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SURGERY ARTICLES
Alternatives to sural nerve grafts in the upper extremity
Louis H. Poppler &Kristen Davidge &Johnny C. Y. Lu &
Jim Armstrong &Ida K. Fox &Susan E. Mackinnon
Published online: 8 November 2014
#American Association for Hand Surgery 2014
Abstract
Background The sural nerve is the most common nerve graft
donor despite requiring a second operative limb and causing
numbness of the lateral foot. The purposes of this study were
to review our experience using nerve autografts in upper
extremity nerve reconstruction and develop recommendations
for donor selection.
Methods A retrospective case series study was performed of
all consecutive patients undergoing nerve grafting procedures
for upper extremity nerve injuries over an 11-year period
(2001–2012).
Results Eighty-six patients received 109 nerve grafts over the
study period. Mean patient age was 42.9± 18.3 years; 57 %
were male. There were 51 median (59 %), 26 ulnar (30 %), 14
digital (13 %), 13 radial (16 %), and 3 musculocutaneous
(4 %) nerve injuries repaired with 99 nerve autografts (71
from upper extremity, 28 from lower extremity). Multiple
upper extremity nerve autograft donors were utilized, includ-
ing the medial antebrachial cutaneous nerve (MABC), third
webspace branch of median, lateral antebrachial cutaneous
nerve (LABC), palmar cutaneous, and dorsal cutaneous
branch of ulnar nerve. By using an upper-extremity donor, a
second operative limb was avoided in 58 patients (67 %), and
a second incision was avoided in 26 patients (30 %). The
frequency of sural graft use declined from 40 % (n=17/43) to
11 % (n=7/64).
Conclusions Our algorithm for selecting nerve graft material
has evolved with our growing understanding of nerve internal
topography and the drive to minimize additional incisions,
maximize ease of harvest, and limit donor morbidity. This has
led us away from using the sural nerve when possible and
allowed us to avoid a second operative limb in two thirds of
the cases.
Keywords Autograft .Donor .Nerve graft .Nerve transfer .
Sural nerve
Manuscript
Interposition grafting of upper-extremity nerve injuries is
often required to perform a tension-free coaptation. Classical-
ly, the sural nerve has been the predominant source of nerve
autograft, especially when a larger amount of graft material is
required. Although sural donor site morbidity is minimal, it
does result in diminished sensation at the lateral foot and a
visible scar. For upper-extremity reconstruction, sural graft
harvest involves a second operative extremity, awkward
intra-operative positioning, and/or position changes that may
lengthen operative time; the latter are especially true in obese
patients [13].
Upper-extremity sources for nerve autograft have several
potential advantages, which include confining donor morbid-
ity to the affected limb, limiting additional incisions, and
simplicity of harvest. Several upper-extremity nerve grafts
have been described, including the medial antebrachial cuta-
neous nerve (MABC) [15,31], lateral antebrachial cutaneous
nerve (LABC) [15,28–30,45], median nerve fascicular
branch to the third webspace (TWM) [5,38,41], palmar-
cutaneous branch of median nerve (PCM) [1], dorsal-
cutaneous branch of ulnar nerve (DCU) [3,19], and posterior
interosseous nerve (PIN) [22].
A summary of the literature on donor options for nerve
autograft, including specific advantages and disadvantages, is
shown in Table 1. Most studies have focused on specific graft
options or reconstruction of specific nerve injuries. The results
L. H. Poppler :K. Davidge :J. C. Y. Lu :J. Armstrong :I. K. Fox :
S. E. Mackinnon (*)
Division of Plastic and Reconstructive Surgery, Washington
University in St. Louis School of Medicine, 660 S. Euclid Ave,
Campus Box 8238, St. Louis, MO 63110, USA
e-mail: mackinnon@wudosis.wustl.edu
HAND (2015) 10:68–75
DOI 10.1007/s11552-014-9699-6
following nerve grafting are well described [9,26,27,
36,40,44,51]. The purposes of this study were to
review our experience using nerve autografts in upper-
extremity nerve reconstruction and develop recommen-
dations for donor site selection with an emphasis on
alternatives to sural nerve.
Materials and Methods
A retrospective case series study was performed of all con-
secutive patients undergoing nerve grafting procedures for
upper extremity nerve injuries over an 11-year period
(2001–2012). Pediatric patients (<18 years) were excluded.
Patient consent and study approval from the Institutional
Review Board were obtained.
