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Two end-to-side neurorrhaphies and nerve graft with removal of the epineural sheath: experimental study in rats
Two end-to-side neurorrhaphies and nerve graft with removal of the epineural sheath: experimental study in rats I-. Vitcrbo,
.I ( ‘. Trindadc.
K. Hoshino
and ;I. Mazzoni
Sl .2/,11:4 R 1’ U’e have studied a new type of end-to-side nerve repair in rats. The healthy (donor) nerve was not divided but an epineural window was created. In our experiment, a nerve graft bridged the ‘tibia1 nerve to the distal end of the divided peroneal nerve. Electrophysiological studies showed electrical impulses conducted through both end-to-side nerve junctions. Histological studies demonstrated axons leaving the lateral surface of the healthy (donor) nerve. Based on these observations, we suggest _<~. that end-to-side neurorrhaphy from a healthy nerve may bridge a neural deiicit.
C‘urrent ,;tudw of nerw repair support an end-to-end Lechniqu.’ ’ Ballancc!’ was the first. in 1903. to report .ln end-to-side technique for the treatment of facial pal<>. HC wtured the distal end of’ the di\idcd facial nertc to the 4idc oI‘ the spinal accessory nerve. Facial .111cl 410 ulder movement:, occurred together. Other ,luthors confirmed the results.“‘,” Most of the same in\c
”
In prc\ ioub publicationx.” “’ \vc studied dencr\,.ition 01‘ rhtx grxilis muscle in dogs. The supa-ficial !v;tnch ol the clhturator nerve was divided and the Andy fixed ap;lrt to pre\‘ent the very strong tendency to qwntanec~u~ reinner\ ation. The next step was ;I clinical stud! ofthc ncurc)rrh~~ph~.joining the divided nerve to ,i health\ neri’c‘. The pturpox of the present study was to evaluate !wo cnnxcuti\e end-to-side nerve repairs Gth a nerkc gall brldw. The new approach of connecting ;I di\ i&d 1,&c cncl to ;I healthy nerve. with or without ,111cpiiiciil-al l,\indo\v. has been published.” ‘Ii Clinical ?IXC‘ ha\ ;IISJ been deinon~trated.” “I Llaterial~~ and methods
Pen iiial~~ Wi\tar rats. 11ith a11 average Lveight of 773 g I range 7-10 30 3) \st‘r-e used. The peroneal newe was Ji\ided .jn the right side of all the animals. The proximal end M2% turned back more than 90” and inserted nto the femoral adductor muscle. The distal end oft hz pet oncal ncr\ c M’X inserted into the femoral .~dducto~ mukclt: I cm apart from and parallel to the iibial iie1 le. .Il‘tcr lhc opening of ;I I mm epineural window in sch. thaw two nerves Lvere then united b\ ;I nerve gait. end-to-side (Fig. I ). The lefr side ws used as control. In half of these .lnimals. the pcroneal ner1.e was divided. both ends :urncd bat_.k and anchored to subjacent muscles with 71) sutures (Fiy. 3). This dcncrvated the tibia1 cranial
muscles (vvhich correspond to the anterior tiblal muscle in the human leg.) In the other half the ncr\es were kept intact on the left side. Table I sho\v\ the \,ariou:, muscles shown and the names used t’or wc11. The animals had standard food ;IIICI water for ;tn a\‘erage recovery period of 7.7 months. One died :lnd was discarded. The nine survi\ or\ \vere zubmittcd to electrclphvsiological tests and hilled u ith high dohe of intrapcrit;>neal sodium pentobarlxtal (ncmbutal). Nerves and muscles were renic)\.ed tcor fiirthcr yttld!.
