Feng Liu
- Department of Hand and Foot Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan 250021, Shandong, China
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Mittal K, Schrenk-Siemens K. Lessons from iPSC research: Insights on peripheral nerve disease. Neurosci Lett 2020; 738:135358. [PMID: 32898616 DOI: 10.1016/j.neulet.2020.135358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/24/2020] [Accepted: 09/02/2020] [Indexed: 01/13/2023]
Abstract
With the publication of their breakthrough discovery describing the induction of pluripotent stem cells (iPSCs) from mouse and human fibroblasts, Takahashi and Yamanaka have changed the scientific landscape. The possibility of deriving human pluripotent stem cells from almost any somatic cell has provided the unprecedented opportunity to study specific hereditary diseases in human cells. In the context of diseases affecting peripheral nerves, iPSC platforms are now being increasingly utilized to investigate the underlying pathology as well as regenerative strategies. Peripheral neuropathies result in peripheral nerve damage, leading to - among other things - the degeneration of affected nerve fibers accompanied by severe sensory, motor and autonomic symptoms, often including intense pain. The generation of iPSCs from hereditary forms of peripheral neuropathies and their directed differentiation into cell types most affected by the disease can be instrumental to better understanding the pathological mechanisms underlying these disorders and to investigating cell replacement strategies for repair. In this minireview, we highlight studies that have used iPSCs to investigate the therapeutic potential of iPSC-derived Schwann cell-like cells for nerve regeneration, as well as studies using patient iPSC derivatives to investigate their contribution to disease pathology.
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Affiliation(s)
- Kritika Mittal
- Department of Anatomy, University of Heidelberg, Im Neuenheimer Feld 307, 69120, Heidelberg, Germany
| | - Katrin Schrenk-Siemens
- Department of Pharmacology, University of Heidelberg, Im Neuenheimer Feld 366, 69120, Heidelberg, Germany.
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Hill EJR, El-Haj M, Giles JA, Fox IK. Using electrodiagnostics to define injury patterns amenable to nerve transfer surgery in tetraplegia: an illustrative case report. Spinal Cord Ser Cases 2020; 6:78. [PMID: 32826861 DOI: 10.1038/s41394-020-00325-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Spinal cord injury is a devastating condition affecting a person's independence and quality of life. Nerve transfers are increasingly used to restore critical upper extremity function. Electrodiagnostic studies guide operative planning but the implications for clinical outcomes is not well defined. This case study delineates how clinical examination and electrodiagnostics can define the varying patterns of neuronal injury to guide timing and strategy for optimal outcomes in nerve transfers. CASE PRESENTATION We discuss a 20-year-old man with a C6-7 spinal cord injury (SCI). We illustrate how history, physical examination, and electrodiagnostic studies predicted patterns of upper and lower motor neuron injury, confirmed intraoperatively via direct nerve stimulation. We undertook brachialis nerve transfer to the median fascicles supplying flexor digitorum superficialis and anterior interosseous nerve (to restore digit flexion), and supinator nerve transfer to posterior interosseous nerve (to restore digit extension). Preoperative electrodiagnostics of the right upper extremity demonstrated a pure upper motor neuron injury to median innervated muscles, and mixed upper and lower motor neuron injury to radial innervated muscles. These findings were confirmed via intraoperative direct neuromuscular stimulation. The preoperative studies provided important information regarding the anatomic basis and time sensitivity of the proposed nerve transfers. At 2 years post operatively the reconstructed digit flexion and extension resulted in improved hand function and independence. DISCUSSION Upper and lower motor neuron injuries can coexist in individuals with SCI. This example provides proof-of-concept that preoperative electrodiagnostic studies predict LMN injury, and surgery can achieve positive outcomes if completed soon after SCI.
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Affiliation(s)
- Elspeth J R Hill
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Madi El-Haj
- Hand and Microvascular Surgery Unit, Hadassah University Hospital, Jerusalem, Israel
| | - James A Giles
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ida K Fox
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, USA.
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20
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Management of Nerve Trauma in the Mangled Extremity. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00195-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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21
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Felder JM, Hill EJR, Power HA, Hasak J, Mackinnon SE. Cross-Palm Nerve Grafts to Enhance Sensory Recovery in Severe Ulnar Neuropathy. Hand (N Y) 2020; 15:526-533. [PMID: 30678516 PMCID: PMC7370395 DOI: 10.1177/1558944718822851] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background: Intrinsic atrophy and debilitating sensory loss are prominent features of severe ulnar neuropathy with limited surgical options to reliably improve recovery. Restoration of sensation is important to provide protection for the vulnerable ulnar border of the hand. Here, we report our experience with side-to-side sensory nerve grafting from the median to ulnar nerve in the palm to enhance ulnar sensory recovery. Methods: A retrospective chart review identified patients with severe ulnar neuropathy who underwent cross-palm nerve grafting. Included patients had objective loss of protective sensation in the ulnar distribution with 2-point discrimination >8 mm, Semmes-Weinstein monofilament testing (SWMT) >4.56, or no sensory response on nerve conduction testing. Cross-palm side-to-side tension-free grafting from median to ulnar sensory components was performed using short-segment allograft or autografts. Analysis included patient etiology, procedures, nerve conduction studies, objective sensory testing, and Disabilities of the Arm, Shoulder, and Hand Disability score. Results: Forty-eight patients with severe ulnar neuropathy underwent cross-palm nerve grafting between 2014 and 2017. Twenty-four patients had adequate follow-up for inclusion. Of the 24 patients, 21 (87%) had return of protective sensation, 16 (66.7%) had return of diminished light touch sensation, and 6 (25%) had return to normal range sensation within 1 year as assessed by SWMT and/or 2-point discrimination. Patients treated with autograft demonstrated referred sensation to the median nerve distribution. Conclusions: Cross-palm nerve grafting may be a useful adjunct to enhance sensory recovery in severe ulnar neuropathy. Further study to quantify differences in sensory recovery between traditional operative techniques and cross-palm nerve grafting is required.
