EVALUATION OF SENSORY RECOVERY AFTER

RECONSTRUCTION OF DIGITAL NERVES OF THE HAND USING

MUSCLE-IN-VEIN CONDUITS IN COMPARISON TO NERVE
SUTURE OR NERVE AUTOGRAFTING
THEODORA MANOLI, M.D.,* LUKAS SCHULZ, STEPHANE STAHL, M.D., PATRICK JAMINET, M.D., and
HANS-EBERHARD SCHALLER, M.D.

Background: Muscle-in-vein conduits are a good alternative solution to nerve autografts for bridging peripheral nerve defects since
enough graft material is available and no loss of sensation at the harvesting area is expected. The purpose of this study was to compare
regeneration results after digital nerve reconstruction with muscle-in-vein conduits, nerve autografts, or direct suture. Patients and Meth-
ods: 46 patients with 53 digital nerve injuries of the hand subjected to direct suture (n 5 22) or reconstruction of 1-6cm long defects with
either nerve autografts (n 5 14) or muscle-in-vein conduits (n 5 17) between 2008 and 2012, were examined using the two-point discrim-
ination and Semmes-Weinstein Monofilaments. Results: The follow-up examinations took place 12 to 58 months after surgery. A median
reduction of sensibility of 2 Semmes-Weinstein monofilaments compared with intact digits was observed after direct suture (DS) and of
2.5 and 2 Semmes-Weinstein monofilaments after reconstruction with autologous nerve grafts (ANG) and muscle-in-vein conduits (MVC),
respectively. No statistically significant differences between all three groups could be found with a significance level set by a P < 0.006
(PDS-ANG 5 0.24, PDS-MVC 5 0.03, PANG-MVC 5 0.52). After harvesting a nerve graft, reduction of sensibility at the donor site occurred in
10 of 14 cases but only in one case after harvesting a muscle-in-vein conduit. Conclusions: Muscle-in-vein conduits may be a good alter-
native solution to autografts for the reconstruction of digital nerves, since no significant differences could be demonstrated between the
two methods. V C 2014 Wiley Periodicals, Inc. Microsurgery 34:608–615, 2014.

In order to achieve the best possible regeneration after use of veins filled with fresh skeletal muscle.9 Veins
reconstruction of peripheral nerve defects, the surgical form a barrier against dispersion of outgrowing axons
technique must provide an optimal milieu for the and they inhibit ingrowth of scar tissue into the con-
ingrowth of the new axon sprouts after Wallerian degen- duit.7,9 Muscle tissue provides an optimal environment
eration takes place. The new axons grow to their original for the ingrowth of regenerating axons into newly formed
target guided by the so-called bands of B€ungner, which bands of proliferating Schwann cells along the basal lam-
are endoneural tubes formed by proliferating non- inae of the muscle fibers. These are biologically similar
innervated Schwann cells and remaining connective tis- to the bands of B€ungner formed in regenerating nerve
sue within the basal lamina of the distal nerve stump.1,2 tissue as described above.10–13 Additionally, the interposi-
In the case of a sharp transected nerve, direct suture of tion of muscle tissue prevents the collapse of the veins
the proximal and distal stumps can be performed if a ten- and therefore enables bridging of larger defects.9 Regen-
sionless coaptation is possible.3,4 Up to date, autologous erating nerves can correctly orientate within muscle-in-
nerve autografts are the gold standard for bridging nerve vein conduits due to the accumulation of neurotrophic
defects in clinical use.4,5 Several disadvantages like the factors from the distal stump, generating a concentration
loss of sensory perception at the donor site, the demand of gradient which enables growing axons to reach their
at least two incisions, different diameters of the harvested proper target.14–18 Muscle fibers or veins alone achieve
and the injured nerve and limited graft material led to the good results up for bridging defects of 1–2 cm in
development of alternative tubulization techniques. length.3,9,19 In combination the distance rises up to 6
Several synthetic (e.g., silicon, polytetrafluoethylene, cm.20 Several previous studies showed that muscle-in-
polyglycolic acid, or collagen) and biological conduits vein conduits are reliable for the repair of peripheral
(e.g., allografts,6 blood vessels, muscles) have been tested nerve defects of both sensory and mixed nerves.5,19,21,22
in the past.3,4,7,8 In 1993, Brunelli et al. described the Brunelli et al. proved histologically that there are higher
numbers of regenerating axons in muscle-in-vein conduits
in gaps up to 2 cm than in nerve grafts of the same
Department of Hand, Plastic and Reconstructive Surgery with Burn Center,
BG Trauma Center, University of Tuebingen, 72076 Tuebingen, Germany length.9 Geuna et al. showed however no significant dif-
*Correspondence to: Theodora Manoli, M.D., Department of Hand, Plastic ferences in the total number, density and size of myelin-
and Reconstructive Surgery with Burn Center, BG Trauma Center, University
of Tuebingen, Schnarrenbergstr. 95, 72076 Tuebingen, Germany.
ated fibers between nerve grafts and vein-in-muscle
E-mail: [Link]@[Link] conduits in the sciatic model of the rat. In an additional
Received 21 February 2014; Revision accepted 4 July 2014; Accepted 15 experiment in the rabbit model, the same group showed
July 2014
that 5.5 cm long nerve defects could be successfully
Published online 2 August 2014 in Wiley Online Library
([Link]). DOI: 10.1002/micr.22302 bridged using muscle-in-vein conduits.21