The animals c\ere :lnaesthetiscd with VX~IUIN pmtobarbital and tised in Lcntral decuhitu\. I (a. ahdvmen down. Both tibial nerves were e\powtl untirl ;I surgical microscope and diCded. The right tibia1 ncrvc XIS diGded 1 cm hclo~ the neurorrhaphy. The ,limulating electrode. with t\vo probes. a;15 plxwi in ~hc sciatic iicr\‘e trunk. The electric impulses were obwrwtl on ;III oscillow~pc (He\vlett-Pachard 132A dual bcatn. DC -500 KC) and photographed. The electrical 4timuIulr UYIS supplied by an LHM-I IO with I III\ dur;lllon. ;it 30 Hertz. from (j- 3 \,olts. SubsequentI!. the distal elld ot the peroneal nerve MXSdivided. appr~~sinlatcl! 1.i cm below the ncurorrhaphy and the test rcpeatal to note possible spurious paths of conduction
On the right side. nerve segments \vcrc idcntilied 111all the limbs in relation to the nerve anastomos<*~ t Fis. 3): N 1 proslmal pernneal ncrw; N2 tibi;ll nerw abo\y neurorrhaphy : N3 tibia1 nerve hells\\ neur~~rrhaphv: NJ neurorrhaphy region. tibial and nrrxx: grat‘t <5 nerve graft: N9 pcroneal nerve distal to nt:r\e graft. On the left side were the denerwted contrcjls. thus: N7 proximal peroneal nerve\; NS distal peroneal nct3.c. And the normal controls: Nh tihlal. U ItI pcroncal.
and at the end-to-side junctions; the latter \vere longitudinal. Two slides were prepared from each segment, one for H.E. staining and the other specific for myelin, Lopes Ferric Haematoxylin.“” Bilateral biopsies were taken of the ~LISC~~‘~ from the middle third, deep portion. I cm x 3 mm. with standard processing.
The size and numbers of fibres bverc determined bq planimetry through camera lucida images from ;I Zeiss microscope, pro_iected on to the screen of the MINIMOP (Kontron Electronic Group) analyser. anti expressed per square micrometers.
Counts were also performed MINI-MOP.
for ner\.e fibrcs uflith the
Sttrti.vtic..s
The material WIS fixed in 101;I formalin and mounted on paraffin blocks. The microtome sections were transverse except in the proximal peroneal nerve
In order to study muscle fibre data. the Student’s t-test was used for independent and dependent samples. The independent was to compare data in different animals while the dependent was used only for the same animals. The analysis of the rates of responses to electriwl stimuli was done with the Goodman’s test for com-
Fig. 2
Thecontrols,
M 1II. M Id. M3n. M3d and M-in. shcl~\cxi
healthy tibres and overall structure. The Icfi detum;ttcd conIro1. Mad. showed ;tn tncrwsc 01‘ c.onncctive tissue in the pcrimysium. The fihrcs were intenseI! polymorphic, typical of dener\ ated IIILLSL-le. The rein-
!
M4n
netxated showed.
right tibia1 cranial muscle. h17n and Mkt. among the 9 cav.3 st udicd. -I I! ilh oplimal
pitter-m. -I L\ tth good pattcrn~ (tihtcx ~~1 nornul tiiorphnlog~ hut with slight ttictusc 111I oiincLti\c tissue). ;I& I wtth small libre\ and much ttlwxw 111
ci)nnecliw
lissue (Fig. 5).
M3d
While both the positive (non-c)pcratcti Iclt Gdc) and the ncgatiw (dcncrkated left side) c‘c>nirols responded ;ts cspected. i.ccKC‘ noted 1 posttiw rnt~~clc t-cspotlsc‘s on the side of nerw repair (44 ” I) of the c) 11:sted) I Fig. 6). the different response frequencte~ Mt’rc not.
