End-to-side neurorrhaphy: an experimental study in rabbits

The concept of end-to-side nerve repair was recently introduced; however, most authors have reported conflicting results with this technique. This study was conducted to assess the effectiveness of end-to-side nerve repair in both fresh and predegenerated specimens by histological evaluation in an animal study in rabbits. Thirty male rabbits were divided into three groups. In group 1 (n = 14), the peroneal nerve was divided and sutured end-to-side to the tibial nerve via an epineurial window. In group 2 (n = 13), the peroneal nerve was divided and sutured end-to-side to the tibial nerve after a 1-week "predegeneration period." In group 3 (n = 3), which was considered the control group, the peroneal nerve was divided and sutured to the adjacent soft tissues. After 3 months, specimens were harvested for histological evaluation. Nerve fiber count, in normal peroneal nerves, averaged 532/cross section. In groups 1 and 2, average nerve fiber count in implanted peroneal nerves was 6.24 and 7.00/cross section, respectively. No significant statistical difference was observed between fresh and "predegenerated" groups (P = 0.90). These data suggest that collateral sprouting of donor nerves is possible after end-to-side neurorrhaphy through an epineurial window, but the number of nerve fibers in recipient nerves is too low to result in any functional recovery in the target organ.     

End-to-side neurorrhaphy for defects of palmar sensory digital nerves.

Ten traumatic nerve defects at the palm or digit level were treated by end-to-side (ETS) neurorrhaphy. The technique included removal of an epineurial window on the donor nerve and coaptation of the sharply cut distal end of the injured nerve by epineurial stitches under microscopic magnification. At final follow-up, the static two-point discrimination test (2 pd) scored at an average of 9.1 mm (range, 6-12 mm) on the repaired nerve, compared to an average of 4.6 mm (range, 4-6 mm) on the contralateral uninjured control side. Moving 2 pd scored at an average of 7 mm (range, 4-9 mm) on the repaired nerve compared to an average of 2.6 mm (range, 2-4 mm) on the control side. This short series showed that ETS neurorrhaphies are effective and give comparable results with those of nerve grafts or vein conduits.     

End-to-side neurorrhaphy supported by transposed active nerve fibers: its functional end result in a rat model

 End-to-side nerve repair is an old-fashioned technique which has been abandoned since the beginning of this century. Recently, new treatment modalities have been investigated to overcome problems associated with peripheral nerve injury where the proximal stumps are not available. In this study, 30 rats were divided into three groups. In the first group the peroneal nerves were sectioned and their distal ends were sutured to the tibial nerve trunk. In the second group, the proximal part of the peroneal nerve was similarly sutured to the tibial trunk. A primary end-to-end neurorrhaphy performed on the peroneal nerves was the control group. At 2, 4, 8, 12, 20, and 28 weeks, functional assessment of nerve regeneration was performed using walking track analysis. The number of myelinated fibers and fiber diameters were measured, and an electron microscopic evaluation was carried out. With morphometric analysis, the values were significantly different in favor of the control group following the end-to-side repair technique. But, according to gait analysis, both groups had a similar satisfactory functional recovery; the classic end-to-side repair group had an unsatisfactory result. It is concluded that end-to-side neurorrhaphy, supported by transposed active nerve fibers, may result in a good integration network at the repair site and is a possible functional reconstruction model where the proximal stump is not available after peripheral nerve injury. Received: 23 September 1996 / Accepted: 24 March 1997     