Ó 2014 Wiley Periodicals, Inc.

 Muscle-In-Vein Conduits for Nerve Repair 609

Table 1. Summary of patients within the tree groups including the distributions of age, of primary or secondary reconstructions,
gap length and time point of follow-ups.

Direct suture (DS) Autologous nerve grafting (ANG) Muscle-in-vein conduit (MVC)
Number (male/female) 22 (13/7) 14 (14/0) 17 (14/3)
Mean age (range of age) 35 (17–63) 32 (11–62) 38 (15–72)
Number of primary reconstructions 22 6 8
Number of secondary reconstructions 0 8 (2–23 weeks post trauma) 9 (2–15 weeks post trauma)
Mean gap length (range) in cm 0 2.18 (1–6) 2.17 (1–6)
Follow-up in months 12–42 13–58 14–29

The purpose of this study was the comparison of the Six patients underwent reconstructions of more than
outcome after reconstruction of sensory nerves of the one digital nerve of the same hand; two of them under-
hand with muscle-in-vein conduits to the standard meth- went a direct suture of two digital nerves, one of them
ods of autologous nerve grafting or direct nerve suture one direct suture and a reconstruction with a muscle-in-
on a clinical level. vein conduit, another one underwent one direct suture
and two reconstructions with muscle-in-vein conduits and
PATIENTS AND METHODS two patients had two reconstructions with muscle-in-vein
conduits. All nerve reconstructions, also from same indi-
The retrospective study was approved by the ethics
viduals, were analyzed as distinct cases.
committee of the University of Tuebingen (117/
Total or subtotal amputations with a combined injury
2012BO2). Patients that underwent either direct suture
of blood vessels, nerves, tendons, and bones were
(DS), autologous nerve grafting (ANG), or reconstruction
excluded from the study. Further exclusion criteria were
by a muscle-in-vein conduit (MVC) of one or more sen-
inadequate compliancy for performing the clinical assess-
sory digital nerves on the palmar side of the hand
ment tests of the follow-up examination reliably and path-
between 2008 and 2012 and met the criteria mentioned
ologies that could have influenced the digital sensibility,
below were invited to a follow-up examination the ear-
i.e., nerve compression syndromes. In total 46 patients
liest 12 months after operation. The age of patients
with 53 digital nerve injuries were included in the study.
ranged between 11 and 72 years. Thirty-six patients with
43 digital nerve injuries were male and 10 patients with
Surgical Procedure
a single digital nerve injury were female. Five patients
with six digital nerve injuries were pediatric cases All sutures were performed with 10-0 nylon with the
between 11 and 17 years of age. The causes of injuries aid of an operating microscope. In case of direct nerve
included sharp transections (nDS 5 17, nANG 5 6, nMVC suture both nerve stumps were directly approximated and
5 6), lacerations (nDS 5 1, nANG 5 4, nMVC 5 8) and sutured with 2–3 epineural stitches avoiding torsion of
saw injuries (nDS 5 4, nANG 5 4, nMVC 5 5). All partic- both stumps. The medial antebrachial cutaneous nerve
ipants had to understand clearly the background of the was harvested at the palmar side of the ipsilateral proxi-
study and to give their written consent. Parents of mal forearm for autografting. A muscle-in-vein conduit
patients under 18 years of age provided their informed was prepared as following: A subcutaneous vein, slightly
consent prior to the examination of their children. wider than the damaged nerve, was harvested from the
The level of injury was between the metacarpopha- palmar side of the forearm. At the same site a fascial
langeal joint and the distal interphalangeal joint. When incision was performed and a thin muscle strip was
no direct suture was possible, patients were consecutively excised (Fig. 1a). The muscle was then pulled into the
treated firstly by ANG between January 2008 and begin- vein along its longitudinal course of fibers using a micro
ning of March 2010 and afterwards by MVC except of forceps (Figs. 1b–1d). The vein ends of the muscle-in-