Eligible patients were identified from a prospectively main-
tained database of nerve surgeries performed by the senior
author (SEM). Data on patient demographics, mechanism and
timing of injury, nerve donor, nerve recipient, gap length, graft
length, cable number, and operative site were collected. De-
scriptive statistics (means, standard deviations, frequencies,
percentages) were performed for all variables, and an algo-
rithm for upper-extremity nerve reconstruction was created.
Tabl e 1 Characteristics of nerve autograft donors based on published data
Donor nerve Harvestable length Fascicle
count
Cross-sectional
area
Disadvantage Advantage
MABC Up to 28 cm (3) 7–10 2–3.15 mm
2
•Medial arm scar •Long length and larger caliber nerve
suitable for larger nerve gaps and/or
multiple cables required
•Can minimize donor morbidity with
end-to-side repair of distal end
MABC to median nerve
LABC 5–8cm(14) 4–9(46) 1.3–1.8 mm
2
(14) •Visible forearm scar •Good for short gaps
5–18 (6)
6–15 (5)
5–7 (14) •Good size match with digital nerve
•Usually injured with SBR and therefore
good nerve graft for SBR injuries
•Dermatome overlap with SBR reduces
donor morbidity (7)
TWM
a
24.5 cm (8) 2–13 4.43 mm
2
•Sensory loss in hand
(non-critical)
•Easy access through volar distal
forearm incisions
PCM
a
Mean length 5.24 cm
(11)
•Sensory loss in palm •Easy access through volar forearm
incisions
DCU
a
Up to 26 cm (12) 2.4 mm
2
at origin
(13)
•Sensory loss to dorsal-
ulnar hand and digits
•Useful if ulnar nerve already injured
and working in same operative site•Dorsal-ulnar hand
divisions, 5–6cm
AIN
a
3–5(14) 0.6–0.7 mm
2
•Deep dissection into
pronator quadratus
•No sensory loss
•Good size match with digital nerves
•Short segment available
PIN
b
2.5 cm (47) 2 (14) 0.5–0.8 mm
2
•Visible dorsal incision •No cutaneous sensory loss
•Small diameter graft
SBR
a
•Potential for hypersensitivity
in donor territory
•Consider if radial nerve already injured
Sural 30–50 cm (48) 9–14 2.5–4mm •Positioning difficult •Long length
MSC 1–3 MSC 1.5 •Requires second extremity
LSC 1.5LSC 5–7
Obturator 9.9–13.6 cm 2–4 (50) •Loss of gracilis as possible
future free functional flap
•No sensory loss
•Expendable motor nerve graft11.5 cm average
(49)
MABC medial antebrachial cutaneous nerve, LABC lateral antebrachial cutaneous nerve, TWM third webspace branch of median nerve, PCM palmar
cutaneous branch of median nerve, DCU dorsal cutaneous branch of ulnar nerve, AIN anterior interosseous nerve, PIN posterior interosseous nerve, SBR
radial sensory nerve, MSC medial sural cutaneous, LSC lateral sural cutaneous
a
Used as non-critical portion of injured nerve
b
Terminal branch
HAND (2015) 10:68–75 69
Results
Patients and Nerve Injury
Eighty-six patients received 109 nerve grafts for upper ex-
tremity nerve reconstruction over the study period. Mean
patient age at time of surgery was 42.9 ± 18.3 years, and
57 % were male. Mechanism of nerve injury was documented
in 80 patients and included sharp laceration (37 %), iatrogenic
lacerations (24 %), traction (9 %), neoplasm (7 %), gunshot
(6 %), fracture (3 %), crush (2 %), and other blunt trauma
(1 %). Nerve repairs were performed at an average of 13.3±
17.2 months after primary injury, and 48 patients (56 %) had
undergone one or more prior attempts at nerve repair. In 14
patients (16 %), multiple nerves were injured but only 6
patients (7 %) required repair of multiple nerves with a nerve
graft.
There were 51 median (59 %), 26 ulnar (30 %), 14 digital
(13 %), 13 radial (16 %), and 3 musculocutaneous (4 %) nerve
injuries repaired with nerve graft. Pure sensory nerve injuries
were most common (n=47, 53 %), followed by mixed (n=32,
36 %) and pure motor nerve injuries (n=10, 11 %).
