Cost-effectiveness analysis of Avance® allograft for the treatment of peripheral nerve injuries in the USA.

Aim: Peripheral nerve injury (PNI) is a debilitating condition with significant associated morbidity, and which places a substantial socioeconomic burden on healthcare systems worldwide. Recently, allograft has emerged as a viable surgical alternative to autograft for the treatment of PNI. This study evaluated the cost effectiveness of allograft (Avance® Nerve Graft) compared with autograft for the peripheral nerve repair, from a US payer perspective. Methods: A Markov cohort model was developed to consider the treatment pathways followed by a patient population undergoing a single transected nerve repair with either allograft, or autograft. The marginal difference in meaningful recovery (MR) (effectiveness), and costs, between the two groups were estimated over a lifetime horizon. Deterministic and probabilistic sensitivity analyses (PSA) were performed to consider the uncertainty surrounding the base-case input parameter values and their effect on the overall incremental cost-effectiveness ratio (ICER). Results: The base-case analysis indicates that there is a small difference in the average probability of MR between the two groups (75.15% vs 70.46%; +4.69% with allograft). Allograft also results in cost savings ($12,677 vs $14,023; -$-1346 with allograft) compared with autograft. Deterministic sensitivity analysis shows that the costs of the initial surgical procedures are the main drivers of incremental cost, but that the intervention is likely to be cost saving compared with autograft regardless of the parameter variations made. Conclusion: The use of allograft with the Avance Nerve Graft has the potential to be a cost-effective alternative to autograft for the surgical treatment of PNI in the USA.

The diagnostic utility of inspiratory-expiratory radiography for the assessment of phrenic nerve palsy associated with brachial plexus injury.

BACKGROUND: The phrenic nerve is commonly injured with trauma to the brachial plexus. Hemi-diaphragmatic paralysis may be well-compensated in healthy individuals at rest but can be associated with persistent exercise intolerance in some patients. This study aims to determine the diagnostic value of inspiratory-expiratory chest radiography compared to intraoperative stimulation of the phrenic nerve for assessing phrenic nerve injury associated with brachial plexus injury. METHODS: Over a 21-year period, the diagnostic utility of three-view inspiratory-expiratory chest radiography for identification of phrenic nerve injury was determined by comparison to intraoperative phrenic nerve stimulation. Multivariate regression analysis was used to identify independent predictors of phrenic nerve injury and having an incorrect radiographic diagnosis. RESULTS: A total of 237 patients with inspiratory-expiratory chest radiography underwent intraoperative testing of phrenic nerve function. Phrenic nerve injury was present in approximately one-fourth of cases. Preoperative chest radiography had a sensitivity of 56%, specificity of 93%, positive predictive negative of 75%, and negative predictive value of 86% for identification of a phrenic nerve palsy. Only C5 avulsion was found to be a predictor of having an incorrect diagnosis of phrenic nerve injury on radiography. CONCLUSION: While inspiratory-expiratory chest radiography has good specificity for detecting phrenic nerve injuries, a high number of false negatives suggest that it should not be relied upon for routine screening of dysfunction after traumatic brachial plexus injury. This is likely multifactorial and relates to variation in diaphragm shape and position, as well as limitations regarding static image interpretation of a dynamic process.

Digital Nerve Injury: Assessment and Treatment.

Undertreated digital nerve injuries may result in sensory deficits and pain. Early recognition and treatment will optimize outcomes, and providers should maintain a high index of suspicion when assessing patients with open wounds. Acute, sharp lacerations may be amenable to direct repair while avulsion injuries or delayed repairs require adequate resection and bridging with nerve autograft, processed nerve allograft, or conduits. Conduits are most appropriate for gaps less than 15 mm, and processed nerve allografts have demonstrated reliable outcomes across longer gaps.

The incidence and management of peripheral nerve injury in England (2005-2020).

