CURRENT CONCEPTS

Nerve Conduits: An Update on Tubular Nerve Repair

and Reconstruction
Robert J. Strauch, MD, Berish Strauch, MD

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Learning Objectives
waive any claim they may have against the ASSH for reliance on any information presented.
• Recall the clinical and basic science evolution of nerve conduits.
The approval of the US Food and Drug Administration is required for procedures and drugs
• Recognize the best nerves for conduits.
that are considered experimental. Instrumentation systems discussed or reviewed during this
• Identify the indications for nerve conduits.
educational activity may not yet have received FDA approval.
• List the different types of nerve conduits.
Provider Information can be found at http://www.assh.org/Pages/ContactUs.aspx. • Explore the current evidence regarding the use of nerve conduits.

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HISTORY ber’s decalcified bone tubes for the purpose of nerve

The concept of using hollow tubes or conduits to re- reconstruction, allowing the nerve to climb, “. . . up the
Current Concepts

construct or repair nerve injuries dates back to the scaffold of the implanted foreign body as vine climbing
1880s, when Themistocles Gluck used Gustave Neu- a staff.”1 In 1909, Wrede was reported to have used
From the Department of Orthopaedic Surgery, Columbia University, New York, NY; Department of Sur- Corresponding author: Robert J. Strauch, MD, Department of Orthopaedic Surgery, Co-
gery, Division of Plastic Surgery, Albert Einstein College of Medicine, Bronx, NY. lumbia University Medical Center, PH 11-1119, New York, NY 10032; e-mail:
Received for publication December 17, 2012; accepted in revised form February 18, 2013. [email protected].

No benefits in any form have been received or will be received related directly or indirectly to the 0363-5023/13/38A06-0038$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2013.02.034
subject of this article.

1252 䉬 ©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved.

 NERVE CONDUITS 1253

saphenous vein to bridge a human median nerve gap, CAN THE 3-CM LENGTH BE EXCEEDED?
and, in 1941, Swan was reported to have reconstructed Nerve conduit use beyond 3 cm has been reported,
an ulnar nerve gap.2 In 1982, Chiu reported successful usually by “supercharging” the conduit by inserting
experimental nerve reconstruction using autogenous substances designed to accelerate nerve growth, such as
vein conduits.3 Walton, in 1989, reported a successful Schwann cells,17 pieces of muscle or nerve, or various
retrospective series of autogenous vein conduit recon- chemicals and biologic agents.17–31 Although anecdotal
struction of digital nerve defects.4 Chiu and Strauch, in successful clinical results beyond 3 cm have been re-
1990, noted excellent clinical recovery in a prospective ported, most clinical use of nerve conduits has been for
series of vein conduits compared with nerve autografts gaps of 3 cm or less.
for digital sensory nerve deficits less than 3 cm in
length.5 Also in 1990, Mackinnon and Dellon reported CAN CONDUITS BE USED FOR MIXED OR
encouraging clinical results using biodegradable poly- MOTOR NERVES?
glycolic acid (PGA) tubes for nerve gaps less than 3 Small clinical case series have reported success with
cm.6 Since the early 1990s, basic and clinical investi- mixed or motor nerves. Stanec, in 1998, used a poly-
gations of nerve conduits have flourished. This article tetrafluoroethylene conduit to reconstruct a 3-cm ulnar
describes the current status of hollow nerve conduits, nerve gap, with excellent recovery.32 Ducic33 success-
also known as nerve tubes or nerve guides. fully reconstructed spinal accessory nerve gaps with
conduits in 2005. Donoghoe et al repaired 2 median
INDICATIONS FOR NERVE CONDUITS nerve gaps with multiple conduits.34 Hung and Dellon,
in 2008, reported a 4-cm median nerve gap repaired
Ideally, nerve injuries can be repaired primarily with
with a conduit containing a slice of autogenous nerve.19
limited tension, although when this is not possible, a
Rosson et al repaired motor nerves with conduits, in
nerve gap is the result. Nerve autograft is still recog-
2009, with favorable results.35 Others have reported
nized as the gold standard for nerve gap reconstruction,
successful repair of mixed or motor nerves.18,36 A
with the associated risk of donor site morbidity. Nerve
meta-analysis of tubular versus nerve graft repair of
conduits and other methods of nerve reconstruction,
median and ulnar nerve defects found no statistical
such as allograft (not the subject of this review), avoid
difference between the techniques in defects less than 5
the morbidity of nerve autograft, with the goal of
cm.37 By contrast, Moore et al, in 2008, reported failed
achieving similar clinical results. The major clinical
conduit repair of large-diameter nerves and recom-
indication for a nerve conduit, therefore, is to bridge a
mended caution in these cases.38 Mackinnon, in 2010,
digital sensory nerve gap that would otherwise require
recommended limiting conduit usage to small diameter,
nerve autograft.7 Less common indications include us- noncritical sensory nerves with a gap of less than 3
ing tubular nerve conduits instead of standard epineural cm.16 Two recent basic science investigations into rat
nerve repair even in situations in which tension-free motor nerve regeneration using hollow or collagen-
nerve repair is possible,8,9 as well as wrapping of nerve glycosaminoglycan–filled conduits versus autograft or
repair/reconstructions to reduce scarring and adhe- allograft found superior motor recovery with autograft
sion.10 Nerve conduits have also been used clinically in compared to the other methods.39,40
the treatment of established neuromas.11
TYPES OF CONDUITS
WHAT LENGTH OF NERVE GAP IS AMENABLE Autogenous
TO CONDUIT REPAIR? Superficial veins have a long history of reliable use as
It is generally accepted that a gap of 3 cm or less can be nerve conduits for gaps shorter than 3 cm, are readily
successfully bridged by a hollow nerve conduit.12 This available, and have minimal donor deficit.3–5,23,41– 46
is based on basic science, as well as clinical research. In The surgical technique is well established.7 Although
Current Concepts

