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Remplir Nerve Wrap

38 citationsUpdated Oct 2026
Illustration: Remplir Nerve Wrap

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Remplir is a sterile, resorbable collagen membrane designed for the repair of peripheral nerve injuries [1]. As a collagen-based nerve wrap, it provides protection to the injured nerve during the healing process [2]. The device is intended for use in peripheral nerve repair to protect the injured nerve following repair [3, 17]. By shielding the site, Remplir creates a favorable environment for nerve regeneration to occur [1, 17].

The membrane is engineered to dissolve within 3 to 6 months [2]. This resorbable characteristic allows the device to support the initial phase of healing without requiring secondary removal. The intended use, principles of operation, and technological characteristics of Remplir are substantially equivalent to the predicate device NeuraWrap [9].

Anatomy & Pathophysiology

Peripheral Nerve Structure and Injury

The peripheral nerve comprises axons, Schwann cells, and connective tissue sheaths including the epineurium, perineurium, and endoneurium [38]. Injuries are classified into three types based on the severity of structural damage [38]. Loss of a 2 cm segment of nerve limits the potential regeneration of the nerve regardless of the type of nerve repair used [10]. Poor motor recovery following repair of transection injuries may be related to poor specificity of reinnervation [20]. Individual fascicular suture may avoid distortion of the central connections of peripheral units, a difference that is statistically significant compared to epineurial suture [19]. The epineurial method of nerve repair appears preferable to other methods because it is technically less cumbersome and the surgical procedure is not as tedious [16].

Nerve Wrap and Conduit Pathophysiology

Remplir is a sterile, resorbable collagen membrane intended for the repair of peripheral nerve injuries to protect the injured nerve and provide a favorable environment for regeneration [1, 3]. As a collagen-based nerve wrap, it provides protection to the injured nerve during healing and dissolves within 3 to 6 months [2]. Nerve wraps reduced collagen deposition within the coaptation, but no differences were observed in axonal regeneration, neuromuscular junction reinnervation, or functional recovery [6]. Use of nerve conduits is preferable over suture repair and nerve grafting, as functional recovery rates are above 80% [7]. Nerve conduits are indicated primarily for bridging digital sensory nerve gaps of 3 cm or less, avoiding donor site morbidity associated with nerve autografts [13]. Nerve conduits may be used to bridge digital sensory nerve gaps of ≤3 cm when direct tensionless repair is not possible, with nerve autograft remaining the benchmark for larger, longer, mixed, or motor nerve defects [21]. Nerve repair using autograft provided superior motor nerve recovery over two collagen conduits for a 10-mm nerve gap in a murine acute transection injury model [15]. Functionalized neurotubes showed significantly better functional results than after end-to-end nerve suture [18]. Therapeutic observations of 75 peripheral nerve repairs using the NeuraGen collagen nerve conduit yielded no conduit rejection and only 2 cases of scar sensitivity [5]. Secondary decompression combined with porcine extracellular matrix nerve wrapping was an effective and safe treatment for patients with recurrent cubital tunnel syndrome [23]. SRN entrapment neuropathy was safely and effectively treated with neurolysis and amnion nerve wrapping in a small series [8]. Purified type 1 bovine collagen conduits are a practical and efficacious method for the repair of median nerves in the distal forearm [24]. Collagen nerve tubes might offer a clinically effective option for restoration of sensory function, with initial results comparing favorably to existing literature for various types of nerve repair and reconstruction [11]. Nerve conduits and processed nerve allografts offer equally effective means of reconstructing sensation of a digital nerve gap less than 3 cm after 12 months of follow-up, although allograft reconstruction showed earlier improved outcomes at 6 months [14]. An epineurial-like collagen device restored functional motor recovery in the upper extremities in patients with peripheral nerve or spinal cord injuries [25]. Data suggest that promoting the M2 response is associated with a remodeling response, whereas collagen conduits exhibited an encapsulation-like appearance [47].

