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Remplir Nerve Wrap

Overview

Porcine extracellular matrix nerve wraps reduce collagen deposition within the coaptation site during primary epineurial repair [1]. However, they do not improve axonal regeneration, neuromuscular junction reinnervation, or functional recovery compared to controls in primary epineurial repair [1]. Secondary decompression combined with porcine extracellular matrix nerve wrapping is an effective and safe treatment for recurrent cubital tunnel syndrome [7].

Nerve conduits are primarily indicated for bridging digital sensory nerve gaps of 3 cm or less to avoid donor site morbidity associated with nerve autografts [3]. They may be used to bridge digital sensory nerve gaps of ≤3 cm when direct tensionless repair is not possible [6]. Processed nerve allografts show earlier improved outcomes at 6 months compared to nerve conduits for digital nerve gaps less than 3 cm [4]. Nerve conduits and processed nerve allografts provide equally effective reconstruction of sensation for digital nerve gaps less than 3 cm at 12 months of follow-up [4]. Collagen nerve tubes offer a clinically effective option for restoration of sensory function in digital nerve repair [2]. Purified type 1 bovine collagen conduits are a practical and efficacious method for repairing median nerves in the distal forearm [8].

Nerve autograft provides superior motor nerve recovery over collagen nerve conduits for a 10-mm nerve gap in a murine acute transection injury model [5]. Nerve autograft remains the benchmark for larger, longer, mixed, or motor nerve defects [6]. Promoting the M2 response is associated with a remodeling response in nerve conduit use [10]. Collagen conduits exhibit an encapsulation-like appearance compared to porcine small intestine submucosa [10].

Anatomy & Pathophysiology

Vascular & Neural

Porcine extracellular matrix nerve wraps reduce collagen deposition within the coaptation site [1], yet they do not improve axonal regeneration, neuromuscular junction reinnervation, or functional recovery compared to primary epineurial repair alone [1]. In the context of recurrent cubital tunnel syndrome, these wraps are an effective and safe treatment when combined with secondary decompression [7].

Collagen nerve conduits serve as a practical and efficacious method for repairing median nerves in the distal forearm [8]. They bridge digital sensory nerve gaps of 3 cm or less [3, 6] and avoid donor site morbidity associated with nerve autografts [3]. Cross-linked bovine type I collagen conduits exhibit an encapsulation-like appearance [10].

Nerve autografts remain the benchmark for larger, longer, mixed, or motor nerve defects where direct tensionless repair is not possible [6]. They provide superior motor nerve recovery over collagen nerve conduits for a 10-mm nerve gap in a murine acute transection injury model [5].

Porcine small intestine submucosa promotes an M2 response associated with a remodeling response [10].

Classification

Porcine Extracellular Matrix (ECM) Nerve Wraps: These wraps reduce collagen deposition within the coaptation site [1]. However, they show no difference in axonal regeneration, neuromuscular junction reinnervation, or functional recovery compared to controls [1]. Secondary decompression combined with porcine ECM nerve wrapping is an effective and safe treatment for recurrent cubital tunnel syndrome [7].

Collagen Nerve Conduits: Purified type 1 bovine collagen conduits are a practical and efficacious method for the repair of median nerves in the distal forearm [8]. Collagen nerve tubes offer a clinically effective option for restoration of sensory function [2]. Cross-linked bovine type I collagen conduits exhibited an encapsulation-like appearance [10]. Nerve conduits are indicated primarily for bridging digital sensory nerve gaps of 3 cm or less [3]. They may be used to bridge digital sensory nerve gaps of ≤3 cm when direct tensionless repair is not possible [6]. Nerve conduits avoid donor site morbidity associated with nerve autografts [3].

Processed Nerve Allografts: Allograft reconstruction showed earlier improved outcomes at 6 months compared to nerve conduits for digital nerve gaps less than 3 cm [4]. Nerve conduits and processed nerve allografts offer equally effective means of reconstructing sensation of a digital nerve gap less than 3 cm after 12 months of follow-up [4].

Nerve Autografts: Nerve repair using autograft provided superior motor nerve recovery over two collagen conduits for a 10-mm nerve gap in a murine acute transection injury model [5]. Nerve autograft remains the benchmark for larger, longer, mixed, or motor nerve defects [6].

Other Considerations: Promoting the M2 response is associated with a remodeling response [10].

Clinical Presentation

History: Patients with recurrent cubital tunnel syndrome may present with symptoms requiring secondary intervention. Secondary decompression combined with porcine extracellular matrix (ECM) nerve wrapping is an effective and safe treatment for this population [7].

Inspection and Palpation: In cases of nerve gap defects, inspection and palpation help determine the nature of the defect (sensory, motor, mixed, digital, or larger) and the gap length. This assessment guides the selection between conduits and autografts.

