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Peripheral nerve injuries (PNIs) are common, with complex defects posing a significant reconstructive challenge. Although vascularised (VNGs) and non-vascularised nerve grafts (NVNGs) are established treatment options, there is no comprehensive summary of the evidence supporting their clinical, electrophysiological, and histological outcomes. This review aims to systematically evaluate the clinical and laboratory literature comparing VNGs and NVNGs to inform future clinical practice and research. This review was prospectively registered and reported according to PRISMA guidelines. PubMed, EMBASE, SCOPUS, and the Cochrane Register were systematically searched. Studies comparing VNGs and NVNGs in PNIs were included. Meta-analyses were performed for outcomes reported in ≥3 laboratory studies. Functional outcomes were synthesised by vote-counting based on direction of effect for clinical studies. Risk-of-bias was assessed using RoB2, ROBINS-I, and SYRCLE, and the certainty of evidence was evaluated using GRADE. Seven clinical and 34 laboratory studies were included. Of the clinical comparisons, 90% and 56% identified an effect on recovery of sensibility (p = 0.01) and motor function (p = 0.05), respectively, that favoured VNGs. Nine (of 13) separate meta-analyses of laboratory studies demonstrated reduced muscular atrophy, superior axonal regeneration, and remyelination in VNGs. VNGs eliminated the 3-day interval of ischaemia otherwise sustained by NVNGs. Overall, the quality of evidence was low. This systematic review indicates that VNGs may offer some advantages over NVNGs in PNI reconstruction. However, due to the low quality of evidence, significant statistical heterogeneity, and clinical diversity of the included studies, these conclusions should be interpreted with caution. Further high-quality clinical trials are necessary to validate these findings. [ABSTRACT FROM AUTHOR]

The use of acellular nerve allografts (ANAs) to reconstruct long nerve gaps (>3 cm) is associated with limited axon regeneration. To understand why ANA length might limit regeneration, we focused on identifying differences in the regenerative and vascular microenvironment that develop within ANAs based on their length. A rat sciatic nerve gap model was repaired with either short (2 cm) or long (4 cm) ANAs, and histomorphometry was used to measure myelinated axon regeneration and blood vessel morphology at various timepoints (2-, 4- and 8-weeks). Both groups demonstrated robust axonal regeneration within the proximal graft region, which continued across the mid-distal graft of short ANAs as time progressed. By 8 weeks, long ANAs had limited regeneration across the ANA and into the distal nerve (98 vs. 7583 axons in short ANAs). Interestingly, blood vessels within the mid-distal graft of long ANAs underwent morphological changes characteristic of an inflammatory pathology by 8 weeks post surgery. Gene expression analysis revealed an increased expression of pro-inflammatory cytokines within the mid-distal graft region of long vs. short ANAs, which coincided with pathological changes in blood vessels. Our data show evidence of limited axonal regeneration and the development of a pro-inflammatory environment within long ANAs. [ABSTRACT FROM AUTHOR]

In the management of brachial plexus birth palsies, the quality of the roots eligible for reconstruction is thought to be a key issue. The aim of the present study was to evaluate the correlations between pathological root examination and motor recovery after brachial plexus reconstructions. Quantitative histopathological analysis of intraneural fibrosis was conducted on 72 nerve transections (40 roots, 18 trunks and 14 suprascapular nerves) in 20 patients. Clinical recovery of targeted muscles after surgery was assessed by standardized functional scores. After a mean follow-up of 32 months, patients with a lower fibrosis rate for the suprascapular nerve had greater global Mallet scores (r = - 0.57; p = - 0.042) as well as a greater active shoulder flexion (r = - 0.66; p = - 0.015). Correlations were also found between C6 root and upper trunk fibrosis rate and some of the subsections of the Mallet score, active movement scale for the biceps and active elbow flexion. These results seem to confirm the relevance of intraoperative pathological evaluation of the roots and nerves after neuroma resection to optimally define the reconstruction strategy. [ABSTRACT FROM AUTHOR]

Background: Isolated radial nerve palsy is a debilitating injury that may potentially be reconstructed with either tendon transfers, nerve grafts, or nerve transfers. Currently, there is no consensus on the optimal technique for reconstruction. We performed a systematic review and analysis to determine which surgical intervention provides the best clinical outcomes. Methods: A systematic review was conducted according to PRISMA guidelines. Twenty-nine papers met inclusion criteria. Grading scales of function and strength were converted into a tripartite scoring system to compare outcomes between techniques. χ2 analyses were performed with a P value <.05. Results: Seven hundred fifty-four patients were analyzed. Tendon transfers resulted in the highest percentage of good outcomes (82%) and the lowest percentage of poor outcomes (9%). Tendon transfers were superior to nerve grafts and nerve transfers for restoration of wrist extension. Nerve transfers for wrist extension were superior to nerve transfers for finger extension. Nerve grafts and nerve transfers had equivalent rates of good and poor clinical outcomes. Conclusions: This study analyzed reported outcomes of tendon transfers, nerve grafts, and nerve transfers for reconstruction of isolated radial nerve palsy. On pooled analysis, tendon transfers had higher rates of superior clinical outcomes as compared with nerve transfers and nerve grafts. Tendon transfers should be considered first-line reconstruction for isolated radial nerve palsy as nerve-based reconstruction is less predictable and reproducible. [ABSTRACT FROM AUTHOR]

