Nerve repair by means of tubulization: Literature review and personal clinical experience comparing biological and synthetic conduits for sensory nerve repair

Abstract

Nerve repair is usually accomplished by direct suture when the two stumps can be approximated without tension. In the presence of a nerve defect, the placement of an autologous nerve graft is the current gold standard for nerve restoration. However, over the last 20 years, an increasing number of research articles reported on the use of non-nervous tubes (tubulization) for repairing nerve defects. The clinical employment of tubes (both biological and synthetic) as an alternative to autogenous nerve grafts is mainly justified by the limited availability of donor tissue for nerve autografts and the related morbidity. In addition, tubulization was proposed as an alternative to direct nerve sutures in order to create optimal conditions for nerve regeneration over the short empty space intentionally left between two nerve stumps. This paper outlines recent important advances in this field. Different tubulization techniques proposed so far are described, focusing in particular on studies that reported on the employment of tubes with patients. Our personal clinical experience on tubulization repair of sensory nerve lesions (digital nerves), using both biological and synthetic tubes, is presented, and the clinical results are compared. In our case series, both types of tubes led to good clinical results. Finally, we speculate about the prospects in the clinical application of tubulization for peripheral nerve repair.

Primary repair of crush nerve injuries by means of biological tubulization with muscle‐vein‐combined grafts

“…26,27 Previous clinical experiences showed that successful results could be obtained in short-gap nerve repair with muscle-vein-combined conduits. 4,18 These results were recently confirmed by Marcoccio and Vigasio,19 who demonstrated the effectiveness of this technique in sec-ondary digital nerve reconstruction, highlighting the possibility of using the wound and surrounding tissues as donor sites for nerve repair in emergency surgery.…”

“…1,4 Experimen-tal research on rat demonstrated that filling the veins with fresh muscle fibers allow to obtain nerve regeneration that similar to that observed with nerve autografting. 22,23 Muscle fibers avoid conduit's collapse and promote axo-nal regeneration and Schwann cell migration by means of basal lamina scaffolds.…”

“…In addition, the technique was applied both in sensory and mixed nerve repair, and the case series is heterogeneous regarding zone of injury and amount of crush, presence of associated vascular injuries, length of the gap, age of the patients, and follow-up interval. However, heterogeneity is common to nerve reconstruction case series, and in comparison to previous reports using the same technique, 4,18 this study has at least eliminated heterogeneity due to variable interval between injury and repair focusing on primary recon-struction only.…”

“…4,14 Blood vessels were used as biological conduits for nerve repair starting from the first decade of the 20th century by Foramitti 15 and Wrede 16 who described the use of blood vessels as vehicles for nerve regeneration and reported successful clinical results in the reconstruction of nerve injuries with loss of substance. In 1993, Brunelli et al 17 described a new biological conduit based on the usage of a vein segment filled with fresh skeletal muscle (muscle-vein-combined graft).…”

“…This technique was then successfully translated to the clinics to treat selected cases of peripheral nerve defect. 4,18,19 However, in previously published case series, most of the patients were treated several months after injury. The aim of this study was to assess the results of nerve reconstruction in a group of patients who underwent, in emergency, a primary repair for crush injuries of sensory and mixed nerves of the upper limb with the musclevein-combined graft.…”