Hand and Wrist Anatomy

The skeleton of the hand and wrist consists of 27 bones, of which 19 are long bones [28]. The skeleton is divided into five rays, each ray making up a polyarticulated chain comprising the metacarpals and phalanges [28]. The wrist has three axes of movement, permitting the hand to be positioned in any spatial configuration and allowing it to be placed as needed for grasping [28]. The thumb metacarpal is the shortest, and the index metacarpal is by far the longest [28]. The proximal and middle phalanges of the long and ring fingers are longer than those of the index finger [28]. The trapezium is clearly angled out in front of the carpal plane so that the first metacarpal makes an angle of about 45 degrees with the second metacarpal in the sagittal plane [28]. The transverse axis of the palm forms an acute angle of approximately 75 degrees with the longitudinal axis [28]. The epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, whereas they are located at the distal ends of the other metacarpals [28].

Control of digital posture requires a complex balance of extrinsic and intrinsic muscle forces [27]. Extrinsic muscles have their origin outside of the hand and their insertion on the hand or carpus, whereas intrinsic muscles have both origin and insertion within the hand [27]. The extrinsic extensors run through six different fibroosseous retinacular compartments at the wrist level [27]. The first extensor compartment contains the abductor pollicis longus and the extensor pollicis brevis [27]. The second extensor compartment contains the extensor carpi radialis longus and the extensor carpi radialis brevis [27]. The third compartment contains the extensor pollicis longus, which runs longitudinally down the forearm through the third compartment and turns abruptly radialward about Lister tubercle [27]. The fourth extensor compartment contains the extensor indicis proprius lying deep to the four tendons of the extensor digitorum communis [27]. The fifth compartment contains the extensor digiti quinti [27]. The extensor carpi ulnaris tendon runs through the sixth compartment and inserts at the base of the little finger metacarpal [27]. The digital extensor tendons are stabilized over the mid-line of the metacarpophalangeal joint by their attachment to sagittal band fibers [27]. With rupture or attenuation of the sagittal band fibers, the extrinsic extensor tendon can sublux to the ulnar side of the metacarpal head causing ulnar deviation of the finger [27].

The extrinsic finger flexors are the flexor digitorum profundus and the flexor digitorum superficialis [27]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx, flexing the distal interphalangeal joint as well as the proximal interphalangeal and metacarpophalangeal joints [27]. There are seven interosseous muscles, four dorsal and three volar [32]. The dorsal interossei are abductors and lie to the radial side of the index and middle fingers and the ulnar side of the middle and ring fingers [32]. The volar interossei are adductors and lie to the ulnar side of the index finger and the radial side of the ring and little fingers [32]. The middle finger has two dorsal interossei (abductors) and no volar interossei (adductors) because the central axis of the hand lies within it [32]. The superficial head of each dorsal interosseous muscle abducts and weakly flexes the proximal phalanx [32]. The deep head of each dorsal interosseous muscle flexes and weakly abducts the proximal phalanx while extending the middle and distal phalanges [32]. The volar interossei form the ulnar lateral band of the index finger and the radial lateral band of the ring and little fingers [32]. The abductor digiti quinti and flexor digiti quinti brevis are similar in both structure and function to the superficial and deep heads of the dorsal interossei, respectively [32]. The opponens digiti quinti arises from the pisohamate ligament and the hook of the hamate and inserts onto the ulnar side of the diaphysis of the fifth metacarpal, which it flexes and supinates [32].

The flexor digitorum profundus originates from the proximal ulna and the interosseous membrane [39]. The flexor digitorum superficialis has two heads: the radial head originates from the proximal shaft of the radius, and the humeral ulnar head originates from the medial humeral epicondyle and coronoid process of the ulna [39]. The flexor pollicis longus originates from two heads: the radial head takes origin from the proximal radius and interosseous membrane, and an accessory head originates from the coronoid process of the ulna and from the medial epicondyle of the humerus [39]. The fibroosseous tunnel, or digital flexor sheath, consists of annular pulleys which provide mechanical stability, and cruciate pulleys which provide flexibility [39]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [39]. The tenosynovium that lines the fibroosseous tunnel supplies both nutrition and lubrication to the poorly vascularized flexor tendons [39].