Nerve Graft Donors
In total, 99 nerve autografts (71 from upper extremity, 28 from
lower extremity) and 10 acellular nerve allografts (ANA) were
used. The type and characteristics of nerve grafts utilized in
this cohort are summarized in Table 2. Figure 1demonstrates
which nerve grafts were utilized by nerve injured.
Multiple upper-extremity nerve autograft donors were uti-
lized, including the MABC, TWM, LABC, PCM, and DCU.
By using an upper-extremity donor, a second operative limb
was avoided in 58 patients (67 %) and a second incision was
avoided in 26 patients (30 %). Lower-extremity autograft
donors included the sural nerve and obturator nerve. Six
patients (7 %) required bilateral sural nerve harvest. The
frequency of sural nerve graft use declined from 40 % (n=
17/43) to 11 % (n=7/64) between the first and second half of
the study period, with a corresponding increase in upper-
extremity nerve donor utilization (Fig. 2). The sural was used
primarily to repair complex injuries involving multiple nerves.
Where possible, the distal cut end of the donor nerve was
repaired in an end-to-side fashion to an adjacent, normal
sensory nerve. This was achieved in 25 of 99 autografts,
specifically following MABC (n=13), TWM (n=7), and
PCM (n=3) harvest. In two cases where a direct end-to-side
repair was not possible, ANA was utilized to bridge the nerve
gap.
An algorithm for nerve graft selection is proposed in Fig. 3.
Discussion
Nerve grafting remains an important reconstructive technique
for acute management of upper-extremity nerve injuries. Our
algorithm for selection of nerve graft material has evolved
over the last decade owing to several factors. First, a growing
understanding of upper-extremity nerve anatomy and internal
topography now allows alternative reconstructions with nerve
transfers and has expanded the available options and harvest-
able length of upper-extremity nerve donors. Second, the
ongoing drive to minimize additional incisions, maximize
ease of harvest, and limit donor morbidity has led us away
from using the sural nerve when possible. Third, with the
increasing prevalence of obesity in North America, the added
difficulty and operative time required for sural nerve harvest is
Tabl e 2 Type and characteristics
of 109 nerve grafts utilized to re-
construct upper-extremity nerve
injuries
MABC medial antebrachial cuta-
neous nerve, LABC lateral
antebrachial cutaneous nerve,
TWM third webspace branch of
median nerve, PCM palmar cuta-
neous branch of median nerve,
DCU dorsal cutaneous branch of
ulnar nerve, AIN anterior
interosseous nerve, SBR radial
sensory nerve, ANA acellular
nerve allograft
a
Using both anterior and posteri-
or branches of MABC
Nerve Number Harvested length (cm)
(mean ± SD, range)
Cable length (cm)
(mean ± SD, range)
Number of cables
(mean ± SD, range)
Upper extremity
MABC 29 17.6±10.7 (4.5–56
a
)6.3±2.9(3–18) 3± 2 (1–8)
TWM 14 8.5 ± 5.3 (3–18) 4.8± 1.8 (2–8) 2± 1 (1–4)
LABC 12 8.4± 4.6 (3.5–18) 4.4±3.3 (2–12) 1± 1 (1–3)
PCM 8 6.5± 3.8 (2–14) 5.6± 2.3 (2–9) 1±0 (1–2)
DCU 6 9.6± 5.9 (3–18) 5.8± 3.0 (3–11) 2 ± 1 (1–3)
AIN 1 2 2 1
SBR 1 12 12 1
Lower extremity
Sural 24 28.0 ± 11.5 (6–48) 10.0±5.2 (3–23) 3±2 (1–7)
Obturator nerve 4 6.8± 3.7 (2–11) 4.5 ± 2 .2 (2 –7) 2±1 (1–2)
Non-autograft
ANA 10 2.5 ± 0.6 (1.5–3) 2.5± 0.6 (1.5–3) 1± 0 (1–1)
70 HAND (2015) 10:68–75
not insignificant. As a result, we now use the sural nerve only
for situations requiring large amounts of graft material, such as
multiple major nerve transection injuries.
For distal nerve injuries in the forearm, the MABC remains
our first choice for repair of median and ulnar nerve injuries
because of its caliber, available length, and proximity. Donor
morbidity from harvesting the MABC can be minimized by
performing an end-to-side anastamosis of the distal cut end
of the MABC to the adjacent median nerve. Recent studies
show that while motor axons require injury for end-to-side
sprouting, sensory axons collaterally sprout spontaneously
without need for additional axonal injury [35,46]. Restoring
some degree of innervation to the donor nerve territory may
reduce forearm anesthesia or hypersensitivity caused by
sprouting of adjacent sensory nerves after MABC harvest
[11,13]. This concept can also be applied to harvest of other
nerves, such as the TWM.