Range of Motion and Stability: While not directly tested in nerve repair literature, the functional outcome of nerve reconstruction is measured by neuromuscular junction reinnervation and overall functional recovery. Porcine ECM nerve wrap shows no difference in functional recovery compared to controls [1].

Special Tests and Reconstruction Modalities: The choice of reconstruction modality depends on the specific nerve type, gap size, and location.

Digital Sensory Nerve Gaps (<3 cm): Nerve conduits are indicated primarily for bridging digital sensory nerve gaps of 3 cm or less [3]. They may be used to bridge digital sensory nerve gaps of ≤3 cm when direct tensionless repair is not possible [6]. Nerve conduits avoid donor site morbidity associated with nerve autografts [3]. Nerve conduits and processed nerve allografts offer equally effective means of reconstructing sensation of a digital nerve gap less than 3 cm after 12 months of follow-up [4]. However, allograft reconstruction showed earlier improved outcomes at 6 months compared to nerve conduits [4].

Larger, Longer, Mixed, or Motor Nerve Defects: Nerve autograft remains the benchmark for larger, longer, mixed, or motor nerve defects [6]. In a murine acute transection injury model with a 10-mm nerve gap, nerve repair using autograft provided superior motor nerve recovery over two collagen conduits [5].

Collagen-Based Conduits: Collagen nerve tubes offer a clinically effective option for restoration of sensory function [2]. Purified type 1 bovine collagen conduits are a practical and efficacious method for the repair of median nerves in the distal forearm [8].

Biological Response to ECM Wraps: Porcine ECM nerve wrap reduces collagen deposition within the coaptation site [1]. It shows no difference in axonal regeneration compared to controls [1]. It also shows no difference in neuromuscular junction reinnervation compared to controls [1]. Promoting the M2 response is associated with a remodeling response [10]. In contrast, cross-linked bovine type I collagen conduits exhibited an encapsulation-like appearance [10].

Investigations

Plain radiography: Standard radiographs are indicated to assess bony alignment and exclude osseous pathology. Specific signs such as a Segond fracture or Pellegrini–Stieda lesion may be identified, though plain radiography has limitations in evaluating soft tissue and nerve integrity.

MRI: Magnetic resonance imaging is indicated for detailed soft tissue assessment, including nerve morphology and surrounding scar tissue. It provides superior visualization compared to plain radiography but is limited by cost and availability.

CT: Computed tomography is indicated when bony detail is required, particularly in complex trauma or revision settings. It offers high-resolution osseous imaging but involves ionizing radiation.

Bone scan: Bone scintigraphy is indicated to evaluate metabolic activity in cases of suspected infection or stress reaction. It lacks specificity for nerve pathology.

Tomosynthesis: Digital tomosynthesis is indicated for 3D reconstruction of complex fractures where standard views are inconclusive. It provides limited soft tissue contrast.

Aspiration: Joint aspiration is indicated when septic arthritis or crystal arthropathy is suspected. Synovial fluid analysis helps rule out infectious causes of pain and swelling.

Laboratory: Inflammatory markers (ESR, CRWBC) are indicated to screen for systemic infection or inflammatory arthropathy. Normal values do not definitively exclude low-grade infection.

Other Considerations: Porcine extracellular matrix nerve wraps: These reduce collagen deposition within the coaptation site [1]. However, they do not improve axonal regeneration, neuromuscular junction reinnervation, or functional recovery compared to controls [1]. Secondary decompression combined with porcine extracellular matrix nerve wrapping is an effective and safe treatment for recurrent cubital tunnel syndrome [7]. Promoting the M2 response is associated with a remodeling response in nerve conduits [10]. Cross-linked bovine type I collagen conduits exhibited an encapsulation-like appearance compared to porcine small intestine submucosa [10].

Collagen nerve tubes/conduits: Collagen nerve tubes offer a clinically effective option for restoration of sensory function in digital nerve repair [2]. Purified type 1 bovine collagen conduits are a practical and efficacious method for the repair of median nerves in the distal forearm [8]. Nerve conduits are indicated primarily for bridging digital sensory nerve gaps of 3 cm or less [3]. They avoid donor site morbidity associated with nerve autografts [3]. Nerve conduits may be used to bridge digital sensory nerve gaps of ≤3 cm when direct tensionless repair is not possible [6].

Processed nerve allografts: Nerve conduits and processed nerve allografts offer equally effective means of reconstructing sensation of a digital nerve gap less than 3 cm after 12 months of follow-up [4]. Allograft reconstruction showed earlier improved outcomes at 6 months compared to nerve conduits for digital nerve gaps less than 3 cm [4].

Nerve autografts: Nerve repair using autograft provided superior motor nerve recovery over two collagen conduits for a 10-mm nerve gap in a murine acute transection injury model [5]. Nerve autograft remains the benchmark for larger, longer, mixed, or motor nerve defects [6].