three cases, which were treated by ANG in 2012 due to vein conduit were then sutured over the nerve stumps
the surgeon’s objective preference of ANG instead of a including all fascicles.
reconstruction with MVCs. All direct nerve sutures were
performed primarily on the day of injury. Nerve recon- Follow-Up Examination
struction by means of nerve autografts or muscle-in-vein Static and moving two-point discrimination tests as
conduits was either performed primarily or secondary, well as the Semmes-Weinstein monofilament (SWM) test
not later than 6 months after injury. The length of the were used to compare the recovered sensibility of the
bridged nerve gap ranged between 1 and 6 cm in both innervated area of the injured nerve to normal sensibility.
groups ANG and MVC. The distribution of patients Normal sensibility was defined as the sensibility assessed
within the three groups is depicted in Table 1. at healthy, not previous harmed fingers. If reconstructions

Microsurgery DOI 10.1002/micr

610 Manoli et al.

Figure 1. Intraoperative photographs depicting the preparation of a muscle-in-vein conduit (scale in mm); (a) Harvest of a subcutaneous
vein and a thin muscle slice from the flexor digitorum superficialis muscle at the palmar side of the forearm, (b-c) The muscle slice was
pulled through the vein using a micro forceps, (d) Muscle-in-vein conduit with retracted vein ends ready for interposition between the
nerve stumps. [Color figure can be viewed in the online issue, which is available at [Link].]

with nerve autografts or muscle-in-vein conduits were ment followed by the next thicker monofilament until the
performed, the Semmes-Weinstein test was also applied tested person stated a perception with closed eyes. Up to
to the graft donor sites at the palmar side of the ipsilat- 17 monofilaments (2.83–6.65) had to be used to obtain a
eral forearm. positive result. Both healthy and injured digits were
Examination of static and moving two-point discrim- examined to calculate a possible reduction of sensibility
ination was carried out with a two-point discriminator at the injured sites by means of a level difference. The
(Touch-TestV R , North Coast Medical, USA). Testing level difference was calculated by the following way; the
intervals of 1 mm ranging from 1 to 15 mm could be 17 monofilaments used were ordered ordinally (1–17 as
assessed. The patients were asked to close their eyes levels). The level difference between injured and healthy
and the examined finger was slightly held from the dor- digits was then calculated.
sal side. Then one or two points were applied to the All clinical tests were performed by the same asses-
skin for at least 3 s. Light pressure was added to the sor (LS) who was independent of the surgical procedure.
weight of the device carefully until blanching of the
skin occurred. The test was applied at the fingertip in Statistical Analysis
line of the anatomical course of the examined sensory Analysis of the collected data was carried out with
digital nerve. Three repetitive responses should be accu- IBM SPSS statistics version 21. The rates of measurable
rate for scoring. versus not measurable two-point discrimination between
Homecraft RolyanV R SWM were used to assess the all three groups were evaluated using the Fisher’s exact
sensibility of the palmar side of the hand. The set con- test for count data. The level of significance was initially
sisted of 20 monofilaments whereas each monofilament set by a P-value of 0.05 and after applying the Bonfer-
was labeled with the logarithm to base 10 of the pressure roni correction for multiple testing (three tests) values
force it produces onto the skin. In order to obtain objec- less than 0.017 were considered to be significant. The
tive results each monofilament was vertically pressed results of two-point discrimination and SWM-test
onto the skin until it slightly bended holding it for 1–2 s. between all three groups were evaluated using the Wil-
The examination began always with the 2.83 monofila- coxon rank-sum-test to find out whether significant

