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Tendon and Nerve Repair

Hand tendon/nerve repair: primary vs secondary reconstruction, Zone II management, and rehabilitation protocols for optimal functional recovery.

131 citationsUpdated Oct 2026

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Overview

Peripheral nerve repair and tendon transfer serve as complementary reconstructive strategies for restoring upper limb function following traumatic or iatrogenic injury. Nerve grafting is indicated especially in young patients with nerve loss or associated lesions that do not allow immediate repair [18]. For large gaps of nine centimeters or greater, an attempt at nerve reconstruction before proceeding to tendon transfers appears to be indicated within 8 months [5]. Tendon transfer remains a useful option to restore function after a nerve injury to the radial, median, or ulnar nerve when surgical repair to the nerve does not result in useful function or nerve repair is not possible [15]. Intrinsic hand muscle reinnervation by median-ulnar end-to-side bridge nerve graft is mainly indicated in high peripheral nerve injury or secondary cases when recovery of the intrinsic muscle of the hand is not expected after end-to-end repair or graft [10].

Nerve transfers have become a first line reconstructive technique in the restoration of function, with fundamental principles such as donor site location, strength, safety, and efficacy introduced by Oberlin et al remaining integral to contemporary nerve surgery [44]. Patients who present early and can tolerate longer time to functional recovery would be optimal candidates for nerve transfers [33]. Conversely, tendon transfer offers an important alternative—possibly the procedure of choice—to microsurgical nerve reconstruction, particularly when early professional and social reintegration is important [25]. Selection of the donor nerve must be carefully weighed against other treatment alternatives, considering the risk of donor nerve impairment and the potential narrowing of future reconstructive options [46]. Simultaneous nerve repair and tendon transfer showed no detrimental results and may provide improved function over tendon transfer alone in a limited case series for rare conditions [3].

Outcome data present mixed signals regarding the superiority of specific techniques. Better outcomes were observed in those who underwent nerve transfer versus tendon transfer procedures for radial nerve paralysis reconstruction [20]. However, tendon transfers had higher rates of superior clinical outcomes as compared with nerve transfers and nerve grafts on pooled analysis for isolated radial nerve palsy [32]. In brachial plexus injury in war victims, end-to-end nerve repair was performed in 10% of cases, and 35% had excellent results [4]. Tendon or tissue transfers in combined nerve palsies require longer follow-up than isolated nerve palsies to make a valid assessment of the outcome [2]. More participants with a longer follow-up are needed to fully demonstrate the superiority of combined nerve and tendon procedures [7]. Techniques for clinical approximation of severed nerve ends have reached an optimal technical refinement, and new concepts are needed to further increase the results from nerve repair [12]. There are no published outcomes studies on the clinical use of the supercharged end-to-side nerve repair to date [24]. The improvement of primary flexor tendon repair has limited the indications of secondary repairs to neglected initial wound care and deficiencies in the surgical technique or rehabilitation [27]. Therapy evaluation and treatment protocols for patients with peripheral nerve repairs with nerve conduits are detailed [1]. More prospective studies using standardized outcome measures are needed to define the precise role of nerve transfers [59]. More homogeneous follow-up protocols are needed for strength measurement and patient-reported outcome measures for both nerve and tendon transfers [11]. An increased need for studies addressing combined nerve and tendon transfer reconstructions alongside patient-perceived outcome investigations is foreseen [6]. Immobilization of nerve repairs is recommended, although this contradicts most recent studies [55].

Anatomy & Pathophysiology

Bony Anatomy

The skeleton of the hand and wrist comprises 27 bones, 19 of which are long bones [39]. This skeleton is organized into five rays, each forming a polyarticulated chain of metacarpals and phalanges [39]. The base of each metacarpal articulates with the distal carpal row, while the carpus connects to the forearm via its proximal row [39]. The radioulnocarpal articulation possesses two axes of movement, supplemented by a third axis of pronation and supination from the forearm [39]. These three axes permit the hand to assume any spatial configuration necessary for grasping [39].

The first ray is the shortest, consisting of a metacarpal and two phalanges [39]. It continues the external carpal column formed by the scaphoid and trapezium [39]. The trapezium is angled anteriorly relative to the carpal plane, creating an approximately 45-degree angle between the first and second metacarpals in the sagittal plane [39]. Among the metacarpals, the thumb metacarpal is the shortest and the index metacarpal is the longest [39]. The proximal and middle phalanges of the long and ring fingers are longer than those of the index finger [39]. Epiphyseal plates are located at the proximal ends of the phalanges and the first metacarpal, but at the distal ends of the other metacarpals [39].

