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Sensory and functional morbidity following sural nerve harvest in paediatric patients
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Journal of Plastic, Reconstructive & Aesthetic Surgery (2018) 000, 1–6
Sensory and functional morbidity following sural nerve harvest in paediatric ✰ ✰✰ ✰✰✰ patients , , Joseph Catapano, MD, PhD a,b, Mark Shafarenko b, Emily S. Ho, BSc, OT Reg. (Ont.), MEd a, Ronald M. Zuker, MD, FRCSC, FACS, FAAP a,b, Gregory H. Borschel, MD, FRCSC, FACS a,b,∗ a
Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, and University of Toronto, Toronto, Ontario, Canada b Department of Surgery, University of Toronto, Toronto, Ontario, Canada Received 20 March 2018; accepted 28 July 2018 Available online xxx
KEYWORDS Sural nerve harvest; Sensory loss; Functional outcome
SUMMARY Background: The sural nerve is a common donor site for nerve reconstruction. The only study describing outcomes in paediatric patients was following bilateral sural nerve harvest before the age of 1 year. Bilateral nerve harvest at such a young age may limit patients’ ability to perceive a sensory difference. The objective of this study was to understand the sensory and functional deficit after unilateral sural nerve harvest in paediatric patients. Methods: A prospective case series was performed in children (age 6-18 years) following unilateral sural nerve harvest. The contralateral foot was used as a control. Sensory Threshold Evaluation was performed by Weinstein Enhanced Sensory Test (WEST) – Foot, and a Functional Sensory and Pain Questionnaire was administered. Sural nerve harvest was performed by a minimally invasive technique using a nerve stripper. Results: Twenty-eight feet of 14 patients that underwent unilateral sural nerve harvest were assessed. As a group, the 14 feet with sural nerve harvest demonstrated significantly higher thresholds in the four areas tested (p <0.05), thus identifying objective sensory loss at each location. The location of sensory loss in each patient was variable, with heavier sensory thresholds detected in 69.6% of areas tested than those in the corresponding location in the contralateral foot. Greater sensory loss was detected at the proximal lateral foot than at the
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The article has not been presented at a meeting. The authors did not receive any financial support from any public or private sources. ✰✰✰ The authors have no financial or proprietary interest in a product, method or material described herein. ∗ Correspondence: Gregory Borschel, Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada. Telephone: 1-416-813-7654 Ext. 228197, Fax: 1-416-813-6637 ✰✰
https://doi.org/10.1016/j.bjps.2018.07.020 1748-6815/© 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article as: J. Catapano et al., Sensory and functional morbidity following sural nerve harvest in paediatric patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2018), https://doi.org/10.1016/j.bjps.2018.07.020
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J. Catapano et al. distal lateral foot. Responses to the questionnaire revealed that only one patient perceived a sensory loss that affected their function. Conclusions: Unilateral sural nerve harvest in paediatric patients resulted in measurable sensory loss. Despite loss of innervation, only two patients reported intermittent dysaesthesia or cold sensitivity, and the majority of the patients reported no functional deficit. © 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
INTRODUCTION Autologous nerve grafts remain the gold standard for the reconstruction of peripheral nerve defects. The sural nerve is a preferred donor site because it is purely sensory, thereby resulting in minimal morbidity from loss of innervation to the distal posterior lateral third of the lower leg, the lateral aspect of the heel and the lateral foot.1,2 Families frequently inquire about the donor site morbidity of sural nerve harvest, but very little is known on this subject in children. Several studies examined the outcomes of sural nerve harvest;3–12 however, only one of these studies has specifically investigated the outcome in paediatric patients.9 The results of these studies concluded that while most patients had objective sensory loss, only 7% had no detectable sensation at any location of the lateral foot and no patients reported a functional deficit or concerns regarding sensation of their feet.9 Although results of these studies suggest limited morbidity after sural nerve harvest in paediatric patients, the patient population consisted exclusively of patients who underwent bilateral sural nerve harvest during the first year of life. Bilateral nerve harvest at such a young age may limit the patients’ ability to perceive a deficit and therefore may not reflect the outcome of sural nerve harvest in older paediatric patients with unilateral sural nerve harvest. The objective of this study was to understand the sensory and functional deficit after unilateral sural nerve harvest in paediatric patients.
PATIENTS AND METHODS Study Population This study was approved by the Research Ethics Board at the Hospital for Sick Children. Informed consent was obtained from both patients and their families. Assent was obtained when appropriate. A prospective case series was performed to evaluate the sensory outcome of children who had sural nerve harvest for cross-face nerve grafting to a gracilis muscle flap for facial reanimation surgery. The contralateral foot was used as a control. Patients were recruited from the SickKids Facial Palsy Clinic during their routine outpatient visit and from an existing database of patients with facial palsy. Only patients 6 to 18 years of age with unilateral sural nerve harvest performed by one of the senior authors (GB or RZ) were included. Only patients older than 6 years of age were included, as sensory evaluation has been shown to be reliable past this age.13 Exclusion criteria included patients with cognitive or developmental delay, patients less
Fig. 1 Locations of sensory testing on the lateral foot. Four locations on the lateral foot, which is variably innervated by the sural nerve, were tested. The midpoint of the vertical height between the posterior border of the lateral malleolus and the sole of the foot (A) was used as a height reference to draw a horizontal line from the heel to D5. The length of the horizontal line (B) was then divided into five sections to determine four points for sensory testing (shown as red stars). The four points were labelled from A to D as shown in red letters.
than 6 months after sural nerve harvest or patients less than 3 months after lower extremity injury. The contralateral unaffected foot was used as a control.
Outcome Measures The study consisted of two assessments: (i) Sensory Threshold Evaluation using Weinstein Enhanced Sensory Test (WEST) – Foot (Touch-Test Sensory Evaluator; North Coast Medical, Inc., San Jose, California), and (ii) Functional Sensory and Pain Questionnaire. The Semmes–Weinstein Monofilament WEST assessment has been recognised as the most reliable and valid test for assessing sensory thresholds.13,14 Testing of both feet was performed during a clinic visit. The test was first explained twice on the patient’s hands with their eyes open. Following the explanation, the child and family were given the opportunity to ask any questions, and once all questions were satisfied, sensory evaluation was performed on the unaffected foot, then on the affected foot. Sensory testing was performed at four predetermined locations on the lateral aspect of the child’s foot as described by Lapid et al9 (Figure 1). The midpoint of the vertical height between the posterior border of the lateral malleolus and the sole of the foot (A) was used as a height reference to draw a horizontal line from the heel to D5. The length of the horizontal line (B) was then divided into five sections to determine four points for sensory testing (shown as
Please cite this article as: J. Catapano et al., Sensory and functional morbidity following sural nerve harvest in paediatric patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2018), https://doi.org/10.1016/j.bjps.2018.07.020
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3 red stars). Testing was performed with five monofilaments (with weights of 0.5 g, 2.0 g, 10.0 g, 50.0 g and 200 g). Each site was tested three times with the child’s vision occluded. One correct response out of three trials was considered a sensory threshold. Testing commenced with the 2.0 g monofilament first. For sites that achieved a sensory threshold for the 2.0 g monofilament, the examiner continued the examination with the lightest monofilament of 0.5 g to see if a greater sensory threshold could be achieved. The site(s) that failed to achieve a sensory threshold for the 2.0 g monofilament were then tested sequentially with the 10.0 g, 50.0 g and 200 g monofilaments. Once a threshold was achieved, the corresponding monofilament value was recorded. One correct response out of three trials was again considered a sensory threshold. Sensory thresholds were recorded on the Sensory Assessment Form (Supplemental Figure 1). A sensory function and pain questionnaire was administered to study participants after the completion of the Semmes–Weinstein assessment (Supplemental Figure 2). The functional questionnaire assessed sensation, numbness, hyperalgesia, cold intolerance, skin changes and level of activity. Descriptive demographic information including patient gender, age, age at surgical procedure and intraoperative or perioperative complications were also recorded.