The vessels and nerves adapt themselves to differences in length and are surrounded by loose fibroadipose connective tissue [40]. The dorsal skin owes its suppleness and mobility to its histological structure, with relative thinness making it more stretchable and loose connections with deeper planes allowing free gliding [41]. Flexion of the fingers produces a significant lengthening of the dorsal skin, with an average increase of 3 cm in the middle finger as it goes from extension to full flexion [41]. The dorsal and palmar areas of skin are independent because of a system of adhesions that anchors their common boundary to the underlying plane [41]. The superficial palmar fascia lies in a coronal plane beneath the palmar subcutaneous tissue and covers a triangular area of the central palm [42]. The digital neurovascular structures are surrounded by a diffuse network of thin transverse oblique fibers, with fibers dorsal to the bundle called Cleland ligament and those palmar to the bundle called Grayson ligament [42].

The metacarpal arch is endowed with a great deal of adaptability because of the mobility of the peripheral metacarpals [35]. The index metacarpal is the most firmly fixed, while the fifth metacarpal is semi-independent with a range of flexion–extension of approximately 20 degrees [35]. The keystones of the longitudinal arches are the metacarpophalangeal articulations, whose thick anterior glenoid capsules, the volar plates, prevent hyperextension [35]. The hand is both an organ designed to obtain information and an organ of execution [30]. The open hand, with fingers extended and in contact, forms a balanced graceful oval in its longitudinal axis [30]. The posterior or dorsal aspect of the hand is convex, and the anterior, palmar or volar aspect is concave [30]. The digits are divided into the thumb and four fingers, with the thumb having a more proximal and lateral position allowing movement inward and outward from the palm [30]. When the fingers are extended and separated, the tips of the fingers lie on the circumference of a circle whose center is the head of the third metacarpal [30]. The hand consists of 19 bones, 17 articulations, and 19 muscles situated entirely within the hand, and about the same number of tendons activated by the forearm muscles [30].

Classification

Device Type: Remplir is a sterile, resorbable collagen membrane intended for use in peripheral nerve repair [3]. It is designed to protect the injured nerve and provide a favourable environment for regeneration [3]. Following repair, the membrane serves to protect the injured nerve and provide a favourable environment for nerve regeneration to occur [17].

Clinical Presentation

Remplir is a sterile, resorbable collagen membrane intended for use in peripheral nerve repair to protect the injured nerve following repair [17].

Investigations

Clinical Evaluation: Clinical evaluation of the injured or dysfunctional hand and wrist requires combining patient history with a careful physical examination to pinpoint or narrow the scope of possible pathologic processes [26]. A careful physical examination is essential to direct care and future testing if indicated [26]. Diagnostic tests such as imaging and serum laboratory studies are useful in determining pathology but can be expensive, time consuming, and often nonspecific [26].

Doppler Assessment: An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences [45]. False-negatives are possible with 8-MHz Doppler tone assessment for identifying neurovascular bundles [45]. Doppler imaging is a promising improvement over tone assessment but higher resolution imaging technology is needed [45].

MRI: MR assessment of Dupuytren’s disease is hindered by the resolution of current equipment, orientation issues due to multiplanar deformities of the fingers, and lack of intraoperative availability [45]. MRI is probably most useful in identifying additional pathology such as flexor tendon bowstringing [45]. MRI may be helpful in providing a quantitative noninvasive measure of cellularity of affected areas, which is an index of biologic activity [45].

Treatment

Operative

Surgical Approach / Technique: The epineurial method of nerve repair is preferable because it is technically less cumbersome and the surgical procedure is not as tedious [16]. Connector-Assisted Coaptation is suggested as an important tool in the nerve repair and reconstruction armamentarium based on clinical experience and current evidence [12].