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Affiliation(s)
- John M. Felder
- Washington University School of Medicine in St. Louis, MO, USA,John M. Felder, Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, 1150 Northwest Tower, 660 South Euclid Avenue, Campus Box 8238, St. Louis, MO 63110, USA.
| | | | - Hollie A. Power
- Washington University School of Medicine in St. Louis, MO, USA
| | - Jessica Hasak
- Washington University School of Medicine in St. Louis, MO, USA
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Kapoor A, Anand KP, Chattopadhyay D, Vathulaya M, Roy C. Early rehabilitation of victims of traumatic ulnar injury using tendon transfer. Injury 2020; 51:1603-1607. [PMID: 32359816 DOI: 10.1016/j.injury.2020.04.007] [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: 01/03/2020] [Revised: 04/02/2020] [Accepted: 04/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Poor awareness among the patients and lack of resources for proper management of nerve injuries leads to delayed presentation of most traumatic ulnar nerve injuries. When this injury is present in the proximal forearm it leads to poor outcomes as Ulnar nerve repair with grafts takes a prolonged time to restore function. Addition of a tendon transfer to this procedure can allow patients to return to work earlier. The purpose of this study is to examine whether the addition of a tendon transfer to nerve repair surgery will lead to improved hand function and rehabilitation earlier than nerve grafting alone in cases of delayed presentation of Ulnar nerve injuries. METHODS A retrospective analysis of patients with traumatic ulnar nerve injury with duration of injury more than 1 month and location > 5 cm proximal to the flexor retinaculum who required a sural nerve graft for repair was done using Sollerman Hand Function test (SHFT). The SHFT scores were recorded for these patients at end of one year following repair with nerve grafting and status of employment at end of 6 and 12 month of surgery recorded as well. Another group of patients with traumatic ulnar injury of the same profile were given Fritchi tendon transfer along with sural nerve graft and followed up prospectively for a period of one year and SHFT score with status of employment recorded. RESULTS On comparison of employment status at 6 months we found that among the tendon transfer group 15/20 (75%) were employed while only 4/16 (20%) in the control group were able to return to work. Chi square test shows a p value of 0.002 (significant at p < 0.05). On evaluation at end of 1 year after surgery we found 18/20 (90%) had returned to work in the tendon transfer group while 8/16 (50%) had found employment again in the control group. Chi square test shows a p value 0.007 (significant at p < 0.05) CONCLUSION: These outcomes suggest that addition of a tendon transfer with nerve grafting promotes early rehabilitation, especially in patients employed in manual labor.
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Affiliation(s)
- Akshay Kapoor
- Department of Burns and Plastic Surgery All India Institute of Medical Sciences, Rishikeh, Virbhadra Road, Uttarakhand, 249203, India.
| | | | - Debarati Chattopadhyay
- Department of Burns and Plastic Surgery All India Institute of Medical Sciences, Rishikeh, Virbhadra Road, Uttarakhand, 249203, India
| | - Madhubari Vathulaya
- Department of Burns and Plastic Surgery All India Institute of Medical Sciences, Rishikeh, Virbhadra Road, Uttarakhand, 249203, India.
| | - Collin Roy
- Department of Plastic Surgery Nil Ratan Sircar Medical College, Kolkata, West Bengal, India
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Abstract
Nerve grafts represent an invaluable tool, when reconstructing nerve defects of more than 1 cm. Historically, the criterion standard use of autografts has relied on the premise of using nonessential sensory nerves to fulfill the principle of replacing "like with like," while simultaneously minimizing the infliction of undue morbidity on the patient. The reconstructive surgeon thus faces a dilemma when extensive nerve damage requires reconstruction, or when donor nerves are not available or limited such as in the pediatric population. Cadaver nerve grafts (CNG) uniquely allow for reconstruction of large nerve lesions without the presence of host morbidity. The following article reviews the use of CNG, its indications, advantages, and disadvantages, as well as provides some case studies of real-world application. In addition, an insight into the future perspectives of CNG is provided.
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Comparison Between Supercharged Ulnar Nerve Repair by Anterior Interosseous Nerve Transfer and Isolated Ulnar Nerve Repair in Proximal Ulnar Nerve Injuries. J Hand Surg Am 2020; 45:104-110. [PMID: 31866151 DOI: 10.1016/j.jhsa.2019.11.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 09/20/2019] [Accepted: 11/06/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare combined ulnar nerve repair with supercharged end-to-side anterior interosseous nerve to ulnar motor nerve transfer (UR+SETS) with conventional isolated ulnar repair techniques in proximal ulnar nerve transection, with respect to intrinsic muscle power recovery and claw hand deformity correction. METHODS We conducted a comparative matched-paired series prospectively on 21 patients with proximal ulnar nerve transection injury. Eleven patients were managed by UR+SETS and 10 by isolated ulnar repair. The outcome was reported at 3, 6, 12, and 18 months using the score of Birch and Raji and Brand's criteria. RESULTS A total of 21 patients with acute proximal ulnar nerve transection injury had completed 18 months' follow-up. We observed better results in the UR+SETS group regarding the return of intrinsic function and reduction of deformity with earlier improvement in the score of Birch and Raji and Brand's criteria. CONCLUSIONS In the short term, UR+SETS transfer appears to result in better intrinsic muscle reinnervation and clawing deformity correction after proximal ulnar nerve transection injury. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Wang Y, Zhang Y, Li X, Zhang Q. The progress of biomaterials in peripheral nerve repair and regeneration. JOURNAL OF NEURORESTORATOLOGY 2020. [DOI: 10.26599/jnr.2020.9040022] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Repair and regeneration of the injured peripheral nerve (PN) is a challenging issue in clinics. Although the regeneration outcome of large PN defects is currently unsatisfactory, recently, the study of PN repair has considerably progressed. In particular, biomaterials for repairing PNs, such as nerve guidance conduits and nerve repair membranes, have been well developed. Herein, we summarize the anatomy of the PN, the pathophysiological features of the nerve injury, and the repair process post injury. Then, we highlight the progress in the development of natural and synthetic biomaterials and summarize the applications, advantages, and disadvantages of these materials. These materials can be used as nerve repair membranes and nerve conduits in the field of PN repair. Finally, we discuss the challenges encountered and development strategies for PN repair in the future.
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Geissler J, Stevanovic M. Management of large peripheral nerve defects with autografting. Injury 2019; 50 Suppl 5:S64-S67. [PMID: 31708089 DOI: 10.1016/j.injury.2019.10.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION A segmental nerve defect from trauma results in significant loss of function of the extremity, and rarely occurs in isolation. Autografting of the nerve defect is the current gold standard. METHODS A review of the recent literature regarding peripheral nerve defects after trauma treated with autograft. RESULTS Identification of the zone of nerve injury is difficult and appropriate resection is critical for good outcomes. Meaningful recovery is more likely with application of excellent technique. Many of the factors affecting outcomes are not modifiable. CONCLUSION Nerve grafting for segmental nerve injuries continues to be an essential and appropriate treatment.
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Affiliation(s)
- J Geissler
- Department of Orthopaedic Surgery, University of Minnesota, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States.
| | - M Stevanovic
- Department of Orthopaedic Surgery, University of Southern California, Keck School of Medicine, 1520 San Pablo St. Suite 2000, Los Angeles, CA 90033, United States.