Microsurgery DOI 10.1002/micr

 Muscle-In-Vein Conduits for Nerve Repair 611

differences between the groups exist. The level of signif- are presented in Figures 2a and 2b. The median static
icance was initially set by a P-value of 0.05 and after spatial discrimination ability in groups DS, ANG, and
applying the Bonferroni correction for multiple testing MVC was 5.0, 5.5, and 5.0 mm, respectively, which
(nine tests) values less than 0.006 were considered to corresponds to a median increase of 2.0, 2.5, and 2.0
be significant. A Spearman’s rank correlation was addi- mm compared with normal sensibility assessed at the
tionally applied to the results of two-point discrimina- not injured digits, respectively. No statistically signifi-
tion and SWM-test. Finally, age distribution, gap cant differences between all three groups could be
lengths greater than 2 cm and bilateral nerve injuries found (PDS-ANG 5 0.13, PDS-MVC 5 0.60, PANG-MVC
were assessed according to the SWM-test results for the 5 0.40). The median moving spatial discrimination
three groups in this study and a Spearman’s rank corre- ability in groups DS, ANG, and MVC was 3.5, 4.0,
lation was additionally applied to the age and SWM- and 4.0 mm, respectively, which corresponds to a
test. median increase of 1.5, 2.0, and 2.0 mm compared
with normal sensibility, respectively. The MVC-group
RESULTS had, however, an interquartile spread towards better
results compared with the ANG-group. No statistically
The follow-up examinations took place 12–42 months significant differences between all three groups could
after direct suture, 13–58 months after nerve autografting be found (PDS-ANG 5 0.61, PDS-MVC 5 0.76, PANG-
and 14–29 months after reconstruction with muscle-in- MVC 5 0.86).
vein conduits (Table 1).
Semmes-Weinstein Monofilament Test (SWM-
Two-Point Discrimination Test)
Since static and moving two-point discrimination Boxplots summarizing the reduction of sensibility at
function did not recover in all cases, the rate of the the injured digits, defined as the level difference between
measurable two-point discriminations (<15 mm) was the values obtained by the SWM-test at the injured and
assessed. In the first group treated with direct suture healthy sites of each individual, are presented in Figure
(DS) the two-point discrimination function recovered in 3. A median reduction of sensibility of 2 levels was
all 22 cases (100%). In the second group treated with observed in group DS and of 2.5 and 2 levels in groups
autologous nerve grafting (ANG) it recovered in 12 out ANG and MVC, respectively. The boxplot of the group
of 14 cases (85.7%) and in the third group treated with ANG demonstrated a wider spread of data in comparison
muscle-in-vein conduits (MVC) in 14 out of 17 cases to groups DS and MVC. Additionally, strong outliers like
(82.4%). No statistically significant differences between a reduction of sensibility of 16 levels in group ANG and
all three groups could be found (PDS-ANG 5 0.14, 10 levels in group MVC did not appear in group DS. No
PDS-MVC 5 0.07, PANG-MVC 5 1.00). statistically significant differences between all three
Boxplots depicting the recovered values of static and groups could be found (PDS-ANG50.24, PDS-MVC50.03,
moving two-point discrimination results of each group PANG-MVC 5 0.52).