Surgical Technique In all patients, sural nerve harvest was performed by a minimally invasive technique to isolate and harvest the tibial component of the sural nerve using a nerve stripper by making only two to three small incisions (Figure 2A). The tibial component of the sural nerve is identified in the popliteal fossa between the two heads of the gastrocnemius muscle (Figure 2B). The nerve stripper is placed around the proximal nerve and advanced distally to dissect the nerve from the surrounding connective tissue (Figure 2C). If advancement is stalled at any location, a small incision is made at that level to dissect the nerve under direct visualisation. The proximal nerve is pulled through the incision, and the nerve stripper is again placed around the nerve and advanced distally (Figure 2D). Once the nerve stripper has advanced to the level of the lateral malleolus, a final incision is made to transect the nerve distally and the entire tibial component to the sural nerve is removed through the distal incision (Figure 2E).
Statistical Analysis Descriptive analysis was used to analyse the minimum sensory threshold in cases (affected foot) and controls (unaffected foot), considering only the mean and median values. Distribution of sensory thresholds for all groups was compared by using the Fisher’s exact test. Thresholds at the numbest point of the foot (highest threshold) were compared between the two groups by using the Wilcoxon paired test. Descriptive statistics was used to analyse the questionnaires.
Fig. 2 Harvest of the tibial contribution to the sural nerve. (A) Planned incisions are first marked at the level of the popliteal fossa and the second posterior to the lateral malleolus. A third incision is planned between the two if necessary to release the nerve. (B) The tibial contribution to the sural nerve the medial sural cutaneous nerve (MSCN), is first identified in the popliteal fossa between the two heads of the gastrocnemius muscle. This is transected proximally and dissected under direct visualisation. (C) A nerve stripper in then placed around the proximal nerve and advanced distally. (D) If resistance is encountered when advancing the nerve stripper, a small incision is made to expose the MSCN to further dissect it under direct visualisation. Once the resistance has been released, the proximal nerve is extracted through the incision and the nerve stripper is again advanced distally. (E) Once the lateral malleolus has been reached, a final incision is made to identify the MSCN. The nerve is extracted through the wound and transected distally.
RESULTS Twenty-eight feet of 14 patients that underwent unilateral sural nerve harvest were assessed. The average age at the time of sural nerve harvest was 10.7 years (±4.2), and the average time elapsed between surgery and assessment was 1.84 years (±1.43). Nine (64%) patients were male, and five (35.7%) patients were female. The right sural nerve was harvested in nine (64.3%) patients, and the left sural nerve was harvested in rest of the patients. Objective sensory testing, as measured with WEST–Foot, revealed that in the controls (unaffected feet), patients could sense the two most sensitive monofilaments in each of the four tested locations along the lateral foot. The threshold achieved was from the most sensitive filament (0.5 g) in 96.4 % of areas tested (Table 1). By contrast, in the cases (affected feet), a comparatively high sensory thresholds were detected in 69.6% of areas tested. All but one
Please cite this article as: J. Catapano et al., Sensory and functional morbidity following sural nerve harvest in paediatric patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2018), https://doi.org/10.1016/j.bjps.2018.07.020
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4 Table 1
J. Catapano et al. Target Thresholds.
Target Threshold (Semmes–Weinstein Filament Number)
Patient Targets (n)
Control Targets (n)
0.5 g 2.0 g 10.0 g 50.0 g 200 g Absence of sensation Total
16 (28.6%) 27 (48.2%) 5 (8.9%) 7 (12.5%) 1 (1.8%)
54 (96.4%) 2 (3.6%)
56 (100%)
56 (100%)
Table 2
Sensory Threshold by Site.
D C B A
Normal (Protective Sensation)
Decreased Sensation
0.5 g
2.0 g
10.0 g
50.0 g
200 g
5 1 3 7
3 9 10 5
2 2 1
4 2 1 -
1
patient (92.9%) demonstrated at least one area that had a sensory threshold higher than the control foot. Greater sensory loss was detected at the proximal lateral foot than at the distal lateral foot (Table 2). Sensory thresholds at areas A, B, C and D were compared between the affected and unaffected feet. Feet with sural nerve harvest demonstrated significantly higher thresholds at areas D, C, B (p <0.001) and A (p = 0.039), thereby identifying objective sensory loss at each location. Responses to the questionnaire revealed that few patients perceived a sensory loss that affected their function. Fifty per cent of patients reported that they never perceived numbness in their foot, 28.5% reported occasional pain in their feet, 14.2% reported dysaesthesia and 21.4% sometimes reported cold hypersensitivity. One patient was excluded who strongly agreed that he was unable to perform activities similar to those performed by other children owing to the pain sensation in his foot. Although neither he nor his parents perceived any change or difficulty in walking, the patient reported difficulty participating in sports with his classmates, as he had calf pain while running. His parents expressed that they did not think this was a significant concern, as the patient was not active in sports before surgery. This patient was a 16-year-old male who had undergone sural nerve harvest 1 year earlier. The pain was described as sharp, intermittent and in the location of the mid-calf. He first noticed the pain 2 weeks post-operation, and there had been minimal resolution in the following years. The pain was not reproducible on physical examination, and a neuroma could not be localised. Neither he nor his parents felt that he required a referral to a pain service or medication to manage his pain.
