Advances of Direct Peripheral Nerve Repair Techniques: Do We Already Have Enough Scientific Evidence?

Purpose: To systematically review the evidence of direct peripheral nerve repair techniques and to determine any differences in outcomes that would guide rational treatment. Additionally, we compare the results and outcomes of these studies and find future directions for peripheral nerve repair techniques. Methods: We searched PubMed, Virtual Health Library, and Embase databases to identify articles involving direct peripheral nerve techniques. We analyzed and compared the results and outcomes of these techniques. We also aimed to look for the differences in outcomes that would guide the current and future treatments. Results: We identified 1390 articles, and 19 met our criteria with evidence ranging from level I to level IV. The nerve repair techniques included direct repair, epineural repair, fascicular repair, and group fascicular repair. These nerve techniques are based on the surgeons' personal experience. The results and the outcome of these studies were based on prognostic factors and not on surgical techniques. Few studies compared the surgical techniques and found no significant difference in nerve repair techniques. Conclusions: Analyzing all direct peripheral nerve techniques and literature of all levels of evidence, our data show no significant difference between different suturing techniques. Currently, there is a lack of scientific evidence on the best direct peripheral nerve repair techniques. Therefore, we need more research to understand the rational treatment methods for peripheral nerve injuries. Level of evidence: IV.

Fingernail injury.

Fingertip injuries are the most common injury to the hand. The nail represents a unique structure in the human body providing in fine pinch, stability and protection. Management of fingertip injuries can often be a challenging experience, especially in presence of complex lesion that include soft tissue loss and distal phalanx injury. In this review we present a variety of options in caring for these injuries to help achieve and avoid the sequels. The goal of treatment is restoration of a painless, functional digit with protective sensation.

Evaluation of peripheral nerve injury by magnetic resonance neurography: A systematic review.

In view of the limitations of current methods for assessing peripheral nerve injury, there is a need for technical innovations to improve diagnosis, surgical approach and postoperative monitoring. The objective of this study was to conduct a systematic review to analyze the applicability of magnetic resonance neurography in peripheral nerve injuries. The present systematic review focused on the use of magnetic resonance neurography. The literature was searched in the PUBMED, Cochrane Library and Virtual Health Library databases using the PICO method. One hundred sixty-two articles were retrieved with the terms "magnetic resonance imaging" and "peripheral nerve injury", with a filter for the last 10 years (2010-2020). Nineteen were eligible for the review. Most were reviews, with few systematic reviews of randomized controlled trials. Although not included in the recommended protocol, MRI is increasingly used due to its numerous advantages: it is non-invasive, providing objective visualization of neural and perineural tissues, fascicular representation as a result of high resolution, and objective visualization of serial interval images of successful treatment. This is one of the first systematic reviews of the literature regarding the use of magnetic resonance imaging neurography to assess peripheral nerve injury, highlighting the need to implement new imaging techniques in this field of medical practice.

Accessory muscles: a cause of nerve compression in the distal forearm. Case report and literature review / Músculos accesorios: una causa de compresión nerviosa en el antebrazo distal. Reporte de casos y revisión de la Literatura

Nerve compression by anomalous muscles located at the wrist and distal forearm is an infrequent condition. Accessory muscles may compress underlying structures in the Carpal Tunnel region or ulnar canal , producing pain and paresthesia. Two cases of ulnar and median nerve compression, caused by prominent accessory muscles at the distal forearm, are described. Literature review is presented.

La compresión nerviosa causada por vientres musculares anómalos localizados en la muñeca y en el tercio distal del antebrazo es una condición poco frecuente. Músculos accesorios pueden comprimir estructuras subyacentes en la región del túnel del carpo o en el canal de ulnar, produciendo dolor y parestesia. Se presentan dos casos de compresión de los nervios ulnar y mediano en el tercio distal del antebrazo, causados por vientres musculares prominentes de músculos accesorios del antebrazo. Se presenta una revisión de la literatura.

Distal phalanx amputation with delayed presentation and successful reconstruction with reposition and flap after 2 weeks.

