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mediated by the vascularized ulnar nerve, and none monofilament measurements was 2.83 mm. In 3 digits, a
scored higher than M2 for either elbow flexion or wrist vascularized and a nonvascularized nerve were used for
extension. These results may have been influenced by the adjacent digital nerve replacement in the same finger. The
delay to surgery, which occurred between 3 and 7 months 3 “reversed venous” grafted nerves recovered with a mean
after the injury. moving 2‑PD of 6.7 mm and a static 2‑PD of 9.3 mm. By
contrast, the conventional grafts returned moving 2‑PD of
Vascularized intercostal nerve transfers 10.3 mm and static 2‑PD of 14.3 mm.
Okinaga and Nagano compared nonvascularized
[70]
(n = 6) with vascularized (n = 5) intercostal nerve Fascicular turnover method
transfers in patients with brachial plexus injuries. There Koshima et al. believe that, in cases with a digital nerve
[47]
were no statistically significant differences in (1) the gap of less than 20 mm in length, a fascicular turnover
time to appearance of a Tinel’s sign, which radiated flap from either the distal or proximal stump is the best
to the chest wall on the upper arm after surgery; (2) option. However, in cases with nerve gaps measuring
the rate of advancement of a Tinel’s sign between the over 20 mm, fascicular turnover flaps from bilateral distal
upper arm and the wrist; (3) the time interval between and proximal stumps are preferred to connect to the
surgery and initiation of reinnervation as demonstrated middle portion of the nerve gap, as excellent blood flow
by needle electromyography; (4) the strength of elbow of bilateral short flaps can be expected rather than from
flexion at the final examination according to the Medical an ipsilateral longer nerve flap.
Research Council’s grading system; and (5) the strength
of elbow flexion at the final examination as measured Nerve reconstructions in the hand, when a VNG is
by a potentiometer held on the wrist at an angle of 100° indicated, appear to be better served by a deep peroneal
of flexion. It is likely that statistical significance was not nerve graft. However, a vascularized lateral femoral nerve
reached due to the small sample size. graft may also be a useful tool, especially in multiple
nerve injuries [Table 5].
Because most clinical evidence is in favor of the ipsilateral
vascularized ulnar nerve trunk graft, we advise its use for Lower limb
reconstruction of a brachial plexus injury. We could not Lower extremity nerve injuries are relatively less common
find evidence in favor of either the pedicled nerve graft than those of the upper extremities. [10,77] The peroneal nerve
or the free VNG [Table 4]. is more susceptible to injury than the posterior tibial nerve
given its superficial course over the neck of the fibula,
Hand where it is relatively fixed with less interfascicular connective
Vascularized deep peroneal nerve tissue. [78,79] Initial outcomes of peroneal nerve reconstruction
Vascularized deep peroneal nerve supplied by a dorsalis were poor and the value of attempted repair of the
[77]
pedis artery: Rose and Kowalski reported five cases peroneal nerve has been questioned. Although recent
[30]
[80]
with good results when reconstructing digital nerves in studies are more encouraging, the functional recovery of
scarred tissue without a concomitant soft tissue defect the peroneal nerve (muscle grade more than three) is still
by means of vascularized deep peroneal nerve segments. low, between 14% for grafts and 75% for neurolysis. Results
They concluded that the deep peroneal nerve‑dorsalis are dependent upon the timing of surgical repair, the graft
pedis artery complex on the dorsum of the foot is an length, and the level of the injury.
ideal donor site for segmental VNGs in digital sensory
nerve reconstruction. Donor morbidity was negligible Taylor’s group reexamined the blood supply of each lower
except for a neuroma in one case and slight superficial limb nerve and assessed the potential of each segment of
[81]
skin loss in another. each nerve for vascularized transfer. VNG and vascularized
posterior calf fascia (VPCF) have been used to improve
Koshima et al. reported one case of a deep peroneal vascularization of the recipient bed and to minimize
[71]
VNG with skin from the first web space for reconstruction postoperative scar formation. When a VNG was required
of a neurocutaneous defect in the finger. This technique for reconstruction of a lower extremity nerve injury, the
has several drawbacks: the skin‑grafted web can be a sural nerve was used, harvested as a pedicled nerve graft
source of major morbidity, [72,73] the skin flap does not based on the superficial sural artery, or as an arterialized
adhere to the bone, and during grasping and gripping it venous nerve graft based on the lesser saphenous vein.
will be unstable. Anatomic variations are quite common A concomitant VPCF can be used to improve vascularization.
at the level of the first web space, and the nerve can
travel far from the nutrient vessels, [74,75] rendering the flap
unusable. [76] Table 4: Indications for brachial plexus injuries
Vascularized ulnar nerve
Reversed venous arterialized deep peroneal nerve graft: Vascularized intercostal nerve
influenced by the works of Townsend and Taylor and
[33]
Gu et al. on reversed venous arterialized nerve grafts,
[61]
Rose et al. investigated the deep peroneal nerve‑dorsalis Table 5: Indications for a nerve injury in the hand
[34]
pedis venae comitantes system. Ten adult patients received Vascularized deep peroneal nerve supplied by a dorsalis pedis artery
a total of 14 VNGs. Mean moving 2‑PD was 5.8 mm, and Reversed venous arterialized deep peroneal nerve graft
Fascicular turnover method
static 2‑PD was 8.3 mm. The median of Semmes‑Weinstein
190 Plast Aesthet Res || Vol 2 || Issue 4 || Jul 15, 2015