The Reversed Venous Arterialized Nerve Graft in Digital Nerve Reconstruction Across Scarred Beds

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Abstract
Conventional nerve grafts in complex digital injuries often yield poor results, particularly when placed in traumatized or avascular beds. Vascularized nerve grafts offer an option; experimental evidence suggests superior axonal regeneration across scarred beds with vascularized nerve grafts. We previously described a vascularized graft based on the dorsalis pedis artery--deep peroneal nerve "system." Reluctance to sacrifice this major artery, combined with the recent description by Townsend and Taylor and Gu, et al, of "reversed venous" arterialized nerve grafts, spurred us on to investigate the deep peroneal nerve--dorsalis pedis venae comitantes system. Fourteen neurovenous grafts were used in scarred or poorly vascularized beds for digital nerve reconstruction in 10 patients over a 4-year period. Graft length averaged 4.4 cm; interval from injury was 1 to 17 months. Sensory parameters of return included average static two-point discrimination of 8.3 mm, moving two-point discrimination of 5.8 mm, and median Semmes-Weinstein monofilament appreciation of 2.83. Two patients received three vascularized grafts and three conventional grafts for adjacent nerve injuries in the same digit, serving as internal controls. In these patients, the vascularized nerve grafts returned mean static two-point discrimination values of 9.3 mm and moving two-point discrimination values of 6.7 mm. The conventional nerve grafts averaged static two-point discrimination of 14.3 mm and moving two-point discrimination values of 10.3 mm. These differences imply enhanced axonal regeneration through vascularized nerve grafts. These data suggest that the reversed neurovenous graft may be the procedure of choice in secondary reconstruction of digital nerves across scarred beds or following injuries with poor soft-tissue vascularity, especially in those patients with cold intolerance.

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