DISCUSSION This study adds to the existing literature by describing the outcomes of unilateral sural nerve harvest in paediatric patients. Our data suggest that most paediatric patients
experience a detectable loss of sensation on the lateral foot. Despite objective sensory loss, patients perceived minimal effect in their lower extremity function. Subjective numbness of the affected foot was not described in half of the patients studied. However, a quarter of patients reported occasional pain, dysaesthesia or cold hypersensitivity. Only one patient (7%) felt that he was unable to perform activities similar to those of other children owing to the pain sensation in his foot. The objective sensory loss demonstrated in this study mirrors that noted in the study of bilateral sural nerve harvest in paediatric patients by Lapid et al. (2007). Using a step-wise technique of sural nerve harvest, they found that 86% of paediatric patients demonstrated a sensory deficit and 7% demonstrated no detectable sensation at any location of the lateral foot.9 Our study showed a similar proportion of patients with a detectable sensory deficit (93 %); however, there were no patients who had complete lack of sensation in our cohort. It is important to note that Semmes– Weinstein monofilaments used in our study were calibrated for the foot. The monofilaments used in the study by Lapid et al. (2007) were calibrated for the hand, thus using thinner monofilaments representing lighter sensory thresholds. Accounting for these differences, a similar number of patients in the two studies demonstrate a minimum of protective sensation (i.e. 2.0 g): 71.43% of areas tested in the study by Lapid et al. and 76.80% of areas tested in this study. Although these results demonstrate that the objective sensory outcomes were similar, important differences were identified through the functional questionnaire. In the paper by Lapid et al. (2007), only one patient complained of tingling sensation in one foot, thus representing a sensory concern in only 3.5% of feet following sural nerve harvest. By contrast, after unilateral harvest, 50% of patients in this study reported numbness of their feet, with 28.6% of patients describing some intermittent pain, 14.2% with intermittent hyperalgesia and 21.4% reported cold insensitivity. One patient in this study (7.14%) felt that he was unable to participate in activities same as those participated by
Please cite this article as: J. Catapano et al., Sensory and functional morbidity following sural nerve harvest in paediatric patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2018), https://doi.org/10.1016/j.bjps.2018.07.020
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other children because of the pain sensation in his foot. The patient, a 16-year-old male, specified that he had difficulty participating in sports at school because of pain in his mid-calf, which occurred when running but not walking. However, as described previously, his parents expressed that this was a minor contributor in his difficulty participating in sports, as the patient was not active in sports preoperatively and had pre-existing obesity. It is difficult to ascertain the relative contribution of calf pain to his concern, but it is important that from the patient’s perspective he felt that he was more limited after the sural nerve harvest. These differences may be attributable to differences in patient population as the previous study by Lapid et al. described outcomes of bilateral sural nerve harvest performed in infants (<1 year), whereas our paper investigated outcomes in older paediatric patients (age 10.7 ±4.2 years) after unilateral sural nerve harvest. The presence of an unaffected contralateral limb for comparison as well as surgery at an older age, where patients are better able to perceive changes after surgery, may explain these differences. Younger children may also possess greater capacity to repopulate a denervated dermatome from adjacent axons. Furthermore, our paper describes earlier outcomes after sural nerve harvest as we assessed outcomes 1.84 years (±1.43) after surgery, whereas Lapid et al. assessed outcomes an average of 8 to 9 years after surgery. Lapid et al. also used a different technique of sural nerve harvest, which is harvesting the sural nerve distal to proximal with several step-wise incisions. The subjective outcomes identified by the questionnaire more closely resemble outcomes in adult patients described by other groups.3–8 , 10–12 Pain after sural nerve harvest is variable, with studies reporting minimal pain after sural nerve harvest3,15 and others demonstrating pain after surgery as high as 73%,11 reducing to 4-17%7,11 1 year after surgery. Cold insensitivity is also variable from 0 to 34% of patients.7,11 , 15 In one study with 41 patients of average age 23 years, Hallgren et al. found that 37% of patients experienced discomfort in their leg and 29% demonstrated cold intolerance. This was similar to the incidence of both these outcomes in this study: 28.5% and 21.4%, respectively. Staniforth and Fisher (1978) demonstrated a higher incidence of leg discomfort after sural nerve harvest (40%); however, they did not distinguish between pain and cold sensitivity, which may explain the high incidence.16 Several studies do agree that pain and cold sensitivity experienced after sural nerve harvest decline in frequency and intensity with time, with a small number of patients experiencing minimal functional impairment after sural nerve harvest.7,11 , 15 This has been variably described and reported as minimal impairment in 17% of patients7 and 15% of patients with affected activities of daily living11 ; Butler et al. demonstrated minimal functional deficit using the lower extremity functional scale, with patients averaging a score of 78.74 (80 representing no impairment)3 . These results are consistent with the findings in this study, and differences may be partially attributed to follow-up time, patient populations and surgical technique. Our study was not sufficiently powered to determine whether outcomes improve with time; however, this can be investigated in the future with a follow-up study with the same patients.
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5 Several surgical techniques for sural nerve harvest have been described, including a single longitudinal incision,17 multiple smaller incisions18 , endoscopic techniques19–21 and techniques using a nerve stripper8,22 , 23 . These techniques result in variable injury to the tissues surrounding the sural nerve and the sural nerve itself, which may affect outcomes. Our surgical method uses a specially designed nervestripping device (as shown in Figure 2) to dissect the sural nerve by making only two or three small incisions. Furthermore, while several techniques identify the nerve distally at the level of the ankle posterior to the lateral malleolus, we identify the tibial contribution to the sural nerve proximally between the two heads of the gastrocnemius muscle. The contribution to the sural nerve from the tibial and peroneal nerves is variable.24,25 Most commonly, the sural nerve is composed from the union of the medial sural cutaneous nerve (MSCN) arising from the tibial nerve and a branch from common peroneal nerve, either the peroneal communicating branch or the lateral sural cutaneous nerve (LSCN).24 We identify the MSCN proximally in an effort to spare the peroneal contribution to the sural nerve, thereby minimising sensory loss. Although the functional outcomes in our patients appear to be similar to those in adult patients by using various techniques, variation in outcomes metrics makes it impossible to distinguish any differences in measurable objective sensory loss. In adults, subjective measurements have demonstrated that sensory loss is highly variable after sural nerve harvest, with average areas of sensory loss measuring as large as 45.4 cm2 to 52.6 cm2 , whereas some patients demonstrate almost no measurable sensory loss.3,10 These studies used subjective measures to assess sensory loss, including questionnaires and visual analogue scales (VAS)5–7 , one of which was performed through a telephone questionnaire26 . The only adult study that did measure objective sensory loss followed this with a binary outcome metric that is not quantifiable, thus limiting direct comparison with this study.17 The only previous study to use a measurable objective outcome metric to assess sensory loss of sural nerve harvest was Lapid et al. (2007); however, the important differences in patient population make it impossible to directly compare sural nerve harvest techniques. Further investigation of whether isolated harvest of the MSCN improves sensory outcomes requires a randomised controlled study with agematched controls.
