A presentation on the principles, surgical technique and applications of end-to-side nerve anastomosis and the use of artificial nerve conduits

1. End-to-side repair &
nerve conduits
technique
Nickolaos A. Darlis, MD, PhD
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3. DONOR
Uninjured
RECIPIENT
Injured
The problem:
“Missing” proximal stump of
transected nerve

4. Terminal sprouting
Collateral nerve
sprouting
COLLATERAL NERVE SPROUTING
• Following nerve transection
(last mm)
• Silicon tube induced
• End to side repair induced

5. • Collateral Sprouting
• Chemotactism by distal
stump
• Axonal progression by
Contact Guidance

7. Courtesy, Marios Lykissas, MD

8. Double end-to-side repair

9. Double end-to-side repair
Courtesy, Marios Lykissas, MD

10. “Auto” end-to-side repair
For painful neuromas

11. “Auto” end-to-side repair

12. “No window” technique

13. Epineural window technique

14. Epineural window technique

16. Clinical applications
• Intact nerve to
musculocutaneous
• Ulnar to median at the
wrist
• Digital nerves
• Painfull neuromas
Sensory
recovery more
predictable
than motor

17. Conduits physiology
Proximal Distal
Axons
Schwann Cells
Neurotrophic
Factors

18. Bioabsorbable Conduits
• NeurotubeTM (Synovis)
– Polyglycolic acid (PGA), external
corrugation
• NeuraGenTM (Integra)
– Collagen (bovine deep flexor
tendon)
• NeurolacTM (Polyganics, Micrins)
– Polylactide caprolactone
(transparent, slower
degradation)

19. Bioabsorbable Conduits
• Semipermeable
• Prevent collapse
• Bioabsorbable
– Neurotube hydrolized by 6 mo
– Neurolac by 12 mo
• Claim to have minimal
inflammatory response
Courtesy, John Taras, MD
Courtesy, Dean Sotereanos, MD

20. Surgical technique
• Resection of nerve ends to intact fascicles
• Release tourniquet, hemostasis

21. Surgical technique
• Hydrate conduit in saline

22. Surgical technique
• Conduit length 1 cm more than gap (or more than 2
X nerve diameter)
• Suture placement
5mm

23. Surgical technique
5mm
• Flush with heparinized saline (10U per cc)

24. Surgical technique
• Healthy soft tissue coverage
• Typical immobilization 3 weeks (except for tendon
repairs)
• Sensory re-education

25. Conduit sizes
• NeuraGen
2, 3, 4, 5, 6, 7mm
• Neurotube
2.3, 4, 8mm
May combine tubes for larger nerves
• Neurolac
1.5, 2, 2.5, 3 mm

26. Conduits
Current clinical indication
short < 3 cm nerve gaps
mainly sensory or mixed nerves
Courtesy, John Taras, MD

27. Thank you
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