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O'Donnell MJ, Hausman MR. High median nerve injury after arthroscopic elbow contracture release with complete recovery at 6 months. J Shoulder Elbow Surg 2019; 28:e352-e356. [PMID: 31427228 DOI: 10.1016/j.jse.2019.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 06/04/2019] [Accepted: 06/07/2019] [Indexed: 02/01/2023]
Affiliation(s)
- Marc J O'Donnell
- Leni & Peter May Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY, USA.
| | - Michael R Hausman
- Leni & Peter May Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, NY, USA
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Resuscitating extremities after soft tissue sarcoma resections: Are functional reconstructions an overlooked option in limb salvage? A systematic review. Eur J Surg Oncol 2019; 45:1762-1769. [DOI: 10.1016/j.ejso.2019.05.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/07/2019] [Accepted: 05/20/2019] [Indexed: 12/27/2022] Open
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Vannucci B, Santosa KB, Keane AM, Jablonka-Shariff A, Lu CY, Yan Y, MacEwan M, Snyder-Warwick AK. What is Normal? Neuromuscular junction reinnervation after nerve injury. Muscle Nerve 2019; 60:604-612. [PMID: 31408210 DOI: 10.1002/mus.26654] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 07/31/2019] [Accepted: 08/04/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION In this study we present a reproducible technique to assess motor recovery after nerve injury via neuromuscular junction (NMJ) immunostaining and electrodiagnostic testing. METHODS Wild-type mice underwent sciatic nerve transection with repair. Hindlimb muscles were collected for microscopy up to 30 weeks after injury. Immunostaining was used to assess axons (NF200), Schwann cells (S100), and motor endplates (α-bungarotoxin). Compound motor action potential (CMAP) amplitude was used to assess tibialis anterior (TA) function. RESULTS One week after injury, nearly all (98.0%) endplates were denervated. At 8 weeks, endplates were either partially (28.3%) or fully (71.7%) reinnervated. At 16 weeks, NMJ reinnervation reached 87.3%. CMAP amplitude was 83% of naive mice at 16 weeks and correlated with percentage of fully reinnervated NMJs. Morphological differences were noted between injured and noninjured NMJs. DISCUSSION We present a reproducible method for evaluating NMJ reinnervation. Electrodiagnostic data summarize NMJ recovery. Characterization of wild-type reinnervation provides important data for consideration in experimental design and interpretation.
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Affiliation(s)
- Bianca Vannucci
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Katherine B Santosa
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Alexandra M Keane
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Albina Jablonka-Shariff
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Chuieng-Yi Lu
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Ying Yan
- Department of Neurosurgery, Washington University School of Medicine, St Louis, Missouri
| | - Matthew MacEwan
- Department of Neurosurgery, Washington University School of Medicine, St Louis, Missouri
| | - Alison K Snyder-Warwick
- Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
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Li L, He WT, Qin BG, Liu XL, Yang JT, Gu LQ. Comparison between direct repair and human acellular nerve allografting during contralateral C7 transfer to the upper trunk for restoration of shoulder abduction and elbow flexion. Neural Regen Res 2019; 14:2132-2140. [PMID: 31397352 PMCID: PMC6788224 DOI: 10.4103/1673-5374.262600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Direct coaptation of contralateral C7 to the upper trunk could avoid the interposition of nerve grafts. We have successfully shortened the gap and graft lengths, and even achieved direct coaptation. However, direct repair can only be performed in some selected cases, and partial procedures still require autografts, which are the gold standard for repairing neurologic defects. As symptoms often occur after autografting, human acellular nerve allografts have been used to avoid concomitant symptoms. This study investigated the quality of shoulder abduction and elbow flexion following direct repair and acellular allografting to evaluate issues requiring attention for brachial plexus injury repair. Fifty-one brachial plexus injury patients in the surgical database were eligible for this retrospective study. Patients were divided into two groups according to different surgical methods. Direct repair was performed in 27 patients, while acellular nerve allografts were used to bridge the gap between the contralateral C7 nerve root and upper trunk in 24 patients. The length of the harvested contralateral C7 nerve root was measured intraoperatively. Deltoid and biceps muscle strength, and degrees of shoulder abduction and elbow flexion were examined according to the British Medical Research Council scoring system; meaningful recovery was defined as M3–M5. Lengths of anterior and posterior divisions of the contralateral C7 in the direct repair group were 7.64 ± 0.69 mm and 7.55 ± 0.69 mm, respectively, and in the acellular nerve allografts group were 6.46 ± 0.58 mm and 6.43 ± 0.59 mm, respectively. After a minimum of 4-year follow-up, meaningful recoveries of deltoid and biceps muscles in the direct repair group were 88.89% and 85.19%, respectively, while they were 70.83% and 66.67% in the acellular nerve allografts group. Time to C5/C6 reinnervation was shorter in the direct repair group compared with the acellular nerve allografts group. Direct repair facilitated the restoration of shoulder abduction and elbow flexion. Thus, if direct coaptation is not possible, use of acellular nerve allografts is a suitable option. This study was approved by the Medical Ethical Committee of the First Affiliated Hospital of Sun Yat-sen University, China (Application ID: [2017] 290) on November 14, 2017.
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Affiliation(s)
- Liang Li
- Department of Orthopedic Trauma and Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Wen-Ting He
- Department of Orthopedic Trauma and Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Ben-Gang Qin
- Department of Orthopedic Trauma and Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Xiao-Lin Liu
- Department of Orthopedic Trauma and Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jian-Tao Yang
- Department of Orthopedic Trauma and Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Li-Qiang Gu
- Department of Orthopedic Trauma and Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
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Raginov IS, Egorov VI, Valiullin LR, Watanabe D, Balakin KV, Murinov YI. Morphological and functional evaluation of the effect of novel pyrimidine derivatives on regeneration of the sciatic nerve in rats. Neurosci Lett 2019; 706:110-113. [PMID: 31078677 DOI: 10.1016/j.neulet.2019.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/24/2019] [Accepted: 05/08/2019] [Indexed: 11/16/2022]
Abstract
Two novel pyrimidine derivatives, RG2 and RG6, were studied using a rat's model of peripheral nerve injury. Toe-spreading reflex and skin sensitivity to pinch in the foot were monitored to follow recovery of motor and sensory functions in the treated animals. The remyelation rate in the distal segment of the damaged nerve was also studied using morphological analysis of cross-sections of the nerve stained with methylene blue. The obtained data demonstrate a high stimulating effect of RG2 and RG6 on the restoration of motor and sensory functions of the sciatic nerve, as well as on the post-traumatic regeneration of myelin fibers. Possible mechanisms of the observed effects are discussed.