Ultrastructure of early axonal regeneration in an end-to-side neurorrhaphy model

The ultrastructure of the early regenerative response in an end-to-side neurorrhaphy rat model was studied using transmission electron microscopy. The ipsilateral saphenous nerve was grafted to the sciatic nerve under the following conditions: Group 1, the epineurium and perineurium of the sciatic nerve remained intact; Group 2, an epineurial and perineurial window was created at the site of the lateral neurorrhaphy; Group 3, the same as in Group 2 and, in addition, the sciatic nerve sustained a partial neurectomy. Rats were perfused through the heart with fixative containing 2 percent paraformaldehyde and 2.5 percent glutaraldehyde in 0.1 M cacodylate buffer (pH 7.4) at 4, 8, 12, 24 and 48 hr after surgery. In Group 1, no regenerating axons were observed and the myelin sheath in the donor nerve did not demonstrate any degenerative changes through 48 hr. In Group 2, an increased diameter of the unmyelinated axons and growth cones was observed in the donor nerve proximal to the coaptation site after 12 hr. Degenerative changes in the myelin sheath were observed after 12 hr within the several layers under the coaptation site. In Group 3, many growth cone-like structures were observed in the area proximal to the coaptation site after 12 hr. After 24 hr, proximal regenerating axons elongated to the coaptation site and, at 48 hr, many regenerating nerves grew inside the Schwann cell basement membrane of the graft nerve. These results indicate that the perineurial window and nerve graft are the critical conditions for inciting nerve regeneration in the donor nerve.     

End-to-side neurorrhaphy as a salvage procedure for irreparable nerve injuries. Technical note

After a few reports on end-to-side nerve repair at the beginning of the last century, the technique was put aside until its recent reintroduction. The authors present their results in three patients with median nerve defects that were between 15 and 22 cm long and treated using end-to-side median-to-ulnar neurorrhaphy through an epineurial window. The follow-up times were between 32 and 38 months. Sensory evaluation involved superficial touch, pinprick, and two-point discrimination tests. Motor evaluation was completed by assessing the presence of opposition and by palpating the abductor pollicis brevis muscle. Sensory recovery was observed in all patients in the median nerve dermatome, and motor recovery was absent, except in Case 1. End-to-side nerve repair can be a viable alternative to nerve grafting in patients with long gaps between the ends of the injured nerve.     

Modified end-to-side neurorrhaphy enhances axonal sprouting: a motor functional and morphological study

This study evaluated the effect of modified end-to-side neurorrhaphy on functional recovery by modulating the epineurial window and contact areas, with a donor nerve, using a rat median nerve and finger flexors. Grasping testing, muscle contractility testing, and a histological study were performed 20 weeks after surgery. The modified end-to-side repair can enhance axonal sprouting from an intact nerve, and improve the functional recovery. Either the epineurial window surface area, or the contact configuration with the donor nerve is an important factors in an end-to-side coaptation model.     

Effects of IGF-II in a new end-to-side model.

Insulin-like growth factor-II (IGF-II) has been shown to increase the rate of axon regeneration in a number of models involving the rat sciatic nerve. This project studied the effects of IGF-II on an end-to-side nerve repair. In this study, the musculocutaneous nerve of a Sprague-Dawley rat was transected and coapted by end-to-side neurorrhaphy to the median nerve. Experimental animals received a local infusion of IGF-II at the repair site, while control animals received a local infusion of placebo solution. This new model allowed for the assessment of functional outcome through the Terzis grooming test. The use of an end-to-side repair minimized potential damage to the motor nerve donor (median nerve) and encouraged lateral axon sprouting into the severed nerve (musculocutaneous nerve). Histologic results showed that the IGF-II treated group had higher axon counts and greater myelin thickness in the reinnervated musculocutaneous nerve. IGF-II-treated animals also had significantly greater motor-end-plate counts in the biceps muscle. Furthermore, the IGF-II group scored consistently higher in the grooming test, compared to the control group.     

Mechanical strain stimulates ROS cell proliferation through IGF-II and estrogen through IGF-I.

