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Reconstruction of a Long Defect of the Median Nerve with a Free Nerve Conduit Flap

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Reconstruction of a Long Defect of the Median Nerve with a Free Nerve Conduit Flap Reconstruction of a long defect of the median nerve with a free nerve conduit flap Andrea Campodonico, Pier Paolo Pangrazi, Francesco De Francesco, Michele Riccio Department of Reconstructive Surgery and Hand Surgery, AOU Ospedali Riuniti di Ancona, Ancona, Italy Upper limb nerve damage is a common condition, and evidence suggests that functional re- Correspondence: covery may be limited following peripheral nerve repair in cases of delayed reconstruction or Francesco De Francesco Case Report Department of Reconstructive Surgery reconstruction of long nerve defects. A 26-year-old man presented with traumatic injury and Hand Surgery, AOU Ospedali from a wide, blunt wound of the right forearm caused by broken glass, with soft tissue loss, Riuniti di Ancona, via Conca 71, complete transection of the radial and ulnar arteries, and a large median nerve gap. The pa- Ancona 60123, Italy tient underwent debridement and subsequent surgery with a microsurgical free radial fascio- Tel: +39-71-5963945 Fax: +39-71-5965297 cutaneous flap to provide a direct blood supply to the hand; the cephalic vein within the flap E-mail: [email protected] was employed as a venous vascularized chamber to wrap the sural nerve graft and to repair the wide gap (14 cm) in the median nerve. During the postoperative period, the patient fol- lowed an intensive rehabilitation program and was monitored for functional performance over 5 years of follow-up. Our assessment demonstrated skin tropism and sufficient muscle power to act against strong resistance (M5) in the muscles previously affected by paralysis, as well as a good localization of stimuli in the median nerve region and an imperfect recovery of two-point discrimination (S3+). We propose a novel and efficient procedure to repair > 10-cm peripheral nerve gap injuries related to upper limb trauma. Keywords Nerve injuries / Free flap / Nerve graft / Nerve conduit flap / Complex trauma Received: May 27, 2019 • Revised: October 9, 2019 • Accepted: October 18, 2019 pISSN: 2234-6163 • eISSN: 2234-6171 • https://doi.org/10.5999/aps.2019.00654 • Arch Plast Surg 2020;47:187-193 INTRODUCTION promote and modulate growth [2]. Over past decades, the technique of tubulisation was proposed Reconstructive surgery is undoubtedly a complicated interven- to address these shortcomings. In this technique, a conduit of tion for the repair of extensive (> 6 cm) peripheral nerve dam- biological or artificial nature (consisting of a vein, mesothelial age. In 1972, Millesi et al. [1] introduced the fascicular graft chambers, silicone conduits, Maxon suture material [Covidien, technique, which was a major improvement on autologous Minneapolis, MN, USA], collagen, or polyglycolic acid) is inter- nerve grafts and a turning point in the ability of surgical treat- posed between the two nerve stumps [3]. This conduit pro- ment for this type of lesion to yield optimal outcomes. However, vides the regenerating axon with a channel for protection and while this technique was feasible in cases of limited nerve sub- guidance, facilitating regeneration. The vein-muscle combina- stance loss, it could not ensure reliable reinnervation of the tar- tion is currently the treatment of choice, as has been confirmed get organ across gaps exceeding 6 cm. Moreover, such nerve via experimental and clinical studies [4,5] illustrating the regen- grafts passively support axon regeneration, but do not directly erative potential of the vein and the ability of the muscle to pre- Copyright © 2020 The Korean Society of Plastic and Reconstructive Surgeons This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/ licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.e-aps.org 187 Campodonico A et al. Nerve conduit flap for long nerve defect vent vein collapse and promote axon reconstruction. The vein- Fig. 1. Surgical debridement with median nerve gap muscle procedure appears to be suitable for sensory nerves with Yellow arrows show the median nerve interruption with a 14-cm gaps of 3 cm or less, but it is less efficient in the repair of larger gap. The white arrow shows the ulnar artery interruption. nerve gaps [6,7]. Ample evidence supports the advantages of conventional nerve flaps over nerve grafts for bridging large nerve gaps, since nerve flaps possess sufficient blood supply at the time of nerve transfer and are associated with reduced risk of central necrosis, fibrosis, and disordered histological findings. Townsend and Taylor (1984) proposed the novel arterialized neurovenous flap to transfer nerve segments with an exclusively venous pedicle [8,9]. In light of this information, we propose an innovative method using a vascularized autologous vein to pro- vide support for nerve regeneration. In