Long-term follow-up of three different nerve repair strategies (repair, autografting and allografting) in one-stage replantation to treat upper extremity amputation

Objective To examine the efficacy of three different nerve repair methods for one-stage replantation to treat complete upper extremity amputation and long-term postoperative functional recovery. Methods Twenty-five patients underwent direct nerve anastomosis (Group A), for patients with nerve defects greater than 3 cm, nerve autograft transplantation be used (Group B), or patients with nerve defects less than 3 cm, nerve allograft transplantation be used (Group C) based on the severity of injury. The Disabilities of the Arm, Shoulder, and Hand (DASH) score (higher score means poorer function-less than 25 means good effect) and visual analogue scale (VAS) scores for pain at rest and under exertion were measured. Sensation recovery time and grip function were recorded. Results The mean follow-up time was 78 ± 29 months. Group A had the lowest DASH score, while Group C had the highest DASH score. DASH score differed significantly between the three groups (P < 0.001). Sensation was not restored in two patients in Group B and two patients in Group C, and there were significant between-group differences in sensation recovery (P = 0.001). Group C had the lowest VAS score, while Group A had the highest, and there were significant differences between groups (P = 0.044). Only one patient in Group C recovered grip function. Conclusion Direct nerve anastomosis should be performed whenever possible in replantation surgery for complete upper extremity amputation, as the nerve function recovery after direct nerve anastomosis is better than that after nerve autograft transplantation or nerve allograft transplantation. Two-stage nerve autograft transplantation can be performed in patients who do not achieve functional recovery long after nerve allograft transplantation.

Masseteric-Facial Anastomosis: A Report of Three Cases

Intoduction The pathways of the facial nerve are variable, and knowledge of that is essential. The worst impact caused by facial paralysis is related to quality of life, especially regarding the self-esteem and social acceptance on the part of the patients, leading to social isolation and disruption on their mental health. Case Report A 33-year-old female patient, with a stage-T3 acoustic neurinoma, presented with a moderate dysfunction (grades II to III) according to the House-Brackmann (HB) Facial Nerve Grading System. A 43-year-old male patient, with a stage-T4B trigeminal schwannoma, underwent a resective surgery and presented grade-VI dysfunction according to the HB scale. And a female patient with a stage-T4A acoustic neurinoma presented grade-IV dysfunction according to the HB scale. Discussion We performed a literature review of papers related to surgeries for masseteric-facial nerve anastomosis and compiled the results in table; then, we compared these data with those obtained from our cases. Conclusion The masseteric nerve is the one that shows the best prognosis among all the cranial nerves that could be used, but it is also necessary to perform well the surgical technique to access the facial branch and consequently achieve a better masseteric-facial nerve anastomosis.

UK based microsurgical training

This describes the UK history of the evolution of microsurgical training. The author has been involved since the start in 1979 and took a sole teaching role in the courses 2 years later. Before teaching microsurgery the necessary skills were obtained by the performance of various organ transplants in mice, rats and rabbits to investigate organ storage and immunosuppression. This experience identified the pitfalls of microsurgery and amplified the then identified need for meticulous microsurgical training. A basic microsurgical program was then instigated to provide step by step exercises of increasing difficulty. This consisted of microscope set-up, correct positioning, instruments, simulated suture exercises, dissection techniques, end to end arterial and venous anastomosis, end to side anastomosis, interpositional vein grafts, nerve anastomosis and groin flaps – all performed on an anaesthetised rat. Latterly we are now running advanced workshops incorporating supramicrosurgical exercises in the chicken (thigh) and the rat. The microsurgical workshops are still running 41 years later!

Electromyography as an intraoperative test to assess the quality of nerve anastomosis – experimental study on rats

BackgroundMany factors contribute to successful nerve reconstruction. The correct technique of anastomosis is one of the key elements that determine the final result of a surgery. The aim of this study is to examine how useful an electromyography (EMG) can be as an objective intraoperative anastomosis assessment method.MethodsThe study material included 12 rats. Before the surgery, the function of the sciatic nerve was tested using hind paw prints. Then, both nerves were cut. The left nerve was sutured side-to-side, and the right nerve was sutured end-to-end. Intraoperative electromyography was performed. After 4 weeks, the rats were reassessed using the hind paw print analysis and electromyography.ResultsAn analysis of left and right hind paw prints did not reveal any significant differences between the length of the steps, the spread of the digits in the paws, or the deviation of a paw. The width of the steps also did not change.Electromyography revealed that immediately after a nerve anastomosis (as well as 4 weeks after the surgery), better nerve conduction was observed through an end-to-end anastomosis. Four weeks after the surgery, better nerve conduction was seen distally to the end-to-end anastomosis.ConclusionsThe results indicate that in acute nerve injuries intraoperative electromyography may be useful to obtain unbiased information on whether the nerve anastomosis has been performed correctly – for example, in limb replantation.When assessing a nerve during a procedure, EMG should be first performed distally to the anastomosis (the part of the nerve leading to muscle fibers) and then proximally to the anastomosis (the proximal part of the nerve). Similar EMG results can be interpreted as a correct nerve anastomosis.The function of the distal part of the nerve and the muscle remains intact if the neuromuscular transmission is sustained.