The mechanism by which mechanical strain stimulates bone cell proliferation was investigated and compared with that of estrogen in ROS 17/2.8 cells. Similarity of strain-related responses between ROS cells and osteoblasts was established by demonstrating that ROS cells respond to a short single period of strain in their substrate (1000-3500 microepsilon, 600 cycles, 1 Hz) by a similar strain magnitude-related increase in glucose 6-phosphate dehydrogenase activity as rat osteoblasts and osteocytes in explants in situ. ROS17/2.8 cells also showed similar proliferative responses to strain and 17beta-estradiol, as assessed by [3H]thymidine incorporation and cell counting, as primary cultures of long bone-derived osteoblast-like cells. Strain-related increase in proliferation in ROS cells was accompanied by a 4-fold increase in levels of insulin-like growth factor-II (IGF-II) in conditioned medium. Neither strain nor estrogen had an effect on the conditioned medium levels of IGF-I. Exogenous truncated IGFs tIGF-I and tIGF-II both increased proliferation in a dose-dependent manner. The neutralizing monoclonal antibody (nMAb) to IGF-I blocked proliferation stimulated by tIGF-I but not that due to tIGF-II and vice versa. IGF-I receptor blocking antibody (IGF-IRBAb) blocked the proliferative effect of tIGF-I but not that to tIGF-II. The proliferative effect of estrogen was abolished by IGF-I nMAb and IGF-IRBAb, but these antibodies had no effect on the proliferative response to strain. In contrast IGF-II nMAb abolished the proliferative effect of strain but had no effect on that of estrogen. These data show that ROS17/2.8 cells have similar responses to strain and estrogen qualitatively and quantitatively as rat osteoblasts in situ and rat long bone-derived osteoblast-like cells in primary culture. Estrogen-related proliferation in ROS17/2.8 cells appears to be mediated by IGF-I acting through the IGF-I receptor and does not involve IGF-II. In contrast, strain-related proliferation appears to be mediated by IGF-II and does not involve either IGF-I or the IGF-I receptor.     

End-to-side anastomoses: A model and a technique with clinical application

Recently, the advantages of end-to-side anastomoses in reconstructive microvascular surgery have been emphasized. This article describes a practical laboratory model for practicing end-to-side anastomoses and a simplified technique for suturing the posterior wall in such anastomoses. The left common iliac artery of a rat is transected and an end-to-side anastomosis with the right common iliac artery is performed. A single clamp is manipulated to present the posterior wall for suturing.     

End-to-side portacaval shunt: a simplified technique.

A simplified technique of end-to-side portacaval shunt in the rat is described, consisting in using a microsuture with a looped end. By using this technique, combined with two-step portal vein venotomy, the portal vein and caval vein can be brought closer together in a single movement, with no need for a knot at the start of the shunt. As a result, this modified technique makes it easier and reduces the time required to perform the shunt, without any rise in associated mortality.     

Role of IGFBP2, IGF-I and IGF-II in regulating long bone growth

The IGF axis is important for long bone development, homeostasis and disease. The activities of IGF-I and IGF-II are regulated by IGF binding proteins (IGFBPs). IGF-I and IGFBP2 are co-expressed in dynamic fashions in the developing long bones of the chick wing, and we have found that IGF-II is present in the cartilage model and surrounding perichondrium, proliferative and hypertrophic chondrocytes and developing periosteum. To gain insight into endogenous roles of IGF-I, IGF-II and IGFBP2 in long bone development, we have overexpressed IGFBP2 in the developing skeletal elements of the embryonic chick wing in vivo, using an RCAS retroviral vector. IGFBP2 overexpression led to an obvious shortening of the long bones of the wing. We have investigated, at the cellular and molecular levels, the mechanism of action whereby IGFBP2 overexpression impairs long bone development in vivo. At an early stage, IGFBP2 excess dramatically inhibits proliferation by the chondrocytes of the cartilage models that prefigure the developing long bones. Later, IGFBP2 excess also reduces proliferation of the maturing chondrocytes and attenuates proliferation by the perichondrium/developing periosteum. IGFBP2 excess does not affect morphological or molecular indicators of chondrocyte maturation, osteoblast differentiation or cell/matrix turnover, such as expression of Ihh, PTHrP, type X collagen and osteopontin, or distribution and relative abundance of putative clast cells. We also have found that IGFBP2 blocks the ability of IGF-I and IGF-II to promote proliferation and matrix synthesis by wing chondrocytes in vitro. Together, our results suggest that the mechanism of action whereby IGFBP2 excess impairs long bone development is to inhibit IGF-mediated proliferation and matrix synthesis by the cartilage model; reduce the proliferation and progression to hypertrophy by the maturing chondrocytes; and attenuate proliferation and formation of the periosteal bony collar. These actions retard the growth and longitudinal expansion of the developing long bones, resulting in shortened wing skeletal elements. Our results emphasize the importance of a balance of IGF/IGFBP2 action at several stages during normal long bone development.     