The polarity of nerve grafts does not interfere with axon growth. Our goal was to investigate whether axons can regenerate in a retrograde fashion within sensory pathways and then extend into motor pathways, leading to muscle reinnervation. Fifty-four rats were randomized into four groups. In Group 1, the ulnar nerve was connected end-to-end to the superficial radial nerve after neurectomy of the radial nerve in the axilla. In Group 2, the ulnar nerve was connected end-to-end to the radial nerve distal to the humerus; the radial nerve then was divided in the axilla. In Group 3, the radial nerve was divided in the axilla, but no nerve reconstruction was performed. In Group 4, the radial nerve was crushed in the axilla. Over 6 months, we behaviorally assessed the recovery of toe spread in the right operated-upon forepaw by lifting the rat by its tail and lowering it onto a flat surface. Six months after surgery, rats underwent reoperation, nerve transfers were tested electrophysiologically, and the posterior interosseous nerve (PIN) was removed for histological evaluation. Rats in the crush group recovered toe spread between 5 and 8 days after surgery. Rats with nerve transfers demonstrated electrophysiological and histological findings of nerve regeneration but no behavioral recovery. Ulnar nerve axons regrew into the superficial radial nerve and then into the PIN to reinnervate the extensor digitorum communis. We were unable to demonstrate behavioral recovery because rats cannot readapt to cross-nerve transfer. [ABSTRACT FROM AUTHOR]

Non-iatrogenic traumatic facial paralysis is most common in intratemporal facial nerve injury caused by temporal bone fracture, followed by intraparotid facial nerve branch injury. Facial paralysis caused by injury to the extratemporal trunk of the facial nerve is extremely rare. We present a case of a 60-year-old man suffering from immediate complete left peripheral facial paralysis due to blunt transection of extratemporal trunk of facial nerve by stabbing with a car key. There was a facial nerve defect about 1 cm in length. The great auricular nerve was grafted to repair the facial nerve. Over 12 months, his facial nerve function improved to a House–Brackmann III/VI. [ABSTRACT FROM AUTHOR]

Background Breast anesthesia is commonly reported after mastectomy and reconstruction. During deep inferior epigastric perforator (DIEP) flap reconstruction, we coapt at least one of the T10 to T12 thoracoabdominal nerves within the flap to the anterior cutaneous branch of the third intercostal nerve using a nerve allograft. We aim to evaluate the efficacy of nerve grafting in improving sensory recovery following neurotized DIEP flap reconstruction.

The arteries supplying the fingers and sensory nerve are located on the radial and ulnar aspects of the fingers, which are called the digital bundle. Masses can be found on this bundle topographically. This study aimed to investigate whether this mass originates from the neurovascular structure in patients presenting with a mass on the digital bundle topographically between the A1 pulley-distal interphalangeal (DIP)/interphalangeal (IP) joint in the finger. Additionally, it aimed to determine whether tumors originating from neurovascular structures originate from the main digital bundle and the steps involved in their reconstruction. We reviewed 27 cases with mass lesions at the digital bundle trace topographically between the A1 pulley and DIP/IP, which underwent surgery and were confirmed by histopathological examination between October 2014 and April 2022. Each patient requested at least two plane radiographs, US and MRI. All patients underwent surgery under a loupe-magnification or microscope. First, we determined whether the mass lesion originated from a main digital artery or nerve. Thereafter, the relationship of the mass with pulley and tendon structures was evaluated. All patients underwent histopathological examination. Mean follow-up 21 months. The mean age was 39.3 years. The pain was the most common presenting complaint and was observed in 13 patients. The tumors originating from neurovascular structures were found in 10 patients. In 5 patients, the tumor originated from the main digital artery and nerve. Three of them were reconstructed with a nerve graft. The most common non-neurovascular tumors were giant cell tendon sheath tumors and epidermal inclusion cysts. Some of the tumors on the topographically digital bundle are of neurovascular in origin. Reconstruction can be made in tumors originating from the main digital bundle. Again, the protection of pulley and tendon structures in this region is important in terms of morbidity. [Med-Science 2023; 12(3.000): 680-4]