CONCLUSIONS Unilateral sural nerve harvest in paediatric patients results in measurable sensory loss along the lateral aspect of the affected foot. Despite objective loss of innervation, most patients demonstrate minimal morbidity, with half of the patients reporting no subjective appreciation of sensory loss. A small number of patients do report intermittent dysaesthesia and cold sensitivity of the lateral foot after sural nerve harvest. Functional outcomes after unilateral sural nerve harvest in older paediatric patients more closely resemble outcomes of adult studies likely because of the patient age and population in the previous paediatric sural nerve study. This study is necessary to better inform patients and families regarding the expected outcome of unilateral sural
Please cite this article as: J. Catapano et al., Sensory and functional morbidity following sural nerve harvest in paediatric patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2018), https://doi.org/10.1016/j.bjps.2018.07.020
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6 nerve harvest for the reconstruction of peripheral nerve defects.
Supplementary materials Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.bjps.2018.07. 020.
References 1. Sekiya SI, Suzuki R, Miyawaki M, Chiba S, Kumaki K. Formation and distribution of the sural nerve based on nerve fascicle and nerve fiber analyses. Anat Sci Int 2006;81(2):84–91. doi:10.1111/j.1447-073X.2006.00135.x. 2. Vuksanovic-Bozaric A, Radunovic M, Radojevic N, Abramovic M. The bilateral anatomical variation of the sural nerve and a review of relevant literature. Anat Sci Int 2014;89(1):57–61. doi:10.1007/s12565- 013- 0195- 9. 3. Butler DP, Johal KS, Wicks CE, Grobbelaar AO. Objective sensory and functional outcomes at the donor site following endoscopic-assisted sural nerve harvest. J Plast Reconstr Aesthetic Surg 2017;70(5):659–65. doi:10.1016/j.bjps.2017.02. 022. 4. Aszmann OC, Muse V, Dellon AL. Evidence in support of collateral sprouting after sensory nerve resection. Ann Plast Surg 1996;37(5):520–5. doi:10.1097/00000637- 199611000- 00011. 5. Ehretsman RL, Novak CB, Mackinnon SE. Subjective recovery of nerve graft donor site. Ann Plast Surg 1999;43(6):606–12. 6. Hallgren A, Björkman A, Chemnitz A, Dahlin LB. Subjective outcome related to donor site morbidity after sural nerve graft harvesting: a survey in 41 patients. BMC Surg 2013;13:39. doi:10.1186/1471- 2482- 13- 39. 7. IJpma FFa, Nicolai J-Pa, Meek MF. Sural nerve donor-site morbidity: thirty-four years of follow-up. Ann Plast Surg 2006;57(4):391–5. doi:10.1097/01.sap.0000221963.66229.b6. 8. Kim ED, Seo JT. Minimally invasive technique for sural nerve harvesting: Technical description and follow-up. Urology 2001;57(5):921–4. doi:10.1016/S0090- 4295(01)00908- 6. 9. Lapid O, Ho ES, Goia C, Clarke HM. Evaluation of the sensory deficit after sural nerve harvesting in pediatric patients. Plast Reconstr Surg 2007;119(2):670–4. doi:10.1097/01.prs. 0000246521.83239.cd. 10. Martins RS, Barbosa Ra, Siqueira MG, et al. Morbidity following sural nerve harvesting: a prospective study. Clin Neurol Neurosurg 2012;114(8):1149–52. doi:10.1016/j.clineuro.2012. 02.045. 11. Miloro M, Stoner Ja. Subjective outcomes following sural nerve harvest. J Oral Maxillofac Surg 2005;63(8):1150–4. doi:10. 1016/j.joms.2005.04.031.
[m6+;September 25, 2018;14:57]
J. Catapano et al. 12. Ng SS, Kwan MK, Ahmad TS. Quantitative and qualitative evaluation of sural nerve graft donor site. Med J Malaysia 2006;61(Suppl B):13–17. 13. Thibault A, Forget R, Lambert J. Evaluation of cutaneous and proprioceptive sensation in children: a reliability study. Dev Med Child Neurol 1994;36(9):796–812. 14. Rosén B, Lundborg G. A model instrument for the documentation of outcome after nerve repair. J Hand Surg Am 2000;25(3):535–43. doi:10.1053/jhsu.2000.6458. 15. Ehretsman R, Novak C, Mackinnon S. Subjective recovery of nerve graft donor site. Ann Plast 1999;43:606–12. http:// journals.lww.com/annalsplasticsurgery/Abstract/1999/12000/ Subjective_Recovery_of_Nerve_Graft_Donor_Site.5.aspx Accessed June 4, 2014. 16. Staniforth P, Fisher TR. The effects of sural nerve excision in autogenous nerve grafting. Hand 1978;10(2):187–90. doi:10. 1016/S0072- 968X(78)80012- 6. 17. Martins RS, Barbosa RA, Siqueira MG, et al. Morbidity following sural nerve harvesting: A prospective study. Clin Neurol Neurosurg 2012;114(8):1149–52. doi:10.1016/j.clineuro.2012. 02.045. 18. Chang DW. Minimal incision technique for sural nerve graft harvest: Experience with 61 patients. J Reconstr Microsurg 2002;18(8):671–5. doi:10.1055/s- 2002- 36498. 19. Koh KS, Park S. Endoscopic harvest of sural nerve graft with balloon dissection. Plast Reconstr Surg 1998;101(3):810–12. doi:10.1097/00006534- 199803000- 00035. 20. Capek L, Clarke HM, Zuker RM. Endoscopic sural nerve harvest in the pediatric patient. Plast Reconstr Surg 1996;98(5):884–8. http://www.ncbi.nlm.nih.gov/pubmed/8823033. 21. Spinks TJ, Adelson PD. Pediatric sural nerve harvest: a fully endoscopic technique. Neurosurgery 2009;64(5 Suppl 2) 360-34. doi:10.1227/01.NEU.0000343740.76951.33. 22. Jaroszynski G. Harvesting of the sural nerve with a tendon stripper. 1997. 23. Hankin FM, Jaeger SH, Beddings A. Autogenous sural nerve grafts: a harvesting technique. Orthopedics 1985;8(9):1160– 1. http://www.ncbi.nlm.nih.gov/pubmed/3832060 Accessed June 20, 2017. 24. Riedl O, Frey M. Anatomy of the sural nerve: cadaver study and literature review. Plast Reconstr Surg 2013;131(4):802–10. doi:10.1097/PRS.0b013e3182818cd4. 25. Solomon LB, Ferris L, Tedman R, Henneberg M. Surgical anatomy of the sural and superficial fibular nerves with an emphasis on the approach to the lateral malleolus. J Anat 2001;199(Pt 6):717–23. doi:10.1046/j.1469-7580.2001. 19960717.x. 26. Miloro M, Stoner JA. Subjective outcomes following sural nerve harvest. J Oral Maxillofac Surg 2005;63(8):1150–4. doi:10. 1016/j.joms.2005.04.031.
