Reconstruction of a long defect of the median nerve with a free nerve conduit flap

Upper limb nerve damage is a common condition, and evidence suggests that functional recovery may be limited following peripheral nerve repair in cases of delayed reconstruction or reconstruction of long nerve defects. A 26-year-old man presented with traumatic injury from a wide, blunt wound of the right forearm caused by broken glass, with soft tissue loss, complete transection of the radial and ulnar arteries, and a large median nerve gap. The patient underwent debridement and subsequent surgery with a microsurgical free radial fasciocutaneous flap to provide a direct blood supply to the hand; the cephalic vein within the flap 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 followed 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

Publication History

Received: 27 May 2019

Accepted: 18 October 2019

Article published online:
22 May 2022

• REFERENCES

• 1 Millesi H, Meissl G, Berger A. The interfascicular nerve-grafting of the median and ulnar nerves. J Bone Joint Surg Am 1972; 54: 727-50
• 2 Riccio M, Marchesini A, Pugliese P. et al. Nerve repair and regeneration: biological tubulization limits and future perspectives. J Cell Physiol 2019; 234: 3362-75
• 3 Patel NP, Lyon KA, Huang JH. An update-tissue engineered nerve grafts for the repair of peripheral nerve injuries. Neural Regen Res 2018; 13: 764-74
• 4 Battiston B, Tos P, Cushway TR. et al. Nerve repair by means of vein filled with muscle grafts I. Clinical results. Microsurgery 2000; 20: 32-6
• 5 Battiston B, Tos P, Geuna S. et al. Nerve repair by means of vein filled with muscle grafts. II. Morphological analysis of regeneration. Microsurgery 2000; 20: 37-41
• 6 Battiston B, Tos P, Conforti LG. et al. Alternative techniques for peripheral nerve repair: conduits and end-to-side neurorrhaphy. Acta Neurochir Suppl 2007; 100: 43-50
• 7 Riccio M, Pangrazi PP, Parodi PC. et al. The amnion muscle combined graft (AMCG) conduits: a new alternative in the repair of wide substance loss of peripheral nerves. Microsurgery 2014; 34: 616-22
• 8 Townsend PL, Taylor GI. Vascularised nerve grafts using composite arterialized neuro-venous systems. Br J Plast Surg 1984; 37: 1-17
• 9 D’Arpa S, Claes KEY, Stillaert F. et al. Vascularized nerve “grafts”: just a graft or a worthwhile procedure. Plast Aesthet Res 2015; 2: 183-94
• 10 Birch R, Bonney G, Winn Parry CB. Surgical disorders of peripheral nerves. London: Churchill Livingstone; 1998
• 11 Bechtol CO. Grip test; the use of a dynamometer with adjustable handle spacings. J Bone Joint Surg Am 1954; 36: 820-32
• 12 Dellon AL. The moving two-point discrimination test: clinical evaluation of the quickly adapting fiber/receptor system. J Hand Surg Am 1978; 3: 474-81
• 13 Poole JL, Burtner PA, Torres TA. et al. Measuring dexterity in children using the Nine-Hole Peg Test. J Hand Ther 2005; 18: 348-51
• 14 Grasel E, Biehler J, Schmidt R. et al. Intensification of the transition between inpatient neurological rehabilitation and home care of stroke patients: controlled clinical trial with follow-up assessment six months after discharge. Clin Rehabil 2005; 19: 725-36
• 15 Geuna S, Raimondo S, Nicolino S. et al. Schwann-cell proliferation in muscle-vein combined conduits for bridging rat sciatic nerve defects. J Reconstr Microsurg 2003; 19: 119-23