1990, Mackinnon and Dellon, in a primate model, some have suggested “inverting” the vein graft inside-
showed excellent regeneration with synthetic and col- out,43,44,47 no clinical support for this technique has
lagen conduits across a 2-cm but not a 5-cm gap.13 emerged. It has also been shown that vein collapse does
Strauch et al, in 1996, in a rabbit model, showed ex- not occur owing to hematoma within the vein.48 A
cellent functional results with vein conduits up to 3 cm prospective, randomized study comparing vein conduits
in length, with decreasing success beyond 3 cm.14 Clin- with interposition of a posterior interosseous nerve seg-
ically, worse results have been demonstrated with hol- ment to sural nerve autograft for reconstruction of dig-
low nerve conduits beyond 3 cm in length.15,16 ital nerve defects (⬍ 3-cm gap) showed equivalent

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 1254 NERVE CONDUITS

results.23 Another recent prospective, randomized study 7. Strauch B. Use of nerve conduits in peripheral nerve repair. Hand
Clin. 2000;16(1):123–130.
compared PGA and autogenous vein conduits for dig- 8. Lundborg G, Rosen B, Dahlin L, et al. Tubular repair of the median
ital nerve gaps (⬍ 3 cm) and found equivalent results or ulnar nerve in the human forearm: a 5-year follow-up. J Hand
with fewer complications using autogenous vein con- Surg Br. 2004;29(2):100 –107.
duits.46 9. Wolfe SW, Strauss HL, Garg R, et al. Use of bioabsorbable nerve
conduits as an adjunct to brachial plexus neurorrhaphy. J Hand Surg
Am. 2012;37(10):1980 –1985.
Nonautogenous 10. Kim PD, Hayes A, Amin F, et al. Collagen nerve protector in rat
Silicone tubes have historically been used clinically for sciatic nerve repair: A morphometric and histological analysis. Mi-
crosurgery. 2010;30(5):392–396.
median or ulnar nerve repair instead of direct epineural 11. Thomsen L, Bellemere P, Loubersac T, et al. Treatment by collagen
repair, with equivalent long-term results,8 although they conduit of painful post-traumatic neuromas of the sensitive digital
are not in current clinical use in the United States. Three nerve: a retrospective study of 10 cases. Chir Main. 2010;29(4):255–
262.
commercial types of nonautogenous nerve conduits are 12. Deal DN, Griffin JW, Hogan MV. Nerve conduits for nerve repair or
presently approved by the U.S. Food and Drug Admin- reconstruction. J Am Acad Orthop Surg. 2012;20(2):63– 68.
istration: collagen, PGA, and caprolactone conduits.12 13. Mackinnon SE, Dellon AL. A study of nerve regeneration across
A basic science study comparing the 3 conduit types synthetic (Maxon) and biologic (collagen) nerve conduits for nerve
gaps up to 5 cm in the primate. J Reconstr Microsurg. 1990;
found similar functional outcomes in autograft and cap- 6(2):117–121.
rolactone, with PGA conduits having the poorest re- 14. Strauch B, Ferder M, Lovelle-Allen S, et al. Determining the max-
sults.49 Conversely, caprolactone conduits (Neurolac; imal length of a vein conduit used as an interposition graft for nerve