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Affiliation(s)
- Ivan S Raginov
- Kazan State Medical University, Butlerova Street 49, Kazan, 420012, Russia.
| | - Vladislav I Egorov
- Federal center for toxicological, radiation and biological safety, Nauchnyi Gorodok 2, Kazan, 420075, Russia
| | - Lenar R Valiullin
- Federal center for toxicological, radiation and biological safety, Nauchnyi Gorodok 2, Kazan, 420075, Russia
| | - Daichi Watanabe
- Shinshu University, 3-1-1, Asahi, Matsumoto City, Nagano Prefecture, 390-8621, Japan
| | - Konstantin V Balakin
- Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya str. 8, bld.2, 119991, Moscow, Russia
| | - Yurii I Murinov
- Ufa Institute of Chemistry of the Russian Academy of Sciences, prospect Oktyabrya 71, Ufa, 450054, Russia
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Can the amniotic membrane be used to treat peripheral nerve defects? A review of literature. HAND SURGERY & REHABILITATION 2019; 38:223-232. [PMID: 31185315 DOI: 10.1016/j.hansur.2019.05.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 05/28/2019] [Accepted: 05/31/2019] [Indexed: 02/03/2023]
Abstract
Human amniotic membrane is currently being used in ophthalmology and dermatology applications. The objective of this review was to establish proof-of-concept for using amniotic membrane to treat peripheral nerve defects. We performed a search using: 1) PubMed with the keywords/MeSH terms: "amnion", "amniotic membrane", "angiogenesis", "anti-microbial", "characteristic", "chorion", "epithelialization", "fibrosis", "gap", "growth factors", "use", "nerve"; 2) the American clinical trials registry with "amniotic membrane"; 3) Lim Jeremy's book "A primer on amniotic membrane regenerative healing"; 4) the search engine Google. Our findings pointed to the amniotic membrane being a biodegradable and bioactive scaffold that contains many growth factors important for efficient nerve regeneration. Multiple animal studies and the single human clinical trial performed up to now have highlighted its role in preventing recurrence of perineural adhesions, reducing fibrosis, accelerating nerve repair and improving nerve function. Thus, the amniotic membrane has ideal properties for treating peripheral nerve injuries. It could very likely prevent neuroma formation. The best format would be a freeze-dried one containing the amnion and chorion layers in order to preserve all its growth factors, and facilitate its handling and storage in the operating room.
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Karamanos E, Rakitin I, Dream S, Siddiqui A. Nerve Transfer Surgery for Penetrating Upper Extremity Injuries. Perm J 2018; 22:17-156. [PMID: 29702048 DOI: 10.7812/tpp/17-156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Nerve transfer surgery is an option for repair of penetrating injuries of the upper extremity. In the right setting, it has advantages over tendon transfers and nerve grafting. OBJECTIVE To review our experience since 2006 of nerve transfer surgery in the upper extremities. DESIGN We included cases performed to repair penetrating trauma within three months of injury with at least three years' follow-up. MAIN OUTCOME MEASURES Preoperative and postoperative muscle strength of the affected extremity. RESULTS All 16 patients were males aged 16 to 43 years. Six patients underwent nerve transfer surgery because of elbow flexion; 5, finger extension; 3, finger flexion; and 2, wrist pronation. Nine patients (56%) had associated vascular injury, and 4 (25%) had fractures. Average follow-up was 6 years. No perioperative complications occurred. Patients had a mean of 3.7 operations after the initial trauma. All patients received physical therapy. All patients improved from 0 of 5 muscle strength preoperatively to a mean of 3.8 (range = 2/5 to 5/5) within 1 year after surgery. In all cases, strength was maintained, and 8 (50%) had continued improvement after Year 1. Ten (63%) returned to their previous employment level. Mean Disabilities of the Arm, Shoulder and Hand score improved from 68 to 83 postoperatively. CONCLUSION Nerve transfer is a safe, effective technique for correcting penetrating trauma-related nerve injury. In appropriate patients it offers advantages over other techniques. Outcomes can be maintained long term, and many patients can return to their previous level of function.
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Affiliation(s)
| | | | | | - Aamir Siddiqui
- Plastic and Reconstructive Surgeon at Henry Ford Hospital in Detroit, MI.
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Baxter C, Miller TA, Ross DC, Doherty C. Treatment of Cervical Spondylotic Amyotrophy With Nerve Transfers. J Hand Surg Am 2018; 43:684.e1-684.e4. [PMID: 29459170 DOI: 10.1016/j.jhsa.2017.12.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 11/21/2017] [Accepted: 12/20/2017] [Indexed: 02/02/2023]
Abstract
Cervical spondylotic amyotrophy is characterized by severe, proximal upper extremity weakness including an inability to abduct the shoulder and flex the elbow. Treatment using both medical and surgical decompression approaches has produced variable results. This paper reports the use of nerve transfers (spinal accessory to suprascapular, flexor carpi ulnaris fascicle of ulnar to biceps motor branch, radial nerve branch to triceps to axillary) to restore shoulder and elbow function in a case of unilateral cervical spondylotic amyotrophy involving C5 and C6 myotomes. Evidence of regeneration was observed on electromyography as well as clinically at 5 months postoperatively. At 3 years after surgery, recovery of elbow flexion and shoulder abduction was Medical Research Council grade 4/5 with improved external rotation and considerably improved patient-rated Disabilities of the Arm, Shoulder and Hand scores. We propose that nerve transfers be considered along with other reconstruction modalities in the treatment of cervical spondylotic amyotrophy.
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Affiliation(s)
- Charmaine Baxter
- Division of Plastic Surgery, McMaster University, Hamilton, ON, Canada
| | - Thomas A Miller
- Department of Physical Medicine and Rehabilitation, Western University, London, ON, Canada
| | - Douglas C Ross
- Division of Plastic Surgery, Roth-McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, Western University, London, ON, Canada.
| | - Christopher Doherty
- Division of Plastic Surgery, Roth-McFarlane Hand and Upper Limb Centre, St Joseph's Health Care, Western University, London, ON, Canada
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Santosa KB, Keane AM, Jablonka-Shariff A, Vannucci B, Snyder-Warwick AK. Clinical relevance of terminal Schwann cells: An overlooked component of the neuromuscular junction. J Neurosci Res 2018; 96:1125-1135. [PMID: 29536564 PMCID: PMC6292684 DOI: 10.1002/jnr.24231] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 12/30/2017] [Accepted: 02/09/2018] [Indexed: 12/13/2022]
Abstract
The terminal Schwann cell (tSC), a type of nonmyelinating Schwann cell, is a significant yet relatively understudied component of the neuromuscular junction. In addition to reviewing the role tSCs play on formation, maintenance, and remodeling of the synapse, we review studies that implicate tSCs in neuromuscular diseases including spinal muscular atrophy, Miller-Fisher syndrome, and amyotrophic lateral sclerosis, among others. We also discuss the importance of these cells on degeneration and regeneration after nerve injury. Knowledge of tSC biology may improve our understanding of disease pathogenesis and help us identify new and innovative therapeutic strategies for the many patients who suffer from neuromuscular disorders and nerve injuries.