Discussion
Results
Y I (right ptx>xinwl perontcil) sho\ved. in iongitudinal \cctic)n. typical neuroma formation with !ibrc\ grn\\~in~ tn di\,erse directions. interspersed with a~~scle. !icgmcnt5 NY N3. N6. NIO and N7 (right iihial and Icft pcronral controls) showed normal, high densit\ ncr\c’. The net-\‘e graft, NS. showed well tdentified tibra in the four available cases. and the ilistal prroneal. N9, showed well-identified nerve tibres in tight ;I\ ailable cases (Fig. 3). The distal left peroneal
Sespenl
S.lc‘nerv:ttt~~n c~~tl!rol. YYX. showed the intense fibrosis of ilt‘generation
An unexpected but positive finding not found itI the literature \V;IS obtained in our study. namcl!. axonal growth through two consecutive end-to+ide ner\‘e junctions and ;I nerve graft. Axons gre\\ from ;I health! ner\‘e through an end-to-side nerve‘ repair. into the graft. and into another nerve. end-tokdc. T’he neuroma found in the prosin~al part of the di\idctl perc~nral precluded nerve. on the right side. in all animals reinnervation of the tibia1 cranial muscle. 4.t the nme junctions. the histology and nerve tihrr counls distal to the repair site shm\Ted functional twgro\\ th. This observation can only be explained b> rcgeneraling tibres growing through the net-1 c’ graft and further into the dilkied distal peroneal (acceptor) ttmc M~~sclc reinnervation. ;IS cvaluatcd by dinxmiom 01‘librc> 111 transvcrst‘ sections. contrasted signiticantly a:ith denervated muscles. These results ~t’re adequateI> controlled through precise identiticatiolt cr!‘all IIILIC~S involved. comparing reinnervated M.ith ncrrmal and denervatsd ones. The gstrocntxnii rnuxI(-.~ \\erc not altered b? the neurnrrhaphy.
British
78
Table 2
Journal
of Plastic
Surgery
Nerve tihrct counts
I5XX 3200 16X2 201 I Ii72 ii2
4 5 6
7 dwea\rd X 4 IO s sd
II;, I,;, 11;1
‘010.60 68X.03
,,;i: not ;I\;allablr.
Fig. 5 Figure s--(A)
Right tibia1 cranial muscle fibres (M2d). (B) Left tiblal cr;mial muscle tibrrh. denervated control
Electrophysiology decisively proved the efficacy of the end-to-side junction. The muscle signals in 44 % of the animals resulted from the neurorrhaphy. since post-test division brought the signals to zero. Some lack of response of muscle may have resulted merely from the dissection. It should be emphasised that axons were not divided,
(Mild). Rat nc>.9. HE. 241y
resulting in adequate reinnervation ofthe tibia1 cranial muscle. The reinnervated muscle recovered without impairing the donor. In spite of the relatively easy technique. we are interested in better axon nrowth into the nerve graft. as well as higher yields ot’motor end plates. Our objective was not to compare end-to-end with
Conclusions
’ -.
End-lo-side neurorrhaphy thrcjuph a11 epincural windw only without damage to the bc~iy of the donor nerve allows recover> of neural It:xlc)ns when only the distal end of ;I ner\ c i\ .I\ ailahlt~. i. We-bclic\e that this technique i5clinicxll!; .Idaptablc.
80 S. R. Benato, H. I’. C. Moraes. C. L. Mqqel. F. Michelin. J. A. Pena and FUNDUNESP (Fundaclio Para o Desenvolvimento da UNESP).