The hand exhibits longitudinal and transverse concavities, forming a cup shape with palmar concavity when the thumb is positioned next to the index finger [39]. The transverse axis of the palm, corresponding to the metacarpophalangeal articulations, is not perpendicular to the longitudinal axis; instead, it forms an acute angle of approximately 75 degrees [39]. The metacarpal arch is highly adaptable due to the mobility of the peripheral metacarpals [78]. The index metacarpal is the most firmly fixed, while the ring metacarpal allows about 10 degrees of flexion and extension, and the fifth metacarpal permits approximately 20 degrees of flexion–extension [78].

The second through fifth metacarpals are bound by fibrous structures, the most distal being the deep transverse intermetacarpal ligament [78]. This ligament is better termed the interglenoid ligament because it connects the anterior “glenoid ligaments” of the metacarpophalangeal joints, known as volar plates [78]. The longitudinal arches consist of a fixed carpometacarpal portion and a mobile digital portion [78]. The metacarpophalangeal joints serve as keystones for these arches, with their thick anterior glenoid capsules (volar plates) preventing hyperextension [78]. Stability of the metacarpophalangeal joints is essential for supporting both the longitudinal and transverse metacarpal arches [78].

Muscular Anatomy

Digital posture control requires a complex balance of extrinsic and intrinsic muscle forces [38]. Extrinsic muscles originate outside the hand and insert on the hand or carpus, whereas intrinsic muscles have both origin and insertion within the hand [38]. Extrinsic muscles function as flexors or extensors, while intrinsic muscles contribute to both digital flexion and extension [38].

The extrinsic extensors traverse six fibroosseous retinacular compartments at the wrist [38]. The first (most radial) compartment contains the abductor pollicis longus and extensor pollicis brevis [38]. The abductor pollicis longus has multiple slips inserting at the base of the thumb metacarpal to radially abduct the thumb [38]. The extensor pollicis brevis inserts on the dorsum of the proximal thumb phalanx to actively extend the thumb metacarpophalangeal joint [38]. The second compartment contains the extensor carpi radialis longus and brevis [38]. The extensor carpi radialis longus inserts on the index metacarpal to dorsiflex and radially deviate the wrist, while the extensor carpi radialis brevis inserts at the base of the middle metacarpal to provide balanced wrist dorsiflexion [38].

The third compartment contains the extensor pollicis longus, which runs longitudinally down the forearm and turns abruptly radialward at Lister tubercle [38]. This tendon provides forceful extension of the thumb interphalangeal joint, with its oblique course adding a substantial adduction component [38]. The fourth compartment contains the extensor indicis proprius, lying deep to the four tendons of the extensor digitorum communis [38]. The fifth compartment contains the extensor digiti quinti [38]. The principal bony insertion for extrinsic digital extensors is the dorsal proximal aspect of the middle phalanx [38]. Metacarpophalangeal joint extension is achieved via extrinsic extensor force transmitted through sagittal bands, while distal interphalangeal joint extension is achieved through conjoined lateral bands composed of tendinous slips from extrinsic and intrinsic tendons [38].

The extensor indicis proprius inserts on the index finger ulnar to the extensor digitorum communis, which inserts on the index, middle, ring, and sometimes little fingers [38]. The extensor digiti quinti tendon inserts on the little finger ulnar to the extensor digitorum communis insertion [38]. The extensor carpi ulnaris runs through the sixth compartment, inserting at the base of the little finger metacarpal to provide wrist extension and ulnar deviation [38]. The extensor digitorum communis tendons of the middle, ring, and little fingers are tethered by juncturae tendinum over the dorsum of the hand proximal to the metacarpophalangeal joint [38]. The extensor indicis proprius tendon is recognizable at the wrist by possessing the most distal muscle belly of any digital extensor tendon [38].