Role of IGFBP2, IGF-I and IGF-II in regulating long bone growth

The IGF axis is important for long bone development, homeostasis and disease. The activities of IGF-I and IGF-II are regulated by IGF binding proteins (IGFBPs). IGF-I and IGFBP2 are co-expressed in dynamic fashions in the developing long bones of the chick wing, and we have found that IGF-II is present in the cartilage model and surrounding perichondrium, proliferative and hypertrophic chondrocytes and developing periosteum. To gain insight into endogenous roles of IGF-I, IGF-II and IGFBP2 in long bone development, we have overexpressed IGFBP2 in the developing skeletal elements of the embryonic chick wing in vivo, using an RCAS retroviral vector. IGFBP2 overexpression led to an obvious shortening of the long bones of the wing. We have investigated, at the cellular and molecular levels, the mechanism of action whereby IGFBP2 overexpression impairs long bone development in vivo. At an early stage, IGFBP2 excess dramatically inhibits proliferation by the chondrocytes of the cartilage models that prefigure the developing long bones. Later, IGFBP2 excess also reduces proliferation of the maturing chondrocytes and attenuates proliferation by the perichondrium/developing periosteum. IGFBP2 excess does not affect morphological or molecular indicators of chondrocyte maturation, osteoblast differentiation or cell/matrix turnover, such as expression of Ihh, PTHrP, type X collagen and osteopontin, or distribution and relative abundance of putative clast cells. We also have found that IGFBP2 blocks the ability of IGF-I and IGF-II to promote proliferation and matrix synthesis by wing chondrocytes in vitro. Together, our results suggest that the mechanism of action whereby IGFBP2 excess impairs long bone development is to inhibit IGF-mediated proliferation and matrix synthesis by the cartilage model; reduce the proliferation and progression to hypertrophy by the maturing chondrocytes; and attenuate proliferation and formation of the periosteal bony collar. These actions retard the growth and longitudinal expansion of the developing long bones, resulting in shortened wing skeletal elements. Our results emphasize the importance of a balance of IGF/IGFBP2 action at several stages during normal long bone development.     

Terminolateral neurorrhaphy: a review of the literature.

Terminolateral neurorrhaphy (TLN) is an experimental technique for repairing peripheral nerves, when the proximal cut nerve stump is not available for traditional end-to-end repair. Over the past 7 years, the efficacy of TLN, its ability to preserve donor nerve function, the necessity of disrupting donor nerve connective tissue layers during the procedure, the mechanism by which TLN affords reinnervation, and the definition of the procedure, have been debated. In this critical review of TLN literature, the authors attempt to demonstrate 1) that a TLN in which the surgeon deliberately transects donor nerve axons is an effective method for peripheral nerve repair; the mechanisms by which axons innervate target muscles following this procedure are well-defined, and there is adequate experimental and clinical evidence to support its clinical application; and 2) that a TLN procedure in which the surgeon attempts to leave the donor nerve intact is neither mechanistically distinct from a TLN with deliberate donor nerve axotomy, nor is it as efficacious. Future studies should assess the degree of donor nerve transection that will maximize reinnervation via the TLN graft, without incurring functionally significant donor nerve deficits.     

