A resorbable nerve conduit as an alternative to nerve autograft in nerve gap repair.

Poly-3-hydroxybutyrate (PHB) occurs within bacterial cytoplasm as granules and is available as bioabsorbable sheets. Previously, the advantage of PHB in primary repair has been investigated while in this study the same material has been used to bridge an irreducible gap. The aim was to assess the level of regeneration in PHB conduits compared to nerve autografts. The rat sciatic nerve was exposed, a 10 mm nerve segment was resected and bridged with either an autologous nerve graft or a PHB conduit. The grafted segments were harvested up to 30 days. Immunohistochemical staining was performed and computerised quantification of penetration distance and volume of axonal regeneration was estimated by protein gene product (PGP) immunostaining and calcitonin gene-related peptide (CGRP) positive fibres. Penetration and proliferation density of Schwann cells into the conduit was measured by quantifying S-100 staining. The inflammatory response was quantified with ED-1 staining for macrophages. Antibodies to vWf provided an assessment of angiogenesis and capillary infiltration. Percentage immunostaining for PGP in autograft and PHB groups showed a progressive increase up to 30 days with a significant linear trend with time and an increase in the volume of axonal regeneration. A similar pattern of progressive increase with time was observed with CGRP immunostaining for both groups and with S-100 in the PHB group. Good angiogenesis was present at the nerve ends and through the walls of the conduit. The results demonstrate good nerve regeneration in PHB conduits in comparison with nerve grafts.     

Neuronal survival using a resorbable synthetic conduit as an alternative to primary nerve repair.

Clinically optimal situations for primary nerve repair are rarely observed. Crushed nerve ends result in either suboptimal repair or a need for nerve grafting. Functional results after nerve surgery are relatively poor, including major sensory deficits, which may be due to the death of primary sensory neurons that follows the nerve injury. The aim of this study was to determine if using polyhydroxybutyrate (PHB), a resorbable nerve conduit, could be an alternative to primary nerve repair in reducing loss of neurons. The superficial radial nerves in 20 cats were sectioned bilaterally and primarily repaired microsurgically by the use of two different strategies; either wrapping the nerve ends in sheets of PHB or epineurally suturing of the nerve. After 6 or 12 months, the surviving neurons within the dorsal root ganglia [C5-T1] were counted. No statistically significant differences were found between the two methods. This may imply a future possibility of using PHB as a synthetic nerve graft in situations where suboptimal primary repair or nerve grafts are the alternatives.     

A new epineural nerve repair technique: oblique nerve coaptation

Despite the existence of various nerve coaptation techniques, functional results of nerve repair are still inadequate. Potential benefits of developing modified coaptation techniques cannot be disregarded. The authors report a new coaptation technique in which the nerves are cut in an oblique fashion to increase the coaptational surface. The sciatic nerves of male Wistar albino rats were cut at an angle of 30 and 45 deg (experimental groups), and 90 deg (control group). The nerves were repaired with nine 10-0 epineural stitches. Functional and histological studies were performed at week 12 on 7 rats from the 30-deg group, 15 rats from the 45-deg group, and 7 rats from the 90-deg group. Mean sciatic function index values of walking track analysis were the following: 30-deg group, -42.4+/-15.4; 45-deg group, -44.7+/-17.9; and 90-deg group, -52.9+/-13.9 (p>0.05). The mean values of myelinated axonal counts for the 30-deg, 45-deg, and 90-deg transection groups were 196.2+/-3.7, 196.1+/- 3.7, and 176.1+/- 5.6 respectively for proximal nerve segments and 180.1+/-6.8, 178.2+/-3.8, and 114.1+/-17.3 respectively for distal samples. Both the 30-deg and 45-deg coaptational groups had a significantly lower reduction of myelinated axonal counts at the regeneration zone in comparison with the 90-deg group (p<0.01). Mean myelinated axonal diameters in the proximal nerve segments were 8.2+/-2.6 microm, 8.4+/-3.1 microm, and 8.1+/-3.2 microm respectively, and were 7.1+/-3.6 microm, 6.9+/-3.4 microm, and 6.7+/-3.4 microm respectively in the distal nerve segments (p>0.05). The oblique nerve coaptation technique may enhance nerve regeneration by enabling a larger sprouting and contact area for nerve fibers, but additional investigation by more experienced centers is needed before relying on the preliminary results of this simple modification.     

Partial gastric wrap-around as an alternative procedure in the treatment of hiatal hernia.

The Allison, Belsey, and Nissen antireflux operations have been widely used over the last 15 yr. A number of problems have followed from these procedures that have prompted us under certain circumstances to seek alternative operations. In the last 2 yr, in selected patients, we have done a partial gastric wrap-around (Dor-Nissen) operation on 16 children from age 2 wk to 13 yr for the following reasons: failed Allison and Nissen repairs, two infants with such a small stomach that only a partial stomach wrap-around was possible, with a Heller cardiomyotomy, and for reflux with or without an accompanying hiatal hernia. All of these Dor-Nissen partial wrap-around operations were technically easy to do and all the postoperative patients have been problem-free both clinically and radiologically. Moreover, the gass bloat syndrome seen with the Nissen fundoplication has not been encountered. We recommended this partial wrap-around antireflux operation as a primary procedure, an alterative to one of the more widely used operations, or when re-operating for recurrence of gastroesophageal reflux.     