Implant Selection: Therapeutic observations of 75 peripheral nerve repairs using the NeuraGen collagen nerve conduit have yielded no conduit rejection and only 2 cases of scar sensitivity [5]. Initial results for collagen nerve tubes in digital nerve repair compare favorably with those reported in existing literature for various types of nerve repair and reconstruction, suggesting that collagen nerve tubes might offer a clinically effective option for restoration of sensory function [11]. Use of nerve conduits is preferable over suture repair and nerve grafting, as the functional recovery rates are above 80% [7]. In a murine acute transection injury model, nerve repair using autograft provided superior motor nerve recovery over two conduits for a 10-mm nerve gap [15].

Adjuncts: Nerve wraps reduced collagen deposition within the coaptation; however, no differences were observed in axonal regeneration, neuromuscular junction reinnervation, or functional recovery [6].

Other Considerations: Perhaps loss of a 2 cm segment of nerve limited the potential regeneration of the nerve regardless of the type of nerve repair used [10]. The poor motor recovery following repair of transection injuries may be related to poor specificity of reinnervation [20].

Complications

Wound complications: Therapeutic observations of 75 peripheral nerve repairs using the NeuraGen collagen nerve conduit yielded no conduit rejection [5]. In the same series, only 2 cases of scar sensitivity were reported [5].

Other Considerations: Nerve wraps reduced collagen deposition within the coaptation [6]. No differences were observed in axonal regeneration between groups with and without nerve wraps [6]. Similarly, no differences were observed in neuromuscular junction reinnervation between groups with and without nerve wraps [6]. Finally, no differences were observed in functional recovery between groups with and without nerve wraps [6].

Recovery

Rehabilitation protocol: Therapy evaluation and treatment protocols for patients with peripheral nerve repairs with nerve conduits are detailed [4].

Other Considerations: No differences were observed in axonal regeneration, neuromuscular junction reinnervation, or functional recovery when using nerve wraps [6]. Loss of a 2 cm segment of nerve limited the potential regeneration of the nerve regardless of the type of nerve repair used [10]. Initial results for collagen nerve tubes in digital nerve repair compare favorably with those reported in existing literature for various types of nerve repair and reconstruction [11]. Collagen nerve tubes might offer a clinically effective option for restoration of sensory function [11]. Connector-Assisted Coaptation is suggested as an important tool in nerve repair and reconstruction armamentarium based on clinical experience and current evidence [12]. Nerve conduits are indicated primarily for bridging digital sensory nerve gaps of 3 cm or less [13]. Nerve conduits avoid donor site morbidity associated with nerve autografts [13]. Nerve conduits and processed nerve allografts offer equally effective means of reconstructing sensation of a digital nerve gap less than 3 cm after 12 months of follow-up [14]. Allograft reconstruction showed earlier improved outcomes at 6 months compared to nerve conduits [14]. Nerve repair using autograft provided superior motor nerve recovery over two collagen nerve conduits for a 10-mm nerve gap in a murine acute transection injury model [15]. Individual fascicular suture may avoid distortion of the central connections of peripheral units [19]. Histologic analysis and nerve axon counting of the recipient peroneal nerve showed significantly more regenerative nerves on the left than on the right in a comparison of end-to-side repair techniques [22].