Figure 2. Boxplots comparing the results of the static (a) and moving (b) two-point discrimination tests, with boundaries at the 25th per-
centile, the median and 75th percentile. Whiskers extended to a maximum distance of 1.5 interquartile ranges. Data beyond these bars
were depicted as outliers. [Color figure can be viewed in the online issue, which is available at [Link].]

Microsurgery DOI 10.1002/micr

612 Manoli et al.

Correlation of Two-Point Discrimination and

SWM-Test
Spearman’s correlation was performed between the
static and moving two-point discrimination as well as
between the Semmes-Weinstein and two-point discrimi-
nation results at the injured sites. Data of all three groups
were used together to perform the correlation. A good
correlation between the static and moving two-point dis-
crimination was obtained (q 5 0.79). The correlations
between the static two-point discrimination and the
SWM-test (q 5 0.17) as well as between the moving
two-point discrimination and the SWM-test (q 5 0.39)
yielded poor results. Since SWM-test is a more sensitive
and objective method to assess sensibility, only the
results yielded by this method were used for further anal-
ysis of the three factors mentioned below.
Figure 3. Boxplots comparing the results obtained by the SWM-test
applied at the injured digits. [Color figure can be viewed in the Age Distribution, Gap Length, and Bilateral Nerve
online issue, which is available at [Link].] Injuries
The age distribution of the individuals according to
the SWM-test results for the three groups is depicted in
Figure 5. Patients older than 60 years demonstrated simi-
lar results to younger ones and patients under 18 years
demonstrated no notable differences compared with
adults. Two patients treated with nerve autografts and
two patients treated with muscle-in-vein conduits that
demonstrated a “loss of protective sensation—LPS” had
an age distribution between 17 and 62 years. Patients

Figure 4. Boxplots comparing the results obtained by the SWM-test

applied at the donor site of nerve autografts or muscle-in-vein con-
duits. [Color figure can be viewed in the online issue, which is
available at [Link].]

Box plots summarizing the results of SWM-test

applied at the harvesting area of nerve autografts or
muscle-in-vein conduits are presented in Figure 4. A
median reduction of sensibility of 2 levels was observed
in group ANG. This box plot demonstrated a wide spread Figure 5. Results of the SWM-test according to the age of the
patients at the day of operation. N, normal sensation; DLT, dimin-
of data with an outlier 16 levels. On the contrary,
ished light touch; DPS, diminished protective sensation; LPS, loss
patients treated with muscle-in-vein conduits did not of protective sensation. Black edged symbols depicted patients
demonstrate any reduction of sensibility at the harvesting with more than one injured nerve. [Color figure can be viewed in
site apart of one case with a reduction of just 1 level. the online issue, which is available at [Link].]

