Review
Management of nerve gaps: Autografts, allografts, nerve transfers, and end-to-side neurorrhaphy

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Introduction

Since its introduction in the late 1879's, surgical restoration of function following peripheral nerve injury has made significant progress (Naff and Ecklund, 2001). The development of the operating microscope, improved microsurgical techniques, and a greater understanding of the internal topography of peripheral nerves has greatly improved functional outcomes. In addition, advances in basic science and clinical research have furthered our understanding of the pathophysiology of nerve injury, recovery, and repair.

There are several factors that influence recovery following a nerve injury: time elapsed, patient age, mechanism, proximity of the lesion to distal targets, and associated soft tissue or vascular injuries (Gilbert et al., 2006, Hentz and Narakas, 1988, Slutsky, 2006). All these factors must be carefully considered in order to optimize the operative approach used in each unique patient. Prompt repair of nerve injuries leads to improved outcomes by allowing for earlier distal motor end plate and sensory receptor reinnervation. In younger patients, the more robust regenerative capacity typically results in better outcomes compared to the elderly. Mechanism of damage is an important determinant of the longitudinal extent of the injury. More proximal lesions must traverse longer distances to reinnervate the distal target. And finally, concomitant soft tissue or vascular injuries can result in significant distortion and scarring, seriously complicating exploration of the affected area.

The ultimate goal of any peripheral nerve reconstruction is the restoration of function as promptly and completely as possible, while minimizing donor site and systemic morbidity. In cases where a tension-free primary end-to-end neurorrhaphy is not possible, several alternatives exist. This review summarizes these options for repair including interpositional nerve grafting, transfers and end-to-side neurorrhaphy (Fig. 1).

Section snippets

Timing of nerve repairs (open vs. closed)

The process of determining optimal timing for nerve repairs begins as soon as the patient presents. Information regarding the mechanism of injury or onset of symptoms will guide the clinician towards the most suitable treatment modality. Patients presenting with open injuries and neurological deficit require early exploration (Fig. 2). While concomitant vascular injuries may necessitate emergency exploration, in general it is appropriate to wait to explore open injuries with neurological

Management of nerve gaps

When tension-free primary repair is not possible, a suitable alternative must be pursued. The surgical technique employed in these alternatives is similar, whether it be a nerve graft, conduit, or nerve transfer. The proximal and distal nerve ends are trimmed until normal fascicular structure is revealed (Figs. 4 A–C), allowing the surgeon to achieve appropriate realignment. While considerable attention to detail is typically devoted to the microsurgical technique of a nerve repair, an

Autogenous nerve grafts

Autogenous nerve grafting has long been considered the “gold standard” for repair of irreducible nerve gaps. Autogenous grafts act as immunogenically inert scaffolds, providing appropriate neurotrophic factors and viable Schwann cells (SCs) for axonal regeneration. The choice of autogenous graft is dependent on several factors: the size of the nerve gap, location of proposed nerve repair, and associated donor-site morbidity. Although the sural nerve is the most commonly used autograft, there

Nerve transfers

Nerve transfers convert a proximal injury into a distal one by transferring “near by” redundant nerve function to a distal denervated nerve close to the target. The concept of nerve transfer itself is not new (Kotani et al., 1971, Tuttle, 1913), but has gained significant momentum over the past decade with many authors reporting good outcomes (Brandt and Mackinnon, 1993, El-Gammal and Fathi, 2002, Samardzic et al., 2002, Waikakul et al., 1999). The use of nerve transfers for proximal upper

End-to-side coaptation

Described over a century ago (Balance et al., 1903, Harris, 1903) end-to-side coaptation is an alternative in cases where the proximal nerve stump is not available or inaccessible; instead, the injured distal stump is coapted to the side of an uninjured donor nerve. In 1994, Viterbo et al. sparked new interest in this technique by reporting axonal regeneration with the use of end-to-side neurorrhaphy in a rat model (Viterbo et al., 1994). This revitalized interest has given rise to a

Nerve conduits

A considerable amount of research has been devoted to the development of a viable synthetic or biologic nerve conduit, and currently several commercially available options exist. The authors limit their use of nerve conduits to the repair of noncritical small diameter sensory nerves, gaps less than 3 cm, and as a nerve repair wrap. We believe the concentration of neurotrophic factors is critical to advancing nerve regeneration, and if the volume of a conduit increases beyond a critical size (

Nerve allografts

The use of donor related or cadaveric nerve allografts is reserved for devastating or segmental nerve injuries. Like all tissue allotransplantation, nerve allografts require systemic immunosuppression; the associated morbidity of immunomodulatory therapy limits the widespread application of nerve allografting. Several techniques (e.g. cold preservation, irradiation, lyophilization) to reduce nerve allograft antigenicity have been described (Anderson and Turmaine, 1986, Campbell et al., 1963,

Rehabilitation following nerve repair/graft/transfer

Postoperative rehabilitation and re-education are critical following any nerve repair or transfer. Early goals involve protected range of motion exercises to prevent adhesions at the nerve repair site and to avoid joint stiffness and contractures. Subsequent goals of rehabilitation include sensory and motor re-education. It is well established that re-education is critical for optimizing outcomes following nerve repair or transfer (Oud et al., 2007). The capacity to re-establish association

Conclusion

Advances in laboratory and translational research will undoubtedly continue to shape current clinical practices. While each repair strategy has its own advantages and disadvantages, careful consideration of outcome goals and individual patient factors usually affords a directed surgical approach. The appropriate intervention is ultimately determined by injury type, patient characteristics, and surgeon preferences.

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