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Upper Extremity Peripheral Nerve Reconstruction: An Algorithm for Injury Classification and Repair Techniques
John M. Felder, MD; Matt Iorio; Ivica Ducic, MD, PhD
Georgetown University Hospital, Washington, DC, USA
Background: 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. In order to identify the optimal sequence of techniques and resources, we reviewed our cases of upper extremity peripheral nerve reconstruction.
Methods: A retrospective review was performed on consecutive patients that underwent upper extremity nerve reconstruction from August 2003 through September 2009. Outcomes were evaluated with the QuickDASH. Grouped outcome results were evaluated with ANOVA analysis. A literature review of available options for nerve reconstruction was performed.
Results: 47 patients were identified. Complete demographic/injury data was 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 following 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.
Conclusion: In order 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 study sample, the adoption of proposed algorithm may help provide uniform outcomes for a given technique, with minimal patient morbidity.
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