Microsurgery DOI 10.1002/micr

 Muscle-In-Vein Conduits for Nerve Repair 613

Table 2. Reduction of sensibility measured with Semmes- ever, no direct comparison to other methods in humans
Weinstein Monofilaments of patients with nerve defects between existed up to date. The current study presents a compari-
3 and 6 cm
son of regeneration results after using muscle-in-vein
Gap length NT VM conduits to the standard methods of nerve suture and
3 cm 5 levels 2 and 5 levels nerve autografts for digital nerve reconstruction on a
4 cm 1 level 7 levels clinical level.
6 cm 6 levels 1 level Although the rate of recovery of the two-point dis-
crimination function was slightly lower in group MVC
than in group ANG, the group MVC showed in general
with more than one nerve reconstructions showed an similar and even slightly better results of the two-point
intraindividual tendency for similar regeneration results. discrimination and the SWM-test than the group ANG.
The correlation between the age and the SWM-test These results were not much worse than the results
yielded very poor results (q 5 0.16). after direct nerve suture. No statistically significant dif-
Long nerve gaps of 3–6 cm were bridged in three ference could be found between all three groups for
cases in the ANG-group and four cases in the MVC- both clinical tests. In another clinical series of 13 digi-
group. Their regeneration results according to the SWM- tal nerves reconstructed with muscle-in-vein conduits,19
test are summarized in Table 2. No notable differences a recovery of the two-point discrimination (<15 mm)
to the other 25 reconstructions with a gap length between could be assessed in 11 cases (85%). This corresponds
1 and 2 cm could be observed. A statistical analysis to a similar rate found in the MVC-group of our study
between the patients with a gap length of 1–2 cm and (82%). The same group reported good results after
the ones with a gap length of 3–6 cm could not be per- reconstruction of long defects up to 6 cm, also in case
formed due to the small number of the latter patients in of mixed nerves.20 In this study, the outcome after
each group. One reconstruction with a 6 cm long bridging nerve defects between 3 and 6 cm was compa-
muscle-in-vein conduit provided even a very good out- rable to the outcome after bridging shorter nerve
come with a reduction of sensibility of only one level. defects of 1–2 cm.
In three cases, both digital nerves of one finger were The overlapping zones of innervation of the digits
injured. In one case the one side was treated by direct making possible a partial reinnervation of the denervated
suture and the other side was bridged with an autograft. region by the contralateral digital nerve should be fairly
Both sides yielded a “diminished light touch—DLT” in discussed at this point. It could be expected that patients
the SWM-test. In the other two cases both sides yielded with a bilateral injury of both digital nerves might had
a “diminished protective sensation—DPS” when treated worse outcomes. However, the three cases with a bilat-
with direct suture and a muscle-in-vein conduit in one eral nerve injury in our study yielded similar final results
case and with two muscle-in-vein conduits in the other as in most of the unilateral cases.
case. Marcoccio and Vigasio published in 2010 a retrospec-
tive series of 21 digital nerve defects, which were treated
with muscle-in-vein conduits with an average nerve gap
DISCUSSION
of 2.2 cm.22 Performing SWM-test they reported 3 cases
According to our current knowledge, nerve autografts with normal recovery (14%), 6 cases with “diminished
are still the most common method used for bridging light touch—DLT” (29%), 8 cases with “diminished pro-
nerve defects, especially if these are longer than 2 cm. tective sensation—DPS” (38%) and 4 cases with “loss of
However, donor sites of nerve autografts are limited and protective sensation—LPS” (19%). In our series we had
their harvest is frequently associated with a reduction of no patients of the MVC-group with a recovery of sensa-
sensibility at the innervated skin area.23 An alternative tion to normal levels. 47% demonstrated a DLT, 41% a
method is the so-called muscle-in-vein conduits for DPS and 12% a LPS.
which enough graft material in appropriate diameters is After harvesting a nerve graft, reduction of sensibility
available since subcutaneous veins and muscle tissue are occurred in 10 of 14 cases, while no reduction of sensi-
dispensable. Muscle-in-vein conduits can therefore be bility occurred at the harvest site of muscle-in-vein con-
used also in cases with an uncertain outcome, like duits apart from one case. The latter could be due to an
replantations or contaminated wounds, without sacrificing accidental injury of a terminal branch of the medial ante-
precious nerve autografts. A great advantage of this brachial cutaneous nerve. This illustrates one of the most
method is the lack of sensibility reduction at the donor important advantages of muscle-in-vein conduits com-
site. Several histological and clinical studies presenting pared with nerve autografts.
good regeneration results after bridging peripheral nerve Disagreement arises concerning the question whether
defects with muscle-in-vein conduits exist.5,12,22 How- the patients’ age influences the regeneration results.