Digital extensor tendons are stabilized over the midline of the metacarpophalangeal joint by attachment to sagittal band fibers [38]. These fibers insert onto the volar proximal phalanx and lateral borders of the volar plate, forming a sling that transmits proximal extrinsic extensor tension to the proximal phalanx [38]. This mechanism permits metacarpophalangeal joint extension without a direct tendinous insertion onto the proximal phalanx [38]. By holding the extrinsic extensor tendon balanced over the metacarpal head prominence, sagittal bands keep the tendon away from the joint’s center of rotation, maximizing mechanical efficiency [38]. Rupture or attenuation of sagittal band fibers allows the extrinsic extensor tendon to sublux to the ulnar side of the metacarpal head, causing ulnar deviation of the finger [38].

The extrinsic finger flexors are the flexor digitorum profundus and flexor digitorum superficialis [38]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx, flexing the distal interphalangeal, proximal interphalangeal, and metacarpophalangeal joints [38]. The flexor digitorum superficialis acts as a flexor of the proximal interphalangeal and metacarpophalangeal joints [38]. The flexor digitorum profundus originates from the proximal ulna and interosseous membrane [82]. In the forearm, it divides into a radial component supplying the index finger and an ulnar component supplying the middle, ring, and little fingers [82]. The flexor digitorum profundus and flexor pollicis longus form the deep compartment of the volar forearm [82]. As these tendons travel through the carpal tunnel, they occupy the floor of the tunnel [82].

The tenosynovial sheath of the flexor pollicis longus is continuous with the radial bursa, while the sheath to the little finger is continuous with the ulnar digital bursa [82]. In some patients, these bursae communicate, allowing a horseshoe abscess to spread between the thumb and little finger if infection occurs in either flexor tendon sheath [82]. The lumbricals originate from the radial side of the index, middle, ring, and little fingers in the palm [82]. The profundus tendon passes through the bifurcation of the flexor digitorum superficialis before inserting into the proximal palmar base of the distal phalanx [82]. The flexor digitorum profundus of the index and middle fingers is innervated by the anterior interosseous branch of the median nerve, while the profundus of the ring and little fingers is innervated by the ulnar nerve [82]. The flexor digitorum profundus provides digital flexion at both the proximal and distal interphalangeal joints [82].

The flexor digitorum superficialis has two heads: a radial head originating from the proximal radius shaft and a humeral ulnar head originating from the medial humeral epicondyle and coronoid process of the ulna [82]. Each digit has a corresponding independent superficialis muscle [82]. As the superficialis tendons pass through the carpal tunnel, the middle and ring finger tendons are more superficial and central than those of the index and little fingers [82]. In the proximal finger, the flexor digitorum superficialis tendon bifurcates around the flexor digitorum profundus at the beginning of the A2 pulley [82]. The tendon slips reunite distally at the Camper chiasm, with approximately half of the fibers staying ipsilateral and half crossing to the contralateral side [82]. The tendon then inserts via radial and ulnar slips into the proximal metaphysis of the middle phalanx [82]. The entire flexor digitorum superficialis muscle receives innervation from the median nerve, and its primary function is digital flexion at the proximal interphalangeal joint [82].

The flexor pollicis longus originates from two heads: a radial head from the proximal radius and interosseous membrane, and an accessory head from the coronoid process of the ulna and medial epicondyle of the humerus [82]. In the palm, the flexor pollicis longus tendon traverses between the abductor pollicis brevis and flexor pollicis brevis [82]. It inserts into the proximal base of the thumb distal phalanx and is innervated by the anterior interosseous branch of the median nerve [82]. The flexor pollicis longus flexes both the interphalangeal and metacarpophalangeal joints of the thumb [82].

There are seven interosseous muscles: four dorsal and three volar [75]. The dorsal interossei are abductors [75]. Because the anatomic axis of the hand coincides with the axis of the third metacarpal, the dorsal interossei lie to the radial side of the index and middle fingers and the ulnar side of the middle and ring fingers [75]. The little finger is abducted by the abductor digiti quinti [75]. The volar interossei are adductors, lying to the ulnar side of the index finger and the radial side of the ring and little fingers [75]. Consequently, the middle finger has two dorsal interossei (abductors) and no volar interossei (adductors) because the central axis of the hand lies within it [75].