Please cite this article as: J. Catapano et al., Sensory and functional morbidity following sural nerve harvest in paediatric patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2018), https://doi.org/10.1016/j.bjps.2018.07.020
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Journal of Plastic, Reconstructive & Aesthetic Surgery (2018) 000, 1–6
Sensory and functional morbidity following sural nerve harvest in paediatric ✰ ✰✰ ✰✰✰ patients , , Joseph Catapano, MD, PhD a,b, Mark Shafarenko b, Emily S. Ho, BSc, OT Reg. (Ont.), MEd a, Ronald M. Zuker, MD, FRCSC, FACS, FAAP a,b, Gregory H. Borschel, MD, FRCSC, FACS a,b,∗ a
Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, and University of Toronto, Toronto, Ontario, Canada b Department of Surgery, University of Toronto, Toronto, Ontario, Canada Received 20 March 2018; accepted 28 July 2018 Available online xxx
KEYWORDS Sural nerve harvest; Sensory loss; Functional outcome
SUMMARY Background: The sural nerve is a common donor site for nerve reconstruction. The only study describing outcomes in paediatric patients was following bilateral sural nerve harvest before the age of 1 year. Bilateral nerve harvest at such a young age may limit patients’ ability to perceive a sensory difference. The objective of this study was to understand the sensory and functional deficit after unilateral sural nerve harvest in paediatric patients. Methods: A prospective case series was performed in children (age 6-18 years) following unilateral sural nerve harvest. The contralateral foot was used as a control. Sensory Threshold Evaluation was performed by Weinstein Enhanced Sensory Test (WEST) – Foot, and a Functional Sensory and Pain Questionnaire was administered. Sural nerve harvest was performed by a minimally invasive technique using a nerve stripper. Results: Twenty-eight feet of 14 patients that underwent unilateral sural nerve harvest were assessed. As a group, the 14 feet with sural nerve harvest demonstrated significantly higher thresholds in the four areas tested (p <0.05), thus identifying objective sensory loss at each location. The location of sensory loss in each patient was variable, with heavier sensory thresholds detected in 69.6% of areas tested than those in the corresponding location in the contralateral foot. Greater sensory loss was detected at the proximal lateral foot than at the
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The article has not been presented at a meeting. The authors did not receive any financial support from any public or private sources. ✰✰✰ The authors have no financial or proprietary interest in a product, method or material described herein. ∗ Correspondence: Gregory Borschel, Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada. Telephone: 1-416-813-7654 Ext. 228197, Fax: 1-416-813-6637 ✰✰
https://doi.org/10.1016/j.bjps.2018.07.020 1748-6815/© 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article as: J. Catapano et al., Sensory and functional morbidity following sural nerve harvest in paediatric patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2018), https://doi.org/10.1016/j.bjps.2018.07.020
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J. Catapano et al. distal lateral foot. Responses to the questionnaire revealed that only one patient perceived a sensory loss that affected their function. Conclusions: Unilateral sural nerve harvest in paediatric patients resulted in measurable sensory loss. Despite loss of innervation, only two patients reported intermittent dysaesthesia or cold sensitivity, and the majority of the patients reported no functional deficit. © 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
INTRODUCTION Autologous nerve grafts remain the gold standard for the reconstruction of peripheral nerve defects. The sural nerve is a preferred donor site because it is purely sensory, thereby resulting in minimal morbidity from loss of innervation to the distal posterior lateral third of the lower leg, the lateral aspect of the heel and the lateral foot.1,2 Families frequently inquire about the donor site morbidity of sural nerve harvest, but very little is known on this subject in children. Several studies examined the outcomes of sural nerve harvest;3–12 however, only one of these studies has specifically investigated the outcome in paediatric patients.9 The results of these studies concluded that while most patients had objective sensory loss, only 7% had no detectable sensation at any location of the lateral foot and no patients reported a functional deficit or concerns regarding sensation of their feet.9 Although results of these studies suggest limited morbidity after sural nerve harvest in paediatric patients, the patient population consisted exclusively of patients who underwent bilateral sural nerve harvest during the first year of life. Bilateral nerve harvest at such a young age may limit the patients’ ability to perceive a deficit and therefore may not reflect the outcome of sural nerve harvest in older paediatric patients with unilateral sural nerve harvest. The objective of this study was to understand the sensory and functional deficit after unilateral sural nerve harvest in paediatric patients.
PATIENTS AND METHODS Study Population This study was approved by the Research Ethics Board at the Hospital for Sick Children. Informed consent was obtained from both patients and their families. Assent was obtained when appropriate. A prospective case series was performed to evaluate the sensory outcome of children who had sural nerve harvest for cross-face nerve grafting to a gracilis muscle flap for facial reanimation surgery. The contralateral foot was used as a control. Patients were recruited from the SickKids Facial Palsy Clinic during their routine outpatient visit and from an existing database of patients with facial palsy. Only patients 6 to 18 years of age with unilateral sural nerve harvest performed by one of the senior authors (GB or RZ) were included. Only patients older than 6 years of age were included, as sensory evaluation has been shown to be reliable past this age.13 Exclusion criteria included patients with cognitive or developmental delay, patients less
Fig. 1 Locations of sensory testing on the lateral foot. Four locations on the lateral foot, which is variably innervated by the sural nerve, were tested. The midpoint of the vertical height between the posterior border of the lateral malleolus and the sole of the foot (A) was used as a height reference to draw a horizontal line from the heel to D5. The length of the horizontal line (B) was then divided into five sections to determine four points for sensory testing (shown as red stars). The four points were labelled from A to D as shown in red letters.
than 6 months after sural nerve harvest or patients less than 3 months after lower extremity injury. The contralateral unaffected foot was used as a control.
Outcome Measures The study consisted of two assessments: (i) Sensory Threshold Evaluation using Weinstein Enhanced Sensory Test (WEST) – Foot (Touch-Test Sensory Evaluator; North Coast Medical, Inc., San Jose, California), and (ii) Functional Sensory and Pain Questionnaire. The Semmes–Weinstein Monofilament WEST assessment has been recognised as the most reliable and valid test for assessing sensory thresholds.13,14 Testing of both feet was performed during a clinic visit. The test was first explained twice on the patient’s hands with their eyes open. Following the explanation, the child and family were given the opportunity to ask any questions, and once all questions were satisfied, sensory evaluation was performed on the unaffected foot, then on the affected foot. Sensory testing was performed at four predetermined locations on the lateral aspect of the child’s foot as described by Lapid et al9 (Figure 1). The midpoint of the vertical height between the posterior border of the lateral malleolus and the sole of the foot (A) was used as a height reference to draw a horizontal line from the heel to D5. The length of the horizontal line (B) was then divided into five sections to determine four points for sensory testing (shown as
Please cite this article as: J. Catapano et al., Sensory and functional morbidity following sural nerve harvest in paediatric patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2018), https://doi.org/10.1016/j.bjps.2018.07.020
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3 red stars). Testing was performed with five monofilaments (with weights of 0.5 g, 2.0 g, 10.0 g, 50.0 g and 200 g). Each site was tested three times with the child’s vision occluded. One correct response out of three trials was considered a sensory threshold. Testing commenced with the 2.0 g monofilament first. For sites that achieved a sensory threshold for the 2.0 g monofilament, the examiner continued the examination with the lightest monofilament of 0.5 g to see if a greater sensory threshold could be achieved. The site(s) that failed to achieve a sensory threshold for the 2.0 g monofilament were then tested sequentially with the 10.0 g, 50.0 g and 200 g monofilaments. Once a threshold was achieved, the corresponding monofilament value was recorded. One correct response out of three trials was again considered a sensory threshold. Sensory thresholds were recorded on the Sensory Assessment Form (Supplemental Figure 1). A sensory function and pain questionnaire was administered to study participants after the completion of the Semmes–Weinstein assessment (Supplemental Figure 2). The functional questionnaire assessed sensation, numbness, hyperalgesia, cold intolerance, skin changes and level of activity. Descriptive demographic information including patient gender, age, age at surgical procedure and intraoperative or perioperative complications were also recorded.
