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A Second-look at Nerve Regeneration Inside Nerve-guides in Human Patients
Antonio Merolli, MD; Lorenzo Rocchi; Luigi Mingarelli; Francesco Catalano
The Catholic University, Rome, Italy
Introduction: We implanted nerve-guides in patients with gap-injuires up to 30 millimeters, from elbow to fingers. Most of patients were treated in emergency and presented associated lesions. We proposed a collagen implant (NeuroMatrix, Stryker; or, Neuragen, Integra) as an option to autologous grafting or neurectomy, informing the patients that a second operation could be enterprised like, for example, a tenolysis in multiple tendon lesions. During these successive surgery we had a second-look at nerve-guides and assessed macroscopically what was inside.
Materials and Methods: In the early 50 implants we treated 15 digital; 11 metacarpal; 10 median nerves; 7 ulnar; 6 superficial radial nerves. We performed 21 second-look: 6 in digital; 2 in metacarpal; 5 in median; 4 in ulnar; 4 in superficial radial implants. Of the remaining 29 implants, in 7 there were no associated lesions requiring a second-look. Protective sensory recovery and motor function was assessed by clinical examination.
Results: Digital implants showed a good sensory recovery and absence of painful neuroma. Guides in proximity of a joint did not add any discomfort and, at second-look, did not show collapse. Second look after 4 months showed a nerve-regenerate inside all guides. In metacarpal implants there was absence of painful neuroma, however the sensory recovery was obtained only in four patients. In median implants there was absence of painful neuroma and sensory recovery in all cases, however motor recovery was not obtained in six cases; furthermore, electrophysiological studies suggested that a Martin-Gruber anastomosis was performing most of the job in motor recovery. Second-look after 9 months showed a regenerate of variable entity. In ulnar implants there was absence of painful neuroma but sensory recovery was present in only two short-gap lesions and motor recovery in only one; second-look after 9 months showed a regenerate only in the guide with recovery. In all superficial radial implants there was, notably, absence of painful neuroma; sensory recovery was present in five cases. Second-look after 9 months showed a regenerate in highly degraded guides.
Conclusions: Pain was never recorded in all patients in this serie. An adequate sensory recovery occurred in all patients where a nerve-regenerate was found inside the guide. The degree of degradation appeard variable and not directly related to the time passed. Motor recovery seemed to be confined only in gap-lesion shorter than 10 millimeters. All patients which received the second-look operation were satisfied of the further improvement in their condition.
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