膈神经端侧吻合移位治疗肌皮神经损伤的实验研究

目的 研究膈神经端侧吻合移位至肌皮神经治疗臂丛神经撕脱伤的可行性.方法 取雄性SD大鼠51只,随机分成4组:A组,单侧全臂丛神经撕脱组;B组,膈神经端端吻合组;C组,膈神经端侧吻合组;D组,膈神经螺旋状端侧吻合组(B、C、D组膈神经均移植2.0 cm腓肠神经至肌皮神经).并于术后进行肢体功能、组织学和神经电生理检测.另取绿色荧光蛋白(green fluorescent protein,GFP)转基因F344大鼠9只,通过荧光显微镜观察膈神经轴突再生情况.方果 各实验组术后手术侧肢体功能逐渐恢复,术后神经电生理和组织学检测表明,术后3个月,C、D组左侧肱二头肌肌张力恢复率和肌湿重恢复率,分别为B组的76.4%和86.3%、85.6%和87.7%,即端侧吻合组肱二头肌功能达到端端吻合组的80%以上,同时保留了膈肌的功能.荧光显微镜观察发现膈神经轴突通过端侧吻合口长入移植神经.方论 膈神经端侧吻合治疗臂丛神经损伤的手术方法是有效、可行的.     

End-to-side nerve coaptation: a qualitative and quantitative assessment in the primate.

There are several reasons why end-to-side nerve coaptation has not been widely adopted clinically. Among these are the putative damage inflicted on the donor nerve and the variable quality of the regeneration in the recipient nerve. So far experiments on end-to-side nerve repair have been short term and mostly carried out on rats. This long-term study of end-to-side nerve repair of ulnar to median and median to ulnar nerve was performed using adult nonhuman primates. Eleven nerve repairs were studied at different time points. Eighteen, 22, 33 and 57 months after surgery a qualitative and quantitative analysis of the donor nerve and regenerating nerve revealed variable levels of percentage axonal regeneration compared with matched controls (1.4%-136%). Morphological evidence of donor nerve damage was identified distal to the coaptation site in four of the 11 cases, and in these cases the best axonal regeneration in the corresponding recipient nerves was observed. This donor nerve damage could neither be demonstrated in terms of a decrease in axon counts distal to the coaptation nor as donor target organ denervation. Recipient target organ regeneration like the axonal regeneration varied, with evidence of motor regeneration in eight out of 11 cases and sensory regeneration, as measured by percentage innervation density compared with matched controls, varied from 12.5% to 49%. Results from the present study demonstrate that the end-to-side coaptation technique in the nonhuman primate does not give predictable results. In general the motor recovery appeared better than the sensory and in those cases where donor nerve damage was observed there was better motor and sensory regeneration overall than in the remaining cases.     

Quantitation of growth factors IGF-I, SGF/IGF-II, and TGF-beta in human dentin

Human bone matrix is known to contain a battery of polypeptide growth factors. Since dentin is a mineralized tissue similar to bone in composition and perhaps in formation, human dentin was assayed for the presence of similar growth factors. Root dentin proteins were extracted by demineralization in 4 M guanidine hydrochloride (Gu) and 30 mM Tris (pH 7.4) containing 20% EDTA and proteinase inhibitors. Gu-EDTA extracts were desalted and used for the following assays: (1) bone cell proliferation in chick calvarial cell mitogenic assay using the incorporation of [3H]thymidine into TCA-insoluble material; (2) osteocalcin by radioimmunoassay (RIA); (3) insulin-like growth factor I (IGF-I) by RIA; (4) skeletal growth factor/insulinlike growth factor II (SGF/IGF-II) by radioreceptor assay; and (5) transforming growth factor beta (TGF-beta) by bioassay. Gu-EDTA extracts stimulated bone cell proliferation. At 10 micrograms/ml, dentin proteins increased the incorporation of [3H]thymidine by calvarial cells to 320% of that by BSA-treated control cells. Consistent with the presence of mitogenic activity, growth factors were found in dentin in the following concentrations (ng/micrograms Gu-EDTA protein): (1) IGF-I, 0.06; (2) SGF/IGF-II, 0.52; and (3) TGF-beta, 0.017. All three growth factors were present in concentrations lower than that found in human bone. Osteocalcin was detected at a concentration of 3.0 mg/g Gu-EDTA protein, also much lower than that in bone.     

