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Vascularized Cable Nerve Graft to Restore a 10-cm Nerve Gap: Histologic Evidence of Nerve Regeneration
Joshua T. Henderson, MD; Lundrim Marku, BS, MSc; Luis H Quiroga, MD, MPH; Hannah K. Smith, BS; Jack Gelman, MD; Stell Patadji Santiago, MD
West Virginia University, Morgantown, WV

Introduction: Cable nerve grafts are commonly employed for defects greater than 5cm, however axonal regeneration of longer defects can be limited by poor vascularization. Vascularized nerve autografts can enhance and possibly expedite regeneration, but microvascular perfusion of cable nerve grafts has only been proposed in animal studies. The current case demonstrates clinical and histologic evidence of efficient regeneration of a vascularized cable nerve graft.
Methods: A 35-year-old left-hand dominant man required wide resection of a myofibroblastic tumor, involving sacrifice of a 10-cm segment of the proximal left radial nerve. A vascularized sural nerve graft was harvested and inset as a cable nerve graft with the accompanying lesser saphenous vein oriented in an arteriovenous loop. Perineural perfusion through the lesser saphenous vein was afforded by microvascular anastomosis to branches of the proximal brachial system. The proximal and distal ends of the nerve graft were coapted to fascicles of the native proximal radial nerve, while the mid-point of the nerve graft was divided and coapted to separate fascicles of the intact distal radial nerve (Fig 1). Three months later, the patient suffered recurrence of the malignancy and required glenohumeral amputation. Our pathology team evaluated histologic sections at 1cm intervals throughout the native radial nerve and interposition vascularized cable nerve graft.
Results: At the time of amputation, the patient had recovered sensation in the posterior antebrachial cutaneous nerve distribution. Motor function had not yet returned. Histologic evaluation revealed intact perineurium surrounding viable fascicles with minimal degenerative changes through the first 5cm of the interposition cable nerve graft (Fig. 2). Distally, degenerative changes gradually increased with fewer and thinner nerve fibers, however the perineurium remained intact with multiple viable nerve fascicles.
Conclusion: This is the first histologic evaluation of nerve regeneration in a vascularized cable nerve graft in a human. The benefit of improved perineural perfusion is corroborated by clinical evidence of distal sensory recovery in only three months following a high radial nerve defect. While our patient unfortunately required amputation before motor recovery, sensation over the dorsal forearm recovered at a much faster rate than would be expected from a non-vascularized nerve graft.


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