Each dorsal interosseous muscle, with the exception of the third, has two muscle heads [75]. The superficial head arises dorsally from the shaft of contiguous metacarpals and inserts deeply via a medial tendon onto the lateral tubercle of the base of the proximal phalanx [75]. This head abducts and weakly flexes the proximal phalanx, with no direct effect on the middle or distal phalanges [75]. The deep head forms a lateral tendon, or lateral band, at the level of the metacarpophalangeal joint [75]. It flexes and weakly abducts the proximal phalanx while extending the middle and distal phalanges [75]. At the mid-proximal phalanx level, transverse fibers arch dorsally from each lateral band to join over the dorsum of the finger, flexing the proximal phalanx [75]. More distally, oblique (spiral) fibers from the lateral bands sweep over the distal third of the proximal phalanx to insert onto the lateral tubercles at the base of the middle phalanx, extending the middle phalanx (proximal interphalangeal joint) [75]. Further distally, the lateral bands join the lateral slips of the extensor tendon to form the conjoined lateral band [75]. The two conjoined lateral bands unite at the distal third of the middle phalanx to form the terminal tendon, which inserts at the base of the distal phalanx to extend it [75].

The flexor digiti quinti brevis is structurally and functionally similar to the deep head of the dorsal interossei, forming the ulnar lateral band of the little finger [75]. The three volar interossei arise from adjacent surfaces of contiguous metacarpal shafts [75]. Unlike the dorsal interossei, each volar interosseous muscle has only one head and none insert onto the proximal phalanx [75]. The volar interossei form the ulnar lateral band of the index finger and the radial lateral band of the ring and little fingers [75]. As with the dorsal interossei, transverse fibers arch over the dorsum of the proximal phalanx to join the opposite lateral band, flexing the proximal phalanx [75]. All lateral bands are joined by extensor tendon lateral slips to form a conjoined lateral band and finally a terminal tendon extending to the distal phalanx [75].

Of the hypothenar muscles, the abductor digiti quinti and flexor digiti quinti brevis are similar in structure and function to the superficial and deep heads of the dorsal interossei, respectively, and arise from the fifth metacarpal [75]. The abductor inserts onto the ulnar lateral tubercle at the base of the little finger proximal phalanx [75]. The flexor digiti quinti forms the ulnar lateral band [75]. A third muscle, the opponens digiti quinti, lies deepest [75]. It arises from the pisohamate ligament and hook of the hamate, inserting onto the ulnar side of the fifth metacarpal diaphysis to flex and supinate it [75].

Tendon Anatomy & Gliding

As flexor tendons pass distal to the metacarpal neck, they enter the fibroosseous tunnel, or digital flexor sheath [82]. This tunnel extends distally to the proximal aspect of the distal phalanx [82]. The tendinous sheath consists of annular pulleys, which provide mechanical stability, and cruciate pulleys, which provide flexibility [82].

Classification

Nerve Injury Classification

Seddon: The Seddon classification (1943) categorizes peripheral nerve injuries into three groups: neurapraxia, axonotmesis, and neurotmesis [61]. This framework aids in evaluating injury prognosis and treatment [61].

Sunderland: The Sunderland classification (1951) expands upon Seddon’s model by assigning histologic injury degrees from first to fifth [61]. * First degree: Corresponds to neurapraxia, involving a localized conduction block with an intact axon [61]. Nerve conduction is slower, but electromyographic findings remain normal due to the absence of denervation [61]. Complete remyelination occurs in two to six weeks, though full recovery may take up to 12 weeks [61]. Etiology typically involves acute nerve compression, such as Saturday Night palsy or crutch paralysis [61]. * Second degree: Corresponds to axonotmesis, characterized by axonal disruption with intact endoneurium [61]. Axons regenerate along the original endoneurial tube, producing a progressing Tinel's sign and appropriate electromyographic and nerve conduction changes [61]. Complete recovery is expected except in proximal injuries where motor targets are more than 12"-24" away [61]. The cause is usually a close stretch injury, such as that sustained by the axillary nerve in a shoulder dislocation [61]. * Third degree: Involves injury to the axon, myelin, and endoneurium, but not the perineurium, leaving the fascicle intact [61]. Recovery is variable and incomplete, dependent on the type of nerve, level of injury, and amount of fibrosis [61].

Tendon Injury Classification

Flexor Digitorum Profundus: A new classification scheme for closed avulsion injuries of the flexor digitorum profundus tendon was proposed to guide surgeons toward the best treatment option [168]. This scheme appeared comprehensive and useful [168].