Abstract Background Surgical management for chondrosarcoma of the temporomandibular joint (TMJ) is challenging due to the anatomical location involving the facial nerve and the functional joint. The purpose of this case series was to analyze the largest number of TMJ chondrosarcoma cases reported from a single institution and to review the literature about chondrosarcoma involving the TMJ. Methods Ten TMJ chondrosarcoma patients at Seoul National University Dental Hospital were included in this study. Radiographic features, surgical approaches, histopathologic subtypes, and treatment modalities were evaluated. All case reports of TMJ chondrosarcoma published in English from 1954 to 2021 were collected under PRISMA guidelines and comprehensively reviewed. Results The lesions were surgically resected in all 10 patients with efforts to preserve facial nerve function. Wide excision including margins of normal tissue was performed to ensure adequate resection margins. All TMJs were reconstructed with a metal condyle except one, which was reconstructed with vascularized costal bone. At last follow-up, all patients were still alive, and there had been no recurrence. Among 47 cases (patients from the literature and our cases), recurrence was specified in 43 and occurred in four (9.5%). Conclusions For surgical management of TMJ chondrosarcoma, wide excision must consider preservation of the facial nerve. Reconstruction using a metal condyle prosthesis and a vascularized free flap is reliable. A more conservative surgical approach correlates with a favorable prognosis for facial nerve recovery. Nevertheless, wide excision is imperative to prevent tumor recurrence. In cases in which the glenoid fossa is unaffected by the tumor, it is deemed unnecessary to reconstruct the glenoid fossa within an oncological setting.

The use of acellular nerve allografts (ANAs) to reconstruct long nerve gaps (>3 cm) is associated with limited axon regeneration. To understand why ANA length might limit regeneration, we focused on identifying differences in the regenerative and vascular microenvironment that develop within ANAs based on their length. A rat sciatic nerve gap model was repaired with either short (2 cm) or long (4 cm) ANAs, and histomorphometry was used to measure myelinated axon regeneration and blood vessel morphology at various timepoints (2-, 4- and 8-weeks). Both groups demonstrated robust axonal regeneration within the proximal graft region, which continued across the mid-distal graft of short ANAs as time progressed. By 8 weeks, long ANAs had limited regeneration across the ANA and into the distal nerve (98 vs. 7583 axons in short ANAs). Interestingly, blood vessels within the mid-distal graft of long ANAs underwent morphological changes characteristic of an inflammatory pathology by 8 weeks post surgery. Gene expression analysis revealed an increased expression of pro-inflammatory cytokines within the mid-distal graft region of long vs. short ANAs, which coincided with pathological changes in blood vessels. Our data show evidence of limited axonal regeneration and the development of a pro-inflammatory environment within long ANAs.

Plexiform schwannoma is an uncommon benign tumour that grows in a plexiform pattern. We report a 47-year-old man with a mass on the palmar aspect of the metacarpophalangeal joint of the right index finger that had been growing gradually for more than 10 years. The mass was palpated from the distal carpal tunnel to the ulnar aspect of the proximal interphalangeal joint of the index finger, with tingling and numbness sensation. The tumour was a multinodular tumour involving the first common palmar digital nerve to the ulnar proper palmar digital nerve. It was resected and reconstructed with a sural nerve graft. Plexiform schwannoma is rare in the digital nerve, with only six cases reported. Generally, classic schwannomas can be enucleated without causing neurologic deficits; however, plexiform schwannoma may require nerve resection. There have been reports of recurrence of plexiform schwannoma; definitive resection and long-term follow-up are necessary. Level of Evidence: Level V (Therapeutic) [ABSTRACT FROM AUTHOR]

Background: Traumatic peroneal nerve injuries are typically associated with high-energy injuries. The aim of this study was to evaluate the demographics and outcomes following surgical management of peroneal nerve injuries. Methods: Patients evaluated at a single institution with peroneal nerve injuries between 2001 and 2022 were retrospectively reviewed. Mechanism of injury, time to surgery, pre- and postoperative examinations, and operative reports were recorded. Satisfactory outcome, defined as the ability to achieve anti-gravity dorsiflexion strength or stronger following surgery, was compared between nerve grafting and nerve transfers in patients with at least 9 months of postoperative follow-up. Results: Thirty-seven patients had follow-up greater than 9 months after surgery, with an average follow-up of 3.8 years. Surgeries included neurolysis (n=5), direct repair (n=2), tibial motor nerve fascicle transfer to the anterior tibialis motor branch (n=18), or interposition nerve grafting using sural nerve autograft (n=12). At last follow-up, 59.5% (n=22) of patients had anti-gravity strength or stronger dorsiflexion. Nineteen (51.4%) patients used an ankle-foot orthosis during all or some activities. In patients that underwent nerve grafting only across the peroneal nerve defect, 44.4% (n=4) were able to achieve anti-gravity strength or stronger dorsiflexion. In patients that had a tibial nerve fascicle transfer to the tibialis anterior motor branch of the peroneal nerve, 42.9% (n=6) were able to achieve anti-gravity strength or stronger dorsiflexion at last follow-up. There was no statistical difference between nerve transfers and nerve grafting in postoperative dorsiflexion strength (p = 0.51). Conclusion: Peroneal nerve injuries frequently occur in the setting of knee dislocations and similar high-energy injuries. Nerve surgery is not universally successful in restoration of ankle dorsiflexion, with one-third of patients requiring an ankle-foot orthosis at mid-term follow-up. Patients should be properly counseled on the treatment challenges and variable outcomes following peroneal nerve injuries. [ABSTRACT FROM AUTHOR]

