What is the gold standard for Digital Nerve Repair?

Orthoracle Forums Upper Limb & Hand What is the gold standard for Digital Nerve Repair?

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    AvatarDominic Power

    The established consensus on the management of digital nerve injuries is that microsurgical suture co-aptation without tension is the gold standard method of repair. Despite this the recent systematic review in the BMJ (https://bmjopen.bmj.com/content/9/3/e025443.info) suggests that the rate of neuroma formation with this approach is approximately 4.6%. This rate is remarkably similar to the rate reported in unprepared nerves (5%). What does this mean for the surgeon contemplating an acutely injured nerve?

    Is this enough evidence not to attempt a repair?
    Is this because digital nerve repairs are often done by trainees and sometimes without senior supervision?
    Is the issue that there is no consensus on how you define a neuroma and so the reported complication rate is meaningless?
    Should surgeons consider suture-less repair techniques using conduits or co-aptation devices?
    What about leaving a small gap in a conduit to detention the nerve co-aptation?
    Could an interposition allograft provide superior results through detensioning, albeit with two co-aptation sites?
    Will polymer glues replace sutures and be of sufficient strength to allow early functional movement?
    What is the functional benefit of repairing a nerve in the hand?
    How do you measure functional recovery after digital nerve injury?

    The challenge is that there are very few papers to help answer any of these questions and certainly the comparative data is lacking. Two recent RCTs have looked at the option of wrapping a repair (Zhu et al. 2017; Neubrech et al. 2018) but neither had a suture-less repair control arm.

    The future options for nerve repair are exciting and the digital nerve repair model is perfect for in vivo examination of repair techniques with frequent injuries and short reinnervation distances. In the absence of evidence, what is your preferred method of primary digital nerve repair?

    • This topic was modified 10 months, 3 weeks ago by AvatarDominic Power.
    AvatarRajive Jose

    I think digital nerve repairs are delegated to the junior surgeons and are often done poorly.
    I have seen some remarkable recoveries from well-performed digital nerve injuries in clean-cut lacerations.
    Like-wise watching some of the repairs I have thought that it will be a surprise if they worked at all.
    I think the key is to perform tension-free repairs under a microscope by surgeons who are well trained in microsurgery. Otherwise, they may well not be repaired. At least the patient will be spared the morbidity from a long operation.
    There are situations where the nature of injuries makes repair difficult. In those cases, we should be looking at allografts or conduits or protecting the repairs.

    AvatarDominic Power

    I couldn’t agree more. The digital nerve repair is an excellent opportunity to learn or practice microsurgical skills for the novice surgeon and all too often there is minimal supervision and as a result a failure to adhere to the important basic principles of nerve repair. Junior surgeons may be less likely to escalate to a nerve graft is under tension and may not have access to expensive products such as conduits or allograft and as such will make do with a simple neurorraphy, perhaps with under debridement.

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