Traumatic finger amputations are common, causing significant functional and cosmetic deficits. Microsurgical replantation techniques are the mainstay of treatment for most such injuries although they require adequate conservation of the amputated segment for a successful result. In distal finger amputations, replantation is the procedure of choice, as long as the amputated fragment is viable. If replantation is not an option, reposition + flap using a neurovascular flap can be an efficient option, as this offers improved skin coverage. To the best of our knowledge, this case illustrates the longest cold ischaemic time with a successful outcome.

Platelet-Rich Fibrin Promotes an Accelerated Healing of Achilles Tendon When Compared to Platelet-Rich Plasma in Rat.

BACKGROUND: Autologous platelet concentrate has been used to improve the function and regeneration of injured tissues. Tendinopathies are common in clinical practice, although long-term treatment is required. On the basis of lead time, we compared the effect of using platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) in repairing rat Achilles tendon. METHODS: The effectiveness of using PRP and PRF was evaluated after 14 and 28 postoperative days by histological analysis. The quantification of collagen types I and III was performed by Sirius red staining. Qualitatively, the data were verified with hematoxylin-eosin (H&E) staining. RESULTS: In Sirius red staining, no significant treatment differences were found between groups. Statistical difference was observed only between PRP (37.2% collagen) and the control group (16.2%) 14 days after treatment. Intra-groups compared twice showed a difference for collagen I (27.8% and 47.7%) and III (66.9% and 46.0%) in the PRF group. The control group showed differences only in collagen I (14.2% and 40.9%) and no other finding was observed in the PRP group. In H&E staining, PRF showed a better cellular organization when compared to the other groups at 28 days. CONCLUSION: Our study suggests that PRF promotes accelerated regeneration of the Achilles tendon in rats, offering promising prospects for future clinical use.

Neurite growth acceleration of adult Dorsal Root Ganglion neurons illuminated by low-level Light Emitting Diode light at 645 nm.

The effect of a 645 nm Light Emitting Diode (LED) light irradiation on the neurite growth velocity of adult Dorsal Root Ganglion (DRG) neurons with peripheral axon injury 4-10 days before plating and without previous injury was investigated. The real amount of light reaching the neurons was calculated by taking into account the optical characteristics of the light source and of media in the light path. The knowledge of these parameters is essential to be able to compare results of the literature and a way to reduce inconsistencies. We found that 4 min irradiation of a mean irradiance of 11.3 mW/cm(2) (corresponding to an actual irradiance reaching the neurons of 83 mW/cm(2)) induced a 1.6-fold neurite growth acceleration on non-injured neurons and on axotomized neurons. Although the axotomized neurons were naturally already in a rapid regeneration process, an enhancement was found to occur while irradiating with the LED light, which may be promising for therapy applications. Dorsal Root Ganglion neurons (A) without previous injury and (B) subjected to a conditioning injury.

Epidermólise bolhosa distrófica: aspectos dermatológicos e cirúrgicos / Dystrophic epidermolysis bullosa: dermatological and surgical aspects

A epidermólise bolhosa é uma doença hereditária que causa alterações em proteínas estruturais da pele e consequente fragilidade da epiderme. Manifesta-se por surgimento de flictenas por todo o corpo e deformidades funcionais de membros, especialmente nas mãos, sendo que as formas mais características são pseudossindactilia e contraturas. Neste trabalho, descrevemos o caso de um paciente de 12 anos com deformidades nas mãos e flictenas pelo corpo que foi submetido à cirurgia da mão para recuperação da movimentação funcional (AU)

Epidermolysis bullosa is a hereditary disease that causes changes in structural proteins of the skin and consequent fragility of the epidermis. It is manifested by the appearance of blisters all over the body and functional deformities of limbs, especially the hands, and the most characteristic forms are pseudosyndactyly and contractures. In this paper, we describe the case of a 12-year-old patient with deformities in his hands and blisters over the body who underwent hand surgery for recovery of functional movement (AU)

Effect of side-stream smoking on random-pattern skin flap survival in rats.

The secondhand exposure to cigarette smoke is being considered evil, and damage caused by this passive exposure has been proven by several studies. To investigate the effects of sidestream smoke exposure on random-pattern skin flap survival, 20 female rats were separated into 2 groups: group A (n = 10) was exposed 6 weeks to the smoke from the burning cigarette (passive smoking) and group B (n = 10) was the control group. After 6 weeks of exposition, a dorsal McFarlane flap of 4 × 10 cm was performed in all rats. Two weeks after this procedure, the ratio of necrotic and total areas was calculated using computer programs. The median area of necrosis in group A was 29.5%, significantly higher than that in group B with 17.5% (P < 0.024). In conclusion, this study suggests increased risk of random-pattern skin flap necrosis after sidestream exposure to cigarette smoke.