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Affiliation(s)
- Katherine B. Santosa
- Postdoctoral Research Fellow, Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Alexandra M. Keane
- Medical Student, Washington University School of Medicine, St. Louis, MO
| | - Albina Jablonka-Shariff
- Research Scientist, Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Bianca Vannucci
- Medical Student, Washington University School of Medicine, St. Louis, MO
| | - Alison K. Snyder-Warwick
- Assistant Professor, Division of Plastic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
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Use of Processed Nerve Allografts to Repair Nerve Injuries Greater Than 25 mm in the Hand. Ann Plast Surg 2018; 78:S292-S295. [PMID: 28328632 DOI: 10.1097/sap.0000000000001037] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Processed nerve allografts (PNAs) have been demonstrated to have improved clinical results compared with hollow conduits for reconstruction of digital nerve gaps less than 25 mm; however, the use of PNAs for longer gaps warrants further clinical investigation. Long nerve gaps have been traditionally hard to study because of low incidence. The advent of the RANGER registry, a large, institutional review board-approved, active database for PNA (Avance Nerve Graft; AxoGen, Inc, Alachua, FL) has allowed evaluation of lower incidence subsets. The RANGER database was queried for digital nerve repairs of 25 mm or greater. Demographics, injury, treatment, and functional outcomes were recorded on standardized forms. Patients younger than 18 and those lacking quantitative follow-up data were excluded. Recovery was graded according to the Medical Research Council Classification for sensory function, with meaningful recovery defined as S3 or greater level. Fifty digital nerve injuries in 28 subjects were included. There were 22 male and 6 female subjects, and the mean age was 45. Three patients gave a previous history of diabetes, and there were 6 active smokers. The most commonly reported mechanisms of injury were saw injuries (n = 13), crushing injuries (n = 9), resection of neuroma (n = 9), amputation/avulsions (n = 8), sharp lacerations (n = 7), and blast/gunshots (n = 4). The average gap length was 35 ± 8 mm (range, 25-50 mm). Recovery to the S3 or greater level was reported in 86% of repairs. Static 2-point discrimination (s2PD) and Semmes-Weinstein monofilament (SWF) were the most common completed assessments. Mean s2PD in 24 repairs reporting 2PD data was 9 ± 4 mm. For the 38 repairs with SWF data, protective sensation was reported in 33 repairs, deep pressure in 2, and no recovery in 3. These data compared favorably with historical data for nerve autograft repairs, with reported levels of meaningful recovery of 60% to 88%. There were no reported adverse effects. Processed nerve allograft can be used to reconstruct long gap nerve defects in the hand with consistently high rates of meaningful recovery. Results for PNA repairs of digital nerve injuries with gaps longer than 25 mm compare favorably with historical reports for nerve autograft repair but without donor site morbidity.
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Bamba R, Riley DC, Kelm ND, Cardwell N, Pollins AC, Afshari A, Nguyen L, Dortch RD, Thayer WP. A novel conduit-based coaptation device for primary nerve repair. Int J Neurosci 2017; 128:563-569. [PMID: 29098916 DOI: 10.1080/00207454.2017.1398157] [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] [Indexed: 12/23/2022]
Abstract
BACKGROUND Conduit-based nerve repairs are commonly used for small nerve gaps, whereas primary repair may be performed if there is no tension on nerve endings. We hypothesize that a conduit-based nerve coaptation device will improve nerve repair outcomes by avoiding sutures at the nerve repair site and utilizing the advantages of a conduit-based repair. METHODS The left sciatic nerves of female Sprague-Dawley rats were transected and repaired using a novel conduit-based device. The conduit-based device group was compared to a control group of rats that underwent a standard end-to-end microsurgical repair of the sciatic nerve. Animals underwent behavioral assessments at weekly intervals post-operatively using the sciatic functional index (SFI) test. Animals were sacrificed at four weeks to obtain motor axon counts from immunohistochemistry. A sub-group of animals were sacrificed immediately post repair to obtain MRI images. RESULTS SFI scores were superior in rats which received conduit-based repairs compared to the control group. Motor axon counts distal to the injury in the device group at four weeks were statistically superior to the control group. MRI tractography was used to demonstrate repair of two nerves using the novel conduit device. CONCLUSIONS A conduit-based nerve coaptation device avoids sutures at the nerve repair site and leads to improved outcomes in a rat model. Conduit-based nerve repair devices have the potential to standardize nerve repairs while improving outcomes.
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Affiliation(s)
- Ravinder Bamba
- a Department of Plastic Surgery , Vanderbilt University Medical Center , Nashville , TN , USA.,b Department of Surgery , Georgetown University , Washington , DC , USA
| | - D Colton Riley
- a Department of Plastic Surgery , Vanderbilt University Medical Center , Nashville , TN , USA.,c Department of Surgery , Georgetown University, School of Medicine , Washington , DC , USA
| | - Nathaniel D Kelm
- d Department of Radiology and Radiological Sciences , Vanderbilt University , Nashville , TN , USA
| | - Nancy Cardwell
- a Department of Plastic Surgery , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Alonda C Pollins
- a Department of Plastic Surgery , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Ashkan Afshari
- a Department of Plastic Surgery , Vanderbilt University Medical Center , Nashville , TN , USA.,e Department of Surgery , Palmetto Health , Columbia , SC , USA
| | - Lyly Nguyen
- a Department of Plastic Surgery , Vanderbilt University Medical Center , Nashville , TN , USA.,f Department of Surgery , Morristown Medical Center , Morristown , NJ , USA
| | - Richard D Dortch
- d Department of Radiology and Radiological Sciences , Vanderbilt University , Nashville , TN , USA
| | - Wesley P Thayer
- a Department of Plastic Surgery , Vanderbilt University Medical Center , Nashville , TN , USA
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Samson D, Power DM. Iatrogenic Injuries of the Palmar Branch of the Median Nerve Following Volar Plate Fixation of the Distal Radius. J Hand Surg Asian Pac Vol 2017; 22:343-349. [DOI: 10.1142/s021881041750040x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Our aims were to identify iatrogenous injuries to the palmar branch of the median nerve sustained during volar plate fixation of the distal radius, make the clinician aware of this relatively uncommon complication of distal radius fixation, to emphasise common threads in symptomatology and to propose an algorithm for evaluation and management. Methods: Retrospectively interrogating our database over a 5 year period, the case records, neurophysiology records, operative records, therapy records were reviewed. The data was analysed with regard to the grade of surgeon performing the procedure, the site of injury, complexity of the fracture, delay to surgery, implant choice and outcome of the treatment. Variations in nerve anatomy were documented during revision surgery and common themes in symptomatology and clinical presentation were identified. Results: Seven patients with an iatrogenic injury involving the palmar branch of the median nerve associated with volar plate fixation of the distal radius were assessed. The male: female ratio was 1:6 and the mean age of patients was 47.8 years (33-74 years). The initial operative fixation was undertaken by a consultant orthopaedic surgeon at a mean of 7.8 (1-17) days from injury. The mean time from fracture fixation surgery to referral to the peripheral nerve injury service was 8.9 (2-36) months. Six patients presented with pain on attempted wrist extension. Five patients had parasthesia, hyperaesthesia or dysaesthesia in the distribution of the PCBMN. Anaesthesia or hypoaesthesia was present in three patients. Two patients presented with symptoms of complex regional pain syndrome (CRPS) Type 2. Conclusions: Revising relevant anatomy and possible variations as well as careful placements of retractors in the region of the median nerve could bring down these injuries. We propose an algorithm for their management.
