Clinical results and thoughts on sensory nerve repair by autologous vein graft in emergency hand reconstruction

doi:10.1016/S1297-3203(02)00109-9

Chirurgie de la Main

Volume 21, Issue 3, 2002, Pages 194-197

https://doi.org/10.1016/S1297-3203(02)00109-9 Get rights and content

Abstract

Lesions of the digital and other sensory nerves in the hand are common. Based on experimental studies on vein graft as a support for peripheral nerve regeneration, the Authors have been using a simple vein graft to bridge sensory nerve gaps when treating acute hand injuries. This is a retrospective study on the results of 22 sensory nerves repaired using vein grafts in cases in which primary suture was not feasible, in emergency hand reconstruction. Patients were informed that a secondary nerve graft could possibly be necessary in the future. Patients were reviewed by two independent observers at least one year after repair and evaluated using the Highet scale as modified by MacKinnon & Dellon. Evaluation chart included influence of repair on rehabilitation program and presence of painful neuromas and scars as well as patient satisfaction. Results were classified according to Sakellarides and 20/22 were classified as very good or good. Cases classified as poor were satisfied and no secondary nerve grafting has been carried out. Rehabilitation of the associated lesions (tendon lacerations or bone and soft tissue damage) was not influenced by the nerve repair and no painful neuroma was reported in the series. In conclusion, since the literature shows unsatisfactory results in repair of digital nerves with nerve grafts, since it's been demonstrated that an unrepaired sensory nerve leads to painful scar and painful neuroma and since we are reluctant to use nerve grafts in emergency procedures, we recommend this simple method because it is easy, low-cost and effective.

Résumé

Les lésions nerveuses de la main sont très fréquentes. En se basant sur les résultats expérimentaux encourageant obtenus avec des greffes de veines pour la réparations des nerfs périphériques, nous avons décidé d'appliqué cette technique en clinique pour le traitement des pertes de substance nerveuses dans les traumatismes de la main. Dans cette étude nous présentons les résultats du traitement immédiat de 22 réparations nerveuses par greffe de veine, en absence d'autres solutions chirurgicales. Les patients avaient été informés sur la nécessité éventuelle d'un traitement secondaire par greffe de nerf. Tous les patients ont été suivis par deux observateurs différents, avec un recul d'un an, en évaluant les résultats selon l'échelle de Highet, modifiée par Mackinnon et Dellon. Les éléments d'évaluations considérés étaient les résultats du programme de rééducation, l'éventuelle présence de nevromes douloureux, l'état des cicatrices et la satisfaction du patient. Vingt patients sur 22 ont obtenu le résultat « bon » ou « très bon » selon la classification de Sakellarides ; néanmoins, les cas jugés « insuffisants » n'ont pas nécessité de chirurgie secondaire. La rééducation requise pour les lésions associées (tendineuse, osseuse, cutanée) n'a pas été influencée par la réparation nerveuse et il n'a été observé aucun nevrome. En conclusion, l'incidence élevée de séquelles cicatricielles douloureuses, le risque de nevrome et la fréquence des résultats insuffisants dans l'usage des greffes de nerf et son manque d'indications dans le traitement immédiat, nous font souhaiter l'emploi de cette technique, qui a l'avantage d'être simple, facile et peu onéreuse.