Effect of Platelet Rich Plasma and Platelet Rich Fibrin on sciatic nerve regeneration in a rat model.

The aim of this study was to evaluate the effect of Platelet Rich Plasma (PRP) and Platelet Rich Fibrin (PRF) on peripheral nerve repair. Thirty-two Wistar rats were randomly divided into four equal treatments groups: autologous nerve grafts (ANG), silicon tube plus saline solution (SS), silicon tube plus PRP, and silicon tube plus PRF. In ANG group, 10 mm segment from sciatic nerve was excised and reimplanted between the nerve stumps. In the SS, PRP, and PRF groups, 5 mm segment from sciatic nerve was excised and bridged with a 12 mm silicone conduit to create a 10 mm nerve gap. The conduit was filled in accordance with the different treatments. Walking track analysis was performed periodically and on the 90th post-operative day histomorphometric analysis was performed. The ANG, PRF, and PRP groups presented a significant functional improvement in relation to the SS group (P = 0.001) on 90 days after surgery. Histomorphometric analysis demonstrated that the ANG group achieved a larger nerve fiber diameter in proximal stump while comparing with the SS group (P =0.037) and showed larger fiber diameter in median stump in comparison to the PRP group (P = 0.002) and PRF group (P = 0.001). Axonal diameter and myelin sheath thickness showed no statistical significant difference between the groups in the three stumps (P ≥ 0.05). This study suggests that PRP and PRF have positive effects on the functional nerve recovery; however, these groups don't achieve a significant improvement on the histomorphometric analysis.

Distraction osteogenesis and free nail graft after distal phalanx amputation.

PURPOSE: To describe the results in patients treated with distraction osteogenesis combined with free nail graft after distal phalanx amputation. METHODS: We analyzed 14 patients with distal phalanx amputation (13 women). Mean age was 35 years. There were 9 amputations of the index finger, 3 of the middle finger, and 1 each of the thumb and ring finger. We started bone distraction 7 days after surgery, with 1 mm distraction every 3 days. After bone elongation, we inserted a free composite nail graft at the dorsal tip of the distracted finger. We evaluated distraction length, consolidation time, aesthetic result (using the Foucher and Leclère score), and complications. RESULTS: The mean bone elongation was 17 mm and mean consolidation time was 149 days. Nail cosmetic results were satisfactory; the mean total Foucher score was 14 out of 20. Mean individual scores were patient's opinion (7.8 out of 10), adequate length (1.2 out of 2.5), adequate alignment (1 out of 1), adequate width (1.8 out of 4), and dorsal scar quality (2.2 out of 2.5). The mean total Leclère score was 14 out of 20. All patients retained sensibility in the grafted area and none had healing abnormalities. The mean opinion about the donor site was 7.5 out of 8. Nail growth less than 50% occurred in 2 patients. Mean follow-up was 62 months. CONCLUSIONS: Distraction osteogenesis combined with free nail graft is a therapeutic option when replantation is not an option or when it fails. However, treatment takes time and requires the involvement of the patient, family, and medical team.

Reconstrução de couro cabeludo após ressecção de condrossarcoma mesenquimal local / Scalp reconstruction after local mesenchymal chondrosarcoma resection

O condrossarcoma mesenquimal é uma variante rara de condrossarcoma, que raramente atinge os tecidos extraósseos. Este tipo de tumor normalmente ocorre em adultos jovens, sendo altamente agressivo, e tende a apresentar recorrência tardia e metástases a distância. No exame histológico, caracteriza-se por apresentar abundantes células mesenquimais indiferenciadas entre ilhas de células cartilaginosas bem diferenciadas. O tratamento cirúrgico com ressecção completa do tumor é o tratamento padrão para o condrossarcoma mesenquimal. Apresentamos aqui o caso de uma paciente de 56 anos que apresentava um condrossarcoma mesenquimal de grandes proporções na região do couro cabeludo. O diagnóstico da lesão foi tardio e, após o estadiamento da mesma, a paciente foi submetida a ressecção total da neoplasia e reconstrução com retalho de rotação extenso de couro cabeludo e enxertia de pele parcial. No presente estudo, pode-se concluir que ainda não há um tratamento realmente efetivo para o condrossarcoma mesenquimal avançado

