Upper extremity peripheral nerve reconstruction: An algorithm for injury classification and repair techniques
Matthew L. Iorio, M.D., Rose Fu, B.A., M.S., Ivica Ducic, M.D., Ph.D..
Georgetown University Hospital, Washington, DC, USA.
The repair of iatrogenic or traumatic nerve injuries requires a logical progression of reconstructive techniques, especially in the setting of late injury scarring and neuroma formation. Autogenous donor nerve harvesting may compound functional and sensory deficits, and a primary repair is frequently precluded by tissue loss or increased tension at the repair site. Methods of reconstruction that instead utilize alloplastic materials for primary injury site grafting and/or backgrafting of the donor site may markedly improve functional results and patient symptoms of pain or numbness. A retrospective review of all patients with upper extremity nerve reconstruction at our institution using this algorithm was performed to determine patient outcomes and functional utility of their reconstructed limb.
A retrospective chart review was performed on all patients that underwent upper extremity nerve reconstruction from January 2003 to March 2010. Reconstruction was performed on a total of 65 nerves, in 49 patients. Surgical indications, methods of reconstruction and sites were reviewed. The QuickDASH survey was utilized to measure postoperative patient outcomes and functional ability.
A combination of reconstructive techniques yielded 45 (69%) conduit repairs, 16 (25%) allograft repairs, and 4 (6%) autograft repairs. All but 5 patients had elimination of pre-operative pain. Four nerves did not regenerate and a partial regeneration of two nerves was identified, while the remainder had restored motor/sensory deficit.
In order to restore maximal target organ function with minimal donor site morbidity, we have created an algorithm centered upon tension-free repair that utilizes known evidence for alloplastic techniques of allogenic donor nerve, conduit use, and autologous donor nerve (Figure 1). An algorithmic approach defined by injury chronicity, nerve defect length and the type of nerve to be reconstructed, may help to define appropriate reconstructive methods and improve patient morbidity and outcomes.
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