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Orthopaedics & Traumatology: Surgery & Research 100 (2014) S267–S270

Available online at

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orkshops of the SOO (2013, Tours). Technical note

euroma-in-continuity of the median nerve managed by nervexpansion and direct suture with vein conduit

. Jeudy ∗, G. Raimbeau , F. Rabarin , P.A. Fouque , Y. Saint-Cast , B. Césari , N. Bigorreentre de la main, Village Santé Angers Loire, 47, rue de la Foucaudière, 49800 Trélazé, France

a r t i c l e i n f o

eywords:erveapeuroma

a b s t r a c t

Autologous nerve grafting is the current standard for bridging large gaps in major sensory and motornerves. It allows both function and pain improvement with predictable results. Clinical observationsof nerve elongation caused by tumours have prompted experimental animal studies of induced gradual

longationxpansion

elongation of the nerve stump proximal to the gap. This technique allows direct suturing of the two nerveends to bridge the gap. Here, we describe a case of neuroma-in-continuity of the median nerve managedby resection and direct suture after nerve elongation with a tissue expander. We are not aware of similarreported cases. Secondary repair 3 years after the initial injury improved the pain and hypersensitivityand restored a modest degree of protective sensory function (grade S1).

© 2014 Elsevier Masson SAS. All rights reserved.

. Introduction

Although emergency microsurgical repair in patients withedian nerve severance is universally recognised, the management

f a neuroma-in-continuity at a later stage from the initial injuryemains poorly standardised. When the gap is large, resection ofhe neuroma followed by autologous nerve grafting is usually indi-ated to restore function, at the expense of crossing two coaptationites.

Slowly growing tumours in contact with nerves cause nervelongation. Similarly, inducing gradual elongation of the proximalerve segment can allow direct suturing of the two nerve stumpso bridge the gap.

We describe a case of neuroma-in-continuity of the medianerve managed by direct suturing after nerve elongation.

. Case report

A 42-year-old male chronic smoker presented with a neuroma-n-continuity of the median nerve 3 years after a self-inflictednjury. Emergent microsurgical repair of multifocal median nerve

everance had been performed at a trauma centre in June 2008.

Partial improvements were noted 3 years after the repair pro-edure. The patient had recovered thumb opposition but still

∗ Corresponding author.E-mail address: jeudy@centredelamain.fr (J. Jeudy).

http://dx.doi.org/10.1016/j.otsr.2014.03.013877-0568/© 2014 Elsevier Masson SAS. All rights reserved.

exhibited severe atrophy of the abductor pollicis brevis muscle. Thesecond and third digits were excluded from pinch grasping.

He showed no recovery of sensory function (S0), with noresponse to the Semmes-Wenstein monofilament test or Weberdiscrimination test.

Pain was assessed using the Elliot score [1,2], which separatelyevaluates five pain modalities:

• spontaneous basal pain;• spikes of pain;• pressure pain;• movement pain;• hypersensitivity.

The patient scores each modality as absent, mild, moderate, orsevere (Fig. 1).

Magnetic resonance imaging (MRI) performed 3 years afterthe injury showed a large, 47-mm, neuroma-in-continuity locatedproximal to the carpal tunnel (Fig. 2). The electromyogram indi-cated partial motor function recovery with about 70% of conductionloss in the opponens pollicis and abductor pollicis brevis muscles.Stimulation of the first three digits failed to produce any electricalsensory response.

Due to residual pain and anaesthesia of the pinch fingers, thepatient could not return to work.

Numerous analgesic treatments had been attempted. Neitherstep-1 analgesics nor weak or strong opioids had provided mean-ingful pain relief. More specific drugs (pregabalin and gabapentin)were only partially effective and induced troublesome side effects.

S268 J. Jeudy et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S267–S270

pain reported by the patient before and after surgery.

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edge of the flexor retinaculum (Fig. 4). En-bloc excision was per-formed with cuts in healthy nerve tissue 5 mm away from eachend of the neuroma. Total gap length was estimated at 60 mm. The

Fig. 1. Scores for each of the five types of nerve

transcutaneous electrical nerve stimulation (TENS®) gloverought transient relief without lasting improvement.

The insufficient sensitive and functional recovery 3 years post-njury prompted surgical treatment. Gradual elongation of theerve followed by direct microsurgical suture after re-cutting inealthy nerve tissue was performed.

. Surgical technique

The nerve repair required a two-stage procedure underltrasound-guided truncal nerve block at the axillary level.

The first stage was performed 3 years after the primary repairrocedure.

A longitudinal incision was made to expose the median nerve,roximal to the neuroma and distal to the forearm motor branches.

silicone tissue expander measuring 4.9 cm by 3.9 cm by 5.1 cm100 mL) (Eurosilicone®, ZI La Peyrolière, France) was positionednder the deep side of the nerve by displacing the muscle belly ofhe flexor tendons at the muscle-tendon junction level. The valveas then placed superficially in the subcutaneous adipose tissue.

he muscle fascia was left open to prevent compartment syndromeuring expansion.

Expansion was started 2 weeks after skin healing was complete,sing two weekly injections of isotonic saline to expand the bal-

oon by 12 mL per week. The injection was stopped if the patienteported pain. After 8 weeks, the expander had achieved its maxi-

al volume of 100 mL (Fig. 3).The second stage was performed 2 months after the first stage.

he initial incision was extended distally to expose the neuroma.he 47-mm neuroma was then dissected and separated from the

ig. 2. Preoperative MRI appearance of the 47-mm long neuroma-in-continuity ofhe median nerve.