Microsurgery DOI 10.1002/micr

614 Manoli et al.

Several previous works support this thesis, whereas these Geuna from the Department of Clinical and Biological
studies analyzed mixed nerves and the influence of con- Sciences of the University of Turin for inspiring us to
founding factors like the denervation time.24 Other use muscle-in-vein conduits for nerve reconstruction on a
authors support the thesis, that only patients younger clinical level.
than 10 years have a better regeneration potential.25 In
our data no correlation between the patients’ age and
regeneration results could be observed. REFERENCES
A relative strong correlation between the static and
moving two-point discrimination could be found, while 1. Ide C. Peripheral nerve regeneration. Neurosci Res 1996;25:101–
121.
both static and moving two-point discrimination were 2. Seckel BR. Enhancement of peripheral nerve regeneration. Muscle
weakly correlated to the SWM-test. Wong et al. found Nerve 1990;13:785–800.
an even poorer correlation between moving two-point 3. Siemionow M, Bozkurt M, Zor F. Regeneration and repair of periph-
discrimination and the SWM-test after repair of the eral nerves with different biomaterials: Review. Microsurgery 2010;
30:574–588.
median nerve.26 These results might be due to several 4. Siemionow M, Brzezicki G. Chapter 8: Current techniques and con-
factors. First, the two point-discrimination test meas- cepts in peripheral nerve repair. Int Rev Neurobiol 2009;87:141–
ures the spatial discrimination whereas the SWM-test 172.
5. Tos P, Battiston B, Ciclamini D, Geuna S, Artiaco S. Primary repair
measures the pressure force onto the skin. Additionally, of crush nerve injuries by means of biological tubulization with
the two-point discrimination test is not objective and muscle-vein-combined grafts. Microsurgery 2012;32:358–363.
reliable enough, since it is not possible to perfectly 6. Brooks DN, Weber RV, Chao JD, Rinker BD, Zoldos J, Robichaux
MR, Ruggeri SB, Anderson KA, Bonatz EE, Wisotsky SM, Cho
standardize the pressure being applied to the skin, espe- MS, Wilson C, Cooper EO, Ingari JV, Safa B, Parrett BM, Buncke
cially when one or two points are applied onto the GM. Processed nerve allografts for peripheral nerve reconstruction:
skin.27 Hence, the SWM-test is our preferable method A multicenter study of utilization and outcomes in sensory, mixed,
and motor nerve reconstructions. Microsurgery 2012;32:1–14.
and is considered to be one of the most reliable and
7. Meek MF, Coert JH. Clinical use of nerve conduits in peripheral-
objective tests to evaluate sensation currently nerve repair: Review of the literature. J Reconstr Microsurg 2002;
available.28 18:97–109.
This study provides the first evidence that muscle-in- 8. Penna V, Wewetzer K, Munder B, Stark GB, Lang EM. The long-
term functional recovery of repair of sciatic nerve transection with
vein conduits are not inferior to nerve autografts concern- biogenic conduits. Microsurgery 2012;32:377–382.
ing the outcome after reconstruction of up to 6 cm long 9. Brunelli GA, Battiston B, Vigasio A, Brunelli G, Marocolo D.
defects of sensory nerves. However, there are some limi- Bridging nerve defects with combined skeletal muscle and vein con-
duits. Microsurgery 1993;14:247–251.
tations like the retrospective design, small number of 10. Geuna S, Raimondo S, Nicolino S, Boux E, Fornaro M, Tos P,
patients in the groups of gap lesions, diversities of causes Battiston B, Perroteau I. Schwann-cell proliferation in muscle-vein
and lengths of defects, which should be considered. Fur- combined conduits for bridging rat sciatic nerve defects. J Reconstr
Microsurg 2003;19:119–123; discussion 124.
ther studies taking into consideration these aspects and 11. Meek MF, Varejao AS, Geuna S. Use of skeletal muscle tissue in
especially examining the outcomes after reconstruction of peripheral nerve repair: Review of the literature. Tissue Eng 2004;
defects greater than 3 cm would be useful to support our 10(7-8):1027–1036.
current observations. 12. Raimondo S, Nicolino S, Tos P, Battiston B, Giacobini-Robecchi
MG, Perroteau I, Geuna S. Schwann cell behavior after nerve repair
by means of tissue-engineered muscle-vein combined guides.
CONCLUSIONS J Comp Neurol 2005;489:249–259.
13. Dornseifer U, Fichter AM, Leichtle S, Wilson A, Rupp A,
The reconstruction of digital nerves using muscle-in- Rodenacker K, Ninkovic M, Biemer E, Machens HG, Matiasek K,
vein conduits yielded similar regeneration results as Papadopulos NA. Peripheral nerve reconstruction with collagen
tubes filled with denatured autologous muscle tissue in the rat
nerve autografts, which have been slightly but not signifi- model. Microsurgery 2011;31:632–641.
cant worse than the ones after direct nerve suture. A 14. Fornaro M, Tos P, Geuna S, Giacobini-Robecchi MG, Battiston B.
great advantage of muscle-in-vein conduits was the lack Confocal imaging of Schwann-cell migration along muscle-vein
combined grafts used to bridge nerve defects in the rat. Microsur-
of loss of sensibility at the donor site. The current study gery 2001;21:153–155.
proposes that muscle-in-vein conduits may be a good 15. Lundborg G, Dahlin L, Danielsen N, Zhao Q. Trophism, tropism,
alternative solution to autografts for the reconstruction of and specificity in nerve regeneration. J Reconstr Microsurg 1994;10:
345–354.
sensory nerves.
16. Lundborg G, Dahlin LB, Danielsen N, Gelberman RH, Longo FM,
Powell HC, Varon S. Nerve regeneration in silicone chambers: Influ-
ACKNOWLEDGMENTS ence of gap length and of distal stump components. Exp Neurol
1982;76:361–375.
The authors are grateful to Aline Naumann from the 17. Lundborg G, Dahlin LB, Danielsen NP, Hansson HA, Larsson K.
Institute of Epidemiology and Applied Biometrics of the Reorganization and orientation of regenerating nerve fibres, perineu-
rium, and epineurium in preformed mesothelial tubes—An experi-
University of Tuebingen for the consultation concerning mental study on the sciatic nerve of rats. J Neurosci Res 1981;6:
data analysis. They are also very grateful to Prof. Stefano 265–281.