References I. C‘olemam CC. Surgical treatment of peripheral nerve injuries. Surg Gyn Obst 1934: 7X: 113-13. 2. Van Beek AL, Kleinert HE. Practical microneurorrhaphy. Orth Clin North Am 1977: X: 377 X6. 3. TerTis J. Chnical microsurgery of the peripheral nerve: the state of the art. Clin Plast Surp 1979; 6: 247-67. 4. Viterbo F Regener&io de nerve. In: Melega JM. .&mini SA. Psillakis JM. editors. Cirugia pldstica repsradora e estPtica. Rio de Janeiro: Medsi. 1988: 57 61. 5. Mackinnon SE. New directions in peripheral nerve surgery. t\nn Pleat Surg 1989: 22: 257 73. 6. BruneII G. Brunelli F. Strategy and timing of peripheralnerve surgery. Neurosurg Rev 1990: 13: 95 102. 7. Mlllesi H. Peripheral nerve surgery toda:: turning point or continuous development’? (Review article). J Hand Surg (.4m) 19%); 15: 281 7. X. Harris ME. Tindall SC. Techniques of peripheral nerve repair. Neurosurg Clin North Am 19YI : 2: 93-104. Y. Ballance CA. Ballance HA. Ste!\cart P. Remark5 on the operative treatment of chronic facial palsy of peripheral origin. BMJ 1903: 2: IOOY I?. IO. Harris W. Lo\v VW. On the Importance of accurate muscular analysis in lesions ofthe brachial plexus; and the treatment of Erb‘s palsy and infantile paralysis of the upper rxtremit!: by cross-union of the nerve roots. BMJ 1903; 24: 1035-X. I I. Sherren J. Some points in the surgery of the peripheral nerves. Edinb Med J 1906: 20: 247 331. 12. Viterbo F. Desncrva~do: contrlbuipdo ao estudo morfol&ico e histoewimoldgico do “M. Gr2icilis” do c20 (Cants &miliaris) (dissertation). Botucatu: Faculdade de Medicma. Universidade Estadual Paulista. 19X4. Ii. Viterbo F, Trindade JCS, Dal Pai V. Cury PR. Number ot muscular fibers by microscopic field: a simple and efficient method to study denervation. Rev Sot Bras Cir Plast 19X9: 4: 4 II. 14. Vitcrbo F. Trindade JCS. Hoshino K. Mazzom Nero A. Lateroterminal neurorrhaphy without removal of the epineural sheath. Experimental study in rats. 50 Paula Medical Journal (Rev Paul Med) l9Y2: I IO: 267-75.
British Journal
of Plastic Surlrerv
15. Viterbo F. Trindade JCS. Hoshino K. Mazrom Neto A Endto-side nerve anastomohis. Experimental study in the rat. Annals of the 2Yth Brazilian Congress of Plastic Surprr! 1992 Nov 8; Porto Alegre: 35. 16. Vitcrbo F. Neurorratia l;itero-terminal. estudo e.xperimental no rato (PhD thesis). Botucatu. Faculdade de Medicine: Ilniversidadc Estadual Paulista. 1991. 17. Viterbo F. Cross-face termino-lateral neurorrhaphy : :I IX:M method for treatment of facial palsy. 6lst Annual Scientitic Meeting of the .4merican Society of Plastic and Reconhtructive Surgeons. the Plastic Surgery Educational Foundation. and the American Society of Mauillofacial Surgeon\: 1992Sept 20; Washington. DC: Plactic Surgical Forum. 1992: 35&X. IX. Viterbo F. End-to-side nerve anaatomosis \\lth and uithout epineurium. Experimental and clinical experience. Pre\cnted at the “grand round” of the Plastic Surgery Llmt. Unicerhity of Alabama. Birmingham. USA: Ott 13. lYY2. IY. Viterbo F. Cross-face termino-lateral neur~wrhaphy : :I new method for treatment of facial palsy. Annala of the 2Yth Brazilian Congress of Plastic Surgery: lYY2 Nov X. Porte Alegre: 28. 20. Behmer OA, Tolosa EMC‘. Frritab Neto AC;. Manual de tPcnicas para histologia normal e patolbgica. Ist rd. S5o Paula: Edart/Edusp. 1976: 146. 11. Goodman LA. Simultaneous contidcncr inter\alb for contrasts among multinomial populations. Annal, of Mathematxll Statistics lY64: is: 716 25. -_. 71 Goodman LA. On \lmultaneous confidence inter\& t’~,rmultinomial proportions. Technometrics 1965: 7: 247~ 5-I
The Authors Faust0 Viterbo, Prof‘ebaor and Chief of Plastic Surgery. Jo& Carlos Trindade, Professor and Chicf of I_lrolosy. Katsumasa Hoshino, Professor of Physiolog August0 Mazzoni, Dental Surgeon. Faculdade de Medicina, Umwrsidade 1861 X-000 Botucatu, SP. Brazil.
Estadual
Requebts for reprints to: Dr F.. Viterbo. 1X60?-790 Botucatu. Sso Paula. Brn7il. Paper recri\ed 7 January lYY3. Accepted 8 November 1943, after rewsmn
Paullsta/ll&ESP.