Immediate and delayed neurorrhaphy in a rabbit model: a functional, histologic, and biochemical comparison

The effect of timing of neurorrhaphy on neuromuscular function was studied. The extensor digitorum longus neuromuscular units of 51 rabbits were used, with repairs performed immediately, 3 weeks, 3 months, and 6 months after nerve transection. Neuromuscular function was assessed 3 months after nerve repair, as was histology, histochemistry, and muscle hydroxyproline content. Force generated by immediately repaired units was 93% of unoperated controls. All functional delayed repairs produced approximately 50% of control force. Mild endomysial and perimysial fibrosis was present in the immediate neurorrhaphy group. Fibrosis was mild to moderate in the functional delayed repairs and moderate to severe in the nonfunctional repairs. Total and regional hydroxyproline content correlated to both function and timing of nerve repair. The data demonstrate that immediate repair of peripheral nerve lacerations gives the best functional recovery in this rabbit model. If immediate repairs are not performed in the rabbit, approximately 50% to 75% of normal function can be obtained when repairs are delayed for periods of 3 weeks to 6 months.     

Quantitative relationship between axonal injury and mechanical response in a rodent head impact acceleration model

A modified Marmarou impact acceleration model was developed to study the mechanical responses induced by this model and their correlation to traumatic axonal injury (TAI). Traumatic brain injury (TBI) was induced in 31 anesthetized male Sprague-Dawley rats (392±13?g) by a custom-made 450-g impactor from heights of 1.25?m or 2.25?m. An accelerometer and angular rate sensor measured the linear and angular responses of the head, while the impact event was captured by a high-speed video camera. TAI distribution along the rostro-caudal direction, as well as across the left and right hemispheres, was determined using β-amyloid precursor protein (β-APP) immunocytochemistry, and detailed TAI injury maps were constructed for the entire corpus callosum. Peak linear acceleration 1.25?m and 2.25?m impacts were 666±165?g and 907±501?g, respectively. Peak angular velocities were 95±24?rad/sec and 124±48?rad/sec, respectively. Compared to the 2.25-m group, the observed TAI counts in the 1.25-m impact group were significantly lower. Average linear acceleration, peak angular velocity, average angular acceleration, and surface righting time were also significantly different between the two groups. A positive correlation was observed between normalized total TAI counts and average linear acceleration (R(2)=0.612, p<0.05), and time to surface right (R(2)=0.545, p<0.05). Our study suggested that a 2.25-m drop in the Marmarou model may not always result in a severe injury, and TAI level is related to the linear and angular acceleration response of the rat head during impact, not necessarily the drop height.     

Motor functional and morphological findings following end-to-side neurorrhaphy in the rat model.

Nerve repair cannot always be achieved by the conventional end-to-end technique. This study evaluated the functional recovery of nerves repaired with end-to-side neurorrhaphy in a rat model. The right peroneal nerves of 80 female rats were transected and divided into four groups. In group A, the nerve ends were separated and remained unrepaired; in group B, the distal peroneal ends were directly sutured to the epineurium of the tibial nerves in end-to-side fashion; in group C, the distal ends were sutured through an epineurial window at the repair site in end-to-side fashion; and in group D, the nerve ends were reconnected by the traditional end-to-end technique. Evaluation included gait analysis by calculation of a peroneal functional index, measurement of contractile function of the extensor digitorum longus muscle, wet weight of the extensor digitorum longus, and histological examination. The findings of this study suggested the following: (a) end-to-side neurorrhaphy allows effective motor functional recovery, demonstrated by earlier improvement of the peroneal functional index, stronger muscle contractile function, greater muscle weight, and higher density of regenerated axons compared with unrepaired nerves; (b) removal of the epineurium of the donor nerve at the nerve coaptation site increases the effectiveness of end-to-side neurorrhaphy, but the epineurium appears to be a partial barrier to axonal regeneration; (c) removal of the epineurium does not affect the structure and function of the donor nerve; and (d) end-to-end repair achieved the best functional recovery among the four groups; therefore, end-to-side repair should be considered as a potential alternative only when no proximal nerve is available.