Innovative treatment of peripheral nerve injuries: combined reconstructive concepts

Although autografts are the gold standard for failed primary nerve repairs, they result in donor-site morbidity. Nerve conduits and decellularized allografts are a novel solution for improved functional outcomes and decreased donor-site morbidity. Unfortunately, previous reconstructive algorithms have not included the use of decellularized allograft nerve segments, either for repair of the primary injury or reconstruction of the autograft donor site. To identify the optimal sequence of techniques and resources, we reviewed our cases of upper extremity peripheral nerve reconstruction.

A retrospective review was performed on consecutive patients who underwent upper extremity nerve reconstruction between August 2003 and September 2009. Outcomes were evaluated with the QuickDASH (disabilities of the arm, shoulder, and hand) questionnaire. Grouped outcome results were evaluated with analysis of variance analysis. A literature review of available options for nerve reconstruction was performed.

In all, 47 patients were identified. Complete demographic/injury data were obtained in 41 patients with 54 discrete nerve repairs: 8 were repaired primarily, 27 with nerve conduits, 8 with allografts, and 11 with autografts. Time from injury to repair averaged 22.3 ± 38.3 weeks, with 12 repairs occurring immediately after tumor resection. Average QuickDASH score was 23.2 ± 19.8. An analysis of variance between repair-type outcomes revealed a P value of 0.58, indicating no outcome difference when each repair was applied for an appropriate gap. No comparable algorithm was identified in the literature analyzing the use of allograft in conjunction with conduit and autografts.

To restore maximal target-organ function with minimal donor-site morbidity, we have created an algorithm based on evidence for nerve reconstruction using allograft, conduit, and autologous donor nerve. Based on our clinical outcomes, despite small sample study, the adoption of the proposed algorithm may help provide uniform outcomes for a given technique, with minimal patient morbidity. Individualized reconstructive technique, based not only on nerve gap size but also on functional importance and the anatomical level of the nerve injury are important variables to consider for optimal outcome.