Advances in peripheral nerve reconstruction: Current clinical conduits, comparative outcomes, limitations, and future...

Peripheral nerve injuries remain a major clinical challenge, often resulting in persistent motor deficits, sensory loss, and neuropathic pain. When direct tension-free repair is not feasible, nerve reconstruction relies on autografts, processed allografts, or conduit-based strategies. Despite decades of innovation, outcomes remain inconsistent, particularly in motor nerves, long-gap defects, and complex traumatic environments.

What are the relative clinical performances and limitations of currently available nerve repair strategies, and which emerging technologies may address their unmet biological shortcomings?

This narrative review synthesizes clinical, experimental, and comparative evidence on autologous nerve grafts, processed nerve allografts, and biological or synthetic nerve conduits. Emphasis is placed on reported functional recovery, gap-length tolerance, complication profiles, and the influence of the injury microenvironment.

Autologous nerve grafting remains the benchmark for reliable regeneration but is limited by donor-site morbidity and graft availability. Processed nerve allografts preserve extracellular matrix architecture and demonstrate outcomes comparable to autografts for moderate-length defects, while avoiding harvest-related complications. In contrast, hollow biological and synthetic conduits show acceptable performance primarily in short sensory gaps, with declining efficacy in motor nerves, long defects, and inflammatory or scar-prone injuries.

Current nerve repair technologies are fundamentally constrained by their passive structural design and limited ability to modulate the inhibitory post-injury microenvironment. Future progress is likely to depend on integrative platforms that combine structural guidance with active biological modulation, including bioactive and hydrogel-based strategies, to enhance regeneration in complex peripheral nerve injuries.