While there are advantages and disadvantages to both processed nerve allografts (PNA) and conduits, a large, well-controlled prospective study is needed to compare the efficacy and to delineate how each of these repair tools can be best applied to digital nerve injuries. We hypothesized that PNA digital nerve repairs would achieve superior functional recovery for longer length gaps compared with conduit-based repairs. Patients (aged 18–69 years) presenting with suspected acute or subacute (less than 24 weeks old) digital nerve injuries were recruited to prticipate at 20 medical centers across the United States. After stratification to short (5–14 mm) and long (15–25 mm) gap subgroups, the patients were randomized (1:1) to repair with either a commercially available PNA or collagen conduit. Baseline and outcomes assessments were obtained either before or immediately after surgery and planned at 3-, 6-, 9-, and 12-months after surgery. All assessors and patients were blinded to the treatment arm. In total, 220 patients were enrolled, and 183 patients completed an acceptable last evaluable visit (at least 6 months and not more than 15 months postrepair). At last follow-up, for the short gap repair groups, average static two-point discrimination was 7.3 ± 2.8 mm for PNA and 7.5 ± 3.1 mm for conduit repairs. For the long gap group, average static two-point discrimination was significantly lower at 6.1 ± 3.3 mm for PNA compared with 7.5 ± 2.4 mm for conduit repairs. Normal sensation (American Society for Surgery of the Hand scale) was achieved in 40% of PNA long gap repairs, which was significantly more than the 18% observed in long conduit patients. Long gap conduits had more clinical failures (lack of protective sensation) than short gap conduits. Although supporting similar levels of nerve regeneration for short gap length digital nerve repairs, PNA was clinically superior to conduits for long gap reconstructions. Therapeutic I. [ABSTRACT FROM AUTHOR]

The arteries supplying the fingers and sensory nerve are located on the radial and ulnar aspects of the fingers, which are called the digital bundle. Masses can be found on this bundle topographically. This study aimed to investigate whether this mass originates from the neurovascular structure in patients presenting with a mass on the digital bundle topographically between the A1 pulley-distal interphalangeal (DIP)/interphalangeal (IP) joint in the finger. Additionally, it aimed to determine whether tumors originating from neurovascular structures originate from the main digital bundle and the steps involved in their reconstruction. We reviewed 27 cases with mass lesions at the digital bundle trace topographically between the A1 pulley and DIP/IP, which underwent surgery and were confirmed by histopathological examination between October 2014 and April 2022. Each patient requested at least two plane radiographs, US and MRI. All patients underwent surgery under a loupe-magnification or microscope. First, we determined whether the mass lesion originated from a main digital artery or nerve. Thereafter, the relationship of the mass with pulley and tendon structures was evaluated. All patients underwent histopathological examination. Mean follow-up 21 months. The mean age was 39.3 years. The pain was the most common presenting complaint and was observed in 13 patients. The tumors originating from neurovascular structures were found in 10 patients. In 5 patients, the tumor originated from the main digital artery and nerve. Three of them were reconstructed with a nerve graft. The most common non-neurovascular tumors were giant cell tendon sheath tumors and epidermal inclusion cysts. Some of the tumors on the topographically digital bundle are of neurovascular in origin. Reconstruction can be made in tumors originating from the main digital bundle. Again, the protection of pulley and tendon structures in this region is important in terms of morbidity. [ABSTRACT FROM AUTHOR]