Mesenchymal chondrosarcoma is a rare variant of chondrosarcoma, which rarely reaches the extra-osseous tissues. This type of tumor usually occurs in young adults and is highly aggressive, tending to present late recurrence and distant metastases. On histological examination it is characterized by abundant undifferentiated mesenchymal cells between islands of well differentiated cartilage cells. Surgical treatment with complete surgical resection is the standard treatment for mesenchymal chondrosarcoma. Here we present the case of a 56-year-old female patient who had a mesenchymal chondrosarcoma of great proportions in the region of the scalp. The diagnosis was late and after the staging of it, the patient underwent total resection of the tumor and reconstruction with extensive rotation flap of scalp and partial skin graft. In this study we can conclude that as yet there is no really effective treatment for advanced mesenchymal chondrosarcoma

Wrist denervation for painful conditions of the wrist.

PURPOSE: To evaluate the long-term (6-y) results of Wilhelm's wrist denervation technique used as an isolated procedure for painful conditions of the wrist. METHODS: We conducted a retrospective review of 49 wrist denervations that were performed as isolated procedures in patients with painful wrist conditions. Indication for surgery was degenerative osteoarthritis of the wrist caused by scaphoid nonunion advanced collapse in 19 patients, Kienböck's disease in 13 patients, and primary degenerative osteoarthritis in 17 patients. RESULTS: The results were analyzed as a group and by comparing the 3 etiologies. Average pain improvement after surgery for all groups was 68% ± 8% after the first month and reached a plateau at the end of the first year, with the percentage remaining stable at 36 months at 79% ± 4%. Grip strength on the treated side improved from 43% of the opposite side before denervation to 69% of the opposite side. The range of motion showed improvements in all axes of movement, without statistical differences between groups. Radiological evaluation after 72 months revealed worsening in 34 patients. There was no difference in results between the 3 groups with regard to grip strength, range of motion, or pain relief obtained. CONCLUSIONS: Wrist denervation resulted in improvement in pain scores in 39 patients despite radiological deterioration noted in 34 after 6 years. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

End-to-end versus end-to-side motor and sensory neurorrhaphy in the repair of the acute muscle denervation.

BACKGROUND: The aim of this study was to experimentally compare end-to-end and end-to-side neurorrhaphy in perineural window model after motor nerve lesion, evaluating which one was the most effective to preserve nerves. Also, differences in motor and sensorial nerve regeneration were tested to verify differences in nerve regeneration. METHODS: A total of 20 adult male Wistar rats were randomly assigned to 5 groups, and, in each one, a different treatment was performed: besides the control group, and end-to-end or end-to-side graft with motor or sensorial nerves was performed. Silastic sheet was used as a mechanical barrier to prevent innervation from adjacent nerves. After 16 weeks, the specimens were histologically assessed and wet weight was evaluated as a direct parameter of atrophy. RESULTS: The end-to-end neurorrhaphy group presented the best results in terms of mass preservation, but it did not differ significantly from the control group. Motor nerves presented similar results in muscular atrophy. The end-to-side neurorrhaphy group with sensory nerve as donor showed the worst results. CONCLUSIONS: The use of sensory nerves to preserve skeletal muscle trophism is not justified, since, according to our model, it affects 50% to 80% of the muscle mass in a period of 16 weeks. End-to-side neurorrhaphy was demonstrated to be an option for re-enervation of a nerve-deprived motor muscle in selected cases.

Randomized prospective study comparing reverse and direct flow island flaps in digital pulp reconstruction of the fingers.