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 Muscle-In-Vein Conduits for Nerve Repair 615

18. Tos P, Battiston B, Geuna S, Giacobini-Robecchi MG, Hill MA, nerve as a graft source in digital nerve reconstruction? Microsurgery
Lanzetta M, Owen ER. Tissue specificity in rat peripheral nerve 2014;34:367–371.
regeneration through combined skeletal muscle and vein conduit 24. Meek MF, Coert JH, Robinson PH. Poor results after nerve grafting
grafts. Microsurgery 2000;20:65–71. in the upper extremity: Quo vadis? Microsurgery 2005;25:396–402.
19. Battiston B, Geuna S, Ferrero M, Tos P. Nerve repair by means of
tubulization: Literature review and personal clinical experience com- 25. Steinberg D, Koman L. Factors affecting the results of peripheral
paring biological and synthetic conduits for sensory nerve repair. nerve repair. In: Gelberman RH, editor. Operative Nerve Repair and
Microsurgery 2005;25:258–267. Reconstruction. Philadelphia: Lippincott Williams and Wilkins 1991.
20. Battiston B, Tos P, Cushway TR, Geuna S. Nerve repair by means pp 349–364.
of vein filled with muscle grafts I. Clinical results. Microsurgery 26. Wong KH, Coert JH, Robinson PH, Meek MF. Comparison of
2000;20:32–36. assessment tools to score recovery of function after repair of trau-
21. Geuna S, Tos P, Battiston B, Giacobini-Robecchi MG. Bridging matic lesions of the median nerve. Scand J Plast Reconstr Surg
peripheral nerve defects with muscle-vein combined guides. Neurol Hand Surg 2006;40:219–224.
Res 2004;26:139–144.
22. Marcoccio I, Vigasio A. Muscle-in-vein nerve guide for secondary 27. Bell-Krotoski J, Weinstein S, Weinstein C. Testing sensibility,
reconstruction in digital nerve lesions. J Hand Surg Am 2010;35: including touch-pressure, two-point discrimination, point localiza-
1418–1426. tion, and vibration. J Hand Ther 1993;6:114–123.
23. Pilanci O, Ozel A, Basaran K, Celikdelen A, Berkoz O, Saydam FA, 28. Bell-Krotoski J. Advances in sensibility evaluation. Hand Clin 1991;
Kuvat SV. Is there a profit to use the lateral antebrachial cutaneous 7:527–546.

Microsurgery DOI 10.1002/micr