Utilization of A Processed Nerve Allograft For Functional Recovery of Military-Related Injuries
Bauback Safa, MD, MBA, FACS; Brian Parrett, MD; Dmitry Tuder, MD; Mickey Cho, MD; Wesley Thayer, MD, PhD; Renata V. Weber, MD; Brian Rinker, MD; Jozef Zoldos, MD; Greg Buncke, MD
The Buncke Clinic, San Francisco, CA, USA
Introduction: Military personnel often suffer extensive peripheral nerve damage to the upper extremities due to combat-related injuries. These traumatic injuries often require very complex reconstructions. While the gold standard in peripheral nerve repair remains the autograft, utilizing processed nerve allograft provides an alternative option when there is limited availability of autologous nerve tissue or when complications of a secondary surgical procedure must be avoided. Here we report outcomes of nerve reconstructions after military combat and civilian"combat-like" injuries from a multicenter registry designed to capture data on the use of processed nerve allografts (Avance® Nerve Graft, AxoGen, Inc.). Methods: The registry, inclusive of 18 centers with 36 surgeons, was designed to continuously monitor peripheral nerve injury, repair, safety and outcomes data using standardized case report forms entered into a centralized database. From this database, injuries from military institutions and analogous civilian injuries were identified and analyzed. Centers followed their own standard of care for treatment and follow-up. Outcome measures were reviewed and reported. Meaningful recovery was defined by the MRCC scale at S3-S4 for sensory and M3-M5 for motor. Results: There were 45 subjects with 50 nerve repairs identified in the database. Sufficient follow-up data was reported for 17 nerve repairs (8 sensory, 6 mixed, and 3 motor) in 16 subjects (15 males and 1 female). There were seven gunshot wounds, five blasts, four crushes, and one blunt trauma. Concomitant repairs included vascular, tendon, muscle, and bony reconstructions. The average ± standard deviation (minimum, maximum) age for these subjects was 36 ± 14 (18, 55) years. The average gap length was 26 ± 15 (8, 50) mm and the median time waited until repair was 11 days. Quantitative outcomes data was reported on 15 of the 17 repairs. Meaningful recovery was reported in 73% of these complex repairs. There were no reported graft related adverse events. Conclusion: In this study, processed nerve allografts performed well for this application. Due to their complex nature, outcomes were slightly lower than those seen in the overall RANGER registry, with 73% vs. the 87% reporting meaningful recovery. These outcomes compared favorably to combat related nerve reconstructions reported in the literature for nerve autograft. This registry is currently in open enrollment; additional data provided by participating military institutions will allow for the continued analysis of processed nerve allografts for the reconstruction of peripheral nerve defects after combat related injuries.
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