Modified nerve autografting of distal nerve branching of upper extremity

Objective : to modify the surgical technique of nerve grafting applicable to distal branching of a nerve depending on topographic anatomical zone of injury.
Methods : the modified techniques of nerve grafting were based on experience of treatment of 34 clinical cases (38 nerve trunks) of nerve complete cut at the distal level. H. M illesi technique is the traditional way of grafting of nerve defects which is time consuming and technically difficult in case of distal nerve defects. A proposed modified nerve grafting technique principally doesn’t make much difference with H. M illesi technique. The technical differences connected with intraneural fascicular anatomy of each of three median, ulnar and radial nerves, shape and length of nerve defect in the area of distal nerve branching. Modified technique requires the proximal nerve stump dissection with identification of fascicular groups identical to terminal distally cut branches in order to prepare for grafting. Separate surgeon team has to make nerve graft harvesting which is identical to the shape and length of nerve loss. The prepared nerve graft sample after positioning on the injury side consecutively sutured proximally and distally cabling each fascicular proximal groups with the same motor or sensory nerve branches distally. Depending on anatomical features and type of nerve 3 invention patents were issued.
Results: late follow up were recorded on patients during 18 months to 18 years after reconstruction. The overall clinical recovery till level S3+, S4 of sensory and M4-M5 of motor functions were achieved in 82–85 % clinical cases depending on type of nerve.
Заключение : Modified nerve grafting techniques is more simple is comparison with the traditional H. M illesi technique. They allow to restore previous anatomy of nerve defects in the zone of distal branching on more high quality which were proved by achieved functional recovery results.

1. Ефименко Н. А. Замещение огнестрельных дефектов верхних конечностей / Н. А. Ефименко [и др.] // Травматология и ортопедия России. — СПб., 2005. — Т. 3 (37). — С. 71

2. Меркулов М. В. Влияние симпатэктомии на регенерацию периферических нервов после аутонейропластики у человека / М. В. Меркулов, И. О. Голубев, А. И. Крупаткин //Физиология человека. — 2015. — Т. 41, № 2. — С. 91–97

3. L eechavengvongs S. Surgical anatomy of the axillary nerve branches to the deltoid muscle / S. L eechavengvongs et al. //Clinical Anatomy. — 2015. — Т. 28, № 1. — P. 118–122

4. M ichael J. F. Intraneural Median Nerve Anatomy and Implications for Treating Mixed Median Nerve Injury in the Hand /J.F. Michael, D. C . Nguyen, Z. B. P hillips, and S. E . M ackinnon// Hand (N Y ). — 2016 Dec. — 11(4). — 416–420. Published online 2016 Apr 5. doi: 10.1177/1558944716643290

5. M illesi H. M icrosurgery of Peripheral Nerves / H. M illesi // World 3. Surg. — 1979. — V. 3 (1). — P. 67–79

6. Черных А. В. Аутотрансплантация икроножным нервом в микрохирургии верхних конечностей у пациентов с сахарным диабетом 2 типа / А. В. Черных, Д. В. Судаков, Н. В. Якушева // Прикладные информационные аспекты медицины. — 2016. — Т. 19, № 3. — С. 107–112

7. Давлатов А. А. Хирургическое лечение последствий одновременного повреждения срединного и локтевого нервов: дис. … канд. мед. наук / А. А. Давлатов. — Душанбе, 2006. — 127 с.

8. M enorca R. M . Nerve physiology. Mechanisms of injury and recovery / R. M . M enorca, T. S. Fussell, and J. C . E lfar // Hand Clinics. — 2013. —vol. 29. — no. 3. — pp. 317–330.

9. R uijs A. C . M edian and ulnar nerve injuries: A meta-analysis of predictors of motor and sensory recovery after modern microsurgical nerve repair / A. C . R uijs [et al.] // Plast. Reconstr. Surg. — 2005. — V. 116. — P. 484–496

10. E rtem K. The effect of injury level, associated injuries, the type of nerve repair, and age on the prognosis of patients with median and ulnar nerve injuries / K. E rtem [et al.] // Acta. Orthop. Traumatol. Turc. — 2005. — V. 39. — P. 322–327

11. Galtrey C. M . C haracterization of tests of functional recovery after median and ulnar nerve injury and repair in the rat forelimb / C. M . Galtrey, J. W . Fawcett // J. P eripher. Nerv. Syst. — 2007. — V. 12 (1). — P. 11–27

12. Flores LP . Comparative Study of Nerve Grafting versus Distal Nerve Transfer for Treatment of Proximal Injuries of the Ulnar Nerve.// J Reconstr Microsurg. — 2015 Nov. — 31(9). — p. 647–53. doi: 10.1055/s‑0035–1556871. Epub 2015 Jul 13.

13. Ходжамурадов ГМ, Одинаев МФ, Саидов МС, Раджабов МФ. Восстановительная хирургия посттравматических дефектов нервных стволов верхней конечности огнестрельной этиологии. Известия Академии наук Республики Таджикистан. Отделение биологических и медицинских наук. 2011;3:75–82.

14. Карим-заде ГД, Маликов МХ, Ибрагимов ЭК, Хайруллои Нарзилло, Мирзобеков ХФ, Махмадкулова НА. Коррекция мягкотканых дефектов и последствий повреждения сосудисто-нервных пучков верхних конечностей. Вестник Авиценны. 2018;20(4):395–401. Available from: http://dx.doi.org/10.25005/2074‑0581‑2018‑20‑4‑395‑401

15. Маликов МХ, Карим-заде ГД, Давлатов АА, Ибрагимов ЭК, Камолов АН, Махмадкулова НА, Хайруллои Нарзилло, Мирзобеков ХФ. Реконструктивная хирургия сочетанных повреждений верхних конечностей. Вестник Авиценны. 2018;20(4):410–415. Available from: http://dx.doi.org/10.25005/2074‑0581‑2018‑20‑4‑410‑415

16. Одинаев МФ, Ходжамурадов ГМ, Шаймонов АХ, Саидов МС. Хирургическая тактика при дистальных поражениях нервных стволов верхних конечностей. Вестник Авиценны. 2019; 21(1): 83–89.