Peripheral nerve repair in humans using muscle autografts. A new technique

Coaxial autografts of skeletal muscle which had been frozen then thawed were used to repair injured digital nerves in eight patients. Assessment from three to 11 months after operation showed recovery to MRC sensory category S3+ in all but one patient, an excellent level of recovery. We conclude that bespoke muscle grafts treated and used in this way may offer significant advantages over conventional nerve grafts or cable grafts especially where large peripheral nerves are involved.     

A new epineural nerve repair technique with external metallic circle

BACKGROUND: Despite the existence of various nerve coaptation techniques, functional results of nerve repair are still inadequate. Potential benefits of developing modified coaptation techniques cannot be disregarded. METHODS: The authors report a new coaptation technique in which the epineural sutures were performed with an external metallic circle to increase the coaptation surface. The sciatic nerves of 30 male Wistar albino rats were used in the study. RESULTS: The mean Sciatic Function Index values in external metallic circle repair (n:11) and conventional epineural repair (n:10) groups were -42.35 +/- 22.95 and -69.34 +/- 17.96, respectively (p = 0.020). Electrophysiological studies revealed that the duration of compound muscle action potentials (CMAP) was (p = 0,012) shorter in conventional nerve repair group than it was in external metallic nerve repair. When external metallic circle repair and conventional epineural repair groups were examined for distal nerve segments, there were significant findings for the diameter of axons (p = 0.005), diameter of nerves (p = 0.000), and for G ratios (p = 0.000). The mean intraepineural cross sectional areas of external metallic circle repair and conventional epineural repair groups were 3.57 +/- 0.21 and 2.92 +/- 0.23 mm(2), respectively (p = 0.000). CONCLUSION: The external metallic circle repair technique enhances nerve regeneration by enabling a larger sprouting and contact area for nerve fibers.     

End-to-side nerve suture--a technique to repair peripheral nerve injury.

End-to-side nerve suture (ETSNS) has until recently been extensively researched in the laboratory animal (rat and baboon). Lateral sprouting from an intact nerve into an attached nerve does occur, and functional recovery (sensory and motor) has been demonstrated. We have demonstrated conclusively that ETSNS in the human is a viable option in treating peripheral nerve injuries, including injuries to the brachial plexus. Among the many advantages of this new technique are: (i) simple and short operation; (ii) shorter recovery time--suture is done closer to the target organs; (iii) nerve grafts to bridge injured gaps are eliminated, reducing the morbidity of nerve surgery to a minimum; (iv) innervation of paralysed muscles, for which there was previously thought to be no hope of recovery, opens up many new treatment options; and (v) certain aspects of nerve function and regeneration, unknown until recently, open new horizons and understanding. ETSNS has given us new dimensions in the management of peripheral nerve injuries.     

A new technique for indirect inguinal hernia repair.

This report concerns a preliminary study of a new technique for indirect herniorraphy, which was used in 242 patients from December 1988 through March 1991. Its main characteristics are the creation of a deep neo-inguinal ring in a more medial site, shortening of the inguinal canal by transposition of the superficial ring to the point where the inferior border of the internal oblique muscle is well represented, reinforcement of the inguinal canal by overlapping the external oblique aponeurosis in a double-breast fashion, and maintenance of the cremasteric muscle. Follow-up in our outpatient clinic was carried out at 1, 6, 12, and 24 months in 71% of our patients. There were no recurrences, except for one crural pseudo-recurrence, no mortality, and no testicular atrophy. Thirteen percent of patients had subcutaneous serous collection; 1% had hematomas; 2% temporary testicular edema; and 0.4% wound infection.     

A new, all-inside technique for meniscus repair.

A new method for arthroscopic meniscal repair using sutures with multiple knots was developed, and its mechanical strength was evaluated. Sutures are passed arthroscopically through the torn meniscus using a needle with a cleft in its tip, and when the needle is withdrawn, knots are placed both in the meniscus and the joint capsule. Our method does not require additional skin incisions and can be performed for repair of posterior tears. Furthermore, this all-inside technique minimizes the risk of popliteal neurovascular injury. Biomechanical analysis using bovine menisci showed that the maximum frictional force between the suture and meniscus was greater than the maximum strength of a suture itself. Our method is simple and rapid, making it easy to insert multiple sutures to achieve adequate stability.     

An alternative repair technique for aortic periprosthetic leakage.

In case of aortic periprosthetic leakage, there are several methods of repair. When valve replacement or refixation is not suitable an alternative repair technique, 'curtaining' with a Dacron patch to prevent leakage is presented.     