Background: Surgical management for chondrosarcoma of the temporomandibular joint (TMJ) is challenging due to the anatomical location involving the facial nerve and the functional joint. The purpose of this case series was to analyze the largest number of TMJ chondrosarcoma cases reported from a single institution and to review the literature about chondrosarcoma involving the TMJ. Methods: Ten TMJ chondrosarcoma patients at Seoul National University Dental Hospital were included in this study. Radiographic features, surgical approaches, histopathologic subtypes, and treatment modalities were evaluated. All case reports of TMJ chondrosarcoma published in English from 1954 to 2021 were collected under PRISMA guidelines and comprehensively reviewed. Results: The lesions were surgically resected in all 10 patients with efforts to preserve facial nerve function. Wide excision including margins of normal tissue was performed to ensure adequate resection margins. All TMJs were reconstructed with a metal condyle except one, which was reconstructed with vascularized costal bone. At last follow-up, all patients were still alive, and there had been no recurrence. Among 47 cases (patients from the literature and our cases), recurrence was specified in 43 and occurred in four (9.5%). Conclusions: For surgical management of TMJ chondrosarcoma, wide excision must consider preservation of the facial nerve. Reconstruction using a metal condyle prosthesis and a vascularized free flap is reliable. A more conservative surgical approach correlates with a favorable prognosis for facial nerve recovery. Nevertheless, wide excision is imperative to prevent tumor recurrence. In cases in which the glenoid fossa is unaffected by the tumor, it is deemed unnecessary to reconstruct the glenoid fossa within an oncological setting. [ABSTRACT FROM AUTHOR]

• Allogeneic nerve grafting led to more successful recovery than end-to-end neurorrhaphy after delayed peripheral nerve repair. • High numbers of Schwann cells are needed to promote NMJ reinnervation in the target muscle. • NMJ remodeling is related to agrin-Lrp4-MuSK signaling, Dok7 and Wnt4 during innervation. • Supplemental Schwann cells are important for delayed nerve repair. Peripheral nerve injury (PNI) induces severe functional loss in extremities. Progressive denervation and atrophy occur in the muscles if the nerve repair is delayed for long periods of the time. To overcome these difficulties, detailed mechanisms should be determined for neuromuscular junction (NMJ) degeneration in target muscles after PNI and regeneration after nerve repair. We established two models of end-to-end neurorrhaphy and allogeneic nerve grafting in the chronic phase after common peroneal nerve injury in female mice (n = 100 in total). We evaluated motor function, histology, and gene expression in the target muscles during their regeneration processes and compared the models. We found that the functional recovery with allogeneic nerve grafting was superior to that with end-to-end neurorrhaphy, and the number of reinnervated NMJs and Schwann cells was increased at 12 weeks after allograft. In addition, NMJ- and Schwann cell-related molecules showed high expression in the target muscle in the allograft model. These results suggest that Schwann cell migrating from the allograft might play a crucial role in nerve regeneration in the chronic phase after PNI. The relationship between the NMJ and Schwann cells should be further investigated in the target muscle. [ABSTRACT FROM AUTHOR]

Purpose: The exact relational anatomy for the anterior axillary approach, targeting the axillary nerve for nerve transfers/grafts, has not been fully investigated. Therefore, this study aimed to dissect and document the gross anatomy surrounding this approach, specifically regarding the axillary nerve and its branches. Methods: Fifty-one formalin-fixed cadavers (98 axilla) were bilaterally dissected simulating the axillary approach. Measurements were taken to quantify distances between identifiable anatomical landmarks and relevant neurovascular structures encountered during this approach. The musculo-arterial triangle, described by Bertelli et al., to aid in identification on localization of the axillary nerve, was also assessed. Results: From the origin of the axillary nerve till (1) latissimus dorsi was 62.3 ± 10.7 mm and till (2) its division into anterior and posterior branches was 38.8 ± 9.6 mm. The origin of the teres minor branch along the posterior division of the axillary nerve was recorded as 6.4 ± 2.9 mm in females and 7.4 ± 2.8 mm in males. The musculo-arterial triangle reliably identified the axillary nerve in only 60.2% of the sample. Conclusion: The results clearly demonstrate that the axillary nerve and its divisions can be easily identified with this approach. The proximal axillary nerve, however, was situated deep and therefore challenging to expose. The musculo-arterial triangle was relatively successful in localising the axillary nerve, however, more consistent landmarks such as the latissimus dorsi, subscapularis, and quadrangular space have been suggested. The axillary approach may serve as a reliable and safe method to reach the axillary nerve and its divisions, allowing for adequate exposure when considering a nerve transfer or graft. [ABSTRACT FROM AUTHOR]

