Adjacent and Spontaneous Neurotization after Distal Digital Replantation in Children

Abstract

In an exclusively pediatric population, this retrospective study examined the functional and aesthetic results after distal replantation without nerve suture. The aim was to demonstrate, in the child, the presence of spontaneous nervous regeneration resulting in a fingertip pulp with discriminatory sensation. Eight amputations in eight children with a mean age of 9 years and 2 months on the day of the accident were reviewed. The cases were managed by a single surgeon over a period of 8 years and were collected from two different hand centers. The patients were then examined by a different surgeon, and the data were collected. Sensibility was evaluated using the Weber, Semmes-Weinstein, and wrinkle tests. The results were excellent, with mean values of 4.6 mm for the Weber test, 3.3 for the Semmes-Weinstein test, and a positive wrinkle test in all subjects. All patients thus recovered discriminatory sensation with minimal aesthetic sequelae. The usual factors adversely affecting the results of the replantation (ischemic time, level and mechanism of the amputation, and quality of the venous return) were examined, but no statistical analysis was performed because of the small sample size. This study demonstrates the presence of the clinical phenomenon of adjacent neurotization in the absence of nerve repair. It thus confirms that children are excellent candidates for replantation of the distal extremities, even when nerve suture is not performed.

Advances of Peripheral Nerve Repair Techniques to Improve Hand Function: A Systematic Review of Literature

“…Faivre et al, [49] review the functional results following distal replantation without nerve suturing in a cohort of 8 children. All children regained discriminatory sensation through the adjacent and spontaneous neurotization after distal digital replantation [49].…”

“…All children regained discriminatory sensation through the adjacent and spontaneous neurotization after distal digital replantation [49]. Thus they report that children are excellent candidates for replantation of distal extremities even without nerve suturing [49]. Schäfer et al, [50].…”

“…The most important ones are the use of resorbable poly[(R)-3-hydroxybutyrate] (PHB) 41, epineural end-to-end suturing [41], graft repair [42, 48, 58, 64], nerve transfer [43, 55], side to side neurorrhaphy and end to side neurorrhaphy between median, radial and ulnar nerves [44], nerve transplant [45], nerve repair [47, 53, 57, 59, 62, 64], external neurolysis and epineural sutures [48], adjacent neurotization without nerve suturing [49], Agee endoscopic operation [50], tourniquet induced anesthesia [51], toe transfer and meticulous intrinsic repair [52], free auto nerve grafting [54], use of distal based neurocutaneous flaps [56] and tubulization [60, 63]. The results have been summarized in Table 1 .…”

“…We also identified factors that may affect the prognosis following surgery. Among the most significant are patient’s age [10, 12, 28, 42, 49, 61, 66-68], time of repair [8, 10, 45, 48, 57, 69-72], level of injury [10, 12, 73], tension of repair [44], and scar formation following surgery [54]. Despite the thorough findings of this systematic review, we suggest that further research in this field is needed.…”

“…They argue that this might be due to lower repair capacity and greater preoperative damage [61]. Faivre et al, [49] state that children are excellent candidates for replantation of distal extremities even without nerve suturing. Contradicting outcomes have been reported by Sunderland [10], who claims that there is no correlation between the patient’s age and functional outcome.…”