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      Sensory Recovery Outcome after Digital Nerve Repair in Relation to Different Reconstructive Techniques: Meta-Analysis and Systematic Review

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          Abstract

          Good clinical outcome after digital nerve repair is highly relevant for proper hand function and has a significant socioeconomic impact. However, level of evidence for competing surgical techniques is low. The aim is to summarize and compare the outcomes of digital nerve repair with different methods (end-to-end and end-to-side coaptations, nerve grafts, artificial conduit-, vein-, muscle, and muscle-in-vein reconstructions, and replantations) to provide an aid for choosing an individual technique of nerve reconstruction and to create reference values of standard repair for nonrandomized clinical studies. 87 publications including 2,997 nerve repairs were suitable for a precise evaluation. For digital nerve repairs there was practically no particular technique superior to another. Only end-to-side coaptation had an inferior two-point discrimination in comparison to end-to-end coaptation or nerve grafting. Furthermore, this meta-analysis showed that youth was associated with an improved sensory recovery outcome in patients who underwent digital replantation. For end-to-end coaptations, recent publications had significantly better sensory recovery outcomes than older ones. Given minor differences in outcome, the main criteria in choosing an adequate surgical technique should be gap length and donor site morbidity caused by graft material harvesting. Our clinical experience was used to provide a decision tree for digital nerve repair.

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          Most cited references125

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          A 25-year perspective of peripheral nerve surgery: evolving neuroscientific concepts and clinical significance.

          G Lundborg (2000)
          In spite of an enormous amount of new experimental laboratory data based on evolving neuroscientific concepts during the last 25 years peripheral nerve injuries still belong to the most challenging and difficult surgical reconstructive problems. Our understanding of biological mechanisms regulating posttraumatic nerve regeneration has increased substantially with respect to the role of neurotrophic and neurite-outgrowth promoting substances, but new molecular biological knowledge has so far gained very limited clinical applications. Techniques for clinical approximation of severed nerve ends have reached an optimal technical refinement and new concepts are needed to further increase the results from nerve repair. For bridging gaps in nerve continuity little has changed during the last 25 years. However, evolving principles for immunosuppression may open new perspectives regarding the use of nerve allografts, and various types of tissue engineering combined by bioartificial conduits may also be important. Posttraumatic functional reorganizations occurring in brain cortex are key phenomena explaining much of the inferior functional outcome following nerve repair, and increased knowledge regarding factors involved in brain plasticity may help to further improve the results. Implantation of microchips in the nervous system may provide a new interface between biology and technology and developing gene technology may introduce new possibilities in the manipulation of nerve degeneration and regeneration.
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            Analysis of upper and lower extremity peripheral nerve injuries in a population of patients with multiple injuries.

            The purpose of this study was to determine the prevalence, cause, severity, and patterns of associated injuries of limb peripheral nerve injuries sustained by patients with multiple injuries seen at a regional Level 1 trauma center. Patients sustaining injuries to the radial, median, ulnar, sciatic, femoral, peroneal, or tibial nerves were identified using a prospectively collected computerized database, maintained by Sunnybrook Health Science Centre, and a detailed chart review was undertaken. From a trauma population of 5,777 patients treated between January 1, 1986, and November 30, 1996, 162 patients were identified as having an injury to at least one of the peripheral nerves of interest, yielding a prevalence of 2.8%. These 162 patients sustained a total of 200 peripheral nerve injuries, 121 of which were in the upper extremity. The mean patient age was 34.6 years (SEM +/- 1.1 year), and 83% of patients were male. The mean injury severity score was 23.1 (+/-0.90), and the mean length of hospital stay was 28 days (+/-1.8). Motor vehicles crashes predominated (46%) as the cause of injury. The most frequently injured nerve was the radial nerve (58 injuries), and in the lower limb, the peroneal nerve was most commonly injured (39 injuries). Diagnosis of a peripheral nerve injury was made within 4 days of admission to Sunnybrook Health Science Centre in 78% of the cases. Surgery was required to treat 54% of patients. Head injuries were the most common associated injury, occurring in 60% of patients. Other common associated injuries included fractures and dislocations. The present report aims to aid in identification and treatment of peripheral nerve injuries.
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              Current applications and future perspectives of artificial nerve conduits.

              Artificial nerve guide conduits have the advantage over autografts in terms of their availability and ease of fabrication. However, clinical outcomes associated with the use of artificial nerve conduits are often inferior to that of autografts, particularly over long lesion gaps. There have been significant advances in the designs of artificial nerve conduits over the years. In terms of materials selection and design, a wide variety of new synthetic polymers and biopolymers have been evaluated. The inclusion of nerve conduit lumen fillers has also been demonstrated as essential to enable nerve regeneration across large defect gaps. These lumen filler designs have involved the integration of physical cues for contact guidance and biochemical signals to control cellular function and differentiation. Novel conduit architectural designs using porous and fibrous substrates have also been developed. This review highlights the recent advances in synthetic nerve guide designs for peripheral nerve regeneration, and the in vivo applicability and future prospects of these nerve guide conduits. Copyright 2009 Elsevier Inc. All rights reserved.
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                Author and article information

                Journal
                Plast Surg Int
                Plast Surg Int
                PSI
                Plastic Surgery International
                Hindawi Publishing Corporation
                2090-1461
                2090-147X
                2013
                30 July 2013
                : 2013
                : 704589
                Affiliations
                1Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675 Munich, Germany
                2Institut für Medizinische Statistik und Epidemiologie, Medizinische Biometrie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675 Munich, Germany
                3Institut für Klinische Radiologie, Campus Grosshadern, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377 München, Germany
                Author notes

                Academic Editor: Georg M. Huemer

                Author information
                http://orcid.org/0000-0002-6481-9504
                Article
                10.1155/2013/704589
                3745965
                23984064
                a26c5be8-12f6-41fa-bfbf-1c7d8dc0616b
                Copyright © 2013 Felix J. Paprottka et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 27 March 2013
                : 30 June 2013
                Categories
                Review Article

                Surgery
                Surgery

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