A new resorbable bone-cartilage replacement transplant. Results of an animal experiment study

Hyaline cartilage is thought to be unable to regenerate. All efforts so far--including autologous chondrocyte cell transplantation--to reconstruct cartilage defects in joints have not been totally convincing. However, mesenchymal cells are able to differentiate into chondrocytes under mechanical pressure conditions. In this study, an open porous resorbable two-layer "bioimplant" was constructed in which mechanical pressure was exerted onto mesenchymal cells when migrated into the open porous structure of the bioimplant. Differentiation of the cells into chondrocytes was thus induced. The bioimplants were implanted into the medial condyles of nine rabbits and left in place for eight or twelve weeks, respectively. In seven of these cases, cartilage formation was found, in contrary to the controls in which only connective tissue and bone had grown into the empty holes. The new bioimplants have proven their effectiveness in cartilage defect repair and might evolve in the future as a new alternative treatment of full thickness defects of joint surfaces.     

Identification of the facial nerve in the translabyrinthine approach: an alternative technique.

An alternative technique for the identification of the facial nerve at the fundus of the internal auditory canal is described.     

Secondary digital nerve repair in the foot with resorbable p(DLLA-epsilon-CL) nerve conduits

Nerve guides are increasingly being used in peripheral nerve repair. In the last decade, much preclinical research has been undertaken into a resorbable nerve guide composed of p(DLLA-epsilon-CL). This report describes the results of secondary digital nerve reconstruction in the foot in a patient with post-traumatic neuromas of the common plantar digital nerves II-III and III-IV. The neuromas were resected and reconstruction of the nerves was carried out with resorbable Neurolac nerve guides. The Pressure Specified Sensory Device was used to measure the static (s) and moving (m) 1- and 2-point discrimination (PD). Fourteen months after nerve repair, the m1-PD returned in all digital nerves. The s1-PD returned only on the lateral side of the second toe. The m2-PD and s2-PD did not return in any of the toes originally innervated by the reconstructed nerves. According to the British Classification System, the sensory nerve recovery was poor. However, there were no complaints of painful neuromas after this procedure. In conclusion, this report shows no beneficial effects of Neurolac nerve guides in terms of return of sensibility after repair of common plantar digital nerves. Painful neuromas, however, could be well-treated.     

Surgeon perspectives on alternative nerve repair techniques

Background

Over the past five decades, microsuturing has been established as the “gold standard” for nerve repair. Alternative techniques such as fibrin glue, protein “welds”, and nerve connectors have been met with variable enthusiasm. While advancements in this area continue, there is little data on surgeon attitude and acceptance of these new techniques.

Methods

A short questionnaire was electronically distributed to the members of the American Society for Surgery of the Hand and the American Association of Hand Surgery. Survey questions ascertained demographic information of participants (specialty, years in practice, practice setting, etc.), attitudes about current techniques (what techniques currently used, why, etc.), and attitudes about new techniques (openness to trying, factors that would persuade for/against, etc.). The surveys were distributed and administered online. Data gathered from responses was analyzed looking for general trends and stratified based on demographic data.

Results

The majority of responders still consider microsuturing as the gold standard for primary nerve repair, and it is by far the most utilized technique. However, over 90 % also reported that they either currently use or would consider using alternate techniques. Common barriers to utilizing alternate techniques included lack of data regarding outcomes and unfamiliarity with new techniques. Only 40 % of responders considered metal as safe around nerves, but most consider absorbable polymers safe. None of the underlying demographic variables including years in practice, number of nerve repair surgeries performed per month, practice setting, or specialty affected these general trends.

Conclusions

Most surgeons performing nerve repairs prefer suturing as their primary repair technique, but a vast majority is open to utilizing alternate repair techniques, especially those that improve outcomes with a faster and easier procedure. While not able to direct clinical practice guidelines, this study can be used to direct focus and funding of further alternate nerve repair techniques.     

Transposition of the lingual thyroid: A new alternative technique.

BACKGROUND: In symptomatic lingual thyroid, surgical transposition of the gland with its vascular supply intact seems to have superior results to those obtained by surgical ablation and autotransplantation. However, the procedure should be simple, reproducible, reliable, and cause less morbidity as well as providing simple access to and evaluation of the gland postoperatively. METHODS: We present the case of a 33-year-old female with lingual thyroid who was treated by transposing the whole gland to the lateral pharyngeal wall through a lateral pharyngotomy incision. The transposed lingual thyroid was nourished by a random tongue muscle pedicle flap. RESULT: At the 5-month postoperative stage, iodine scanning reviewed the radioactivity uptake of the transposed gland. Even though the patient was not on postoperative thyroid hormone supplement, her thyroid function gradually returned to normal after initially showing hypothyroid postoperatively. CONCLUSION: This new technique for transposition of lingual thyroid is simple and reliable and should be considered as an alternative method in the management of symptomatic patients.