Extensor Tendons: An additional Type 3 category was proposed to the Türker classification system to encompass rare findings of two radial-sided accessory extensor tendons in the same individual [173]. The panel recommends adapting a simpler classification system resembling that for flexor tendons for extensor tendon injuries [151]. This extensor tendon classification system outlines specific treatment approaches for acute extensor tendon injuries in each zone to facilitate surgical decision-making and rehabilitation [151]. A survey of views in a hand surgery department suggests that a revisit of popular extensor tendon zone classification systems may be necessary for future clinical practice and communication among surgeons [176].

Other Considerations: * Mallet Injuries: The Crawford classification was used to grade outcomes in a study comparing early and delayed treatment of soft-tissue mallet injuries [185]. Patient groups in this study were classified according to tendon healing biology, with tendon stumps appearing to fuse by fibrous bridging after 2 weeks [185]. * Trigger Digits: The Newport et al. classification was used to present the distribution of trigger digits in a study correlating clinical presentations with histologic aspects of the A1 pulley [200]. * Flexor Tendon Zones: Tang's classification was used to define zones 2A and 2B for flexor tendon injuries in a study examining lateral release of pulleys [192]. * Reconstruction Strategy: The IFSSH Flexor Tendon Committee report notes that surgical opinion is split regarding one-stage versus two-stage tendon grafting, with no definitive evidence that one technique is clearly superior [165]. One group of surgeons believes two-stage reconstruction is never necessary [165]. Another group uses two-stage reconstruction for fingers with severe skin or deep scarring, trophic alterations from nerve damage, or damaged pulleys, while using one-stage for fingers with minimal scars and mobile joints [165]. A third group uses two-stage reconstruction always, believing that adhesions cannot be predicted even in apparently good fingers [165].

Clinical Presentation

History and Initial Assessment

A thorough history must elucidate both the cause and the probable injury location [108]. The initial evaluation requires assessment of motor and sensory deficits, strength of potential donor muscles, and passive joint motion [108]. Patients with an injury pattern that may lead to nerve injury warrant prompt referral to an upper extremity specialist to optimize outcomes [107].

Diagnostic Modalities

MRI and ultrasound have been of limited use for objective measures in acute nerve injury evaluation [108]. Electromyography and nerve conduction velocity studies are rarely helpful acutely except when continuity is unknown [108]. However, slowed but intact conduction on electrodiagnostic studies indicates some nerve continuity [108]. These studies are recommended around 3 to 4 months after injury [108]. Larger polyphasic motor action potentials of longer duration may be seen before clinical recovery, although the degree of recovery is unclear [108]. If the amplitude of motor nerve conduction velocity is low, less than 0.3 mV, exploration can be undertaken [108]. Repair remains a viable option even 5 to 6 months after injury if motor nerve conduction velocity amplitude is low [108].

Prognostic Indicators and Risk Factors

A migrating Tinel's phenomenon is a good prognostic indicator [108]. The presence of fractures is associated with a higher incidence of nerve and tendon injuries [17]. Involvement of nerve and tendon structures in ballistic injuries is linked to an increased risk of long-term disability [17]. Specific factors associated with a poorer prognosis in median and ulnar nerve injuries at the wrist include the existence of nerve contusion and a high number of tendon injuries [102].

Tendon Integrity and Imaging

Partial laceration of a flexor tendon can result in morbidity at varying times after injury, including entrapment, delayed rupture, and triggering [117]. In case pain is pronounced and the patient is not cooperative for preoperative examination, ultrasonography can be conducted to assess the continuity of the tendon [113]. If doubt persists regarding tendon continuity after ultrasonography, an MRI is performed [113].

Chronic Sequelae

The management of the patient with painful sequelae of nerve injury is the most challenging of all peripheral nerve reconstructions [16]. The painful neuroma is a debilitating sequela of nerve injury with poorly understood pathophysiology involving fascicular escape and scarring [118]. Treatment for painful neuromas must be tailored to the individual patient as there are a number of approaches available [118]. This case contributes further to our understanding of the clinical presentation of hand function following high median nerve transection [105].

Investigations

Clinical Evaluation and History

A careful physical examination is essential to direct care and future testing, as diagnostic tests such as imaging and serum laboratory studies can be expensive, time-consuming, and often nonspecific [37]. Patients often have difficulty accurately describing their symptoms and may incorrectly attribute pathology to a perceived deficit, whether real or imagined [37]. The task of the clinician is to combine the patient history with a careful physical examination to pinpoint or at least narrow the scope of possible pathologic processes [37]. A systematic method to approaching the physical examination is essential due to the number of structures in a small space [37].

