Nerve Repair and Grafting in the Upper Extremity

S. Houston Payne, Jr., MD

J South Orthop Assoc. 2001;10(2) 

In This Article

Historical Perspective

Difficulty in achieving successful nerve repair is well-chronicled in the recorded history of medicine. From the time of Galen in the second century AD, nerve regeneration was considered impossible. Although there were merely sporadic reports of successful nerve repair in the Middle Ages, Haighton (1795)[1] reported survival after bilateral staged vagotomies and immediate repair in dogs as a historic milestone in confirming the efficacy of neurorrhaphy. Since simultaneous vagotomy is fatal, this exercise demonstrated that a delay of 6 weeks between vagotomies (a time adequate for regeneration) resulted in survival and provided indirect evidence that nerve regeneration was possible. Subsequently, Muller[2] identified regenerating axons distal to the site of repair in the rabbit sciatic nerve and confirmed Haighton's conclusions.

Once the concept of nerve repair was established, a variety of surgical techniques was examined; suturing of epineural flaps,[3] tangential sectioning of nerves prior to suture,[4] side-to-side repair,[5] and intussusception[3] have all been reported.

Though early reports lack specific outcome information, Sherren[6] in 1906 achieved a "successful" nerve graft with improvement in outcome after use of a xenograft. In 1917, Mayo-Robson[7] reported that a nerve allograft could successfully bridge a 2.5-cm defect in the median nerve. A lack of any consistent success with either repair or grafting kept enthusiasm for nerve repair low throughout the 19th century.

Silas Weir Mitchell[8] reported on his experiences with nerve injury during the Civil War in his book, Injuries of Nerves. During World War I, Tinel[9] described the "tingling" of nerve regeneration that is elicited by gentle percussion along the course of an injured nerve. During World War II, Sir Herbert Seddon[10] and Barnes Woodhall, in a classic contribution, tabulated the results and variability of primary nerve repair, secondary nerve repair, and nerve grafting.

The development of improved suture material, specialized instrumentation, and operative magnification improved surgical capability. Sir Sydney Sunderland[11] detailed descriptions of the internal architecture of various peripheral nerves, allowing clinicians to perform more accurate nerve repairs. These advances permitted the present concepts used in epineural and group fascicular repair.

The present focus of basic nerve research is directed toward a better understanding of the biology of nerve regeneration. The ability to manipulate nerve recovery at the cellular or gene level will provide the next significant improvement in nerve recovery.

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