Peripheral nerve injury (PNI) is a significant health problem that confers lifelong impact on those injured. Current interventions are purely surgical; however, outcomes remain poor. There is a lack of high-quality epidemiological data that is needed to identify populations involved, current healthcare demands, and ensure resources are distributed to the greatest effect, to reduce the injury burden. METHODS: Anonymized hospital episode statistical (HES) data on admitted patient care was obtained from NHS Digital for all National Health Service (NHS) patients sustaining PNI of all body regions between 2005 and 2020. Total numbers of finished consultant episodes (FCEs) or FCEs/100,000 population were used to demonstrate changes in demographic variables, anatomical locations of injury, mechanisms of injury, speciality, and main operation. RESULTS: There was a mean national incidence of 11.2 (95% CI 10.9, 11.6) events per 100,000 population per year. Males were at least twice as likely (p < 0.0001) to sustain a PNI. Upper limb nerves at or distal to the wrist were most commonly injured. Knife injuries increased (p < 0.0001), whereas glass injuries decreased (p < 0.0001). Plastic surgeons increasingly managed PNI (p = 0.002) as opposed to orthopaedic surgeons (p = 0.006) or neurosurgeons (p = 0.001). There was an increase in neurosynthesis (p = 0.022) and graft procedures (p < 0.0001) during the study period. DISCUSSION: PNI is a significant national healthcare problem predominantly affecting distal, upper limb nerves of men of working age. Injury prevention strategies, improved targeted funding and rehabilitation pathways are needed to reduce the injury burden and improve patient care.

Ontario wait times for delayed surgical treatment of traumatic peripheral nerve injury.

BACKGROUND: To better understand the occurrence and operative treatment of peripheral nerve injury (PNI) and the potential need for additional resources, it is essential to define the frequency and distribution of peripheral nerve procedures being performed. The objective of this study was to evaluate Ontario's wait times for delayed surgical treatment of traumatic PNI. METHODS: We retrieved data on wait times for peripheral nerve surgery from the Ontario Ministry of Health and Long-Term Care Wait Time Information System. We reviewed the wait times for delayed surgical treatment of traumatic PNI among adult patients (age ≥ 18 yr) from April 2009 to March 2018. Data collected included total cases, mean and median wait times, and demographic characteristics. RESULTS: Over the study period, 7313 delayed traumatic PNI operations were reported, with variability in the case volume distribution across Local Health Integration Networks (LHINs). The highest volume of procedures (2788) was performed in the Toronto Central LHIN, and the lowest volume (< 6) in the Waterloo Wellington and North Simcoe Muskoka LHINs. The population incidence of traumatic PNI requiring surgery was 5.1/10 000. The mean and median wait times from surgical decision to surgical repair were 45 and 27 days, respectively. Both the longest and shortest wait times occurred in LHINs with low case volumes. The provincial target wait time was met in 93% of cases, but women waited significantly longer than men (p < 0.001). CONCLUSION: The provincial distribution of traumatic PNI surgery was variable, and the highest volumes were in the LHINs with large populations. The provincial wait time strategy for traumatic PNI surgery is effective, but women waited longer than men. Precise reporting from all hospitals is necessary to accurately capture and understand the delivery of care after traumatic PNI.

Donor nerve graft assessment for covering thumb nerve defects: a cadaveric study.

BACKGROUND: Even though several studies reported donor autologous nerve grafts for digital nerve defects, there is no report in the literature regarding acceptable graft for thumb nerves. The purpose of this study is to provide guidelines for autologous nerve graft selection by detecting similarities between thumb nerve zones and donor nerve with regard to the number of fascicles and cross-sectional area. MATERIALS AND METHODS: Five cadavers were used in this study. An anatomical zoning system was defined for thumb nerves (zones 1, 2, 3). Sural nerve (SN), medial antebrachial cutaneous nerve (MABCN), lateral antebrachial cutaneous nerve (LABCN), posterior interosseous nerve (PIN), and anterior interosseous nerve (AIN) were selected as donor nerve grafts. The number of fascicles and surface area (mm2) was defined. RESULTS: The mean of the fascicle number in zone 1, zone 2, zone 3, AIN, PIN, LABCN, MABCN, and SN were 3.8, 4.7, 6.1, 2.2, 1.8, 4.5, 3.1, and 6.4, respectively. The mean of the surface area in zone 1, zone 2, zone 3, AIN, PIN, LABCN, MABCN, and SN were 2.19, 6.26, 4.04, 1.58, 0.71, 5.00, 3.01, and 8.06, respectively. CONCLUSIONS: LABCN is the best choice for all zones that has fascicular matching with all three zones of thumb nerves and caliber matching with zones 2 and 3. In zone 1, the best nerve graft is MABCN which has both suitable caliber and fascicle count.

A comparative assessment of lengthening followed by end-to-end repair and isograft repair of chronically injured peripheral nerves.