Utilizing non-critical portions of the injured nerve also
helps to minimize donor morbidity, avoid additional incisions,
and minimize operative time. For example, the DCU becomes
a useful donor in more proximal ulnar nerve injuries, as do the
PCM and TWM in median nerve injuries. In this study, using
DCU and TWM for graft material avoided a second incision in
3 of 6 patients and 10 of 14 patients, respectively. Owing to its
small caliber and short length, we tend to reserve the PCM as a
secondary source of graft material in distal median nerve
injuries where the TWM alone was insufficient. Addition of
the PCM in this review eliminated the need for a second
incision in four of eight patients.
Along the same lines, our preference for radial sensory
nerve reconstruction for short gap injuries in the forearm is
the LABC because of its proximity, ease of harvest, and the
likelihood that it is also injured in distal forearm injuries.
Although the radial sensory nerve does not provide critical
sensation tothe hand, we prefer to reconstruct it because of the
propensity for hyperalgesia in this region secondary to collat-
eral sprouting [11]. Alternatively, in high radial nerve injuries,
we will crush and proximally transpose the injured radial
Fig. 1 Upper-extremity graft use
by injured nerve. Histogram
representing the frequency of use
of each donor nerve and the nerve
repaired with that donor. Includes
ANAs used to facilitate and end-
to-side repair of nerve graft do-
nors and repair of other sensory
nerves not specifically listed.
Fig. 2 Utilization of different
nerve grafts over time. Histogram
comparing the use of each donor
nerve in the first half of the study
period to the second half. Sural
nerve use decreased as use of
upper extremity donors increased
HAND (2015) 10:68–75 71
sensory nerve to avoid formation of a painful neuroma when
reconstruction is not feasible. The distal radial sensory nerve
can then be transferred end-to-side to the normal median nerve
for recovery of sensation. We strongly advise against harvest-
ing an uninjured radial sensory nerve as graft material.
Our preference for digital nerve reconstruction de-
pends on the specific nerve injured. Critical sensory
nerves supplying the ulnar and radial borders of the
hand should be reconstructed with nerve autograft. Mul-
tiple donor options exist; however, we prefer the MABC
and LABC owing to their size match and limited donor
morbidity. The distal PIN is described as a graft source
for digital nerve reconstruction [22] but it is small in
diameter and leaves a visible scar on the dorsal forearm.
Therefore, we tend not to use this graft.
We reserve the use of ANA for non-critical digital nerve
injuries less than 3 cm in length. While a comprehensive
discussion on the advantages and disadvantages of ANA is
outside the scope of this manuscript, evidence supporting
good outcomes following ANA reconstruction of proximal
nerve injuries or large nerve gaps is lacking [4,8]. In fact, we
will utilize long ANA segments specifically when we wish to
encourage incomplete nerve regeneration, as in the manage-
ment of painful neuromas. As such, our personal practice is to
use autogenous nerve for critical sensory or motor nerve
repair.
The vast majority of autograft donors in this study were
sensory nerves. In four cases, we utilized the obturator motor
nerve for reconstruction of motor nerve injuries based on the
hypothesis that motor and sensory Schwann cell specificity
would markedly improve regeneration [21]. However, subse-
quent experimental work revealed that nerve architecture and
endoneurial tube size are likely more important factors in
facilitating nerve regeneration [23,34]. Our current indica-
tions for harvesting a motor nerve as a graft source are there-
fore limited to critical motor nerve reconstruction not amena-
ble to motor transfer, such as the deep ulnar motor branch in
the hand and the spinal accessory nerve.