Electrophysiology and Nerve Assessment

Electrophysiological techniques provide objective information needed to assess the degree of injury and can assist the surgeon in making proper decisions regarding treatment of peripheral nerve lesions [220]. Ultrasonographic assessment may serve as a valuable complementary tool for objectively evaluating nerve recovery [218].

Imaging

MRI: MRI provides important preoperative information for surgical decision-making and planning in patients who present late with closed flexor tendon injuries of the hand [180]. Surgical reconstruction of degenerate abductor tendons should be considered in the presence of an MRI confirmed separation where clinical findings are consistent with the known tendon disruption [182]. In Dupuytren’s disease, MRI may be helpful in providing a quantitative noninvasive measure of cellularity of affected areas, which is an index of biologic activity [89]. However, 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 [89].

CT: 3D CT volume rendering has been used to diagnose a previously unreported site of flexor tendon entrapment [225].

Doppler Imaging: An 8-MHz Doppler tone assessment may be used to identify superficially displaced neurovascular bundles when Dupuytren cords lie beneath soft fleshy prominences, but false-negatives are possible [89]. Doppler imaging is a promising improvement for identifying palmar structures, but higher resolution imaging technology is needed [89].

Other Considerations: Although diagnosing the cause of ulnar collateral ligament locking may be complicated by the lack of evidence in imaging studies, open surgical treatment has traditionally been the most often used with a high success rate [232].

Outcome Measurement and Follow-up

They foresee an increased need for studies addressing combined nerve and tendon transfer reconstructions alongside patient-perceived outcome investigations [6].

Treatment

Non-Operative

In the absence of a space-occupying lesion, a trial of nonoperative management is advisable; however, exploration of the nerve is recommended if there is no sign of muscle recovery after 6 weeks of observation or if there is progressive weakness [188].

Operative

Indications: Options for treatment of peripheral nerve injuries include direct repair, single or cabled autografts, allografts, conduit-assisted repairs, nerve transfers, and tendon- and muscle-based salvage options [106]. The goals for treating surgeons should be to (1) accurately describe the injury, (2) make a best available assessment as to the likelihood of improvement without intervention, and (3) choose the optimal intervention at the earliest time point when clarity is available [106]. Tendon lengthening and transfer are indicated for neuromuscular disorders, nerve injuries, and congenital or traumatic lesions [54]. Modern nerve-to-nerve transfers are mainly indicated in high peripheral nerve injury or secondary cases when recovery of the intrinsic muscle of the hand is not expected after end-to-end repair or graft [10].

Surgical Approach / Technique: The timing of repair, the overall management of the wound, and the technical performance of nerve suture are the only ways in which a surgeon can directly affect the outcome of the treatment of a transected nerve [13]. Tension at the site of repair is identified as one of the most frequent reasons for failure, and the application of autologous nerve grafts has become more popular to avoid suture lines with fibrosis or distraction [205]. Nerve grafting is a valuable and important technique in the management of a nerve gap in appropriate situations [209]. Delay in repair of less than 6 months, defect length of less than 5 cm, or grafting with three or more donor nerve cables achieved better recovery [22]. End to end nerve repair was performed in 10% of cases and 35% had excellent results [4]. The epineurial method of nerve repair appears preferable because technically it is less cumbersome to perform and the surgical procedure is not as tedious [88]. Resection of a nerve as a tendon graft is a serious surgical complication which may be avoided by the very knowledge of the possibility [14]. Wrapping the nerve with fibrin sealant before division and immediate fixation resulted in less protrusion of the nerve end [197]. It allows a safe, tension-free approximation of severed ends of nerves or tendons [207]. The method allows for the early evaluation of the success of nerve repair by demonstrating conduction across the repair site through the localization of tingling sensations in the area of sensory loss [199].