Rua Jox! Dal Farra.
32.
.I ( ‘. Trindadc.
K. Hoshino
and ;I. Mazzoni
Sl .2/,11:4 R 1’ U’e have studied a new type of end-to-side nerve repair in rats. The healthy (donor) nerve was not divided but an epineural window was created. In our experiment, a nerve graft bridged the ‘tibia1 nerve to the distal end of the divided peroneal nerve. Electrophysiological studies showed electrical impulses conducted through both end-to-side nerve junctions. Histological studies demonstrated axons leaving the lateral surface of the healthy (donor) nerve. Based on these observations, we suggest _<~. that end-to-side neurorrhaphy from a healthy nerve may bridge a neural deiicit.
C‘urrent ,;tudw of nerw repair support an end-to-end Lechniqu.’ ’ Ballancc!’ was the first. in 1903. to report .ln end-to-side technique for the treatment of facial pal<>. HC wtured the distal end of’ the di\idcd facial nertc to the 4idc oI‘ the spinal accessory nerve. Facial .111cl 410 ulder movement:, occurred together. Other ,luthors confirmed the results.“‘,” Most of the same in\c
”
In prc\ ioub publicationx.” “’ \vc studied dencr\,.ition 01‘ rhtx grxilis muscle in dogs. The supa-ficial !v;tnch ol the clhturator nerve was divided and the Andy fixed ap;lrt to pre\‘ent the very strong tendency to qwntanec~u~ reinner\ ation. The next step was ;I clinical stud! ofthc ncurc)rrh~~ph~.joining the divided nerve to ,i health\ neri’c‘. The pturpox of the present study was to evaluate !wo cnnxcuti\e end-to-side nerve repairs Gth a nerkc gall brldw. The new approach of connecting ;I di\ i&d 1,&c cncl to ;I healthy nerve. with or without ,111cpiiiciil-al l,\indo\v. has been published.” ‘Ii Clinical ?IXC‘ ha\ ;IISJ been deinon~trated.” “I Llaterial~~ and methods
Pen iiial~~ Wi\tar rats. 11ith a11 average Lveight of 773 g I range 7-10 30 3) \st‘r-e used. The peroneal newe was Ji\ided .jn the right side of all the animals. The proximal end M2% turned back more than 90” and inserted nto the femoral adductor muscle. The distal end oft hz pet oncal ncr\ c M’X inserted into the femoral .~dducto~ mukclt: I cm apart from and parallel to the iibial iie1 le. .Il‘tcr lhc opening of ;I I mm epineural window in sch. thaw two nerves Lvere then united b\ ;I nerve gait. end-to-side (Fig. I ). The lefr side ws used as control. In half of these .lnimals. the pcroneal ner1.e was divided. both ends :urncd bat_.k and anchored to subjacent muscles with 71) sutures (Fiy. 3). This dcncrvated the tibia1 cranial
muscles (vvhich correspond to the anterior tiblal muscle in the human leg.) In the other half the ncr\es were kept intact on the left side. Table I sho\v\ the \,ariou:, muscles shown and the names used t’or wc11. The animals had standard food ;IIICI water for ;tn a\‘erage recovery period of 7.7 months. One died :lnd was discarded. The nine survi\ or\ \vere zubmittcd to electrclphvsiological tests and hilled u ith high dohe of intrapcrit;>neal sodium pentobarlxtal (ncmbutal). Nerves and muscles were renic)\.ed tcor fiirthcr yttld!.
