What is new in peripheral nerve surgery management. Recent developments in investigation and research in nerve injury and their management.

1. Mr Vaikunthan Rajaratnam
MBBS(Mal),AM(Mal),FRCS(Ed),FRCS(Glasg),FICS(USA),
Dip Hand Surgery(Eur), Dip MedEd(Dundee), MIDT Dist. (OUM),
MBA(USA), FHEA(UK), FFST(Ed)
https://tinyurl.com/nervereview
MSSH
20 Oct 2018

3. Resting posture left hand Resting posture right hand

4. Passive extension

6. FCU
fascicle
Biceps
branch
Brachialis
branch
FCR
fascicle

7. Radial
artery
AIN
Median
nerve

9. Challenges of peripheral nerve injury

10. Electrodiagnostic
evaluation
Lu, C., Park, S., Richner, T. J., Derry, A., Brown, I., Hou, C., …
Anikeeva, P. (2017). Flexible and stretchable nanowire-coated
fibers for optoelectronic probing of spinal cord circuits.
Science Advances, 3(3)

11. Imaging assessment
van Alfen, N., & Mah, J. K. (2018). Neuromuscular Ultrasound: A New Tool in Your Toolbox. The Canadian Journal of
Neurological Sciences. Le Journal Canadien Des Sciences Neurologiques, 45(5), 504–515.

12. MR neurography (MRN)

13. Nerve ultrasound
Heinen, C., Dömer, P., Schmidt, T., Kewitz, B., Janssen-Bienhold, U., & Kretschmer, T. (2018). Fascicular Ratio Pilot Study: High-Resolution
Neurosonography-A Possible Tool for Quantitative Assessment of Traumatic Peripheral Nerve Lesions Before and After Nerve Surgery.
Neurosurgery
July 11, 2018

14. Soares, J. M., Marques, P., Alves, V., & Sousa, N. (2013).
A hitchhiker’s guide to diffusion tensor imaging.
Frontiers in Neuroscience, 7

15. Nerve Injury and Regeneration
Nam, A. S., Easow, J. M., Chico-Calero, I., Villiger, M., Welt, J., Borschel, G. H., … Vakoc,
B. J. (2018). Wide-Field Functional Microscopy of Peripheral Nerve Injury and
Regeneration. Scientific Reports, 8(1), 14004.
Published: 18 September 2018
Massachusetts Institute of Technology

17. 28 days

18. Wide-Field Functional
Microscopy
Fascicular vessels are green
Scale bars = 1 mm.

19. 7 14 28 days

20. Clinical indicators of recovery

21. SURGICAL ADVANCES
Fekrazad, R., Mortezai, O., Pedram, M., Kalhori, K. A., Joharchi, K., Mansoori, K., …
Mashhadiabbas, F. (2017). Transected sciatic nerve repair by diode laser protein soldering.
Journal of Photochemistry and Photobiology. B, Biology, 173, 441–447.

23. Nerve grafting techniques
• Tensgerity
• Autologous
nerve grafts
• Allograft
• Xenograft
Battiston, B., Titolo, P., Ciclamini, D., & Panero, B. (2017). Peripheral Nerve Defects:
Overviews of Practice in Europe. Hand Clinics, 33(3), 545–550.

24. Donor Nerves
Neligan – Plastic Surgery
Sebastin & Chung – Operative techniques in hand surgery, 2nd
ed
**SRN – only used when there is a irrepairable prox nerve injury e.g.
BPI
- no expectation of functional recovery of sensation

25. Terminal branch of PIN
• Floor of 4th
extensor
compartment
• 5 cm (1-3 fascicles)
• Ideal size for digital
nerve defects
• No loss of function

26. USE OF HUMAN NERVE
ALLOGRAFTS FOR
PRIMARY
MANAGEMENT
PERIPHERAL NERVE
INJURIES OUR
EXPERIENCE
April 2017 to ongoing
Patient review 3, 6,12 monthly
Prospective interventional
study
“Axogen” allograft

27. Sites
• DN – Digital nerves
• SRN – Sensory branch
of the radial nerve
• UMN – Ulnar motor
nerve
• MN – Median nerve
• DSN – UN – Dorsal
sensory branch of the
ulnar nerve