BACKGROUND: This study compares two therapies for the reconstruction of digital pulp: direct and reverse flow island flaps. Discriminatory sensation and loss of active range of motion were analyzed, with random allocation of nerve suturing. METHODS: The authors conducted a randomized prospective study of 122 patients with loss of digital pulp substance in one finger between 1995 and 2005. Patients were divided into two groups: direct flow island flap (n = 62) and reverse flow island flap (n = 60). The main outcomes were the capacity to discriminate between two points, and proximal and distal interphalangeal joint motion loss. RESULTS: In the direct flap group, there was no loss of articular mobility in 51 percent of patients in the proximal interphalangeal joint and in 55 percent of patients in the distal interphalangeal joint. The reverse flap group showed no loss of articular mobility of the proximal interphalangeal joint in 85 percent of patients and of distal interphalangeal joint in 82 percent. Maximum amplitude losses of 10 and 15 degrees were observed only in the direct flap group in proximal interphalangeal joint articulation (p < 0.001), and of 10 degrees in 10 percent of patients in distal interphalangeal joint articulation (p < 0.002). All patients (n = 29) with suturing showed a Weber score less than or equal to 8, whereas only four (13 percent) of those without suturing had a score of 8; the rest had higher Weber scores (p < 0.001). CONCLUSION: The direct island flap resulted in motion loss in both articulations of the finger but with better discriminatory sensation in comparison with the reverse flap.

Cobertura cutânea pós-ressecção oncológica: a difícil missão de escolher a melhor reconstrução no terço distal da perna / Cutaneous covering after oncologic resection: the difficult task of choosing the best reconstruction in the distal third leg

O objetivo deste trabalho é discutir as várias opções terapêuticas para as perdas de substâncias do terço distal da perna, com destaque para o retalho desepidermizado. Para ilustrar, apresentamos o caso de um paciente com perda de substância extensa no terço distal anterior da perna após ressecção de sarcoma da bainha de nervo periférico. Esta é uma área de difícil reconstrução devido à escassez de zonas doadoras regionais, pelo qual o retalho desepidermizado aparece como uma excelente opção na medida em que promove total cobertura do defeito sem prejuízos estéticos ou funcionais maiores à área doadora (AU)

This work discusses the various therapeutic options for the losses of substances in the distal third of the leg, highlighting the de-epithelialized flap. To illustrate, we present the case of a patient with extensive loss of substance in the distal third of the leg after resection of peripheral nerve sheath sarcoma. Reconstruction in this area is difficult due to the scarcity of regional donor zones, for which the de-epithelialized flap appears as an excellent option as it promotes total covering of the defect with no major aesthetic or functional impairments to the donor area (AU)

Sources of processed lipoaspirate cells: influence of donor site on cell concentration.

BACKGROUND: Recently, adipose tissue harvested by liposuction has been identified as a source of processed lipoaspirate cells. The aim of this study was to determine the concentration of processed lipoaspirate cells in adipose tissue obtained by liposuction from different harvest areas in women. METHODS: A prospective cross-sectional study was conducted in 25 women in whom liposuction in four or more different zones in the same procedure was indicated. After selective liposuction, the material was sent to the laboratory, where it was processed for extraction of processed lipoaspirate cells, which were separated from the adipose tissue, quantified, and characterized through determination of c-kit expression. The following harvest regions were evaluated: upper abdomen, lower abdomen, trochanteric region, inner thigh, knee, and flank. The cell concentration obtained at each site was compared by analysis of variance for mixed models. RESULTS: A significant difference was found for cell concentration obtained at the different harvest sites. The cell concentration in the lower abdomen was greater than in other areas, but no significant difference was found in relation to the inner thigh. CONCLUSIONS: The lower abdomen and the inner thigh may have higher processed lipoaspirate cell concentrations. These sites may turn out to be better sources of adult mesenchymal stem cells.

Correction of the alveolar gap and nostril deformity by presurgical passive orthodontia in the unilateral cleft lip.

The use of the nasoalveolar molding technique (NAM) aims to reduce passively the width of the alveolar gap, while improving the AP discrepancy but also focusing on the nose. We developed a within-subjects study in which 11 infants with unilateral lip deformity and varying degrees of alveolar gaps were treated by NAM. Patients included in the study presented alveolar gap at the first appointment to configure the molding device. Alveolar gap was then measured again at the time of lip repair to evaluate the impact of the appliance utilization, and the nostril shape was reassessed to verify the benefit relative to nose symmetry. All patients obtained significant reduction of the alveolar gap. The appliance also facilitated primary nasal positioning, significantly improving nasal symmetry and nostril shape. NAM constitutes an important adjunct to ameliorate the results of primary definitive lip repair while also improving the surgeon's ability to provide nasal symmetry.