Key Evidence

  • [L4] Therapy evaluation and treatment protocols for patients with peripheral nerve repairs with nerve conduits are detailed. [4] (10.1197/j.jht.2005.02.012)
  • [L4] Therapeutic observations of the aforementioned 75 peripheral nerve repairs using the NeuraGen collagen nerve conduit have yielded no conduit rejection and only 2 cases of scar sensitivity. [5] (10.1097/bth.0b013e31815e6334)
  • [L5] Nerve wraps reduced collagen deposition within the coaptation; however, no differences were observed in axonal regeneration, neuromuscular junction reinnervation, or functional recovery. [6] (10.1016/j.jhsa.2020.11.023)
  • [L1] Despite major methodological limitations in the studies, we can conclude that use of nerve conduits is preferable over suture repair and nerve grafting, as the functional recovery rates are above 80%. [7] (10.1016/j.hansur.2016.10.212)
  • [L4] SRN entrapment neuropathy was safely and effectively treated with neurolysis and amnion nerve wrapping in this small series. [8] (10.1142/s0218810417200015)
  • [Paper] Perhaps loss of a 2 cm segment of nerve limited the potential regeneration of the nerve regardless of the type of nerve repair used. [10] (10.1016/s0363-5023(80)80178-x)
  • [L4] Although the patients in this study are still within the early follow-up period, our initial results compare favorably with those reported in the existing literature for various types of nerve repair and reconstruction, suggesting that collagen nerve tubes might offer a clinically effective option for restoration of sensory function. [11] (10.1016/j.jhsa.2008.03.015)
  • [L5] Authors suggest Connector-Assisted Coaptation as an important tool in nerve repair and reconstruction armamentarium based on clinical experience and current evidence. [12] (10.1002/micr.30151)
  • [L5] Nerve conduits are indicated primarily for bridging digital sensory nerve gaps of 3 cm or less, avoiding donor site morbidity associated with nerve autografts. [13] (10.1016/j.jhsa.2013.02.034)
  • [L4] Nerve conduits and processed nerve allografts offer equally effective means of reconstructing sensation of a digital nerve gap less than 3 cm after 12 months of follow-up, although allograft reconstruction showed earlier improved outcomes at 6 months. [14] (10.1016/j.jhsa.2018.06.040)
  • [L5] Nerve repair using autograft provided superior motor nerve recovery over the 2 conduits for a 10-mm nerve gap in a murine acute transection injury model. [15] (10.1016/j.jhsa.2018.10.008)
  • [L3] The epineurial method of nerve repair appears preferable because technically it is less cumbersome to perform and the surgical procedure is not as tedious. [16] (10.1016/s0363-5023(76)80006-8)
  • [L5] Functionalized neurotubes showed significantly better functional results than after end-to-end nerve suture. [18] (10.1016/j.hansur.2020.05.007)
  • [L3] These differences are statistically significant, supporting the hypothesis that individual fascicular suture may avoid distortion of the central connections of peripheral units. [19] (10.1016/s0363-5023(83)80152-x)
  • [L3] The poor motor recovery following repair of transection injuries may be related to poor specificity of reinnervation. [20] (10.1002/jor.1100150506)
  • [L5] Nerve conduits may be used to bridge digital sensory nerve gaps of ≤3 cm when direct tensionless repair is not possible, with nerve autograft remaining the benchmark for larger, longer, mixed, or motor nerve defects. [21] (10.5435/jaaos-20-02-063)
  • [L3] Histologic analysis and nerve axon counting of the recipient peroneal nerve showed significantly more regenerative nerves on the left than on the right. [22] (10.1053/jhsu.2002.32953)
  • [L4] This study found that secondary decompression combined with porcine extracellular matrix nerve wrapping was an effective and safe treatment for patients with recurrent cubital tunnel syndrome. [23] (10.1016/j.jhsa.2015.02.031)
  • [L4] This study indicates that purified type 1 bovine collagen conduits are a practical and efficacious method for the repair of median nerves in the distal forearm. [24] (10.1016/j.jhsa.2013.03.028)
  • [L4] The device restored functional motor recovery in the upper extremities in patients with peripheral nerve or spinal cord injuries. [25] (10.1055/s-0044-1785213)
  • [L5] Data suggest that promoting the M2 response is associated with a remodeling response, whereas Col conduits exhibited an encapsulation-like appearance. [47] (10.1016/j.jhsg.2021.06.006)

See Also

References

[1] Remplir Nerve Wrap IFU (Singapore). n.d..

[2] Remplir Patient Information Leaflet (AUS). 2024.