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Affiliation(s)
- Deepak Samson
- Peripheral Nerve Injury Service, Birmingham Hand Centre, Queen Elizabeth University Hospital, Edgbaston, UK
| | - Dominic M. Power
- Peripheral Nerve Injury Service, Birmingham Hand Centre, Queen Elizabeth University Hospital, Edgbaston, UK
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Abel NA, Januszewski J, Vivas AC, Uribe JS. Femoral nerve and lumbar plexus injury after minimally invasive lateral retroperitoneal transpsoas approach: electrodiagnostic prognostic indicators and a roadmap to recovery. Neurosurg Rev 2017; 41:457-464. [PMID: 28560607 DOI: 10.1007/s10143-017-0863-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 05/12/2017] [Indexed: 10/19/2022]
Abstract
Injury to the lumbosacral (LS) plexus is a well-described complication after lateral retroperitoneal transpsoas approaches to the spine. The prognosis for functional recovery after lumbosacral plexopathy or femoral/obturator neuropathy is unclear. We designed a retrospective case-control study with patients undergoing one-level lateral retroperitoneal transpsoas lumbar interbody fusion (LLIF) between January 2011 and June 2016 to correlate electrodiagnostic assessments (EDX) to physiologic concepts of nerve injury and reinnervation, and attempt to build a timeline for patient evaluation and recovery. Cases with post-operative obturator or femoral neuropathy were identified. Post-operative MRI, nerve conduction studies (NCS), electromyography (EMG), and physical examinations were performed at intervals to assess clinical and electrophysiologic recovery of function. Two hundred thirty patients underwent LLIF. Six patients (2.6%) suffered severe femoral or femoral/obturator neuropathy. Five patients (2.2%) had immediate post-operative weakness. One of the six patients developed delayed weakness due to a retroperitoneal hematoma. Five out of six patients (83%) demonstrated EDX findings at 6 weeks consistent with axonotmesis. All patients improved to at least MRC 4/5 within 12 months of injury. In conclusion, neurapraxia is the most common LS plexus injury, and complete recovery is expected after 3 months. Most severe nerve injuries are a combination of neurapraxia and variable degrees of axonotmesis. EDX performed at 6 weeks and 3, 6, and 9 months provides prognostic information for recovery. In severe injuries of proximal femoral and obturator nerves, observation of proximal to distal progression of small-amplitude, short-duration (SASD) motor unit potentials may be the most significant prognostic indicator.
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Affiliation(s)
- Naomi A Abel
- Department of Neurological Surgery and Brain Repair, University of South Florida, 2 Tampa Gen Circle, 7th FL, Tampa, FL, 33606, USA
| | - Jacob Januszewski
- Department of Neurological Surgery and Brain Repair, University of South Florida, 2 Tampa Gen Circle, 7th FL, Tampa, FL, 33606, USA.
| | - Andrew C Vivas
- Department of Neurological Surgery and Brain Repair, University of South Florida, 2 Tampa Gen Circle, 7th FL, Tampa, FL, 33606, USA
| | - Juan S Uribe
- Department of Neurological Surgery and Brain Repair, University of South Florida, 2 Tampa Gen Circle, 7th FL, Tampa, FL, 33606, USA
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Abstract
BACKGROUND Peripheral nerve injury can have a devastating impact on our military and veteran population. Current strategies for peripheral nerve repair include techniques such as nerve tubes, nerve grafts, tissue matrices, and nerve growth guides to enhance the number of regenerating axons. Even with such advanced techniques, it takes months to regain function. In animal models, polyethylene glycol (PEG) therapy has shown to improve both physiologic and behavioral outcomes after nerve transection by fusion of a portion of the proximal axons to the distal axon stumps. The objective of this study was to show the efficacy of PEG fusion in humans and to retrospectively compare PEG fusion to standard nerve repair. METHODS Patients with traumatic lacerations involving digital nerves were treated with PEG after standard microsurgical neurorrhaphy. Sensory assessment after injury was performed at 1 week, 2 weeks, 1 month, and 2 months using static two-point discrimination and Semmes-Weinstein monofilament testing. The Medical Research Council Classification (MRCC) for Sensory Recovery Scale was used to evaluate the level of injury. The PEG fusion group was compared to patient-matched controls whose data were retrospectively collected. RESULTS Four PEG fusions were performed on four nerve transections in two patients. Polyethylene glycol therapy improves functional outcomes and speed of nerve recovery in clinical setting assessed by average MRCC score in week 1 (2.8 vs 1.0, p = 0.03). At 4 weeks, MRCC remained superior in the PEG fusion group (3.8 vs 1.3, p = 0.01). At 8 weeks, there was improvement in both groups with the PEG fusion cohort remaining statistically better (4.0 vs 1.7, p = 0.01). CONCLUSION Polyethylene glycol fusion is a novel therapy for peripheral nerve repair with proven effectiveness in animal models. Clinical studies are still in early stages but have had encouraging results. Polyethylene glycol fusion is a potential revolutionary therapy in peripheral nerve repair but needs further investigation. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Deng JX, Zhang DY, Li M, Weng J, Kou YH, Zhang PX, Han N, Chen B, Yin XF, Jiang BG. Autologous transplantation with fewer fibers repairs large peripheral nerve defects. Neural Regen Res 2017; 12:2077-2083. [PMID: 29323049 PMCID: PMC5784358 DOI: 10.4103/1673-5374.221167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Peripheral nerve injury is a serious disease and its repair is challenging. A cable-style autologous graft is the gold standard for repairing long peripheral nerve defects; however, ensuring that the minimum number of transplanted nerve attains maximum therapeutic effect remains poorly understood. In this study, a rat model of common peroneal nerve defect was established by resecting a 10-mm long right common peroneal nerve. Rats receiving transplantation of the common peroneal nerve in situ were designated as the in situ graft group. Ipsilateral sural nerves (10–30 mm long) were resected to establish the one sural nerve graft group, two sural nerves cable-style nerve graft group and three sural nerves cable-style nerve graft group. Each bundle of the peroneal nerve was 10 mm long. To reduce the barrier effect due to invasion by surrounding tissue and connective-tissue overgrowth between neural stumps, small gap sleeve suture was used in both proximal and distal terminals to allow repair of the injured common peroneal nerve. At three months postoperatively, recovery of nerve function and morphology was observed using osmium tetroxide staining and functional detection. The results showed that the number of regenerated nerve fibers, common peroneal nerve function index, motor nerve conduction velocity, recovery of myodynamia, and wet weight ratios of tibialis anterior muscle were not significantly different among the one sural nerve graft group, two sural nerves cable-style nerve graft group, and three sural nerves cable-style nerve graft group. These data suggest that the repair effect achieved using one sural nerve graft with a lower number of nerve fibers is the same as that achieved using the two sural nerves cable-style nerve graft and three sural nerves cable-style nerve graft. This indicates that according to the ‘multiple amplification’ phenomenon, one small nerve graft can provide a good therapeutic effect for a large peripheral nerve defect.