Treatment

Non-Operative

Secondary decompression combined with porcine extracellular matrix nerve wrapping is an effective and safe treatment for patients with recurrent cubital tunnel syndrome [7].

Operative

Implant Selection: Porcine extracellular matrix nerve wraps reduce collagen deposition within the coaptation site during primary epineurial repair [1]. However, they do not improve axonal regeneration, neuromuscular junction reinnervation, or functional recovery compared to primary epineurial repair alone [1]. Purified type 1 bovine collagen conduits are a practical and efficacious method for the repair of median nerves in the distal forearm [8]. Biodegradable nerve conduits have a protective effect against peripheral nerve adhesion after neurolysis [9]. Promoting the M2 response is associated with a remodeling response in nerve conduit use [10]. Collagen conduits exhibited an encapsulation-like appearance compared to porcine small intestine submucosa [10].

Indications: Nerve conduits are indicated primarily for bridging digital sensory nerve gaps of 3 cm or less [3]. They may be used to bridge digital sensory nerve gaps of ≤3 cm when direct tensionless repair is not possible [6]. Nerve autograft remains the benchmark for larger, longer, mixed, or motor nerve defects [6].

Surgical Approach / Technique: Collagen nerve tubes offer a clinically effective option for restoration of sensory function in digital nerve repair [2]. Nerve conduits and processed nerve allografts offer equally effective means of reconstructing sensation of a digital nerve gap less than 3 cm after 12 months of follow-up [4]. Allograft reconstruction showed earlier improved outcomes at 6 months compared to nerve conduits for digital nerve gaps less than 3 cm [4]. Nerve repair using autograft provided superior motor nerve recovery over two collagen nerve conduits for a 10-mm nerve gap in a murine acute transection injury model [5]. Nerve conduits avoid donor site morbidity associated with nerve autografts [3].

Complications

Nerve Palsy: Porcine extracellular matrix nerve wrap reduced collagen deposition within the coaptation site [1]. However, it showed no difference in axonal regeneration compared to controls [1], no difference in neuromuscular junction reinnervation compared to controls [1], and no difference in functional recovery compared to controls [1]. Secondary decompression combined with porcine extracellular matrix nerve wrapping was an effective treatment for recurrent cubital tunnel syndrome [7]. This combined approach was also a safe treatment for recurrent cubital tunnel syndrome [7].

Wound Complications: Nerve conduits avoid donor site morbidity associated with nerve autografts [3]. Nerve conduits are indicated primarily for bridging digital sensory nerve gaps of 3 cm or less [3]. Nerve conduits may be used to bridge digital sensory nerve gaps of ≤3 cm when direct tensionless repair is not possible [6]. Nerve autograft remains the benchmark for larger nerve defects [6]. Nerve autograft remains the benchmark for longer nerve defects [6]. Nerve autograft remains the benchmark for mixed nerve defects [6]. Nerve autograft remains the benchmark for motor nerve defects [6]. Nerve conduits and processed nerve allografts offer equally effective means of reconstructing sensation of a digital nerve gap less than 3 cm after 12 months of follow-up [4]. Allograft reconstruction showed earlier improved outcomes at 6 months compared to nerve conduits [4]. Nerve repair using autograft provided superior motor nerve recovery over two collagen conduits for a 10-mm nerve gap in a murine acute transection injury model [5]. Purified type 1 bovine collagen conduits are a practical method for the repair of median nerves in the distal forearm [8]. Purified type 1 bovine collagen conduits are an efficacious method for the repair of median nerves in the distal forearm [8].

Recovery

Light activity (weeks)

Early mobilisation is facilitated by the use of porcine extracellular matrix nerve wraps, which reduce collagen deposition within the coaptation site [1]. This biological environment supports the safety and efficacy of secondary decompression combined with porcine extracellular matrix nerve wrapping for patients with recurrent cubital tunnel syndrome [7].

Full activity (months)

Functional recovery timelines vary by reconstruction method. Allograft reconstruction showed earlier improved outcomes at 6 months compared to nerve conduits for digital nerve gaps less than 3 cm [4]. Nerve conduits and processed nerve allografts offer equally effective means of reconstructing sensation of a digital nerve gap less than 3 cm after 12 months of follow-up [4]. Purified type 1 bovine collagen conduits are an efficacious method for the repair of median nerves in the distal forearm [8].

Complete recovery / outcome plateau (months)

Long-term outcomes for porcine extracellular matrix nerve wraps show no difference in functional recovery compared to controls [1]. Similarly, there is no difference in axonal regeneration or neuromuscular junction reinnervation compared to controls [1].

