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Endoscopically assisted sural nerve harvest for upper extremity posttraumatic nerve defects: an evaluation of functional outcomes.
by Lin CH, Mardini S, Levin SL, Lin YT, Yeh JTPlastic and reconstructive surgery.
Article Abstract:
BACKGROUND: Peripheral nerve injuries in the upper extremity often require interposition of sural nerve grafts for reconstruction. Due to the poor donor-site appearance with standard techniques, and the potential for trauma to the nerve because of poor visualization during the harvest when the stepladder technique is used, the endoscope has been employed for nerve harvest. METHODS: From January of 1997 until December of 2003, 15 patients with an average age of 27.5 years with posttraumatic upper limb nerve defects of the ulnar, median, or posterior interosseous nerves (crush, cutting, or avulsion injuries) underwent reconstruction with endoscopically harvested sural nerve. The nerves were harvested using atraumatic techniques under video monitor visualization. The functional results of sensation and motor function were assessed using British Medical Research Council scales. RESULTS: All patients regained at least cutaneous pain and tactile sensibility, with most regaining two-point discrimination (nine patients achieved S3+). Two patients achieved complete recovery (S4). The 11 patients with motor nerve involvement achieved between M1+ and M5 after the initial reconstruction. Eight patients required a total of one immediate and nine secondary procedures to achieve the final outcome. The procedures included tenolysis (three patients), intrinsic tendon transfers (four patients), and opponensplasty (three patients). At the 4-year mean follow-up, grip power was M5 in 13 patients (86.7 percent) and M4 in two patients (13.3 percent). CONCLUSIONS: Upper extremity sensory and motor nerve defects can be reconstructed with interposition of endoscopically harvested sural nerve grafts. The procedure is reliable, quick, and atraumatic, and results in reasonable motor and sensory recovery.
Endoscopically assisted sural nerve harvest for upper extremity posttraumatic nerve defects: an evaluation of functional outcomes.
By: Anonymous - Tue 2/27/2007 PMSo what sural nerve harvest technique will prove optimal: open, stepladder, endoscopic, nerve stripper? I (and my patients) do not like the open technique because of the incision length. Nevertheless, because of common anatomical variations in the sural nerve, I continue to use it for many patients in whom I need as much graft as possible. An excellent anatomical study published in Clinical Anatomy in 2002 revealed that 66% of sural nerves originate from the medial and lateral sural cutaneous nerves not at the gastrocnemius cleft, but more commonly in the lower third of the leg. Furthermore, in 33% of patients the lateral sural cutaneous nerve did not merge with the medial sural cutaneous nerve at all, or potentially below the ankle (do these variations reveal why some sural nerves appear smaller than others?). A technique with direct visualization (either open or endoscopic) would allow for the identification and removal of these variations. I would like to move to using an endoscopic technique similar to that presented here. Sural nerve removal without complete visualization (e.g., nerve stripper or stepladder) may miss these variations, thus limiting potential graft length and size (which may be acceptable if not much is required), or even cause avulsion/stretch injury (controversial) where branches, especially the lateral sural cutaneous, occur.
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