Surgical Technique In all patients, sural nerve harvest was performed by a minimally invasive technique to isolate and harvest the tibial component of the sural nerve using a nerve stripper by making only two to three small incisions (Figure 2A). The tibial component of the sural nerve is identified in the popliteal fossa between the two heads of the gastrocnemius muscle (Figure 2B). The nerve stripper is placed around the proximal nerve and advanced distally to dissect the nerve from the surrounding connective tissue (Figure 2C). If advancement is stalled at any location, a small incision is made at that level to dissect the nerve under direct visualisation. The proximal nerve is pulled through the incision, and the nerve stripper is again placed around the nerve and advanced distally (Figure 2D). Once the nerve stripper has advanced to the level of the lateral malleolus, a final incision is made to transect the nerve distally and the entire tibial component to the sural nerve is removed through the distal incision (Figure 2E).
Statistical Analysis Descriptive analysis was used to analyse the minimum sensory threshold in cases (affected foot) and controls (unaffected foot), considering only the mean and median values. Distribution of sensory thresholds for all groups was compared by using the Fisher’s exact test. Thresholds at the numbest point of the foot (highest threshold) were compared between the two groups by using the Wilcoxon paired test. Descriptive statistics was used to analyse the questionnaires.
Fig. 2 Harvest of the tibial contribution to the sural nerve. (A) Planned incisions are first marked at the level of the popliteal fossa and the second posterior to the lateral malleolus. A third incision is planned between the two if necessary to release the nerve. (B) The tibial contribution to the sural nerve the medial sural cutaneous nerve (MSCN), is first identified in the popliteal fossa between the two heads of the gastrocnemius muscle. This is transected proximally and dissected under direct visualisation. (C) A nerve stripper in then placed around the proximal nerve and advanced distally. (D) If resistance is encountered when advancing the nerve stripper, a small incision is made to expose the MSCN to further dissect it under direct visualisation. Once the resistance has been released, the proximal nerve is extracted through the incision and the nerve stripper is again advanced distally. (E) Once the lateral malleolus has been reached, a final incision is made to identify the MSCN. The nerve is extracted through the wound and transected distally.
RESULTS Twenty-eight feet of 14 patients that underwent unilateral sural nerve harvest were assessed. The average age at the time of sural nerve harvest was 10.7 years (±4.2), and the average time elapsed between surgery and assessment was 1.84 years (±1.43). Nine (64%) patients were male, and five (35.7%) patients were female. The right sural nerve was harvested in nine (64.3%) patients, and the left sural nerve was harvested in rest of the patients. Objective sensory testing, as measured with WEST–Foot, revealed that in the controls (unaffected feet), patients could sense the two most sensitive monofilaments in each of the four tested locations along the lateral foot. The threshold achieved was from the most sensitive filament (0.5 g) in 96.4 % of areas tested (Table 1). By contrast, in the cases (affected feet), a comparatively high sensory thresholds were detected in 69.6% of areas tested. All but one
Please cite this article as: J. Catapano et al., Sensory and functional morbidity following sural nerve harvest in paediatric patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2018), https://doi.org/10.1016/j.bjps.2018.07.020
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4 Table 1
J. Catapano et al. Target Thresholds.
Target Threshold (Semmes–Weinstein Filament Number)
Patient Targets (n)
Control Targets (n)
0.5 g 2.0 g 10.0 g 50.0 g 200 g Absence of sensation Total
16 (28.6%) 27 (48.2%) 5 (8.9%) 7 (12.5%) 1 (1.8%)
54 (96.4%) 2 (3.6%)
56 (100%)
56 (100%)
Table 2
Sensory Threshold by Site.
D C B A
Normal (Protective Sensation)
Decreased Sensation
0.5 g
2.0 g
10.0 g
50.0 g
200 g
5 1 3 7
3 9 10 5
2 2 1
4 2 1 -
1
patient (92.9%) demonstrated at least one area that had a sensory threshold higher than the control foot. Greater sensory loss was detected at the proximal lateral foot than at the distal lateral foot (Table 2). Sensory thresholds at areas A, B, C and D were compared between the affected and unaffected feet. Feet with sural nerve harvest demonstrated significantly higher thresholds at areas D, C, B (p <0.001) and A (p = 0.039), thereby identifying objective sensory loss at each location. Responses to the questionnaire revealed that few patients perceived a sensory loss that affected their function. Fifty per cent of patients reported that they never perceived numbness in their foot, 28.5% reported occasional pain in their feet, 14.2% reported dysaesthesia and 21.4% sometimes reported cold hypersensitivity. One patient was excluded who strongly agreed that he was unable to perform activities similar to those performed by other children owing to the pain sensation in his foot. Although neither he nor his parents perceived any change or difficulty in walking, the patient reported difficulty participating in sports with his classmates, as he had calf pain while running. His parents expressed that they did not think this was a significant concern, as the patient was not active in sports before surgery. This patient was a 16-year-old male who had undergone sural nerve harvest 1 year earlier. The pain was described as sharp, intermittent and in the location of the mid-calf. He first noticed the pain 2 weeks post-operation, and there had been minimal resolution in the following years. The pain was not reproducible on physical examination, and a neuroma could not be localised. Neither he nor his parents felt that he required a referral to a pain service or medication to manage his pain.