In order to repair chronic nerve injuries (injuries repaired after a long delay), the damaged nerve segments are resected and stumps are bridged by grafts. Autografts remain the gold-standard, but outcomes are typically poor, even after long periods of recovery. In a recent study, we described the use of a nerve lengthening device to gradually elongate the proximal stump of a transected nerve towards the distal stump, enabling a tension-free end-to-end repair. This approach showed significantly improved outcomes in comparison to autografts in repairing acutely injured nerves. In this study, we compared the use of nerve lengthening/end-to-end repair (LETER) to isograft repair of chronically transected nerves in a rat model. Structural and functional regenerative outcomes following LETER were comparable to isograft-based repair, with no significant differences found in outcomes involving functional recovery or axon growth. These data demonstrate the feasibility of nerve lengthening as a viable graft-free strategy for repairing chronically injured nerves. Not unexpectedly, outcomes for chronic nerve injuries were less favorable in both groups compared to repair of acutely injured nerves. Nonetheless, the findings provide insight into barriers to restoring function after chronic nerve injury through novel comprehensive characterization of a diverse set of neuromuscular outcomes. This analysis revealed key parameters predicting functional recovery.

Neurologic Assessment and Management of the Multiple Ligament Injured Knee: A Review and Synthesis of Current Evidence.

Knee dislocations are rare but devastating injuries that can often be associated with concomitant nerve injury, most often of the common peroneal nerve. Prompt diagnosis, investigation, and appropriate treatment are important in this subset of patients. This article provides an overview of relevant injury demographics, anatomy, diagnosis, and prognosis, and suggests a treatment algorithm for nerve injury associated with multiligament knee injury.

Probabilistic Assessment of Nerve Regeneration with Diffusion MRI in Rat Models of Peripheral Nerve Trauma.

Nerve regeneration after injury must occur in a timely fashion to restore function. Unfortunately, current methods (e.g., electrophysiology) provide limited information following trauma, resulting in delayed management and suboptimal outcomes. Herein, we evaluated the ability of diffusion MRI to monitor nerve regeneration after injury/repair. Sprague-Dawley rats were divided into three treatment groups (sham = 21, crush = 23, cut/repair = 19) and ex vivo diffusion tensor imaging (DTI) and diffusion kurtosis imaging (DKI) was performed 1-12 weeks post-surgery. Behavioral data showed a distinction between crush and cut/repair nerves at 4 weeks. This was consistent with DTI, which found that thresholds based on the ratio of radial and axial diffusivities (RD/AD = 0.40 ± 0.02) and fractional anisotropy (FA = 0.53 ± 0.01) differentiated crush from cut/repair injuries. By the 12th week, cut/repair nerves whose behavioral data indicated a partial recovery were below the RD/AD threshold (and above the FA threshold), while nerves that did not recover were on the opposite side of each threshold. Additional morphometric analysis indicated that DTI-derived normalized scalar indices report on axon density (RD/AD: r = -0.54, p < 1e-3; FA: r = 0.56, p < 1e-3). Interestingly, higher-order DKI analyses did not improve our ability classify recovery. These findings suggest that DTI may provide promising biomarkers for distinguishing successful/unsuccessful nerve repairs and potentially identify cases that require reoperation.

An assessment of fatigability following nerve transfer to reinnervate elbow flexor muscles.

AIMS: Improvements in the evaluation of outcomes following peripheral nerve injury are needed. Recent studies have identified muscle fatigue as an inevitable consequence of muscle reinnervation. This study aimed to quantify and characterize muscle fatigue within a standardized surgical model of muscle reinnervation. PATIENTS AND METHODS: This retrospective cohort study included 12 patients who underwent Oberlin nerve transfer in an attempt to restore flexion of the elbow following brachial plexus injury. There were ten men and two women with a mean age of 45.5 years (27 to 69). The mean follow-up was 58 months (28 to 100). Repeated and sustained isometric contractions of the elbow flexors were used to assess fatigability of reinnervated muscle. The strength of elbow flexion was measured using a static dynamometer (KgF) and surface electromyography (sEMG). Recordings were used to quantify and characterize fatigability of the reinnervated elbow flexor muscles compared with the uninjured contralateral side. RESULTS: The mean peak force of elbow flexion was 7.88 KgF (sd 3.80) compared with 20.65 KgF (sd 6.88) on the contralateral side (p < 0.001). Reinnervated elbow flexor muscles (biceps brachialis) showed sEMG evidence of fatigue earlier than normal controls with sustained (60-second) isometric contraction. Reinnervated elbow flexor muscles also showed a trend towards a faster twitch muscle fibre type. CONCLUSION: The assessment of motor outcomes must involve more than peak force alone. Reinnervated muscle shows a shift towards fast twitch fibres following reinnervation with an earlier onset of fatigue. Our findings suggest that fatigue is a clinically relevant characteristic of reinnervated muscle. Adoption of these metrics into clinical practice and the assessment of outcome could allow a more meaningful comparison to be made between differing forms of treatment and encourage advances in the management of motor recovery following nerve transfer. Cite this article: Bone Joint J 2019;101-B:867-871.

