Wednesday, January 31, 2007

Endoscopically assisted sural nerve harvest for upper extremity posttraumatic nerve defects: an evaluation of functional outcomes.

(Plast Reconstr Surg. 2007 Feb;119(2):616-26)

Abtract: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17230098&query_hl=7&itool=pubmed_docsum

72 comments:

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This well-illustrated article presents another variation of endoscopic sural nerve harvesting in 15 patients. Their technique utilized one small ankle incision, supine positioning, thigh tourniquet, a 28cm endoscope, nerve retractor/isolator, and long laproscopic scissors. The sural nerve (with or without the lesser saphenous vein as a vascularized pedicle) along with one or both of its branches of origin (medial or lateral sural cutaneous nerves) were readily harvested under direct vision in about 30 minutes. A large portion of the article presented the clinical outcomes of the subsequent upper extremity nerve repairs to show that endoscopically harvested nerves can lead to regeneration as do sural nerves harvested using a open technique. I do not believe anyone thinks a sural nerve removed with atraumatic technique under direct visualization has any difference in recovery potential, regardless of the technique used.

So what sural nerve harvest technique will prove optimal: open, stepladder, endoscopic, nerve stripper? I (and my patients) do not like the open technique because of the incision length. Nevertheless, because of common anatomical variations in the sural nerve, I continue to use it for many patients in whom I need as much graft as possible. An excellent anatomical study published in Clinical Anatomy in 2002 revealed that 66% of sural nerves originate from the medial and lateral sural cutaneous nerves not at the gastrocnemius cleft, but more commonly in the lower third of the leg. Furthermore, in 33% of patients the lateral sural cutaneous nerve did not merge with the medial sural cutaneous nerve at all, or potentially below the ankle (do these variations reveal why some sural nerves appear smaller than others?). A technique with direct visualization (either open or endoscopic) would allow for the identification and removal of these variations. I would like to move to using an endoscopic technique similar to that presented here. Sural nerve removal without complete visualization (e.g., nerve stripper or stepladder) may miss these variations, thus limiting potential graft length and size (which may be acceptable if not much is required), or even cause avulsion/stretch injury (controversial) where branches, especially the lateral sural cutaneous, occur.

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