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Affiliation(s)
- Jiu-Xu Deng
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Dian-Yin Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Ming Li
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Jian Weng
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Yu-Hui Kou
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Pei-Xun Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Na Han
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Bo Chen
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Xiao-Feng Yin
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Bao-Guo Jiang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
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Peripheral Nerve Injury: Stem Cell Therapy and Peripheral Nerve Transfer. Int J Mol Sci 2016; 17:ijms17122101. [PMID: 27983642 PMCID: PMC5187901 DOI: 10.3390/ijms17122101] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Revised: 11/29/2016] [Accepted: 12/08/2016] [Indexed: 01/03/2023] Open
Abstract
Peripheral nerve injury can lead to great morbidity in those afflicted, ranging from sensory loss, motor loss, chronic pain, or a combination of deficits. Over time, research has investigated neuronal molecular mechanisms implicated in nerve damage, classified nerve injury, and developed surgical techniques for treatment. Despite these advancements, full functional recovery remains less than ideal. In this review, we discuss historical aspects of peripheral nerve injury and introduce nerve transfer as a therapeutic option, as well as an adjunct therapy to transplantation of Schwann cells and their stem cell derivatives for repair of the damaged nerve. This review furthermore, will provide an elaborated discussion on the sources of Schwann cells, including sites to harvest their progenitor and stem cell lines. This reflects the accessibility to an additional, concurrent treatment approach with nerve transfers that, predicated on related research, may increase the efficacy of the current approach. We then discuss the experimental and clinical investigations of both Schwann cells and nerve transfer that are underway. Lastly, we provide the necessary consideration that these two lines of therapeutic approaches should not be exclusive, but conversely, should be pursued as a combined modality given their mutual role in peripheral nerve regeneration.
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Abstract
Combined peripheral nerve injuries present a unique set of challenges to the hand surgeon when considering tendon transfers. They are often associated with severe soft tissue trauma, including lacerations to remaining innervated muscles and tendons, significant scar formation, and substantial sensory loss. In the case of combined nerve injuries, there are typically fewer options for tendon transfers due to fewer tendons of shared function that are expendable as well as associated injuries to tendon or muscle bellies. As such, careful preoperative planning must be performed to make the most of remaining muscle tendon units.
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Affiliation(s)
- Christopher A Makarewich
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Room A0100, Salt Lake City, UT 84108, USA
| | - Douglas T Hutchinson
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Room A0100, Salt Lake City, UT 84108, USA.
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Three-dimensional Reconstruction of the Microstructure of Human Acellular Nerve Allograft. Sci Rep 2016; 6:30694. [PMID: 27476584 PMCID: PMC4967907 DOI: 10.1038/srep30694] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 07/06/2016] [Indexed: 01/04/2023] Open
Abstract
The exact inner 3D microstructure of the human peripheral nerve has been a mystery for decades. Therefore, it has been difficult to solve several problems regarding peripheral nerve injury and repair. We used high-resolution X-ray computed microtomography (microCT) to scan a freeze-dried human acellular nerve allograft (hANA). The microCT images were then used to reconstruct a 3D digital model, which was used to print a 3D resin model of the nerve graft. The 3D digital model of the hANA allowed visualization of all planes. The magnified 3D resin model clearly showed the nerve bundles and basement membrane tubes of the hANA. Scanning electron microscopy (SEM) was used to analyse the microstructure of the hANA. Compared to the SEM images, the microCT image clearly demonstrated the microstructure of the hANA cross section at a resolution of up to 1.2 μm. The 3D digital model of the hANA facilitates a clear and easy understanding of peripheral nerve microstructure. Furthermore, the enlarged 3D resin model duplicates the unique inner structure of each individual hANA. This is a crucial step towards achieving 3D printing of a hANA or nerve that can be used as a nerve graft.
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Knaus WJ, Alluri R, Bakri K, Iorio ML. Oncologic reconstruction of the hand and upper extremity: Maximizing functional outcomes. J Surg Oncol 2016; 113:946-54. [DOI: 10.1002/jso.24196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Accepted: 01/21/2016] [Indexed: 11/08/2022]
Affiliation(s)
- William J. Knaus
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
| | - Ram Alluri
- Department of Orthopaedic Surgery, University of Southern California; Keck School of Medicine; Los Angeles California
| | - Karim Bakri
- Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
| | - Matthew L. Iorio
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts
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Abstract
The purpose of this article is to provide an overview of the various nerve transfer options for restoration of elbow function. This article describes nerve transfer strategies for elbow flexion and extension including the indications, limitations, and expected outcomes based on current literature.