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Repairing neurological injury, especially in the central nervous system (CNS), is one of the greatest challenges faced by modern medicine. Cellular therapies have proved promising, but are insufficient to repair major lesions. Developing a tissue engineering (TE) approach based on combining and integrating advanced functional biomaterials with cells and regulators, to mimic the natural milieu and support neuroregeneration, is critical in achieving successful repair of the nervous system. In this article, we discuss TE tools, techniques, and strategies that are used for repair and regeneration of peripheral nerves, as well as those being developed to repair damage of the CNS.
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Despite an intrinsic regenerative capacity of the peripheral nervous system, in most cases of peripheral nerve injury, especially those involving substantial nerve gaps, therapeutic interventions are always required to support peripheral nerve regeneration and functional recovery. With the advancement of tissue engineering and translational medicine, extensive research has focused on the development of tissue-engineered nerve grafts, as a promising alternative to autologous nerve grafts, for bridging nerve gaps in peripheral nerve repair. The typical design of tissue-engineered nerve grafts is composed of a nerve scaffold combined with cellular and/or molecular components. This chapter separately describes a diverse array of physical and biochemical components of tissue-engineered nerve grafts with regard to their features, functions, structure or composition, and fabrication or procurement, and further discusses many representative examples of tissue-engineered nerve grafts and their pros and cons. We also highlight the current clinical applications of tissue-engineered nerve grafts and outline the future prospects for tissue engineering in peripheral nerve regeneration.
Evaluation of emergency nerve grafting for proper palmar digital nerve defects: A retrospective single centre study
2014, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
The results of using the latter grafts, typically with smaller defects, are no better than the results in the current study. Fewer patients had regained S4 sensitivity than in the current study, except for the Risitano study where 58% of urgently operated patients had regained S4 sensitivity [30]. However the average defect size in his study was only 15 mm, versus 38 mm in the current study.
Finger trauma often results in discontinuity of the proper palmar digital nerves. The goal of this study was to retrospectively evaluate the clinical outcomes of emergency nerve grafting and the resulting donor site morbidity.
Three women and 13 men who had been operated between 2008 and 2012 were reviewed. The average patient age was 39 years (range 18–78). All were operated on an emergency basis. The average defect was 38 mm long (range 15–60). The nerves were harvested from four sites: lateral antebrachial cutaneous nerve (12 cases), banked finger (2 cases), terminal portion of posterior interosseous nerve (1 case) and anterior interosseous nerve (1 case). The evaluation consisted of patient questioning and clinical examination of the treated finger and donor site. An objective sensory exam was also performed. The results were expressed according to the British Medical Research Council (MRC) classification.
There was little donor site morbidity (2 cases of symptomatic hypoesthesia, 1 case of scar hypersensitivity). Sixty-nine percent of patients stated that their grafted finger did not cause them any trouble during activities of daily living. Three patients required job retraining. Pain in the grafted finger was 0.6 (range 0–5) on the VAS. Normal sensation was restored in 31% of cases based on the monofilament sensory test; 25% had a slight decrease in touch sensitivity and 25% had reduced protective sensations. Weber's two-point discrimination test found 50% normal sensibility (threshold < 6 mm) and 6% with mediocre sensibility (threshold of 6–10 mm). On the MRC grading scale, 50% of patients were at S4, 6% at S3+, 19% at S3, 12% at S2 and 12% at S1.
There were 56% good results in this patient series (S3+/S4) and no patients at S0. Donor site morbidity was rare. Thus use of nerve grafting is still a relevant option in an emergency setting.
Level IV.
Evaluation of emergency nerve grafting for proper palmar digital nerve defects: A retrospective single center study
2014, Revue de Chirurgie Orthopedique et Traumatologique
Les lésions des nerfs collatéraux digitaux palmaires avec perte de substance sont fréquentes dans les traumatismes des doigts. Notre objectif était d’étudier rétrospectivement les résultats cliniques des greffes nerveuses réalisées en urgence et la morbidité du site donneur.
Trois femmes et 13 hommes opérés entre 2008 et 2012 ont été revus. L’âge moyen était de 39 ans (18/78). Tous ont été opérés en urgence. La perte de substance nerveuse était de 38 mm (15/60). Quatre sites donneurs ont été utilisés : nerf cutané latéral de l’avant-bras (12 cas), doigt banque (2 cas), portion terminale du nerf interosseux postérieur (1 cas) et du nerf interosseux antérieur (1 cas). L’évaluation comportait un interrogatoire et un examen clinique du doigt traité et du site donneur. Un examen objectif de sensibilité était effectué. Les résultats étaient exprimés selon la classification du British Medical Research Council (BMRC).
La morbidité du site donneur était faible (2 cas d’hypoesthésie symptomatique, 1 cas d’hypersensibilité cicatricielle). Concernant le doigt greffé, 69 % des patients ne ressentaient aucune gêne dans leurs activités quotidiennes. Trois patients ont nécessité un aménagement du poste de travail. La douleur du doigt greffé était de 0,6 (0/5) sur l’échelle visuelle analogique. Le test au monofilament retrouvait 31 % de sensibilité normale, 25 % de diminution du toucher léger, 25 % de diminution de sensibilité de protection. Le test de Weber constatait 50 % de sensibilité normale (discrimination entre 2 points < 6 mm), 6 % de résultat médiocre (discrimination entre 6 et 10 mm). Selon le BMRC, on obtenait 50 % de S4, 6 % de S3+, 19 % de S3, 12 % de S2 et 12 % de S1.
Notre série retrouve 56 % de très bons résultats (S3+/S4) et aucun patient S0. La morbidité du site donneur est faible. L’utilisation des greffes nerveuses est donc toujours licite en urgence.
IV.
Peripheral nerve tissue engineering
2014, Tissue Engineering Using Ceramics and Polymers: Second Edition
The chapter summarises the pathophysiological response to peripheral nerve injury and subsequent regeneration reactions, with a particular focus on nerve gap injuries. To repair and bridge the tissue defects, nerve guidance conduits (NGCs) have been proposed as an alternative approach to autografts. Designing optimal NGCs requires development of (i) the conduit body, (ii) intraluminal structures and (iii) addition of regeneration promoting biological components to the lumen. The chapter provides a historical background to this research area and describes the current state of the art with a range of biomaterial constructs, which can be supplemented with Schwann cells or alternatively a variety of stem cells.

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^☆: Presented on Thursday 22 June, at the session on “nerves” (ref. no. 0106) at the VII Congress of the Federation of the European Societies for Surgery of the Hand, 21–24 June 2000, in Barcelona, Spain.

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Article originalClinical results and thoughts on sensory nerve repair by autologous vein graft in emergency hand reconstructionRésultats cliniques et réflexions sur la réparation des nerfs sensitifs par une greffe nerveuse autologue pour la reconstruction de la main en urgence☆

Abstract

Résumé

J Hand Surg

J Hand Surg B

J Hand Surg

J Hand Surg B

Br J Plast Surg

J Oral Maxillofac Surg

Article original
Clinical results and thoughts on sensory nerve repair by autologous vein graft in emergency hand reconstructionRésultats cliniques et réflexions sur la réparation des nerfs sensitifs par une greffe nerveuse autologue pour la reconstruction de la main en urgence☆