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Technical Assessment of Connector-Assisted Nerve Repair

https://doi.org/10.1016/j.jhsa.2016.04.015Get rights and content

Purpose

Clinical outcomes of nerve repair have not substantially improved over the last several decades. Although clearly a multifactorial problem, basic principles including proper fascicular alignment are not always realized. The use of short conduits as connectors may enhance nerve alignment by entubulating and directing the approximation of nerve ends.

Methods

Ten hand surgeons (5 experienced and 5 inexperienced) performed a series of in vitro human cadaver nerve repairs. Three small-diameter (2 mm), 3 medium-diameter (3–4 mm), and 3 large-diameter (5–6 mm) nerves were repaired (under 10× magnification) utilizing each of 3 techniques: suture-only, connector-only (sutures placed through the ends of the connector), and connector-assisted (alignment sutures at the nerve interface plus connector). Three judges (blinded to who performed the repairs) assessed each repair for fascicular alignment based on predetermined qualitative scales.

Results

Across all surgeons, 23 of 30 connector-assisted repairs were judged good or excellent versus 18 of 30 of the suture-only and 13 of 30 of the connector-only repairs. Experienced surgeons in general did better repairs and in particular were more likely to obtain superior alignment for conduit-only repairs (73.3% vs 13.3% good or excellent) and suture-only repairs (73.3% vs 46.7% good or excellent) and were not statistically different for connector-assisted repairs (86.7% vs 66.7% good or excellent) compared with inexperienced surgeons.

Conclusions

In a cadaver nerve model, there was no significant difference in the technical alignment of conduit-assisted repairs between experienced and inexperienced surgeons whereas inexperienced surgeons were more likely to achieve inadequate alignment with suture-only or conduit-only repairs.

Clinical relevance

Connector-assisted repairs combining suture-approximation and entubulation may improve the technical alignment of nerve repairs performed, especially by less-experienced surgeons.

Section snippets

Materials and Methods

Ten surgeons participated in this study. Five were experienced fellowship trained hand surgeons (>5 years of experience) and 5 were fellows with approximately 8 months of hand and upper extremity fellowship experience. All participants were given verbal instructions on what types of repairs were to be performed and were shown the grading scales that would be used to judge both conduit and suture repairs. Specifically, they were advised that the goal of repair was end-to-end alignment of

Results

Across all surgeon levels, 77% (23 of 30) of connector-assisted repairs were judged good or excellent compared with 60% (18 of 30) of the suture-only repairs and 43% (13 of 30) of the connector-only repairs (P < .05 for connector-assisted vs connector-only).

However, when comparing scores broken down by level of experience (Table 1), the experienced surgeons were statistically more likely to achieve excellent or good repairs (35 out of 45 total attempts) than the inexperienced surgeons who had

Discussion

Although clinical recovery following nerve repair is based on many factors including mechanism of injury, level of injury,17 and patient age,18 the technical quality of the actual coaptation may represent 1 of the few variables within the surgeon’s control. Any discussion on improving outcomes would be incomplete without acknowledging the need to improve the rate and accuracy of axon regeneration. However, the incidental finding in Bernstein et al’s study9 that, regardless of magnification, a

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AxoGen, Inc., provided supplies and covered some travel expenses; no authors received financial compensation for the manuscript. J.I., B.S., P.J.E., and J.G. are all on the speakers’ bureau for AxoGen, Inc. J.I. is a co-principle investigator on an industry-sponsored study (grant through the author’s university).

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