bhandari2019 (1)
bhandari2019 (1)
a r t i c l e i n f o
Article history:
Received 8 July 2019
Accepted 8 August 2019
Available online 13 August 2019
https://doi.org/10.1016/j.jcot.2019.08.003
0976-5662/© 2019 Delhi Orthopedic Association. All rights reserved.
P.S. Bhandari / Journal of Clinical Orthopaedics and Trauma 10 (2019) 862e866 863
Fig. 3. Skin flaps raised both proximally and distally to get a good exposure of nerve
ends.
Fig. 5. Graft coaptation with fibrin glue.
Fig. 4. Nerve gaps bridged with sural nerve grafts. Fig. 6. Distal nerve transfer in isolated musculocutaneous nerve injury.
P.S. Bhandari / Journal of Clinical Orthopaedics and Trauma 10 (2019) 862e866 865
transplantation using end to side neurorraphy in facial palsy.23 Amr advances there remains limited indications for its application
et al. reported satisfactory results in 11 cases of brachial plexus which include insufficient nerve autografts,34 limb transplantation
injury managed with end to side neurorraphy.24 Other authors25 and pre-existing immunesuppression. The duration of immune
have also reported promising results with this technique. Never- suppression required for nerve allograft remains undetermined.
theless this is an interesting technique and in the future it may be a Mackinnon reported return of motor and sensory functions in 6 out
viable option in peripheral nerve injuries. of 7 nerve allograft transplants to upper and lower limbs.35
Use of cylindrical tube to bridge a gap between nerve ends has The use of immunosuppressant FK 506 (Tacrolimus) has been
been widely reported in current literature. Through neurotrophism shown to accelerate the nerve regeneration and functional recov-
the regeneration of axons occurs within this tube. Axons regener- ery. It acts via FK 506 binding protein (FKBP) receptors. The FKBP 12
ating from proximal stump grow through the conduit and selec- in receptor is responsible for immune suppression.36 The current
tively find their original pathways in the distal stump by application of FK 506 is in enhancing the nerve regeneration after
chemotactic attraction. This would negate the problem of cross nerve repair but its role as an adjunct to nerve allografting is
innervation of motor and sensory bundles. promising. Yan et al. in their experimental study on rat demon-
It avoids the morbidity associated with nerve graft. The semi strated significant therapeutic impact in short term use of FK 506 in
rigid tube prevents the soft tissue coming in between the nerve nerve regeneration. In future, the use of FK 506 is likely to play an
ends. Several studies have indicated the comparable results to important role in nerve regeneration.37
direct nerve repair and nerve grafts when nerve conduit was used
to reconstruct a short segment of nerve26,27(Fig. 7). The limitation 2.5. Results after peripheral nerve repair
of nerve conduits is the distance between the divided ends which
can be bridged. The 3e4 cms is the defining upper limit of nerve The outcomes of nerve reconstruction are influenced by multi-
gap which can be bridged with comparable results.28,29 Conduits factorial variables. In 1991, Sunderland made certain observations
from various biological and synthetic sources have been used. The regarding nerve repair. He found that outcomes in younger pa-
biological tubes include the use of arteries, veins, muscles and tients, early repair, repair close to target muscle, repair of single
modified biological tissues such as laminin and collagen. The lim- function nerve and short nerve graft had better outcomes. Kallio
itations of biological conduits in terms of early fibrosis, scar infil- et al.38 reported their results of 132 median nerve reconstruction
tration and tissue reaction have led to emergence of conduits made which were managed with nerve grafting and secondary neuror-
from synthetic materials. Commonly used synthetic conduits are raphy. They reported good to excellent results in 49%, fair results in
polyester such as polyglycolic acid, polylactic acid and poly- 11% and poor results in 40% of patients. The poor results were
galactin.30 In order to enhance nerve regeneration in these conduits associated with injury proximal to the elbow, age more than 54
the use of exogenous growth factors and neurotrophic factors have years, graft length of more than 7 cms and delayed surgery of more
been used.31 However for digital nerve repair excellent to good than 23 months. Similar results were published by Vastamaki
sensory function in 75% has been reported and for larger mixed et al.39 in reconstruction of ulnar nerve with 52% of patients
nerves functional recovery was obtained in 75% of patients with achieving useful recovery.
1e4 cms nerve gap reconstructed with conduits. Therefore the use
of nerve conduits in selected patients can produce comparable 3. Conclusion
results obviating the need for donor nerves and its resultant
morbidity. Despite advances in understanding of pathophysiology of nerve
injuries and advent of microsurgical techniques, the outcomes of
2.3. Nerve allografts repair have still not reached its zenith, with about 50% of patients
achieving useful nerve function. Current research in nerve injuries
The use of nerve allografts have been reported in primates by is challenging and newer modalities are under evaluation to further
Bain et al..32 The immunosuppressant FK 506 (Tacrolimus) has improve the results of nerve reconstruction.
benefitted the experimental allografting results which are compa-
rable with autografting in animal studies.33 However despite these Conflicts of interest
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