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Purpose: To investigate the safety and feasibility of spider silk interposition for erectile nerve reconstruction in patients undergoing robotic radical prostatectomy (RARP). Methods: The major-ampullate-dragline from Nephila edulis was used for spider silk nerve reconstruction (SSNR). After removal of the prostate with either uni- or bilateral nerve-sparing, the spider silk was laid out on the site of the neurovascular bundles. Data analysis included inflammatory markers and patient reported outcomes. Results: Six patients underwent RARP with SSNR. In 50% of the cases, only a unilateral nerve-sparing was performed, bilateral nerve-sparing could be performed in three patients. Placement of the spider silk conduit was uneventful, contact of the spider silk with the surrounding tissue was mostly sufficient for a stable connection with the proximal and distal ends of the dissected bundles. Inflammatory markers peaked until postoperative day 1 but stabilized until discharge without any need for antibiotic treatment throughout the hospital stay. One patient was readmitted due to a urinary tract infection. Three patients reported about erections sufficient for penetration after three months with a continuous improvement of erectile function both after bi- and unilateral nerve-sparing with SSNR up to the last follow-up after 18 months. Conclusion: In this analysis of the first RARP with SSNR, a simple intraoperative handling without major complications was demonstrated. While the series provides evidence that SSNR is safe and feasible, a prospective randomized trial with long-term follow-up is needed to identify further improvement in postoperative erectile function due to the spider silk-directed nerve regeneration. [ABSTRACT FROM AUTHOR]

Background: We examined the effect of free tissue neurotization on speech and swallowing outcomes for patients undergoing reconstruction of hemiglossectomy defects with a radial forearm free flap (RFFF). Methods: A retrospective study was performed in patients with oral cavity squamous cell carcinoma undergoing a hemiglossectomy and reconstruction with a RFFF. Functional outcomes including nutritional mode, range of liquids and solids, and speech understandability were analyzed 1‐year post‐treatment. Results: Eighty‐four patients were included in this analysis, 41 of whom had neurotized flaps (49%). No significant differences in demographic or clinical variables were seen between the neurotized and non‐neurotized groups. On multivariate analysis controlling for BMI, flap area, and N‐classification, patients with neurotized flaps were significantly more likely to have normal range of liquids and solids and less likely to have a G‐tube. Conclusions: Neurotization of RFFF reconstructing hemiglossectomy defects results in decreased G‐tube dependence and improved range of liquids and solids. [ABSTRACT FROM AUTHOR]

Corneal neurotization is a promising surgical approach for the treatment of moderate to severe neurotrophic keratopathy. This technique aims to restore corneal sensation by transferring healthy nerves, either directly or via a conduit, to the anesthetic cornea. This review provides a report on the current state of development, evidence, and experience in the field. We summarize the data available from clinical reports and case series, placing an emphasis on the diversity of the surgical techniques reported. While these data are encouraging, they also highlight the need for a consensus in reporting outcomes and highlight how the next step will involve validating putative outcome parameters when researching and reporting corneal neurotization surgery. [ABSTRACT FROM AUTHOR]

Introduction/Aims: Although therapeutic electrical stimulation (TES) of injured peripheral nerve promotes axon regeneration and functional recovery, clinical applications of this therapy are limited to the intraoperative timeframe. Implantable, thin‐film wireless nerve stimulators offer a potential solution to this problem by enabling delivery of electrical stimuli to an injured nerve over a period of several days post‐surgery. The aim of this study was to determine the optimal time course of stimulation for maximizing functional recovery in a rat sciatic nerve isograft repair model. Methods: Adult male Lewis rats underwent thin‐film wireless nerve stimulator implantation following sciatic nerve transection and 40 mm nerve isograft repair. Immediately after surgery, animals began a daily regimen of TES for up to 12 consecutive days. Functional recovery was assessed by compound muscle action potential (CMAP), evoked muscle force, wet muscle mass, and axon counting. Results: Serial CMAP measurements increased in amplitude over the course of the study, yet no significant difference between cohorts for serial or terminal CMAPs was observed. Axon counts and wet muscle mass measurements were greatest in the 6‐day stimulation group, which correlated with a significant increase in evoked muscle force for the 6‐day stimulation group at the terminal time point. Discussion: Six daily sessions of TES were found to be most effective for augmenting functional recovery compared to other time courses of stimulation. Future studies should incorporate additional subjects and track axonal sprouting or measure neurotrophin levels during the therapeutic window to further elucidate the mechanisms behind, and ideal amount of, TES. [ABSTRACT FROM AUTHOR]

Substantial progress has been made in peripheral nerve surgery, owing to the advances in pathophysiological understanding, microsurgical techniques and the improvement of synthetic materials. Despite this, large gaps caused by trauma, tumor resection and congenital deformities show unsatisfactory results. While primary direct end-to-end tension-free nerve repair remains as the gold standard for surgical treatment, an autologous nerve graft is recommended for nerve gaps greater than 2 to 3 cm. Studies cite remarkable clinical reports with decellularized nerve allografts after overcoming the previous immune suppression and cost issues with allograft nerve transfers. New light is being shed regarding synthetic nerve conduits that combines various cytokines and growth factors. Stem cell studies applying biomolecular and biological engineering technologies also show good results. Despite this, further assessment are required for clinical application because these results are based primarily on animal studies. [ABSTRACT FROM AUTHOR]

