Alternatives to Sural Nerve Grafts in the Upper Extremity

Abstract

Background The sural nerve is the most common nerve graft donor despite requiring a second operative limb and causing numbness of the lateral foot. The purposes of this study were to review our experience using nerve autografts in upper extremity nerve reconstruction and develop recommendations for donor selection. Methods A retrospective case series study was performed of all consecutive patients undergoing nerve grafting procedures for upper extremity nerve injuries over an 11-year period (2001-2012). Results Eighty-six patients received 109 nerve grafts over the study period. Mean patient age was 42.9±18.3 years; 57 % were male. There were 51 median (59 %), 26 ulnar (30 %), 14 digital (13 %), 13 radial (16 %), and 3 musculocutaneous (4 %) nerve injuries repaired with 99 nerve autografts (71 from upper extremity, 28 from lower extremity). Multiple upper extremity nerve autograft donors were utilized, including the medial antebrachial cutaneous nerve (MABC), third webspace branch of median, lateral antebrachial cutaneous nerve (LABC), palmar cutaneous, and dorsal cutaneous branch of ulnar nerve. By using an upper-extremity donor, a second operative limb was avoided in 58 patients (67 %), and a second incision was avoided in 26 patients (30 %). The frequency of sural graft use declined from 40 % (n=17/43) to 11 % (n=7/64). Conclusions Our algorithm for selecting nerve graft material has evolved with our growing understanding of nerve internal topography and the drive to minimize additional incisions, maximize ease of harvest, and limit donor morbidity. This has led us away from using the sural nerve when possible and allowed us to avoid a second operative limb in two thirds of the cases.

The Role of the Peripheral Nerve Surgeon in the Treatment of Pain

“…Noncritical sensory nerves with a small diameter and gap less than 3 cm are reconstructed with acellular allograft [92,93]. When selecting autograft, we prefer to borrow from the injured nerve to avoid creating new areas of anesthesia and potentially painful new neuromas [94]. If this is not possible, we will use the medial antebrachial cutaneous nerve if already operating in the upper extremity, or the sural nerve if operating in the lower extremity or depending on patient preference.…”

Treatment of Postsurgical Neuroma in Foot and Ankle Surgery

“…Nerve autografts are currently the preferred method of gap repair; however, they are associated with donor site scarring, potential sensory deficits, and the possibility of new neuroma formation. 37 The sural nerve is the most common donor site; however, other cutaneous nerves such as the saphenous, lateral femoral cutaneous, and superficial peroneal are also potential donors in the lower extremity. 4,32,37 Kon and Bloem reported on 18 patients with 42 neuromas of the fingers treated with microsurgical neurectomy and centrocentral anastomosis.…”

Radial nerve palsy

“…This usually follows an ‘in group’ fascicular grafting technique. 45,46 Recovery of radial nerve motor function may be expected if the repair is carried out within 15 months of the injury. 47,48 …”