Functional MR Neurography in Evaluation of Peripheral Nerve Trauma and Postsurgical Assessment.

Evaluation of traumatic peripheral nerve injuries has classically been based on clinical and electrophysiologic criteria. US and MRI have been widely used for morphologic assessment of nerve injury sites and concomitant lesions. In the past few years, morphologic MR neurography has significantly increased its clinical applications on the basis of three-dimensional or two-dimensional images with and without fat-suppression techniques. However, these sequences have a major drawback: absence of pathophysiologic information about functional integrity or axonal flow of peripheral nerves. In this scenario, functional MRI techniques such as diffusion-weighted imaging (DWI) or diffusion tensor imaging (DTI) can be used as a complementary tool in initial evaluation of peripheral nerve trauma or in assessment of trauma undergoing surgical repair. These approaches provide not only morphologic but also functional information about extent and degree of nerve impairment. Functional MR neurography can also be applied to selection, planning, and monitoring of surgical procedures that can be performed after traumatic peripheral nerve injuries, such as neurorrhaphy, nerve graft, or neurolysis, as it provides surgeons with valuable information about the functional status of the nerves involved and axonal flow integrity. The physical basis of DWI and DTI and the technical adjustments required for their appropriate performance for peripheral nerve evaluation are reviewed. Also, the clinical value of DWI and DTI in assessment of peripheral nerve trauma is discussed, enhancing their potential impact on selection, planning, and monitoring of surgical procedures employed for peripheral nerve repair. Online supplemental material is available for this article. ©RSNA, 2019.

Trends and Cost Analysis of Upper Extremity Nerve Injury Using the National (Nationwide) Inpatient Sample.

OBJECTIVE: Epidemiology in upper extremity peripheral nerve injury (PNI) has not been comprehensively evaluated. The aim of this study was to calculate updated incidence of upper extremity PNIs in the United States and examine clinical trends and costs using a national database. METHODS: The National (Nationwide) Inpatient Sample was used to evaluate patients with upper extremity PNI (International Classification of Diseases, Ninth Revision, Clinical Modification 9534, 9550-9559) in 2001-2013. RESULTS: A weighted total of 170,579 patients experienced upper extremity PNI, representing a mean incidence of 43.8/1 million people annually. Mean (± SEM) age of patients was 38.1 ± 0.05 years, 74.3% of patients were male, and 49.0% were Caucasian. PNIs occurred to the ulnar (17.8%), radial (15.1%), digital (18.0%), median (13.0%), multiple (11.5%), and other (10.1%) nerves and brachial plexus (14.5%). The number of upper extremity PNIs decreased overall. Average care charge was $47,004 ± $185, with an average increase of $4623/year and compound annual growth rate of 9.59%. Although surgical nerve repair and home disposition were common with isolated PNIs, patients with brachial plexus PNIs did not have nerve surgery and were more likely to be discharged to skilled nursing facilities. Multivariate analysis showed that length of stay (ß = 0.677, P = 0.0001) and number of procedures (ß = 0.188, P = 0.0001) most affected total patient charges. CONCLUSIONS: These results suggest an overall decrease in number of PNIs, suggesting lower incidence or frequency of detection; however, the cost of care has increased. Despite advances in nerve repair techniques, nerve surgery rates have not increased, especially for brachial plexus injuries, which may be undertreated.

Fascicular Ratio Pilot Study: High-Resolution Neurosonography-A Possible Tool for Quantitative Assessment of Traumatic Peripheral Nerve Lesions Before and After Nerve Surgery.