Fig. 3. Appearance of the forearm after full expansion of the balloon (100 mL).

fibrous scar tissue under optical magnification. The distal endof the neuroma was found to be in contact with the proximal

Fig. 4. Intra-operative appearance of the neuroma-in-continuity of the mediannerve.

J. Jeudy et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S267–S270 S269

Fig. 5. Lengthening of the median nerve after removal of the silicone expander.

Fig. 6. Bridging the gap by direct microsurgical suturing of the median nerve.

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the best option remains resection of the neuroma by re-cutting in

Fig. 7. Appearance of the repair after wrapping in a venous conduit graft.

ilicone expander was removed (Fig. 5) and the nerve was thenirectly sutured end-to-end by epi-perineural stitches of Ethilon®

/0 (Ethicon, Auneau, France) (Fig. 6) before being wrapped in aenous conduit graft harvested at the elbow according to standardractice in our department (Fig. 7) [3].

The upper limb was immobilised in a long-arm splint with the

lbow in 90◦ of flexion and the wrist in slight flexion of 20◦, for 6eeks, to avoid any additional tension on the suture. The elbowas released after 3 weeks.

Fig. 8. Postoperative MRI appearance of the median nerve 2 years after the coapta-tion procedure.

Analgesic therapy combining a strong opioid and pregabalin wasgiven for 3 months.

4. Results

MRI was performed after 2 years of follow up. Median nervediameter was regular, with continuity of the intra-neural fasciculesand no neuromatous thickening (Fig. 8).

The degree of thumb opposition recovery was good and similarto that noted preoperatively. The wasting of the abductor pollicisbrevis was unchanged.

The patient continued to perform pinch grasping using the ulnardigits instead of the second and third digits.

Sensory function was slightly improved, with recovery of pro-tective deep sensation graded S1; the patient felt the largestSemmes-Wenstein monofilament (6.65) on the tips of all threedigits. Weber’s two-point discrimination test was 20 mm.

The overall degree of pain relief was good, with no spontaneouspain, pain to mobilisation, or hypersensitivity (Fig. 1).

The patient was able to return to work 12 months after the surgi-cal procedure. Nevertheless, he was disappointed by the final result,which he felt failed to meet his expectations.

5. Discussion

Early primary repair of median nerve injuries is commonpractice to ensure the best recovery of sensory and motor functionand to minimise the severity of pain due to nerve scarring.

At a longer interval from the repair procedure, the painfuldysaesthesia related to nerve regrowth is difficult to interpret [4].A neuroma-in-continuity with incomplete recovery is difficult tomanage, particularly as the patients themselves often raise specificchallenges.

In patients with good motor recovery and residual isolated paindue to nerve regrowth in a zone of fibrous scar tissue, wrappingthe neuroma in a fascial flap relieves the pain without objectivelyimproving sensory function, motor function, or hypersensitivity[2].

Nerve coaptation is crucial to allow the recovery of sensory andmotor function and also appears to be the best solution for relievingthe pain [5,6]. In the absence of satisfactory functional recovery,

healthy nerve tissue followed by direct coaptation.Direct microsurgical suturing with mild tension of the

two stumps may be feasible if the gap is small. Temporary

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[expansion of peripheral nerves: comparison of nerve grafting and nerve expan-

270 J. Jeudy et al. / Orthopaedics & Traumatolo

mmobilisation of the adjacent joints in flexion may be requiredo limit the tension applied to the sutures [7,8].

Larger gaps do not allow direct suturing. Autologous graftings then indicated to allow axon regeneration. However, due to theeed for two suture rows, nerve grafting increases the risk of axonal

oss due to scar formation and misdirection, resulting in lowerecovery rates compared to direct suturing [5,6].

To overcome the nerve gap, an alternative to grafting may beerve elongation. The additional length obtained by elongatinghe nerve proximally to the neuroma can allow direct tension-freeuturing. This technique can be likened to the stretching of nerves inontact with slowly growing tumours, which can double the lengthf the nerve, while having only a minimal effect on function [9]. These of slow expansion for nerve lengthening was first suggested byeveral authors in 1989 [10–12]. D’Anjou et al. [10] and Milner [11]onducted electrophysiological investigations to evaluate the ratciatic nerve behaviour in response to gradual elongation inducedy a balloon expander.

Sudden nerve elongation (greater than 8% of the nerve length)an cause a conduction block due to alterations in the intra-neuralicrovasculature [13]. In contrast, gradual elongation spares the

ocal blood supply [14]. Histological studies show inflammationf the endoneurium, changes in axon distribution, and segmen-al axon demyelination without cytoskeleton alterations [15–17].hese structural histological and immuno-histochemical changesnduced by the balloon expander are minimal and constitute indi-ators of nerve adaptability [14,18]. Nerve elongation by up to 200%eems feasible without functional impairments, despite a transientecrease in nerve conduction [10,11,15].

The results in our patient were modest and the subjectivemprovement disappointing due to the insufficient degree of sen-ory recovery. The long time interval of 3 years between thensuccessful primary repair and secondary nerve repair proce-ures may have contributed to this result, and shorter delays may

mprove the outcomes [9,12]. The degree of pain relief, however,as marked and at least as substantial as that reported with flaprapping in the absence of neuroma resection [2].

Animal studies comparing nerve expansion to autologous graft-ng have shown comparable results with the two techniques inerms of conduction and muscle recovery [19–21].

. Conclusion

The potential of nerves for elongating and the feasibility of

nduced nerve elongation open up new therapeutic possibilitiesnd create new surgical indications in patients with nerve gaps. Tour knowledge, ours is the first instance in which nerve elongationas transferred from animal studies to a human patient.

[

rgery & Research 100 (2014) S267–S270

Disclosure of interest

The authors declare that they have no conflicts of interest con-cerning this article.

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