The advent of distal nerve transfers has limited our require-
ments for long nerve grafts. Our improved understanding of
nerve injury and regeneration now cautions us against the use
of long grafts (>6 cm) whenever possible [42]. A state of
Schwann cell senescence following denervation was recently
described and correlated with failures of axonal regeneration
through long nerve grafts [42]. Irreversible arrest of prolifer-
ation, altered gene expression, and changes in the secretory
profile characterize the senescent state [2,6,7,10,12,14,18,
24,32,33,37,39,43,47,48]. Compared with short grafts,
long and large diameter nerve grafts expose distal Schwann
cells to prolonged ischemia-related oxidative stress and
prolonged denervation, which may induce Schwann cell se-
nescence [42,49,50]. This phenomenon may explain poor
Fig. 3 Algorithm for sural alternatives. Flow diagram representing our
algorithm for choosing donor nerves. ANA acellular nerve allograft, DCU
dorsal cutaneous branch of ulnar nerve, LABC lateral antebrachial
cutaneous nerve, MABC medial antebrachial cutaneous nerve, PCM
palmar cutaneous branch of median nerve, TWM third webspace branch
of median nerve
72 HAND (2015) 10:68–75
regeneration across long grafts and grafts without immediate
distal repair [17,20,25].
Based on this knowledge, we prefer to acutely manage
single nerve injuries in the upper arm with distal nerve or
tendon transfers rather than direct repair with nerve grafting
(Table 3). Increased experience with nerve transfer and the use
of MABC as graft material has reduced the need for sural
nerve graft. We now only address a proximal single nerve
injury if there is neuropathic pain. In these situations, rather
than directly repair the nerve with a nerve graft, we address the
injury with neuroma excision, and crushing the nerve
proximal to the injury to create a neurotmetic injury
and thus, “reset”the regenerative process. Finally, the nerve
end is transposed into an adjacent muscle for pain control. As
a result, even if nerve grafts are needed to complete a portion
of reconstruction, donors from the upper extremity typically
suffice. Sural nerve grafting is reserved for multiple major
nerve transection injuries, where distal nerve or tendon trans-
fers are not possible.
In summary, upper-extremity nerve reconstruction can be
successfully accomplished using nerve donors from the ipsi-
lateral limb in the majority of cases. Judicious selection of
nerve donors can reduce patient morbidity and operative time
but necessitates a thorough understanding of nerve anatomy
and topography. While the sural nerve remains a useful
donor for extensive, multiple nerve injury reconstruc-
tion, a growing body of scientific and clinical evidence
suggests that in situations requiring large amounts of
nerve autograft, alternative reconstructions such as nerve
transfers may provide better results [16,36]. In cases of
distal injury requiring interposition grafting, we recom-
mend use of alternative graft material including TWM
and DCU for median and ulnar nerve injuries respec-
tively,aswellasMABCandLABC.
Conflict of Interest Louis H. Poppler declares that he has no conflict of
interest.
Kristen Davidge declares that she has no conflict of interest.
Johnny C.Y. Lu declares that he has no conflict of interest.
Jim Armstrong declares that he has no conflict of interest.
Ida K. Fox declares that she has no conflict of interest.
Susan E. Mackinnon declares that she has no conflict of interest.
Statement of Human and Animal Rights The Institutional Review
Board at Washington University approved this study and ensured that all
data collection and analysis was performed with respect to human rights.
Statement of Informed Consent All data in this study had nopersonal
identifiers and therefore informed consent was not necessary.
Tabl e 3 “Recipes”for high-level
nerve injuries as alternatives to
sural graft
Used with permission from
Mackinnon SE, ed. Nerve
Surgery. New York, NY: Thieme;
2015
AIN anterior interosseous nerve,
ETE end-to-end, ETS end-to-side,
DCU dorsal cutaneous branch of
ulnar nerve, PCM palmar cutane-
ous branch of median, SBR radial
sensory nerve, TWM third
webspace branch of median nerve
a
All motor transfers are end-to-
end
Nerve
injury
Priorities Reconstruction technique
Median AIN function
Thumb opposition
Pronation
Sensation
Motor nerve transfers
a
-ECRBtoPT
- Brachialis or supinator to AIN
Sensory transfers
- DCU to thumb and radial index sensory fascicles ETE
- TWM and distal DCU to ulnar sensory fascicles ETS
Tendon transfers
-Opponensplasty
Radial Wrist, finger, and thumb extension
Sensation
Motor nerve transfers
- FDS to ECRB
-FCRtoPIN
Sensory transfers
-LABCtoSBRETE
- SBR to median ETS
Tendon transfers
- PT to ECRB for early wrist extension (optional)
Ulnar Intrinsic function
Ring and small finger flexion
Sensation
Motor nerve transfers
- AIN to ulnar motor
Sensory transfers
- TWM to ulnar sensory fascicles ETE
- PCM to DCU ETE or DCU to median ETS
Tendon transfers
- Tenodesis of FDP tendons
HAND (2015) 10:68–75 73
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