Ducic Ivica, Fu Rose, Iorio Matthew L
Department of Plastic Surgery, Georgetown University Hospital, Washington, DC 20007, USA.
Ann Plast Surg. 2012 Feb;68(2):180-7. doi: 10.1097/SAP.0b013e3182361b23.
Although autografts are the gold standard for failed primary nerve repairs, they result in donor-site morbidity. Nerve conduits and decellularized allografts are a novel solution for improved functional outcomes and decreased donor-site morbidity. Unfortunately, previous reconstructive algorithms have not included the use of decellularized allograft nerve segments, either for repair of the primary injury or reconstruction of the autograft donor site. To identify the optimal sequence of techniques and resources, we reviewed our cases of upper extremity peripheral nerve reconstruction.
A retrospective review was performed on consecutive patients who underwent upper extremity nerve reconstruction between August 2003 and September 2009. Outcomes were evaluated with the QuickDASH (disabilities of the arm, shoulder, and hand) questionnaire. Grouped outcome results were evaluated with analysis of variance analysis. A literature review of available options for nerve reconstruction was performed.
In all, 47 patients were identified. Complete demographic/injury data were obtained in 41 patients with 54 discrete nerve repairs: 8 were repaired primarily, 27 with nerve conduits, 8 with allografts, and 11 with autografts. Time from injury to repair averaged 22.3 ± 38.3 weeks, with 12 repairs occurring immediately after tumor resection. Average QuickDASH score was 23.2 ± 19.8. An analysis of variance between repair-type outcomes revealed a P value of 0.58, indicating no outcome difference when each repair was applied for an appropriate gap. No comparable algorithm was identified in the literature analyzing the use of allograft in conjunction with conduit and autografts.
To restore maximal target-organ function with minimal donor-site morbidity, we have created an algorithm based on evidence for nerve reconstruction using allograft, conduit, and autologous donor nerve. Based on our clinical outcomes, despite small sample study, the adoption of the proposed algorithm may help provide uniform outcomes for a given technique, with minimal patient morbidity. Individualized reconstructive technique, based not only on nerve gap size but also on functional importance and the anatomical level of the nerve injury are important variables to consider for optimal outcome.
尽管自体移植是原发性神经修复失败后的金标准，但会导致供区发病。神经导管和脱细胞同种异体移植物是一种新型解决方案，可改善功能结局并降低供区发病率。不幸的是，先前的重建算法未包括使用脱细胞同种异体神经段来修复原发性损伤或重建自体移植供区。为了确定技术和资源的最佳顺序，我们回顾了我们的上肢周围神经重建病例。
对2003年8月至2009年9月期间连续接受上肢神经重建的患者进行回顾性研究。采用QuickDASH（手臂、肩部和手部功能障碍）问卷评估结局。采用方差分析评估分组结局结果。对神经重建的可用选项进行文献综述。
共确定47例患者。41例患者获得了完整的人口统计学/损伤数据，共进行了54次离散神经修复：8例为一期修复，27例使用神经导管，8例使用同种异体移植物，11例使用自体移植物。从损伤到修复的平均时间为22.3±38.3周，其中12例在肿瘤切除后立即进行修复。平均QuickDASH评分为23.2±19.8。修复类型结局之间的方差分析显示P值为0.58，表明当每种修复应用于合适的间隙时，结局无差异。在分析同种异体移植物与导管和自体移植物联合使用的文献中，未发现可比算法。
为了以最小的供区发病率恢复最大的靶器官功能，我们基于使用同种异体移植物、导管和自体供体神经进行神经重建的证据创建了一种算法。基于我们的临床结局，尽管样本量较小，但采用所提出的算法可能有助于为给定技术提供一致的结局，同时使患者发病率最小化。不仅基于神经间隙大小，还基于功能重要性和神经损伤的解剖水平的个体化重建技术是实现最佳结局需要考虑的重要变量。