BACKGROUND: Clinical and electrophysiological assessments prevail in evaluation of traumatic nerve lesions and their regeneration following nerve surgery in humans. Recently, high-resolution neurosonography (HRNS) and magnetic resonance neurography have gained significant importance in peripheral nerve imaging. The use of the grey-scale-based "fascicular ratio" (FR) was established using both modalities allowing for quantitative assessment. OBJECTIVE: To find out whether FR using HRNS can assess nerve trauma and structural reorganization in correlation to postoperative clinical development. METHODS: Retrospectively, 16 patients with operated traumatic peripheral nerve lesions were included. The control group consisted of 6 healthy volunteers. All imaging was performed with a 15 to 6 MHz ultrasound probe (SonoSite X-Porte; Fujifilm, Tokyo, Japan). FR was calculated using Fiji () on 8-bit-images ("MaxEntropy" using "Auto-Threshold" plug-in). RESULTS: Thirteen of 16 patients required autologous nerve grafting and 3 of 16 extra-intraneural neurolysis. There was no statistical difference between the FR of nonaffected patients' nerve portion with 43.48% and controls with FR 48.12%. The neuromatous nerve portion in grafted patients differed significantly with 85.05%. Postoperatively, FR values returned to normal with a mean of 39.33%. In the neurolyzed patients, FR in the affected portion was 78.54%. After neurolysis, FR returned to healthy values (50.79%). Ten of 16 patients showed clinical reinnervation. CONCLUSION: To our best knowledge, this is the first description of FR using HRNS for quantitative assessment of nerve damage and postoperative structural reorganization. Our results show a significant difference in healthy vs lesioned nerves and a change in recovering nerve portions towards a more "physiological" ratio. Further evaluation in larger patient groups is required.

Assessment of the Forearm Tendon Transfer with Irreparable Radial Nerve Injuries Caused by War Projectiles.

INTRODUCTION: Injuries to the radial nerve can occur at any point along its anatomical route, and the etiology quite varies. A particular entity are war injuries of the extremities, which have high morbidity but low mortality. After irreparable radial nerve injury, the only treatment is tendon transfer (if we neglect arthrodesis) with over then 40 methods. Four tendon transfers are considered as better than the other and two of them are the subject of our article flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU). AIM: To evaluate the ultimate functional results of forearm tendon transfers for irreparable radial nerve damage caused by war injuries and indicate the better operative treatment choice in accordance with the evaluation schemes. METHODS: This retrospective research included 40 patients with isolated irreparable radial nerve damage. Patients were operated from 1993 to 1996. The follow-up period is from 3.5 to 11.5 years (until 2007). Twenty patients were operated using FCR tendon transfer method and twenty patients were operated using FCU tendon transfer method. The surgery was performed at the Clinic for Reconstructive and Plastic Surgery, Clinical Center University of Sarajevo. Three score evaluation schemes were used: Zachary, Neumann Pertecke and Tajima scheme, along with subjective evaluation of treatment. RESULTS: Measured by the Zachary Evaluation Scheme, the overall score in patients undergoing FCR tendon transfer is 92.25%. In patients undergoing FCU tendon transfer, the total score was 82.20%. The total result of all 40 operated patients was 87.25%. The Zachary evaluation scheme showed a significant difference between FCR and FCU results by tendon transfer (p <0.05) in favor of the FCR tendon transfer. Tajima scheme proved a statistically significant difference between the two tendon transfers (p = 0.024), also in favor of FCR tendon transfers. CONCLUSION: Forearm tendon transfer is a relevant method to compensate for the loss of function of the wrist, fingers and thumb extensions as a result of irreparable damage to the radial nerve. FCR tendon transfer provides better functional results than FCU tendon transfer in irreparable radial nerve damage. The time elapsed from the injury to the performed surgery of the tendon transfer has no effect on the final functional result. There is no surgical tendon transfer procedure that can be recommended as a standard for any patient. Practically, the surgeon must tailor the surgery to the patient's needs. It is necessary to develop a unique and generally accepted evaluation scheme for the results of tendon transfers that will enable comparisons of results achieved. Both methods can be used for irreparable damage of radial nerve due to any etiology.

Functional, motor, and sensory assessment instruments upon nerve repair in adult hands: systematic review of psychometric properties.