this study, we report the use of a free nerve conduit flap for successful reconstruction of a peripheral nerve injury with a >10-cm gap following severe trauma of the extremity. The injury involved considerable sub- stance loss of the volar surface of the forearm and indirect vascu- also presented with median palsy and was unable to abduct and larization of the hand due to traumatic radial and ulnar artery oppose the thumb (ape hand deformity), indicative of a lesion occlusion, as well as a median nerve gap exceeding 14 cm. of the main trunk of the median nerve proximal to the emer- This report describes the delayed reconstruction of a long ner- gence of the anterior interosseous nerve branch. He reported vous defect (> 10 cm) with considerable substance loss using a sensory loss in the thumbs, index fingers, long fingers, and the technique we termed a nerve conduit flap. The goal of this re- radial aspect of the ring finger with impaired pronation of the port is to demonstrate: (1) the reconstruction of a long defect forearm (due to involvement of the pronator branch) and diffi- of the median nerve using an autologous nerve graft vascular- culty flexing the wrist and fingers at the metacarpophalangeal ized and protected by the cephalic vein; (2) the reconstruction and proximal interphalangeal joints. Difficulty flexing the wrist of a defect with extensive soft tissue loss; and (3) the details of along the main axis of the forearm has been clinically attributed how this reconstruction was performed in the context of a single to a deficit of the radial carpus flexor. However, no tendon con- surgical intervention. traction was evident in this area; instead, wrist flexion along the ulnar axis was present and normal, with contraction of the rela- CASE tive tendon of the ulnar carpus flexor. Clinical assessment remains the most important step in the di- A 26-year-old man from Albania presented with a broken glass agnosis of nerve injury or other nerve conditions, as detailed in injury to the proximal third of the volar surface of the right fore- our previous review [2]. We assessed motor function using the arm. The patient had initially been referred to a hospital for British Medical Research Council scale, modified by Birch et al. treatment and underwent muscle and skin surgery with 3-0 Vic- [10] and proposed by Highet, and we assessed strength using a ryl mattress sutures (Fig. 1), but was admitted 2 weeks later to JAMAR dynamometer (JLW Instruments, Chicago, IL, USA) our reconstructive and hand surgery clinic as an outpatient. [11]. We determined sensory function using a Visual Analogue This investigation was performed in compliance with the Decla- Scale (VAS) and tactile two-point discrimination using the test ration of Helsinki and the Guidelines for Good Clinical Practice. proposed by Dellon [12], which built on the work of Weber. Fi- The patient provided written informed consent both for surgery nally, the Nine-Hole Peg Test [13] and the Frenchay Arm Test and for follow-up. The follow-up study protocol was approved [14] were conducted to assess motor function (Table 1). At T0 by the Ethics Committee (AG_1). Information regarding the (first evaluation), we observed a strength of M0/M1, with a per- initial procedure (including the operative report from the out- ceptible contraction in proximal muscles and a total active range side hospital) was unavailable. of motion (or total active motion) of less than 20% for motor A physical examination revealed abundant purulent secretions function. We also observed a result of S0 with no recovery of from the wound. The patient reported tingling and numbness sensibility in the autonomous zone of the median nerve. The in the median nerve distribution and displayed a flexion motor two-point discrimination test yielded a result of 15 mm. Elec- deficit of the long fingers and the opponens pollicis. The patient troneuromyography (ENMG) revealed chronic median neurot- 188 Vol. 47 / No. 2 / March 2020 Table 1. Patient assessment Test T0 T1 T2 T3 T4 T5–7 Medical Research Council (%, compared to healthy 20 30 50 60 80 80 hand function) JAMAR dynamometry test (%, compared to healthy 10 10 40 60 80 80 hand function) Thumb opposition movement Absent Absent Weak Weak Normal Normal Frenchay Arm Test 0 0 0 5 5 5 Nine-Hole Peg Test Subject was Subject was Task completed in Task completed in Task completed in Task completed in unable to perform unable to perform 120 sec 70 sec 50 sec 50 sec the task the task Visual Analogue Scale sensitivity 0 0 0 0 5–6 5–6 Weber test (mm) >15 >15 >15 >15 13–15 13–15 British Medical Research, Council test/Dellon test M0/S0 M0/S0 M2/S2+ M3-M4/S3 M4/S3+ M5/S3+ Electroneuromyography Negative Negative Positive for hand Positive for hand Positive for hand Positive for hand reinnervation- reinnervation- reinnervation- reinnervation- related signs related signs related signs related signs mesis at the proximal forearm.
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