The animals c\ere :lnaesthetiscd with VX~IUIN pmtobarbital and tised in Lcntral decuhitu\. I (a. ahdvmen down. Both tibial nerves were e\powtl untirl ;I surgical microscope and diCded. The right tibia1 ncrvc XIS diGded 1 cm hclo~ the neurorrhaphy. The ,limulating electrode. with t\vo probes. a;15 plxwi in ~hc sciatic iicr\‘e trunk. The electric impulses were obwrwtl on ;III oscillow~pc (He\vlett-Pachard 132A dual bcatn. DC -500 KC) and photographed. The electrical 4timuIulr UYIS supplied by an LHM-I IO with I III\ dur;lllon. ;it 30 Hertz. from (j- 3 \,olts. SubsequentI!. the distal elld ot the peroneal nerve MXSdivided. appr~~sinlatcl! 1.i cm below the ncurorrhaphy and the test rcpeatal to note possible spurious paths of conduction
On the right side. nerve segments \vcrc idcntilied 111all the limbs in relation to the nerve anastomos<*~ t Fis. 3): N 1 proslmal pernneal ncrw; N2 tibi;ll nerw abo\y neurorrhaphy : N3 tibia1 nerve hells\\ neur~~rrhaphv: NJ neurorrhaphy region. tibial and nrrxx: grat‘t <5 nerve graft: N9 pcroneal nerve distal to nt:r\e graft. On the left side were the denerwted contrcjls. thus: N7 proximal peroneal nerve\; NS distal peroneal nct3.c. And the normal controls: Nh tihlal. U ItI pcroncal.
and at the end-to-side junctions; the latter \vere longitudinal. Two slides were prepared from each segment, one for H.E. staining and the other specific for myelin, Lopes Ferric Haematoxylin.“” Bilateral biopsies were taken of the ~LISC~~‘~ from the middle third, deep portion. I cm x 3 mm. with standard processing.
The size and numbers of fibres bverc determined bq planimetry through camera lucida images from ;I Zeiss microscope, pro_iected on to the screen of the MINIMOP (Kontron Electronic Group) analyser. anti expressed per square micrometers.
Counts were also performed MINI-MOP.
for ner\.e fibrcs uflith the
Sttrti.vtic..s
The material WIS fixed in 101;I formalin and mounted on paraffin blocks. The microtome sections were transverse except in the proximal peroneal nerve
In order to study muscle fibre data. the Student’s t-test was used for independent and dependent samples. The independent was to compare data in different animals while the dependent was used only for the same animals. The analysis of the rates of responses to electriwl stimuli was done with the Goodman’s test for com-
Fig. 2
Thecontrols,
M 1II. M Id. M3n. M3d and M-in. shcl~\cxi
healthy tibres and overall structure. The Icfi detum;ttcd conIro1. Mad. showed ;tn tncrwsc 01‘ c.onncctive tissue in the pcrimysium. The fihrcs were intenseI! polymorphic, typical of dener\ ated IIILLSL-le. The rein-
!
M4n
netxated showed.
right tibia1 cranial muscle. h17n and Mkt. among the 9 cav.3 st udicd. -I I! ilh oplimal
pitter-m. -I L\ tth good pattcrn~ (tihtcx ~~1 nornul tiiorphnlog~ hut with slight ttictusc 111I oiincLti\c tissue). ;I& I wtth small libre\ and much ttlwxw 111
ci)nnecliw
lissue (Fig. 5).
M3d
While both the positive (non-c)pcratcti Iclt Gdc) and the ncgatiw (dcncrkated left side) c‘c>nirols responded ;ts cspected. i.ccKC‘ noted 1 posttiw rnt~~clc t-cspotlsc‘s on the side of nerw repair (44 ” I) of the c) 11:sted) I Fig. 6). the different response frequencte~ Mt’rc not.