Facial nerve weakness can cause deficient eye closure with reduced corneal protection. Surgical remedies can be static to oppose the levator muscle (lid loading) or dynamic procedures, which act to increase the strength of closure. This retrospective cohort study compares these groups. The hypothesis is that dynamic reconstruction has advantages over static techniques in terms of eye closure, symptomatic improvement, blink restoration, and complication rate. Two cohorts were compared: those treated with a gold weight insertion into the upper eyelid and those who had received dynamic reconstruction. These included temporalis transfer; cross face nerve grafting alone (CFNG) and CFNG followed by free tissue transfer. Assessments included standard photography and video; measurement of eyelid excursion including residual gap and if full eye closure was possible. The presence of the blink reflex and symptoms of dry eye was assessed. Overall improvement in eye closure was similar with the gold weight compared to dynamic procedures (5.1 mm vs 5.3 mm). Dynamic procedures however gave improved results in terms of symptom relief and restoration of blink. They also had fewer complications and revision rates overall. The study confirms the hypothesis that dynamic reconstructions of the paralysed eyelid confer advantages compared to simple lid loading techniques. Improvements in lid excursion are similar, but symptom improvement and blink restoration are significantly better. A decision regarding eyelid reanimation should be made early in the patient's journey of facial reanimation to allow for accurate planning and placement of nerve grafts at an early stage. [ABSTRACT FROM AUTHOR]

Background and Objectives: Neuralgic amyotrophy (NA), also known as Parsonage-Turner syndrome, is a rare and acute neuropathy of the shoulder and/or arm. It is characterized by sudden pain attacks, followed by patchy muscle paresis in the upper extremity. The frequency of remaining neurological deficits varies in the literature between 10% and 66%. In addition to other therapeutic strategies, nerve branch transposition might be a possible treatment option to improve muscle strength and reduce pain symptoms. Transposition of the first motor triceps branch to the axillary nerve was first described in 2003 to regain the deltoid muscle function in patients with C5 (C6) root injury.To our knowledge, this is the first description of nerve transfer for treating permanent paresis in NA. Methods: We present the case and the surgical treatment of a 16-year-old male with loss of axillary nerve function due to NA on both upper extremities. Neurological examination before surgery, 6 and 12 months after surgery included analysis of the upper extremity range of motion and muscle strength evaluated using the Medical Research Council Scale. Results: Shoulder function and muscle strength improved significantly 12 months after surgery. The range of motion of arm abduction improved from 90° preoperatively, to as high as 120° at 6 months, and to 130° at 12 months. Muscle strength was strength grade 2/5 preoperatively, 3/5 at 6 months, and 4+/5 at 12 months. Subjectively, the patient also has a significantly improved quality of life. Conclusion: Nerve transfer is a promising treatment method for patients suffering from NA.

Background: Nerve injury following arthroscopic shoulder procedures is a rare complication. Most patients will have gradual resolution of symptoms. Operative management may be required in the setting of complete nerve injury. Purpose: We present a case detailing our experience managing a patient with a complete median nerve transection following shoulder arthroscopy for a rotator cuff injury. Case Description: A thirty-nine-year-old female was referred to our office five months after undergoing a shoulder arthroscopy for a rotator cuff repair. Upon waking up from her initial surgery, she reported pain, numbness, and weakness in her right arm and hand, including the inability to make a fist or fully flex her first or second fingers. She was found to have right thenar eminence atrophy. Motor exam revealed profound weakness in flexors of the thumb and index finger. Because of the high likelihood of median nerve injury given the patient’s clinical presentation and surgical history along with an unremarkable brachial plexus MRI, surgery was recommended. Upon surgical exposure, the median nerve was found to be completely transected with a large neuroma. The neuroma was removed, and the nerve ends were trimmed with a sural nerve graft used to complete the repair. At her one and a half year follow up, she continued to demonstrate improvement although still complained of numbness in her first three fingers and weakness in her right hand. However, unlike preoperatively, her pain was well-controlled. Conclusion: Although distal neuropathies are a common preoperative complaint of patients with rotator cuff injuries, new onset nerve injuries as a complication from surgical repair should not be overlooked. Prevention of nerve injury is critical through adequate exposure and positioning during surgery. If a nerve injury does occur, examination during follow up visits are critical for monitoring the progression of symptoms and need for additional interventions.