BACKGROUND: Outcome after nerve repair of the hand needs standardized psychometrically robust measures. We aimed to systematically review the psychometric properties of available functional, motor, and sensory assessment instruments after nerve repair. METHODS: This systematic review of health measurement instruments searched databases from 1966 to 2017. Pairs of raters conducted data extraction and quality assessment using a structured tool for clinical measurement studies. Kappa correlation was used to define the agreement prior to consensus for individual items, and intraclass correlation coefficient (ICC) was used to assess reliability between raters. A narrative synthesis described quality and content of the evidence. RESULTS: Sixteen studies were included for final critical appraisal scores. Kappa ranged from 0.31 to 0.82 and ICC was 0.81. Motor domain had manual muscle testing with Kappa from 0.72 to 0.93 and a dynamometer ICC reliability between 0.92 and 0.98. Sensory domain had touch threshold Semmes-Weinstein monofilaments (SWM) as the most responsive measure while two-point discrimination (2PD) was the least responsive (effect size 1.2 and 0.1). A stereognosis test, Shape and Texture Identification (STI), had Kappa test-retest reliability of 0.79 and inter-rater reliability of 0.61, with excellent sensibility and specificity. Manual tactile test had moderate to mild correlation with 2PD and SWM. Function domain presented Rosén-Lundborg score with Spearman correlations of 0.83 for total score. Patient-reported outcomes measurements had ICC of 0.85 and internal consistency from 0.88 to 0.96 with Patient-Rated Wrist and Hand Evaluation with higher score for reliability and Spearman correlation between 0.38 and 0.89 for validity. CONCLUSIONS: Few studies included nerve repair in their sample for the psychometric analysis of outcome measures, so moderate evidence could be confirmed. Manual muscle test and Rotterdam Intrinsic Hand Myometer dynamometer had excellent reliability but insufficient data on validity or responsiveness. Touch threshold testing was more responsive than 2PD test. The locognosia test and STI had limited but positive supporting data related to validity. Rosén-Lundborg score had emerging evidence of reliability and validity as a comprehensive outcome following nerve repair. Few questionnaires were considered reliable and valid to assess cold intolerance. There is no patient-reported outcome measurement following nerve repair that provides comprehensive assessment of symptoms and function by patient perspective.

A Preliminary Assessment of the Utility of Large-Caliber Processed Nerve Allografts for the Repair of Upper Extremity Nerve Injuries.

Background: Cabled sensory nerve autografts are the historical gold standard for overcoming gaps in larger diameter nerves as repair utilizing large-diameter autograft risks central graft necrosis. Commercially available processed nerve allograft (PNA) is available in diameters up to 5 mm but represents an acellular 3-dimensional matrix as opposed to viable tissue. The purpose of this study is to specifically evaluate whether similar concerns regarding the use of large-caliber PNA are warranted. Methods: The RANGER Registry is an active database designed to collect injury, repair, safety, and outcomes data for PNAs (Avance® Nerve Graft; AxoGen, Inc, Alachua, Florida) according to an institutional review board-approved protocol. The database was queried for patients presenting with large-caliber nerve allograft repairs in the upper extremity. Identified patients reporting quantitative outcomes with a minimum of 9-month follow-up were included in the data set. Results: The large-caliber PNA subgroup included 13 patients with 15 injuries. The mean ± SD age was 36 ± 22 years. Large-caliber single-stranded repairs included twelve 4- to 5-mm-diameter grafts. Large-caliber cabled repairs included the combined use of 3- to 4-mm and 4- to 5-mm-diameter nerve allografts in 3 repairs. The mean nerve gap was 33 ± 10 mm with a mean follow-up time of 13 months. Available quantitative data reported meaningful recovery of sensory and motor function in 67% and 85% of the repairs, respectively. Conclusion: Although based on a small subset of patients, PNAs of up to 5 mm in diameter appear capable of supporting successful nerve regeneration.

Surgical exploration of hand wounds in the emergency room: Preliminary study of 80 personal injury claims.

BACKGROUND: The SHAM Insurance Company in Lyon, France, estimated that inadequate hand wound exploration in the emergency room (ER) accounted for 10% of all ER-related personal injury claims in 2013. The objective of this study was to conduct a critical analysis of 80 claims that were related to hand wound management in the ER and led to compensation by SHAM. MATERIAL AND METHODS: Eighty claims filed between 2007 and 2010 were anonymised then included into the study. To be eligible, claims had to be filed with SHAM, related to the ER management of a hand wound in an adult, and closed at the time of the study. Claims related to surgery were excluded. For each claim, we recorded 104 items (e.g., epidemiology, treatments offered, and impact on social and occupational activities) and analysed. RESULTS: Of the 70 patients, 60% were manual workers. The advice of a surgeon was sought in 16% of cases. The most common wound sites were the thumb (33%) and index finger (17%). Among the missed lesions, most involved tendons (74%) or nerves (29%). Many patients had more than one reason for filing a claim. The main reasons were inadequate wound exploration (97%), stiffness (49%), and dysaesthesia (41%). One third of patients were unable to return to their previous job. Mean sick-leave duration was 148 days and mean time from discharge to best outcome was 4.19%. Most claims (79%) were settled directly with the insurance company, 16% after involvement of a public mediator, and 12% in court. The mean compensatory damages award was 4595Euros. CONCLUSION: Inadequate surgical exploration of hand wounds is common in the ER, carries a risk of lasting and sometimes severe residual impairment, and generates considerable societal costs. LEVEL OF EVIDENCE: IV.