regeneration. J Reconstr Microsurg. 1996;12(8):521–527.
Ascension Orthopedics, Austin, TX), in a recent report, 15. Tang JB, Gu YQ, Song YS. Repair of digital nerve defect with
were found to be difficult to handle and occasionally autogenous vein graft during flexor tendon surgery in zone 2. J Hand
extruded, leading to unfavorable clinical experiences.50 Surg Br. 1993;18(4):449 – 453.
16. Mackinnon SE. Technical use of synthetic conduits for nerve repair.
Other authors have reported problems with the Neuro- J Hand Surg Am. 2011;36(1):183.
lac conduit, as well.51,52 A recent systematic review53 17. Strauch B, Rodriguez DM, Diaz J, et al. Autologous Schwann cells
of digital nerve reconstruction found low-quality evi- drive regeneration through a 6-cm autogenous venous nerve conduit.
dence in favor of PGA conduits compared to primary J Reconstr Microsurg. 2001;17(8):589 –595; discussion 596 –587.
18. Kuffler DP, Reyes O, Sosa IJ, et al. Neurological recovery across a
repair or nerve autograft in digital nerve gaps of less 12-cm-long ulnar nerve gap repaired 3.25 years post trauma: case
than 4 mm and greater than 8 mm, but this was based on report. Neurosurgery. 2011;69(6):E1321–1326.
one prospective, randomized study by Weber et al54 in 19. Hung V, Dellon AL. Reconstruction of a 4-cm human median nerve
gap by including an autogenous nerve slice in a bioabsorbable nerve
2000. conduit: case report. J Hand Surg Am. 2008;33(3):313–315.
20. Tang JB. Vein conduits with interposition of nerve tissue for periph-
CURRENT EVIDENCE eral nerve defects. J Reconstr Microsurg. 1995;11(1):21–26.
21. Francel PC, Francel TJ, Mackinnon SE, et al. Enhancing nerve
Although nerve conduits have been successful for dig- regeneration across a silicone tube conduit by using interposed
ital nerve reconstruction less than 3 cm in length, they short-segment nerve grafts. J Neurosurg. 1997;87(6):887– 892.
should be used with caution for mixed nerves, motor 22. Keskin M, Akbas H, Uysal OA, et al. Enhancement of nerve regen-
eration and orientation across a gap with a nerve graft within a vein
nerves, or longer gaps. Intraluminal interposition of conduit graft: a functional, stereological, and electrophysiological
various substances may improve outcomes and await study. Plast Reconstr Surg. 2004;113(5):1372–1379.
larger scale clinical studies. 23. Calcagnotto GN, Braga Silva J. The treatment of digital nerve
defects by the technique of vein conduit with nerve segment. A
randomized prospective study [in French]. Chir Main. 2006;25(3–
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JOURNAL CME QUESTIONS

Nerve Conduits: An Update on Tubular Nerve Which of the following nerves is a primary
Repair and Reconstruction indication for a nerve conduit?
What maximum length of a nerve gap is a. Lateral cord of the brachial plexus
amenable to a nerve conduit? b. Posterior interosseous nerve
a. 1 cm c. Median nerve in the forearm
b. 3 cm d. Common digital nerve
c. 5 cm e. Ulnar nerve in Guyon canal
d. 7 cm
Current Concepts

e. 9 cm

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