Discussion
Results
Y I (right ptx>xinwl perontcil) sho\ved. in iongitudinal \cctic)n. typical neuroma formation with !ibrc\ grn\\~in~ tn di\,erse directions. interspersed with a~~scle. !icgmcnt5 NY N3. N6. NIO and N7 (right iihial and Icft pcronral controls) showed normal, high densit\ ncr\c’. The net-\‘e graft, NS. showed well tdentified tibra in the four available cases. and the ilistal prroneal. N9, showed well-identified nerve tibres in tight ;I\ ailable cases (Fig. 3). The distal left peroneal
Sespenl
S.lc‘nerv:ttt~~n c~~tl!rol. YYX. showed the intense fibrosis of ilt‘generation
An unexpected but positive finding not found itI the literature \V;IS obtained in our study. namcl!. axonal growth through two consecutive end-to+ide ner\‘e junctions and ;I nerve graft. Axons gre\\ from ;I health! ner\‘e through an end-to-side nerve‘ repair. into the graft. and into another nerve. end-tokdc. T’he neuroma found in the prosin~al part of the di\idctl perc~nral precluded nerve. on the right side. in all animals reinnervation of the tibia1 cranial muscle. 4.t the nme junctions. the histology and nerve tihrr counls distal to the repair site shm\Ted functional twgro\\ th. This observation can only be explained b> rcgeneraling tibres growing through the net-1 c’ graft and further into the dilkied distal peroneal (acceptor) ttmc M~~sclc reinnervation. ;IS cvaluatcd by dinxmiom 01‘librc> 111 transvcrst‘ sections. contrasted signiticantly a:ith denervated muscles. These results ~t’re adequateI> controlled through precise identiticatiolt cr!‘all IIILIC~S involved. comparing reinnervated M.ith ncrrmal and denervatsd ones. The gstrocntxnii rnuxI(-.~ \\erc not altered b? the neurnrrhaphy.
British
78
Table 2
Journal
of Plastic
Surgery
Nerve tihrct counts
I5XX 3200 16X2 201 I Ii72 ii2
4 5 6
7 dwea\rd X 4 IO s sd
II;, I,;, 11;1
‘010.60 68X.03
,,;i: not ;I\;allablr.
Fig. 5 Figure s--(A)
Right tibia1 cranial muscle fibres (M2d). (B) Left tiblal cr;mial muscle tibrrh. denervated control
Electrophysiology decisively proved the efficacy of the end-to-side junction. The muscle signals in 44 % of the animals resulted from the neurorrhaphy. since post-test division brought the signals to zero. Some lack of response of muscle may have resulted merely from the dissection. It should be emphasised that axons were not divided,
(Mild). Rat nc>.9. HE. 241y
resulting in adequate reinnervation ofthe tibia1 cranial muscle. The reinnervated muscle recovered without impairing the donor. In spite of the relatively easy technique. we are interested in better axon nrowth into the nerve graft. as well as higher yields ot’motor end plates. Our objective was not to compare end-to-end with
Conclusions
’ -.
End-lo-side neurorrhaphy thrcjuph a11 epincural windw only without damage to the bc~iy of the donor nerve allows recover> of neural It:xlc)ns when only the distal end of ;I ner\ c i\ .I\ ailahlt~. i. We-bclic\e that this technique i5clinicxll!; .Idaptablc.
80 S. R. Benato, H. I’. C. Moraes. C. L. Mqqel. F. Michelin. J. A. Pena and FUNDUNESP (Fundaclio Para o Desenvolvimento da UNESP).