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Affiliation(s)
- Liselotte F Bulstra
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Zhu S, Liu J, Zheng C, Gu L, Zhu Q, Xiang J, He B, Zhou X, Liu X. Analysis of human acellular nerve allograft reconstruction of 64 injured nerves in the hand and upper extremity: a 3 year follow-up study. J Tissue Eng Regen Med 2016; 11:2314-2322. [PMID: 27098545 DOI: 10.1002/term.2130] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 11/15/2015] [Accepted: 12/10/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Shuang Zhu
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery; the First Affiliated Hospital of Sun Yat-sen University; Guangzhou People's Republic of China
- Center for Peripheral Nerve Tissue-engineering and Technology Research Guangdong; Guangzhou People's Republic of China
| | - Jianghui Liu
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery; the First Affiliated Hospital of Sun Yat-sen University; Guangzhou People's Republic of China
- Center for Peripheral Nerve Tissue-engineering and Technology Research Guangdong; Guangzhou People's Republic of China
| | - Canbin Zheng
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery; the First Affiliated Hospital of Sun Yat-sen University; Guangzhou People's Republic of China
- Center for Peripheral Nerve Tissue-engineering and Technology Research Guangdong; Guangzhou People's Republic of China
| | - Liqiang Gu
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery; the First Affiliated Hospital of Sun Yat-sen University; Guangzhou People's Republic of China
- Center for Peripheral Nerve Tissue-engineering and Technology Research Guangdong; Guangzhou People's Republic of China
| | - Qingtang Zhu
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery; the First Affiliated Hospital of Sun Yat-sen University; Guangzhou People's Republic of China
- Center for Peripheral Nerve Tissue-engineering and Technology Research Guangdong; Guangzhou People's Republic of China
| | - Jianping Xiang
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery; the First Affiliated Hospital of Sun Yat-sen University; Guangzhou People's Republic of China
- Center for Peripheral Nerve Tissue-engineering and Technology Research Guangdong; Guangzhou People's Republic of China
| | - Bo He
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery; the First Affiliated Hospital of Sun Yat-sen University; Guangzhou People's Republic of China
- Center for Peripheral Nerve Tissue-engineering and Technology Research Guangdong; Guangzhou People's Republic of China
| | - Xiang Zhou
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery; the First Affiliated Hospital of Sun Yat-sen University; Guangzhou People's Republic of China
- Center for Peripheral Nerve Tissue-engineering and Technology Research Guangdong; Guangzhou People's Republic of China
| | - Xiaolin Liu
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery; the First Affiliated Hospital of Sun Yat-sen University; Guangzhou People's Republic of China
- Center for Peripheral Nerve Tissue-engineering and Technology Research Guangdong; Guangzhou People's Republic of China
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Abstract
Nerve injuries above the elbow are associated with a poor prognosis, even with prompt repair and appropriate rehabilitation. The past 2 decades have seen the development of numerous nerve transfer techniques, by which a denervated peripheral target is reinnervated by a healthy donor nerve. Nerve transfers are indicated in proximal brachial plexus injuries where grafting is not possible or in proximal injuries of peripheral nerves with long reinnervation distances. Nerve transfers represent a revolution in peripheral nerve surgery and offer the potential for superior functional recovery in severe nerve injuries. However, the techniques have not been universally adopted due in part to a misconception that nerve transfers can only be understood and performed by superspecialists. Nerve transfer procedures are not technically difficult and require no specialized equipment. Numerous transfers have been described, but there are a handful of transfers for which there is strong clinical evidence. To restore shoulder abduction and external rotation in upper trunk brachial plexus injury, the key transfers are the spinal accessory to suprascapular nerve and the medial triceps branch to axillary nerve. For elbow flexion, the flexor carpi ulnaris branch of ulnar nerve to the biceps and brachialis branches of the musculocutaneous nerve is the key transfer. For ulnar intrinsic function, the distal anterior interosseous nerve to ulnar motor branch transfer has yielded excellent functional results. Nerve transfers form a therapeutic triad with traditional tendon transfers and functional motor unit rehabilitation which, when applied appropriately, can yield excellent functional results in complex nerve injuries. Nerve transfers are a powerful yet underused tool for proximal nerve injuries, which offer hope for traditionally discouraging injuries.
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Bulstra LF, Hundepool CA, Friedrich PF, Nijhuis THJ, Bishop AT, Shin AY. Motor Nerve Recovery in a Rabbit Model: Description and Validation of a Noninvasive Ultrasound Technique. J Hand Surg Am 2016; 41:27-33. [PMID: 26710731 DOI: 10.1016/j.jhsa.2015.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 11/01/2015] [Accepted: 11/01/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To develop and validate a noninvasive ultrasound technique for the longitudinal analysis of functional recovery after segmental peroneal nerve reconstruction in a rabbit model. METHODS Twelve male New Zealand White rabbits underwent a 1-cm peroneal nerve autograft reconstruction. Ultrasound measurements were performed before surgery and at 1, 2, 4, 8, 12, and 16 weeks postoperatively. All rabbits were managed with manual restraint for the ultrasound procedure, avoiding the risks of anesthetics. At 12 and 16 weeks, we evaluated functional recovery using compound muscle action potential, isometric tetanic force measurements, wet muscle weight, and nerve histomorphometry. Data were compared with ultrasound measurements by calculating the Pearson correlation coefficient. We determined intra-rater and inter-rater reliability of the ultrasound measurements. RESULTS Ultrasound demonstrated good correlation with isometric tetanic force measurements and wet muscle weight, good correlation with nerve histomorphometry, and moderate correlation with compound muscle action potential. Both intra-rater and inter-rater reliability of the ultrasound technique was excellent. CONCLUSIONS Ultrasound analysis of the tibialis anterior muscle provided a reliable method for analysis of functional recovery in a rabbit peroneal nerve reconstruction model. The noninvasive nature allowed for longitudinal follow-up within the same animal and measurement of early recovery without the use of anesthesia. CLINICAL RELEVANCE Application of this noninvasive technique can reduce the variability and sample size necessary in peripheral nerve reconstruction studies and may provide an ideal tool for comparative studies in larger animal models.
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Affiliation(s)
- Liselotte F Bulstra
- Department of Orthopedic Surgery, Microvascular Research Laboratory, Mayo Clinic, Rochester, MN; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Caroline A Hundepool
- Department of Orthopedic Surgery, Microvascular Research Laboratory, Mayo Clinic, Rochester, MN; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Patricia F Friedrich
- Department of Orthopedic Surgery, Microvascular Research Laboratory, Mayo Clinic, Rochester, MN
| | - Tim H J Nijhuis
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Allen T Bishop
- Department of Orthopedic Surgery, Microvascular Research Laboratory, Mayo Clinic, Rochester, MN
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Microvascular Research Laboratory, Mayo Clinic, Rochester, MN.
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Nerve Transfers to Restore Upper Extremity Function in Cervical Spinal Cord Injury: Update and Preliminary Outcomes. Plast Reconstr Surg 2015; 136:780-792. [PMID: 26397252 DOI: 10.1097/prs.0000000000001641] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Cervical spinal cord injury can result in profound loss of upper extremity function. Recent interest in the use of nerve transfers to restore volitional control is an exciting development in the care of these complex patients. In this article, the authors review preliminary results of nerve transfers in spinal cord injury. METHODS Review of the literature and the authors' cases series of 13 operations in nine spinal cord injury nerve transfer recipients was performed. Representative cases were reviewed to explore critical concepts and preliminary outcomes. RESULTS The nerve transfers used expendable donors (e.g., teres minor, deltoid, supinator, and brachialis) innervated above the level of the spinal cord injury to restore volitional control of missing function such as elbow extension, wrist extension, and/or hand function (posterior interosseous nerve or anterior interosseous nerve/finger flexors reinnervated). Results from the literature and the authors' patients (after a mean postsurgical follow-up of 12 months) indicate gains in function as assessed by both manual muscle testing and patients' self-reported outcomes measures. CONCLUSIONS Nerve transfers can provide an alternative and consistent means of reestablishing volitional control of upper extremity function in people with cervical level spinal cord injury. Early outcomes provide evidence of substantial improvements in self-reported function despite relatively subtle objective gains in isolated muscle strength. Further work to investigate the optimal timing and combination of nerve transfer operations, the combination of these with traditional treatments (tendon transfer and functional electrical stimulation), and measurement of outcomes is imperative for determining the precise role of these operations. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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