Beyond One-Size-Fits-All: Pioneering a Zone-Based Strategy in Digital Nerve Autografting

Digital nerve injuries significantly affect hand function and quality of life, necessitating effective reconstruction strategies. Autologous nerve grafting remains the gold standard due to its superior biocompatibility, despite recent advancements in nerve conduits and allogenic grafts. This study aims to propose a novel zone-based strategy for donor nerve selection to improve outcomes in digital nerve reconstruction.

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, searching PubMed, Embase, Cochrane Library, and Web of Science for articles published from January 2004 to December 2023. Inclusion criteria included studies involving adult human subjects undergoing autologous nerve grafting for digital nerve reconstruction, with sensory recovery and donor site morbidity as primary outcome measures. Additionally, an anatomical study comparing donor nerves to digital nerves was included.

Five studies met the inclusion criteria: 4 clinical studies and 1 anatomical study. Analysis of the 4 included clinical studies showed that the posterior interosseous nerve had the lowest donor site morbidity (6.25%), while the lateral antebrachial cutaneous nerve (LABCN) demonstrated the best sensory recovery outcomes (mean 2-point discrimination of 5.92 mm, with 100% of patients achieving good to excellent recovery). The sural nerve exhibited acceptable donor site morbidity (15%) but showed the lowest sensory recovery outcomes (mean 2-point discrimination of 10.8 mm, with only 46% of patients reporting good to very good recovery). The anatomical study indicated that the LABCN had the closest match in cross-sectional area and fascicle count to most zones of the digital nerve, supporting its suitability as a graft source.

Although there are many nerve reconstruction techniques available, autologous nerve grafting remains the gold standard. Based on the analysis of five studies, this review proposes a new zone-based approach for donor nerve selection, emphasizing matching donor nerves to specific injury zones. This tailored strategy can potentially optimize both functional recovery and donor site morbidity, moving beyond the one-size-fits-all paradigm. The posterior interosseous nerve, LABCN, and SN each provide unique benefits depending on the zone of injury, suggesting that this approach may lead to improved patient outcomes. Future research is needed to validate this framework.