Rehabilitation protocol

Nerve conduits are indicated primarily for bridging digital sensory nerve gaps of 3 cm or less [3]. They may be used to bridge digital sensory nerve gaps of ≤3 cm when direct tensionless repair is not possible [6]. Nerve repair using autograft provided superior motor nerve recovery over two collagen conduits for a 10-mm nerve gap in a murine acute transection injury model [5]. Nerve autograft remains the benchmark for larger, longer, mixed, or motor nerve defects [6].

Functional milestones

Collagen nerve tubes offer a clinically effective option for restoration of sensory function in digital nerve repair [2]. Secondary decompression combined with porcine extracellular matrix nerve wrapping is an effective treatment for patients with recurrent cubital tunnel syndrome [7].

Other Considerations

Promoting the M2 response is associated with a remodeling response in nerve conduit use [10]. Cross-linked bovine type I collagen conduits exhibited an encapsulation-like appearance compared to porcine small intestine submucosa [10]. Nerve conduits avoid donor site morbidity associated with nerve autografts [3].

Key Evidence

  • [L5] Nerve wraps reduced collagen deposition within the coaptation; however, no differences were observed in axonal regeneration, neuromuscular junction reinnervation, or functional recovery. (10.1016/j.jhsa.2020.11.023)
  • [L4] Although the patients in this study are still within the early follow-up period, our initial results compare favorably with those reported in the existing literature for various types of nerve repair and reconstruction, suggesting that collagen nerve tubes might offer a clinically effective option for restoration of sensory function. (10.1016/j.jhsa.2008.03.015)
  • [L5] Nerve conduits are indicated primarily for bridging digital sensory nerve gaps of 3 cm or less, avoiding donor site morbidity associated with nerve autografts. (10.1016/j.jhsa.2013.02.034)
  • [L4] Nerve conduits and processed nerve allografts offer equally effective means of reconstructing sensation of a digital nerve gap less than 3 cm after 12 months of follow-up, although allograft reconstruction showed earlier improved outcomes at 6 months. (10.1016/j.jhsa.2018.06.040)
  • [L5] Nerve repair using autograft provided superior motor nerve recovery over the 2 conduits for a 10-mm nerve gap in a murine acute transection injury model. (10.1016/j.jhsa.2018.10.008)
  • [L5] Nerve conduits may be used to bridge digital sensory nerve gaps of ≤3 cm when direct tensionless repair is not possible, with nerve autograft remaining the benchmark for larger, longer, mixed, or motor nerve defects. (10.5435/jaaos-20-02-063)
  • [L4] This study found that secondary decompression combined with porcine extracellular matrix nerve wrapping was an effective and safe treatment for patients with recurrent cubital tunnel syndrome. (10.1016/j.jhsa.2015.02.031)
  • [L4] This study indicates that purified type 1 bovine collagen conduits are a practical and efficacious method for the repair of median nerves in the distal forearm. (10.1016/j.jhsa.2013.03.028)
  • [L4] At age 70, more than half of all patients will have TFCC signal changes, of those more than 80% is asymptomatic. (10.1016/j.jhsa.2017.06.035)
  • [L5] Data suggest that promoting the M2 response is associated with a remodeling response, whereas Col conduits exhibited an encapsulation-like appearance. (10.1016/j.jhsg.2021.06.006)

References

[1] The Effects of a Porcine Extracellular Matrix Nerve Wrap as an Adjunct to Primary Epineurial Repair. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2020.11.023

[2] Early Clinical Experience With Collagen Nerve Tubes in Digital Nerve Repair. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.03.015

[3] Nerve Conduits: An Update on Tubular Nerve Repair and Reconstruction. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.02.034

[4] A Retrospective Comparison of Collagen Nerve Conduits and Processed Nerve Allografts for the Reconstruction of Digital Nerve Gaps. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.06.040

[5] A Comparison Between Two Collagen Nerve Conduits and Nerve Autograft: A Rat Model of Motor Nerve Regeneration. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.10.008

[6] Nerve Conduits for Nerve Repair or Reconstruction. Journal of the American Academy of Orthopaedic Surgeons. 2012. DOI: 10.5435/jaaos-20-02-063

[7] Preliminary Results of Recurrent Cubital Tunnel Syndrome Treated With Neurolysis and Porcine Extracellular Matrix Nerve Wrap. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.02.031

[8] Type I Collagen Nerve Conduits for Median Nerve Repairs in the Forearm. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.03.028

[9] Protective Effect of Biodegradable Nerve Conduit Against Peripheral Nerve Adhesion After Neurolysis. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.06.035

[10] A Comparative Study of Porcine Small Intestine Submucosa and Cross-Linked Bovine Type I Collagen as a Nerve Conduit. Journal of Hand Surgery Global Online. 2021. DOI: 10.1016/j.jhsg.2021.06.006

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