BACKGROUND AND OBJECTIVES: In complex hand traumas nerves and vessels are often destructed without the possibility for primary repair. For bridging defects of nerves, veins and arteries grafts are necessary. Commonly nerve and vein grafts from adjacent donor sites as the wrist, forearm or cubital region are harvested. METHODS: This study is a retrospective cohort study. Between 2017 and 2019, 10 patients with complex hand injuries were treated. There were 8 males and 2 females, with an average age of 39 years (range 8–63 years). In all cases grafts were used of the dorsum of the foot for reconstructing of the severed digital nerves and arteries. All donor sites could be closed primarily. RESULTS: In 100% of cases nerves and veins of the dorsum of the foot showed a good size match as well as adequate length for a sufficient repair. The overall Hand Injury Severity Score (HISS) was determined with a median of 86 (range 57 to 286). In the area of the donor site no relevant complications were seen. CONCLUSIONS: In complex hand injuries the dorsum of the foot is a favorable donor site for nerve and vein graft harvest. [ABSTRACT FROM AUTHOR]

We report a case of a bilateral glass injury to the wrist with transection of flexor tendons and the ulnar nerve and artery in a 60-year-old male patient. Two days after his accident, we repaired all divided structures, and on the right hand, we added the transfer of the opponens motor branch to the deep terminal division of the ulnar nerve aimed at first dorsal interosseous and adductor pollicis muscle reinnervation. After surgery, the patient was followed over 24 months. Postoperative dynamometry of the hand, which included grasping, key-pinch, subterminal-key-pinch, pinch-to-zoom, and first dorsal interosseous muscle strength, indicated recovery only in the nerve transfer side. [ABSTRACT FROM AUTHOR]

Acellular nerve allografts conducted via chemical extraction have achieved satisfactory results in bridging whole facial nerve defects clinically, both in terms of branching a single trunk and in connecting multiple branches of an extratemporal segment. However, in the clinical treatment of facial nerve defects, allogeneic donors are limited. In this experiment, we exposed the left trunk and multiple branches of the extratemporal segment in six rhesus monkeys and dissected a gap of 25 mm to construct a monkey model of a whole left nerve defect. Six monkeys were randomly assigned to an autograft group or a xenogeneic acellular nerve graft group. In the autograft group, the 25-mm whole facial nerve defect was immediately bridged using an autogenous ipsilateral great auricular nerve, and in the xenogeneic acellular nerve graft group, this was done using a xenogeneic acellular nerve graft with trunk-branches. Examinations of facial symmetry, nerve-muscle electrophysiology, retrograde transport of labeled neuronal tracers, and morphology of the regenerated nerve and target muscle at 8 months postoperatively showed that the faces of the monkey appeared to be symmetrical in the static state and slightly asymmetrical during facial movement, and that they could actively close their eyelids completely. The degree of recovery from facial paralysis reached House-Brackmann grade II in both groups. Compound muscle action potentials were recorded and orbicularis oris muscles responded to electro-stimuli on the surgical side in each monkey. FluoroGold-labeled neurons could be detected in the facial nuclei on the injured side. Immunohistochemical staining showed abundant neurofilament-200-positive axons and soluble protein-100-positive Schwann cells in the regenerated nerves. A large number of mid-graft myelinated axons were observed via methylene blue staining and a transmission electron microscope. Taken together, our data indicate that xenogeneic acellular nerve grafts from minipigs are safe and effective for repairing whole facial nerve defects in rhesus monkeys, with an effect similar to that of autologous nerve transplantation. Thus, a xenogeneic acellular nerve graft may be a suitable choice for bridging a whole facial nerve defect if no other method is available. The study was approved by the Laboratory Animal Management Committee and the Ethics Review Committee of the Affiliated Wuxi No. 2 People’s Hospital of Nanjing Medical University, China (approval No. 2018-D-1) on March 15, 2018.

Both interposition nerve grafts and masseter nerve transfers have been successfully used for facial reanimation after irreversible injuries to the cranial portion of the facial nerve. However, no comparative study of these two procedures has yet been reported. In this two-site, two-arm, retrospective case review study, 32 patients were included. Of these, 17 patients (eight men and nine women, mean age 42.1 years) underwent interposition nerve graft after tumor extirpation or trauma between 2003 and 2006 in the Ear Institute, School of Medicine, Shanghai Jiao Tong University, China, and 15 patients (six men and nine women, mean age 40.6 years) underwent masseter-to-facial nerve transfer after tumor extirpation or trauma between November 2010 and February 2016 in Shanghai Ninth People’s Hospital, China. More patients achieved House-Brackmann III recovery after masseter nerve repair than interposition nerve graft repair (15/15 vs. 12/17). The mean oral commissure excursion ratio was also higher in patients who underwent masseter nerve transfer than in patients subjected to an interposition nerve graft. These findings suggest that masseter nerve transfer results in strong oral commissure excursion, avoiding obvious synkinesis, while an interposition nerve graft provides better resting symmetry. This study was approved by the Institutional Ethics Committee, Shanghai Ninth People’s Hospital, China (approval No. SH9H-2019-T332-1) on December 12, 2019.