DISCUSSION This study adds to the existing literature by describing the outcomes of unilateral sural nerve harvest in paediatric patients. Our data suggest that most paediatric patients
experience a detectable loss of sensation on the lateral foot. Despite objective sensory loss, patients perceived minimal effect in their lower extremity function. Subjective numbness of the affected foot was not described in half of the patients studied. However, a quarter of patients reported occasional pain, dysaesthesia or cold hypersensitivity. Only one patient (7%) felt that he was unable to perform activities similar to those of other children owing to the pain sensation in his foot. The objective sensory loss demonstrated in this study mirrors that noted in the study of bilateral sural nerve harvest in paediatric patients by Lapid et al. (2007). Using a step-wise technique of sural nerve harvest, they found that 86% of paediatric patients demonstrated a sensory deficit and 7% demonstrated no detectable sensation at any location of the lateral foot.9 Our study showed a similar proportion of patients with a detectable sensory deficit (93 %); however, there were no patients who had complete lack of sensation in our cohort. It is important to note that Semmes– Weinstein monofilaments used in our study were calibrated for the foot. The monofilaments used in the study by Lapid et al. (2007) were calibrated for the hand, thus using thinner monofilaments representing lighter sensory thresholds. Accounting for these differences, a similar number of patients in the two studies demonstrate a minimum of protective sensation (i.e. 2.0 g): 71.43% of areas tested in the study by Lapid et al. and 76.80% of areas tested in this study. Although these results demonstrate that the objective sensory outcomes were similar, important differences were identified through the functional questionnaire. In the paper by Lapid et al. (2007), only one patient complained of tingling sensation in one foot, thus representing a sensory concern in only 3.5% of feet following sural nerve harvest. By contrast, after unilateral harvest, 50% of patients in this study reported numbness of their feet, with 28.6% of patients describing some intermittent pain, 14.2% with intermittent hyperalgesia and 21.4% reported cold insensitivity. One patient in this study (7.14%) felt that he was unable to participate in activities same as those participated by
Please cite this article as: J. Catapano et al., Sensory and functional morbidity following sural nerve harvest in paediatric patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2018), https://doi.org/10.1016/j.bjps.2018.07.020
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other children because of the pain sensation in his foot. The patient, a 16-year-old male, specified that he had difficulty participating in sports at school because of pain in his mid-calf, which occurred when running but not walking. However, as described previously, his parents expressed that this was a minor contributor in his difficulty participating in sports, as the patient was not active in sports preoperatively and had pre-existing obesity. It is difficult to ascertain the relative contribution of calf pain to his concern, but it is important that from the patient’s perspective he felt that he was more limited after the sural nerve harvest. These differences may be attributable to differences in patient population as the previous study by Lapid et al. described outcomes of bilateral sural nerve harvest performed in infants (<1 year), whereas our paper investigated outcomes in older paediatric patients (age 10.7 ±4.2 years) after unilateral sural nerve harvest. The presence of an unaffected contralateral limb for comparison as well as surgery at an older age, where patients are better able to perceive changes after surgery, may explain these differences. Younger children may also possess greater capacity to repopulate a denervated dermatome from adjacent axons. Furthermore, our paper describes earlier outcomes after sural nerve harvest as we assessed outcomes 1.84 years (±1.43) after surgery, whereas Lapid et al. assessed outcomes an average of 8 to 9 years after surgery. Lapid et al. also used a different technique of sural nerve harvest, which is harvesting the sural nerve distal to proximal with several step-wise incisions. The subjective outcomes identified by the questionnaire more closely resemble outcomes in adult patients described by other groups.3–8 , 10–12 Pain after sural nerve harvest is variable, with studies reporting minimal pain after sural nerve harvest3,15 and others demonstrating pain after surgery as high as 73%,11 reducing to 4-17%7,11 1 year after surgery. Cold insensitivity is also variable from 0 to 34% of patients.7,11 , 15 In one study with 41 patients of average age 23 years, Hallgren et al. found that 37% of patients experienced discomfort in their leg and 29% demonstrated cold intolerance. This was similar to the incidence of both these outcomes in this study: 28.5% and 21.4%, respectively. Staniforth and Fisher (1978) demonstrated a higher incidence of leg discomfort after sural nerve harvest (40%); however, they did not distinguish between pain and cold sensitivity, which may explain the high incidence.16 Several studies do agree that pain and cold sensitivity experienced after sural nerve harvest decline in frequency and intensity with time, with a small number of patients experiencing minimal functional impairment after sural nerve harvest.7,11 , 15 This has been variably described and reported as minimal impairment in 17% of patients7 and 15% of patients with affected activities of daily living11 ; Butler et al. demonstrated minimal functional deficit using the lower extremity functional scale, with patients averaging a score of 78.74 (80 representing no impairment)3 . These results are consistent with the findings in this study, and differences may be partially attributed to follow-up time, patient populations and surgical technique. Our study was not sufficiently powered to determine whether outcomes improve with time; however, this can be investigated in the future with a follow-up study with the same patients.
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5 Several surgical techniques for sural nerve harvest have been described, including a single longitudinal incision,17 multiple smaller incisions18 , endoscopic techniques19–21 and techniques using a nerve stripper8,22 , 23 . These techniques result in variable injury to the tissues surrounding the sural nerve and the sural nerve itself, which may affect outcomes. Our surgical method uses a specially designed nervestripping device (as shown in Figure 2) to dissect the sural nerve by making only two or three small incisions. Furthermore, while several techniques identify the nerve distally at the level of the ankle posterior to the lateral malleolus, we identify the tibial contribution to the sural nerve proximally between the two heads of the gastrocnemius muscle. The contribution to the sural nerve from the tibial and peroneal nerves is variable.24,25 Most commonly, the sural nerve is composed from the union of the medial sural cutaneous nerve (MSCN) arising from the tibial nerve and a branch from common peroneal nerve, either the peroneal communicating branch or the lateral sural cutaneous nerve (LSCN).24 We identify the MSCN proximally in an effort to spare the peroneal contribution to the sural nerve, thereby minimising sensory loss. Although the functional outcomes in our patients appear to be similar to those in adult patients by using various techniques, variation in outcomes metrics makes it impossible to distinguish any differences in measurable objective sensory loss. In adults, subjective measurements have demonstrated that sensory loss is highly variable after sural nerve harvest, with average areas of sensory loss measuring as large as 45.4 cm2 to 52.6 cm2 , whereas some patients demonstrate almost no measurable sensory loss.3,10 These studies used subjective measures to assess sensory loss, including questionnaires and visual analogue scales (VAS)5–7 , one of which was performed through a telephone questionnaire26 . The only adult study that did measure objective sensory loss followed this with a binary outcome metric that is not quantifiable, thus limiting direct comparison with this study.17 The only previous study to use a measurable objective outcome metric to assess sensory loss of sural nerve harvest was Lapid et al. (2007); however, the important differences in patient population make it impossible to directly compare sural nerve harvest techniques. Further investigation of whether isolated harvest of the MSCN improves sensory outcomes requires a randomised controlled study with agematched controls.
