A comparison between complete immobilisation and protected active mobilisation in sensory nerve recovery following isolated digital nerve injury

Comparative Effectiveness Systematic Review and Meta-analysis of Peripheral Nerve Repair Using Direct Repair and Connector-assisted Repair

Background

This clinical literature systematic review and meta-analysis were performed to assess differences in outcomes between nerves repaired with direct repair (DR) and connector-assisted repair (CAR).

Methods

A systematic literature review for DR and CAR was performed. Studies from 1980 through August 2023 were included if DR or CAR repairs were performed in upper extremities with nerve gaps less than 5 mm and reported sensory Medical Research Council Classification (MRCC) outcomes or equivalent. Comparative analyses were planned for meaningful recovery (MR) rate (at both S3 and S3+ or better), postsurgical neuroma, cold intolerance, altered sensation, pain, and revision rate.

Results

There were significant differences in MR rates for CAR and DR. At the MRCC S3 threshold, 96.1% of CAR and 81.3% of DR achieved MR (P < 0.0001). At the MRCC S3+ threshold, 87.1% of CAR and 54.2% of DR achieved this higher threshold of MR (P < 0.0001). There were no differences in neuroma rate or pain scores in our dataset. Altered sensation (dysesthesia, paresthesia, hyperesthesia, or hypersensitivity) was not discussed in any CAR studies, so no analysis could be performed. The revision rate for both procedures was 0%. The proportion of patients with cold intolerance was 46.2% in the DR studies, which was significantly higher than the 10.7% of patients in the CAR group.

Conclusions

Significantly more patients achieved sensory MR and fewer had cold intolerance when the CAR technique, instead of the DR technique, was performed to repair peripheral nerve injuries.

Influence of immobilization and sensory re-education on the sensory recovery after reconstruction of digital nerves with direct suture or muscle-in-vein conduits

The influence of duration of immobilization and postoperative sensory re-education on the final outcome after reconstruction of digital nerves with direct suture or muscle-in-vein conduits was investigated. The final sensory outcome of 35 patients with 41 digital nerve injuries, who either underwent a direct suture (DS) or a nerve reconstruction with muscle-in-vein conduits (MVC), was assessed the earliest 12 months postoperatively using static and moving two-point discrimination as well as Semmes-Weinstein monofilaments. There was no significant difference in sensory recovery in cases with an immobilization of 3-7 days versus 10 days in the DS or MVC group. Moreover, no statistically significant difference in sensory recovery was found in cases receiving postoperative sensory re-education versus those not receiving in the DS or MVC group. An early mobilization does not seem to have a negative impact on the final outcome after digital nerve reconstruction. The effect of sensory re-education after digital nerve reconstruction should be reconsidered.

Early Passive Movement in flexor tendon injuries of the hand

INTRODUCTION

Flexor tendon injuries are underestimated considering their anatomical function in the hand. According to the publications of Kleinert, Verdan and Kessler, primary suturing of the flexor tendon combined with immediate postoperative physiotherapy in terms of "Early Passive Movement" became the standard form of therapy following acute flexor tendon injuries of the hand.

MATERIALS AND METHODS

In a study between 2007 and 2009, a total of 115 flexor tendon injuries were analysed retrospectively. All patients were treated using a two-strand repair technique according to Zechner. They received physiotherapy from the first postoperative day according to the Viennese flexor tendon rehabilitation protocol. For statistical purposes, the factors: age, gender, range of motion (ROM), follow up interval, affected flexor tendon and zone were analysed. The time between injury and surgery was also determined, classified into groups and included in the study. On the basis of the range of motion AROM, the Buck-Gramcko and modified Strickland Score was calculated.

RESULTS

The mean follow-up interval was 7 months. Using the Buck-Gramcko and Strickland Score an "excellent" overall result was achieved. Complications occurred in 3.5 %, one secondary rupture (0.9 %), two tendon adhaesions requiring tenolysis (1.7 %) and one case of infection (0.9 %). The time interval between injury and operation, gender, affected zone, flexor tendon and affected finger nerve had no influence on the Buck-Gramcko and Strickland Score.

CONCLUSIONS

Using Zechner's core suture technique as the primary treatment, combined with immediate postoperative physiotherapy in terms of "Early Passive Movement" according to the Viennese flexor tendon rehabilitation programme, an excellent clinical outcome and low complication rate was acchieved.

LEVEL OF EVIDENCE

IV: case series.

Prevalence of cold sensitivity in patients with hand pathology

BACKGROUND

The purpose of this study was to evaluate the prevalence of cold sensitivity in patients with hand- and wrist-related diagnoses.

METHODS

We included English-speaking adults who were more than 1 month following hand injury or onset of symptoms. Patients were asked if exposure to cold air or water provoked cold-related symptoms and to rank symptom severity (scale 0-10). Statistical analyses evaluated the relationships between the cold sensitivity and independent variables (age, gender, history of trauma, and time from injury/symptoms).

RESULTS

There were 197 patients (mean age 49 ± 16 years): 98 trauma and 99 non-trauma cases. Cold-induced symptoms were reported by 34 %, with 10 % reporting severe symptoms. Exposure to cold air is the most common catalyst; mean severity score was 6.7 ± 2.2. Those with traumatic injuries compared to non-trauma diagnoses reported significantly more cold-induced symptoms (p = .04). Using backward linear regression, the significant predictors of cold symptom severity were trauma (p = .004) and time since onset (p = .003). Including only the trauma patients in the regression model, the significant predictor was time since injury (p = .005).

CONCLUSIONS

Cold-induced symptoms are reported by more than 30 % of hand-related diagnoses, and exposure to cold air was the most commonly reported trigger. The significant predictors of cold-induced symptoms are traumatic injuries and longer time from injury. This study provides evidence of the common problem of cold sensitivity in patients with hand pathology.

LEVEL OF EVIDENCE

Prognostic Level II.