Supercharge nerve transfer to enhance motor recovery: a laboratory study.

PURPOSE: To investigate the ability of a supercharge end-to-side (SETS) nerve transfer to augment the effect of regenerating native axons in an incomplete rodent sciatic nerve injury model. METHODS: Fifty-four Lewis rats were randomized to 3 groups. The first group was an incomplete recovery model (IRM) of the tibial nerve complemented with an SETS transfer from the peroneal nerve (SETS-IRM). The IRM consisted of tibial nerve transection and immediate repair using a 10-mm fresh tibial isograft to provide some, but incomplete, nerve recovery. The 2 control groups were IRM alone and SETS alone. Nerve histomorphometry, electron microscopy, retrograde labeling, and muscle force testing were performed. RESULTS: Histomorphometry of the distal tibial nerve showed significantly increased myelinated axonal counts in the SETS-IRM group compared with the IRM and SETS groups at 5 and 8 weeks. Retrograde labeling at 8 weeks confirmed increased motoneuron counts in the SETS-IRM group. Functional recovery at 8 weeks showed a significant increase in muscle-specific force in the SETS-IRM group compared with the IRM group. CONCLUSIONS: An SETS transfer enhanced recovery from an incomplete nerve injury as determined by histomorphometry, motoneuron labeling within the spinal cord, and muscle force measurements. CLINICAL RELEVANCE: An SETS distal nerve transfer may be useful in nerve injuries with incomplete regeneration such as proximal Sunderland II- or III-degree injuries, in which long regeneration distance yields prolonged time to muscle reinnervation and suboptimal functional recovery.

Reverse end-to-side nerve transfer: from animal model to clinical use.

PURPOSE: Functional recovery after peripheral nerve injury is predominantly influenced by time to reinnervation and number of regenerated motor axons. For nerve injuries in which incomplete regeneration is anticipated, a reverse end-to-side (RETS) nerve transfer might be useful to augment the regenerating nerve with additional axons and to more quickly reinnervate target muscle. This study evaluates the ability of peripheral nerve axons to regenerate across an RETS nerve transfer. We present a case report demonstrating its potential clinical applicability. METHODS: Thirty-six Lewis rats were randomized into 3 groups. In group 1 (negative control), the tibial nerve was transected and prevented from regenerating. In group 2 (positive control), the tibial and peroneal nerves were transected, and an end-to-end (ETE) nerve transfer was performed. In group 3 (experimental model), the tibial nerve and peroneal nerves were transected, and an RETS nerve transfer was performed between the proximal end of the peroneal nerve and the side of the denervated distal tibial stump. Nerve histomorphometry and perfused muscle mass were evaluated. Six Thy1-GFP transgenic Sprague Dawley rats, expressing green fluorescent protein in their neural tissues, also had the RETS procedure for evaluation with confocal microscopy. RESULTS: Nerve histomorphometry showed little to no regeneration in chronic denervation animals but statistically similar regeneration in ETE and RETS animals at 5 and 10 weeks. Muscle mass preservation was similar between ETE and RETS groups by 10 weeks and significantly better than negative controls at both time points. Nerve regeneration was robust across the RETS coaptation of Thy1-GFP rats by 5 weeks. CONCLUSIONS: Axonal regeneration occurs across an RETS coaptation. An RETS nerve transfer might augment motor recovery when less-than-optimal recovery is otherwise anticipated. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Long-term role of external breast prostheses after total mastectomy.

After total mastectomy, many women choose to wear external breast prosthesis rather than undergo breast reconstruction. The purpose of this study was to evaluate long-term satisfaction among external breast prosthesis wearers and the impact of satisfaction on prosthesis use. A questionnaire was designed to assess demographic information, prosthesis information provision, prosthesis use, and satisfaction with prosthesis. Fifty-nine women who had undergone total mastectomy without breast reconstruction completed the questionnaire. The majority of women (68%) were at least 5 years out from mastectomy. Approximately half (49%) of the women had received information about breast prostheses prior to mastectomy; 29% received information from the surgeon performing the operation. Frequent and prolonged prosthesis use was prevalent with 64% of participants reporting prosthesis use all the time, 6-7 days/week. Participants showed high rates (83%) of overall satisfaction. However, women who wore their prosthesis out in public only were less satisfied than more frequent wearers (50% versus 89%, chi(2) = 8.83, d.f. = 1, alpha = 0.05). Satisfaction increased over time, as women who were greater than 5 years out from mastectomy were more satisfied than women less that 5 years post-mastectomy (90% versus 67%, chi(2) = 4.43, d.f. = 1, alpha = 0.05). The vast majority of women are satisfied with their external breast prosthesis several years after mastectomy. Most women used their prosthesis all the time and overall satisfaction contributed to higher levels of prosthesis use. Given the long-term importance of external breast prostheses for women who have undergone mastectomy, a greater effort to inform patients about external breast prostheses prior to surgery is needed.

Clinical strategies to enhance nerve regeneration in composite tissue allotransplantation.

Reinnervation of a hand transplant ultimately dictates functional recovery but provides a significant regenerative challenge. This article highlights interventions to enhance nerve regeneration through acceleration of axonal regeneration or augmentation of Schwann cell support and discuss their relevance to composite tissue allotransplantation. Surgical techniques that may be performed at the time of transplantation to optimize intrinsic muscle recovery--including appropriate alignment of ulnar nerve motor and sensory components, transfer of the distal anterior interosseous nerve to the recurrent motor branch of the median nerve, and prophylactic release of potential nerve entrapment points--are also presented.

A novel model for evaluating nerve regeneration in the composite tissue transplant: the murine heterotopic limb transplant.

PURPOSE: For individuals who have experienced debilitating upper extremity injury or amputation, hand transplantation holds the potential for drastic quality of life improvement. This potential depends on adequate nerve regeneration into the transplant and reanimation of graft musculature. In this study, we demonstrate the use of a murine heterotopic limb transplant model for evaluation of nerve regeneration in a composite tissue allograft (CTA). We also compare the effects of various immunosuppressive regimens on nerve regeneration in this model. METHODS: The study consisted of five groups of mice, all of which underwent heterotopic limb transplant with coaptation of the recipient and donor sciatic nerves. The groups received the following immunosuppressive regimens: group A (positive control)-syngeneic transplant, no immunosuppression; group B (negative control)-allogeneic transplant, no immunosuppression; group C-allogeneic transplant, FK-506 + MR1; group D-allogeneic transplant, MR1 + CTLA4-Ig; group E-syngeneic transplant, FK-506 treatment with preloading. RESULTS: Group B animals showed signs of transplant rejection as early as 5 days postoperatively. Except for one mouse from group C and one mouse from group D, all other animals had viable transplants and nerve regeneration present in the donor sciatic nerve at the 3-week endpoint of the study. CONCLUSIONS: To our knowledge, this represents the first report of the use of a mouse CTA model for evaluation of nerve regeneration. The mouse heterotopic limb transplant model will be a valuable tool for CTA research since it can be performed with more ease, and with less host morbidity and mortality than the mouse orthotopic model.