American Society for Peripheral Nerve

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Using Joint Positioning to Overcome a Nerve Gap and Avoid the Use of a Nerve Graft: Surgical Technique and Clinical Outcome
Justin Brown, MD and Mehrnoush Gorjian, MD, Massachusetts General Hospital, Boston, MA

Introduction: Tensile loading is an influence on nerve growth and function that has been underutilized in the context of nerve regeneration. The traditional dogma indicates that undue tension at the nerve repair site will reduce final functional recovery and should be avoided in nerve repair surgery. We report our experience with direct nerve repair under mild tension and results that appear to supercede that of a similar graft repair.

Materials & Methods: A retrospective review of patients with a primary nerve injury who underwent a direct nerve repair under mild tension by the senior author between 2015 and 2018 was performed. Three patients with nerve injuries with a gap of greater than 3 cm were repaired directly. Intraoperatively, the injured section of the nerve (or neuroma) was resected, distal joint was positioned in flexion, and the nerve gap was reconstructed with a nerve tube to alleviate tension at the actual site of axon crossing. At the end of the procedure, a range of motion brace was used to maintain the joint in flexion with gradual extension of the joint over 12 weeks. Outcome measures included preoperative and postoperative MRC score, active and passive range of motion and sensation by Ten test.

Results: Patients were followed over at least 12 months or until recovery plateaued. Motor and sensory scores were recorded and video outcomes were obtained. All patients appeared to recover function both more rapidly and more robustly than similar injuries reconstruction with interposition grafts.

Conclusion: Although grafting is a reasonable alternative to direct repair when severe tension at the repair site is unavoidable, it presents several challenges that may downgrade the number of axons conveyed. Recent studies suggest that moderate levels of tension may, in fact, promote neuronal growth and accelerate functional recovery. Additionally, direct nerve repair has only one coaptation site for axons to cross compared to two in grafting and it ensures an anatomic and functional match to the distal stump in a primary injury that may further enhance the outcome.

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