[3] Remplir Instructions for Use. n.d..

[4] Nerve Conduits. Journal of Hand Therapy. 2005. DOI: 10.1197/j.jht.2005.02.012

[5] Repair of Lacerated Peripheral Nerves With Nerve Conduits. Techniques in Hand & Upper Extremity Surgery. 2008. DOI: 10.1097/bth.0b013e31815e6334

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

[7] Nerve conduits for treating peripheral nerve injuries: A systematic literature review. Hand Surgery and Rehabilitation. 2017. DOI: 10.1016/j.hansur.2016.10.212

[8] Neurolysis with Amniotic Membrane Nerve Wrapping for Treatment of Secondary Wartenberg Syndrome: A Preliminary Report. The Journal of Hand Surgery (Asian-Pacific Volume). 2017. DOI: 10.1142/s0218810417200015

[9] FDA 510(k) K243889 — Remplir Nerve Wrap Clearance. 2024.

[10] Neurorrhaphy after loss of a nerve segment: Comparison of epineurial suture under tension versus multiple nerve grafts. The Journal of Hand Surgery. 1980. DOI: 10.1016/s0363-5023(80)80178-x

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

[12] Refinements of nerve repair with connector-assisted coaptation. Microsurgery. 2017. DOI: 10.1002/micr.30151

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

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

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

[16] Epineurial and perineurial fascicular nerve repairs: A critical comparison. The Journal of Hand Surgery. 1976. DOI: 10.1016/s0363-5023(76)80006-8

[17] ARTG Entry 385752 — Remplir Nerve Guide Public Summary. 2022.

[18] Functionalized nerve conduits for peripheral nerve regeneration: A literature review. Hand Surgery and Rehabilitation. 2020. DOI: 10.1016/j.hansur.2020.05.007

[19] Specificity of muscle reinnervation after epineurial and individual fascicular suture of the rat sciatic nerve. The Journal of Hand Surgery. 1983. DOI: 10.1016/s0363-5023(83)80152-x

[20] Functional recovery following neurorrhaphy of the rat sciatic nerve by epineurial repair compared with tubulization. Journal of Orthopaedic Research. 1997. DOI: 10.1002/jor.1100150506

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

[22] A modified end-to-side method for peripheral nerve repair: Large epineurial window helicoid technique versus small epineurial window standard end-to-side technique. The Journal of Hand Surgery. 2002. DOI: 10.1053/jhsu.2002.32953

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

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

[25] Reconstruction of Upper Extremity Peripheral Nerve Injuries Using an Epineurial-Like Collagen Device — A Prospective Clinical Study. J Reconstr Microsurg Open. 2024. DOI: 10.1055/s-0044-1785213

[26] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Evaluation and Clinical Examination: Current Concepts.

[27] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > Image DISORDERS OF THE MUSCULATURE OF THE HAND.

[28] Exam Of The Hand Wrist 2Ed. 1.1 SKELETON OF THE HAND > The osseous skeleton.

[30] Exam Of The Hand Wrist 2Ed. INTRODUCTION.

[32] Green S Operative Hand Surgery. Interosseous and Hypothenar Muscles.

[35] Exam Of The Hand Wrist 2Ed. The arches of the hand > The metacarpal arch.

[38] Orthopaedic Basic Science Fifth Edition Print Ebook. Biology and Mechanics of the Skeletal Extracellular Matrix > References.

[39] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > FLEXOR TENDON INJURY.

[40] Exam Of The Hand Wrist 2Ed. 1.3 MOVEMENTS OF THE HAND AND WRIST > Gliding mechanisms.

[41] Exam Of The Hand Wrist 2Ed. The dorsal skin.

[42] Green S Operative Hand Surgery. PERTINENT ANATOMY.

[45] Dupuytren S Disease And Related Hyperproliferative Disorders. 54. The Future of Dupuytren’s Research and Treatment > 54.4 Mechanical Measurements and Procedures > 54.4.4 Imaging.

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

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a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.