CONCLUSIONS Unilateral sural nerve harvest in paediatric patients results in measurable sensory loss along the lateral aspect of the affected foot. Despite objective loss of innervation, most patients demonstrate minimal morbidity, with half of the patients reporting no subjective appreciation of sensory loss. A small number of patients do report intermittent dysaesthesia and cold sensitivity of the lateral foot after sural nerve harvest. Functional outcomes after unilateral sural nerve harvest in older paediatric patients more closely resemble outcomes of adult studies likely because of the patient age and population in the previous paediatric sural nerve study. This study is necessary to better inform patients and families regarding the expected outcome of unilateral sural
Please cite this article as: J. Catapano et al., Sensory and functional morbidity following sural nerve harvest in paediatric patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2018), https://doi.org/10.1016/j.bjps.2018.07.020
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6 nerve harvest for the reconstruction of peripheral nerve defects.
Supplementary materials Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.bjps.2018.07. 020.
References 1. Sekiya SI, Suzuki R, Miyawaki M, Chiba S, Kumaki K. Formation and distribution of the sural nerve based on nerve fascicle and nerve fiber analyses. Anat Sci Int 2006;81(2):84–91. doi:10.1111/j.1447-073X.2006.00135.x. 2. Vuksanovic-Bozaric A, Radunovic M, Radojevic N, Abramovic M. The bilateral anatomical variation of the sural nerve and a review of relevant literature. Anat Sci Int 2014;89(1):57–61. doi:10.1007/s12565- 013- 0195- 9. 3. Butler DP, Johal KS, Wicks CE, Grobbelaar AO. Objective sensory and functional outcomes at the donor site following endoscopic-assisted sural nerve harvest. J Plast Reconstr Aesthetic Surg 2017;70(5):659–65. doi:10.1016/j.bjps.2017.02. 022. 4. Aszmann OC, Muse V, Dellon AL. Evidence in support of collateral sprouting after sensory nerve resection. Ann Plast Surg 1996;37(5):520–5. doi:10.1097/00000637- 199611000- 00011. 5. Ehretsman RL, Novak CB, Mackinnon SE. Subjective recovery of nerve graft donor site. Ann Plast Surg 1999;43(6):606–12. 6. Hallgren A, Björkman A, Chemnitz A, Dahlin LB. Subjective outcome related to donor site morbidity after sural nerve graft harvesting: a survey in 41 patients. BMC Surg 2013;13:39. doi:10.1186/1471- 2482- 13- 39. 7. IJpma FFa, Nicolai J-Pa, Meek MF. Sural nerve donor-site morbidity: thirty-four years of follow-up. Ann Plast Surg 2006;57(4):391–5. doi:10.1097/01.sap.0000221963.66229.b6. 8. Kim ED, Seo JT. Minimally invasive technique for sural nerve harvesting: Technical description and follow-up. Urology 2001;57(5):921–4. doi:10.1016/S0090- 4295(01)00908- 6. 9. Lapid O, Ho ES, Goia C, Clarke HM. Evaluation of the sensory deficit after sural nerve harvesting in pediatric patients. Plast Reconstr Surg 2007;119(2):670–4. doi:10.1097/01.prs. 0000246521.83239.cd. 10. Martins RS, Barbosa Ra, Siqueira MG, et al. Morbidity following sural nerve harvesting: a prospective study. Clin Neurol Neurosurg 2012;114(8):1149–52. doi:10.1016/j.clineuro.2012. 02.045. 11. Miloro M, Stoner Ja. Subjective outcomes following sural nerve harvest. J Oral Maxillofac Surg 2005;63(8):1150–4. doi:10. 1016/j.joms.2005.04.031.
[m6+;September 25, 2018;14:57]
J. Catapano et al. 12. Ng SS, Kwan MK, Ahmad TS. Quantitative and qualitative evaluation of sural nerve graft donor site. Med J Malaysia 2006;61(Suppl B):13–17. 13. Thibault A, Forget R, Lambert J. Evaluation of cutaneous and proprioceptive sensation in children: a reliability study. Dev Med Child Neurol 1994;36(9):796–812. 14. Rosén B, Lundborg G. A model instrument for the documentation of outcome after nerve repair. J Hand Surg Am 2000;25(3):535–43. doi:10.1053/jhsu.2000.6458. 15. Ehretsman R, Novak C, Mackinnon S. Subjective recovery of nerve graft donor site. Ann Plast 1999;43:606–12. http:// journals.lww.com/annalsplasticsurgery/Abstract/1999/12000/ Subjective_Recovery_of_Nerve_Graft_Donor_Site.5.aspx Accessed June 4, 2014. 16. Staniforth P, Fisher TR. The effects of sural nerve excision in autogenous nerve grafting. Hand 1978;10(2):187–90. doi:10. 1016/S0072- 968X(78)80012- 6. 17. Martins RS, Barbosa RA, Siqueira MG, et al. Morbidity following sural nerve harvesting: A prospective study. Clin Neurol Neurosurg 2012;114(8):1149–52. doi:10.1016/j.clineuro.2012. 02.045. 18. Chang DW. Minimal incision technique for sural nerve graft harvest: Experience with 61 patients. J Reconstr Microsurg 2002;18(8):671–5. doi:10.1055/s- 2002- 36498. 19. Koh KS, Park S. Endoscopic harvest of sural nerve graft with balloon dissection. Plast Reconstr Surg 1998;101(3):810–12. doi:10.1097/00006534- 199803000- 00035. 20. Capek L, Clarke HM, Zuker RM. Endoscopic sural nerve harvest in the pediatric patient. Plast Reconstr Surg 1996;98(5):884–8. http://www.ncbi.nlm.nih.gov/pubmed/8823033. 21. Spinks TJ, Adelson PD. Pediatric sural nerve harvest: a fully endoscopic technique. Neurosurgery 2009;64(5 Suppl 2) 360-34. doi:10.1227/01.NEU.0000343740.76951.33. 22. Jaroszynski G. Harvesting of the sural nerve with a tendon stripper. 1997. 23. Hankin FM, Jaeger SH, Beddings A. Autogenous sural nerve grafts: a harvesting technique. Orthopedics 1985;8(9):1160– 1. http://www.ncbi.nlm.nih.gov/pubmed/3832060 Accessed June 20, 2017. 24. Riedl O, Frey M. Anatomy of the sural nerve: cadaver study and literature review. Plast Reconstr Surg 2013;131(4):802–10. doi:10.1097/PRS.0b013e3182818cd4. 25. Solomon LB, Ferris L, Tedman R, Henneberg M. Surgical anatomy of the sural and superficial fibular nerves with an emphasis on the approach to the lateral malleolus. J Anat 2001;199(Pt 6):717–23. doi:10.1046/j.1469-7580.2001. 19960717.x. 26. Miloro M, Stoner JA. Subjective outcomes following sural nerve harvest. J Oral Maxillofac Surg 2005;63(8):1150–4. doi:10. 1016/j.joms.2005.04.031.
Please cite this article as: J. Catapano et al., Sensory and functional morbidity following sural nerve harvest in paediatric patients, Journal of Plastic, Reconstructive & Aesthetic Surgery (2018), https://doi.org/10.1016/j.bjps.2018.07.020