References I. C‘olemam CC. Surgical treatment of peripheral nerve injuries. Surg Gyn Obst 1934: 7X: 113-13. 2. Van Beek AL, Kleinert HE. Practical microneurorrhaphy. Orth Clin North Am 1977: X: 377 X6. 3. TerTis J. Chnical microsurgery of the peripheral nerve: the state of the art. Clin Plast Surp 1979; 6: 247-67. 4. Viterbo F Regener&io de nerve. In: Melega JM. .&mini SA. Psillakis JM. editors. Cirugia pldstica repsradora e estPtica. Rio de Janeiro: Medsi. 1988: 57 61. 5. Mackinnon SE. New directions in peripheral nerve surgery. t\nn Pleat Surg 1989: 22: 257 73. 6. BruneII G. Brunelli F. Strategy and timing of peripheralnerve surgery. Neurosurg Rev 1990: 13: 95 102. 7. Mlllesi H. Peripheral nerve surgery toda:: turning point or continuous development’? (Review article). J Hand Surg (.4m) 19%); 15: 281 7. X. Harris ME. Tindall SC. Techniques of peripheral nerve repair. Neurosurg Clin North Am 19YI : 2: 93-104. Y. Ballance CA. Ballance HA. Ste!\cart P. Remark5 on the operative treatment of chronic facial palsy of peripheral origin. BMJ 1903: 2: IOOY I?. IO. Harris W. Lo\v VW. On the Importance of accurate muscular analysis in lesions ofthe brachial plexus; and the treatment of Erb‘s palsy and infantile paralysis of the upper rxtremit!: by cross-union of the nerve roots. BMJ 1903; 24: 1035-X. I I. Sherren J. Some points in the surgery of the peripheral nerves. Edinb Med J 1906: 20: 247 331. 12. Viterbo F. Desncrva~do: contrlbuipdo ao estudo morfol&ico e histoewimoldgico do “M. Gr2icilis” do c20 (Cants &miliaris) (dissertation). Botucatu: Faculdade de Medicma. Universidade Estadual Paulista. 19X4. Ii. Viterbo F, Trindade JCS, Dal Pai V. Cury PR. Number ot muscular fibers by microscopic field: a simple and efficient method to study denervation. Rev Sot Bras Cir Plast 19X9: 4: 4 II. 14. Vitcrbo F. Trindade JCS. Hoshino K. Mazzom Nero A. Lateroterminal neurorrhaphy without removal of the epineural sheath. Experimental study in rats. 50 Paula Medical Journal (Rev Paul Med) l9Y2: I IO: 267-75.
British Journal
of Plastic Surlrerv
15. Viterbo F. Trindade JCS. Hoshino K. Mazrom Neto A Endto-side nerve anastomohis. Experimental study in the rat. Annals of the 2Yth Brazilian Congress of Plastic Surprr! 1992 Nov 8; Porto Alegre: 35. 16. Vitcrbo F. Neurorratia l;itero-terminal. estudo e.xperimental no rato (PhD thesis). Botucatu. Faculdade de Medicine: Ilniversidadc Estadual Paulista. 1991. 17. Viterbo F. Cross-face termino-lateral neurorrhaphy : :I IX:M method for treatment of facial palsy. 6lst Annual Scientitic Meeting of the .4merican Society of Plastic and Reconhtructive Surgeons. the Plastic Surgery Educational Foundation. and the American Society of Mauillofacial Surgeon\: 1992Sept 20; Washington. DC: Plactic Surgical Forum. 1992: 35&X. IX. Viterbo F. End-to-side nerve anaatomosis \\lth and uithout epineurium. Experimental and clinical experience. Pre\cnted at the “grand round” of the Plastic Surgery Llmt. Unicerhity of Alabama. Birmingham. USA: Ott 13. lYY2. IY. Viterbo F. Cross-face termino-lateral neur~wrhaphy : :I new method for treatment of facial palsy. Annala of the 2Yth Brazilian Congress of Plastic Surgery: lYY2 Nov X. Porte Alegre: 28. 20. Behmer OA, Tolosa EMC‘. Frritab Neto AC;. Manual de tPcnicas para histologia normal e patolbgica. Ist rd. S5o Paula: Edart/Edusp. 1976: 146. 11. Goodman LA. Simultaneous contidcncr inter\alb for contrasts among multinomial populations. Annal, of Mathematxll Statistics lY64: is: 716 25. -_. 71 Goodman LA. On \lmultaneous confidence inter\& t’~,rmultinomial proportions. Technometrics 1965: 7: 247~ 5-I
The Authors Faust0 Viterbo, Prof‘ebaor and Chief of Plastic Surgery. Jo& Carlos Trindade, Professor and Chicf of I_lrolosy. Katsumasa Hoshino, Professor of Physiolog August0 Mazzoni, Dental Surgeon. Faculdade de Medicina, Umwrsidade 1861 X-000 Botucatu, SP. Brazil.
Estadual
Requebts for reprints to: Dr F.. Viterbo. 1X60?-790 Botucatu. Sso Paula. Brn7il. Paper recri\ed 7 January lYY3. Accepted 8 November 1943, after rewsmn
Paullsta/ll&ESP.
Rua Jox! Dal Farra.
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