Despite extensive research and surgical innovation, the treatment of peripheral nerve injuries remains a complex issue, particularly in nonsharp lesions. The aim of this study was to assess the clinical outcome in a group of 16 patients who underwent, in emergency, a primary repair for crush injury of sensory and mixed nerves of the upper limb with biological tubulization, namely, the muscle-vein-combined graft. The segments involved were sensory digital nerves in eight cases and mixed nerves in another eight cases (four median nerves and four ulnar nerves). The length of nerve defect ranged from 0.5 to 4 cm (mean 1.9 cm). Fifteen of 16 patients showed some degree of functional recovery. Six patients showed diminished light touch (3.61), six had protective sensation (4.31), and three showed loss of protective sensation (4.56) using Semmes-Weinstein monofilament test. All the patients who underwent digital nerve repair had favorable results graded as S4 in one case, S3þ in six cases, and S3 in one case. With respect to mixed nerve repair, we observed two S4, two S3þ, two S3, one S2, and one S0 sensory recovery. Less favorable results were observed for motor function with three M4, one M3, two M2, and two M0 recoveries. Altogether, the results of this retrospective study demonstrates that tubulization nerve repair in emergency, in case of short nerve gaps, may restore the continuity of the nerve avoiding secondary nerve grafting. This technique preserves donor nerve and, in case of failure, does not preclude a delayed repair with a nerve graft.Despite continuous researches and surgical innovations, the treatment of peripheral nerve injuries remains a com-plex problem. 1,2 Direct nerve repair is often impossible in case of loss of substance, thus requiring a different solu-tion to manage the gap. Nowadays, nerve autograft is still considered the ''gold standard'' for such lesions because it restores the continuity of nerve trunk without tension and offers and ideal support to regenerating axons. 2-7 A nerve autograft is rich of Schwann cells which have a major role in nerve repair due to basal membrane pro-teins (fibronectin and laminin) that promote and address axonal regeneration. [8][9][10][11] However, clinical outcome is often unsatisfactory and thus alternative types of nerve guides are sought. 1,5,12 The timing of intervention and the type of injury are major issues in nerve repair. As general rule, an open nerve injury should be early treated and repaired directly when optimal conditions, such as a) a clean-uncontami-nated wound and b) a sharp cut injury, are present. 12 Pri-mary nerve repair with nerve graft in crush injuries could be a risk because the extent of resection might be diffi-cult to judge in case of nerve laceration and contusion; in addition, sometimes it is better to avoid primary repair because of the conditions of the surrounding tissues. 13 In these circumstances, it may be advisable to identify and suture the nerve ends to avoid retraction, and then look-ing forward to a secondary recons...
Many surgical techniques are available for bridging peripheral nerve defects. Autologous nerve grafts are the current gold standard for most clinical conditions. In selected cases, alternative types of conduits can be used. Although most efforts are today directed towards the development of artificial synthetic nerve guides, the use of non-nervous autologous tissue-based conduits (biological tubulization) can still be considered a valuable alternative to nerve autografts. In this paper we will overview the advancements in biological tubulization of nerve defects, with either mono-component or multiple-component autotransplants, with a special focus on the use of a vein segment filled with skeletal muscle fibers, a technique that has been widely investigated in our laboratory and that has already been successfully introduced in the clinical practice.
End-to-side neurorrhaphy constitutes an interesting option to regain nerve function after damage in selected cases, in which conventional techniques are not feasible. In the last twenty years, many experimental and clinical studies have been conducted in order to understand the biological mechanisms and to test the effectiveness of this technique, with contrasting results. In this updated review, we consider the state of the art about end-to-side coaptation, focusing on all the current clinical applications, such as sensory and mixed nerve repair, treatment of facial palsy, and brachial plexus injuries and painful neuromas management.
Background The “spare parts” approach to the reconstruction of below knee amputation, applied in acute trauma patients, can also be employed in elective surgery, ensuring knee salvage and a sensitive stump and enabling tissue harvesting without further donor-site morbidity. Methods We present a series of eight cases, where leg amputation due to trauma or its sequelae was followed by reconstruction with skin or a composite flap from the foot. An osteocutaneous flap was used in two emergency patients with below knee amputation, where it allowed stump elongation and knee coverage, and in five secondary procedures, where it provided both stump length and sensitive skin coverage. The skin of the foot was used in one case to cover the tibial stump. Fixation was accomplished with 2-mm Kirschner wires in the emergency patients and with an external fixator (n = 5) or by internal fixation (n = 1) in the elective procedures. Any complications were minor. Secondary compression with an external fixator was required in one emergency patient due to delayed bone healing. Results All knees healed. Sensibility was restored in all patients with a posterior tibial nerve suture (S4) and was well preserved in those without nerve coaptation. No patients reported problems with the prosthesis at a minimum follow-up of 3 years. Knee flexion and extension were comparable to those of the contralateral limb. Conclusion The “spare parts” concept is a reliable approach to tibial stump reconstruction. External fixation in elective procedures allowed immediate weight bearing and bone healing. In emergency patients, rapid fixation with wires provided satisfactory results.
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