Technical Assessment of Connector-Assisted Nerve Repair.

PURPOSE: Clinical outcomes of nerve repair have not substantially improved over the last several decades. Although clearly a multifactorial problem, basic principles including proper fascicular alignment are not always realized. The use of short conduits as connectors may enhance nerve alignment by entubulating and directing the approximation of nerve ends. METHODS: Ten hand surgeons (5 experienced and 5 inexperienced) performed a series of in vitro human cadaver nerve repairs. Three small-diameter (2 mm), 3 medium-diameter (3-4 mm), and 3 large-diameter (5-6 mm) nerves were repaired (under 10× magnification) utilizing each of 3 techniques: suture-only, connector-only (sutures placed through the ends of the connector), and connector-assisted (alignment sutures at the nerve interface plus connector). Three judges (blinded to who performed the repairs) assessed each repair for fascicular alignment based on predetermined qualitative scales. RESULTS: Across all surgeons, 23 of 30 connector-assisted repairs were judged good or excellent versus 18 of 30 of the suture-only and 13 of 30 of the connector-only repairs. Experienced surgeons in general did better repairs and in particular were more likely to obtain superior alignment for conduit-only repairs (73.3% vs 13.3% good or excellent) and suture-only repairs (73.3% vs 46.7% good or excellent) and were not statistically different for connector-assisted repairs (86.7% vs 66.7% good or excellent) compared with inexperienced surgeons. CONCLUSIONS: In a cadaver nerve model, there was no significant difference in the technical alignment of conduit-assisted repairs between experienced and inexperienced surgeons whereas inexperienced surgeons were more likely to achieve inadequate alignment with suture-only or conduit-only repairs. CLINICAL RELEVANCE: Connector-assisted repairs combining suture-approximation and entubulation may improve the technical alignment of nerve repairs performed, especially by less-experienced surgeons.

Nonexpanded Adipose Stromal Vascular Fraction Local Therapy on Peripheral Nerve Regeneration Using Allografts.

AIM OF THE STUDY: Adipose tissue possesses a population of multi-potent stem cells which can be differentiated to a Schwann cell phenotype and may be of benefit for treatment of peripheral nerve injuries. Effects of local therapy of nonexpanded adipose stromal vascular fraction (SVF) on peripheral nerve regeneration was studied using allografts in a rat sciatic nerve model. MATERIALS AND METHODS: Thirty male white Wistar rats were divided into three experimental groups (n = 10), randomly: Sham-operated group (SHAM), allograft group (ALLO), SVF-treated group (ALLO/SVF). In SHAM group left sciatic nerve was exposed through a gluteal muscle incision and after homeostasis muscle was sutured. In the ALLO group the left sciatic nerve was exposed through a gluteal muscle incision and transected proximal to the tibio-peroneal bifurcation where a 10 mm segment was excised. The same procedure was performed in the ALLO/SVF group. The harvested nerves of the rats of ALLO group were served as allograft for ALLO/SVF group and vice versa. The SHAM and ALLO groups received 100 µL phosphate buffered saline and the ALLO/SVF group received 100 µL SVF (2.25 ± 0.45 × 10(7) cells) locally where the grafting was performed. RESULTS: Behavioral, functional, biomechanical, and gastrocnemius muscle mass showed earlier regeneration of axons in ALLO/SVF than in ALLO group (p < .05). Histomorphometic and immunohistochemical studies also showed earlier regeneration of axons in ALLO/SVF than in ALLO group (p < .05). CONCLUSIONS: Administration of nonexpanded SVF could accelerate functional recovery after nerve allografting in sciatic nerve. It may have clinical implications for the surgical management of patients after nerve transection.