28. • 33 patients
• 36 lesions
• Males 25
• Females 8
• Average age 35
• Lacerations (28) neuromas(8)
• Majority digital nerves (21)
• 3 partial lesions
• 3 double nerve lesions
• Graft length 4mm – 45mm
• Average graft length 15.5mm
• Avg operation time 62 min

29. Results
Two point discrimination - static
•19 patients were reviewed
•Volar 6.07mm Average (6mm – 20 mm)
•Dorsum SRN injuries – Normal compared with
opposite side
Motor
Cases of motor nerve grafting 6/19
– M0 – 1 (Sural graft done)
– M2 - 1
– M3 - 1
– M4 – 2
– M5 – 1
Neuropathic pain - DN4 5 cases (26%)
Disability Q DASH Average 19.2 ( 0 – 68.75)

30. Synthetic conduits
• limited in defects of more than 10 mm
• Neurotrophic factors

31. Nerve Conduits
Rivlin et al (2010) The role of nerve allografts and conduits for nerve injuries. Hand Clin;26:435-446

32. Vein conduits
• Superficial veins,
gaps<3cm
• Equivalent results to nerve
autograft1,2
• Equivalent results to PGA,
fewer complications3
1 Calcagnotto & Silva (2006) The treatment of digital nerve defects by the technique of vein conduit with nerve segment. A
randomised prospective study. Chir Main;25(34):126-30
2 Chiu & Strauch (1990) A prospective clinical evaluation of autogenous vein grafts used as a nerve conduit for distal sensory
nerve defects of 3cm or less. Plast Reconstr Surg;86:928-34
3 Rinker & Liau (2011) Prospective randomized study comparing woven PGA & autogenous vein conduits for reconstruction
of digital nerve gaps. J Hand Surg Am;36(5):775-81

33. Evidence?
• PGA vs vein conduits – equivalent sensory recovery1
• Caprolactone vs primary repair – equivalent sensory recovery2
• PGA - improved sensory recovery compared to primary repair
& autologous nerve graft (gaps ≤4mm or ≥8mm)3
• Collagen conduit vs autograft – comparable results, PGA
conduits poorer4
• Caprolactone tubes – only 1/12 major nerve repair achieved
good outcome5
1 Rinker & Liau (2011) Propsective randomized study comparing woven PGA & autogenous vein conduits for reconstruction
of digital nerve gaps. J Hand Surg Am;36(5):775-81
2 Bertleff (2005) A prospective clinical evaluation of biodegradable neurolac nerve guides for sensory nerve repair in the
hand. J Hand Surg Am;30(3):513-8
3 Weber et al (2000) A randomized prospective study of PGA conduits for digital nerve reconstruction in humans. Plast
Reconstr Surg;106(5):1036-45
4 Waitayawinyu et al (2007) A comparison of PGA vs type 1 collagen bioabsorbable nerve conduits in a rat model: an
alternative to autografting. J Hand Surg Am;32(10):1521-9
5 Chiriac et al (2012) Experience of using the bioresorbable copolyester nerve conduit Neurolac for nerve repair in peripheral
nerve defects. J Hand Surg Eur;37(4):342-9

34. Nerve wraps
• Following nerve repairs /
neurolysis
• Protect the repair site
from adhesion
formation
• Vein / Synthetic
• Synthetic: Selective
permeability allowing
nutrient diffusion while
blocking fibroblast
migration
Orthopaedics 2017

35. Prevention and management of
traumatic neuroma
• Targeted muscle
reinnervation
• Nerve wraps
• Nerve ensheathing
with vein

36. Peripheral Nerve Injuries

37. Neurotisation
free functioning muscle transfe

38. REHABILITATION AND NON-
SURGICAL APPROACHES
low-intensity electrical stimulation of repaired
nerve for 1 h resulted in increased axonal
regeneration

39. Central adaptation after nerve
injury

40. Basic & Advance
Peripheral Nerve Transfer Course
https://tinyurl.com/NERVE2019
9-11 May 2019 Singapore