Implant Selection: Tubular repair is an attractive alternative to primary, delayed primary, or secondary repair of severed major nerve trunks in the human forearm [8]. When direct suture is not possible because of tension, tubular repair leaving a short distance between the nerve ends may be the key to avoiding nerve grafting [8]. Leaving an intentional distance between the nerve ends and enclosing the injury site in a “biological chamber" is a physiological approach that may allow neurotrophic and neurotropic mechanisms to act [8]. The use of type I collagen conduit is a reliable alternative to nerve grafting for gaps up to 10 mm in length [203]. Collagen conduits reliably provide a repair that restores nerve function for nerve gaps measuring less than 2 cm [204]. In median nerve implants, sensory recovery was obtained in 14 cases, but motor recovery was not obtained in 6 cases [211]. The active tendon implant is a reliable, biologically acceptable temporary tendon implant, with the major advantage being the ability to use the digit for extended periods between stage I and stage II [68]. The use of interference screws for fixation of tendon grafts to bone for hand ligament reconstructions is a promising new surgical technique [195]. This work may inform future improvements in surgical techniques for tendon-to-bone fixation [198]. A single piece of tendon does not readily fulfil both requirements for ligament reconstruction and filling the arthroplasty space [206].

Pain Management: The rationale for grafting an injured superficial branch of the radial at the wrist level includes restoration of sensibility and treatment of the painful neuroma by directing the proximal axons across the nerve graft and into the original distal neural territory of the superficial branch of the radial [70]. The goal is primarily pain relief and secondarily restoration of sensibility [70]. The graft can be highly successful in restoring sensibility, but it is not always successful in relieving pain [70].

Adjuncts: The use of the ASSI nerve and tendon cutting instrumentation will almost assuredly simplify the complex task of tendon repair, regardless of the suture technique used [93]. This technique allows for precise repair and easy gliding, and can be easily performed by orthopedic and hand surgeons [35].

Other Considerations: The results of nerve repair today are far better than they were 50 years ago, largely due to the control of wound infection and the recognition of the complex internal structure of nerves [36]. Evidence for good nerve recovery or improved function following nerve repair is poor, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels [23]. We recommend immobilization of nerve repairs, although this contradicts most recent studies [55]. Simultaneous nerve repair and tendon transfer showed no detrimental results and may provide improved function over tendon transfer alone [3]. The TWZL technique offers an alternative treatment option for patients with tendon deficiency and nerve injuries, avoiding donor site morbidity associated with autograft harvest [91]. This technique allows the tendon to be harvested with minimal scarring [65]. I would recommend it to anyone who does a significant number of tendon transfers [145]. Non-repair of partially divided flexor tendons produces excellent results with none of the complications reported by Kleinert and Schlenker [190]. Why should a severed tendon be sutured? There is only one reason: to restore an essential function to the part the tendon serves [34]. Even for large gaps, within 8 months, an attempt at nerve reconstruction before proceeding to tendon transfers appears to be indicated [5]. The anterior approach yields similar results to the posterior approach and has the advantage of allowing easier access for simultaneously performing nerve or tendon transfers to reconstruct grasp and pinch [90]. To date there are no published outcomes studies on the clinical use of the supercharged end-to-side nerve repair [24]. Surgical treatment consisting of flexor tendon sheath release is effective in restoring motion with minimal risks of recurrence and neurovascular complication, although the optimal age for surgical treatment is unclear [183]. With modern anesthesia techniques, tendon lacerations in a healthy neonate can be managed in a timely and safe manner [187]. Unless patients, their caregivers, and nonsurgical health care providers have baseline knowledge of tendon and/or nerve transfers, they are unlikely to obtain de novo awareness of surgical options with self-initiated searches [184]. The committee was charged to define techniques and establish scales for evaluation of the clinical result after surgical treatment of peripheral nerve injury [62]. The study notes that while non-randomised, the technique appears better without an increased rate of rupture but with a shorter rehabilitation period [194].

Complications

Flexor Tendon Repair

Reoperation and Rupture: The overall rate of reoperation after flexor tendon repair across all zones is 6% [189], with a median time to reoperation of 140 days in New York state [189]. The literature reports a repair rupture rate of 4% [189], while the specific rate of reoperation for rupture in New York state is 2.3% [189].

Adhesions and Tenolysis: The reported rate of tendon adhesions following flexor tendon repair is 4% [189]. In New York state, the rate of tenolysis performed after repair is 3.6% [189].

Other Mechanical and Surgical Complications: Additional complications include triggering, pulley failure, quadriga, and lumbrical plus deformity [189]. Intraoperative complications may involve injury to nerves or vessels, while postoperative infections are also possible [191]. Injury to major pulleys during repair can result in insufficient functional outcome [191].

Specific Series Outcomes: In a series of 38 patients with direct end-to-end repair of flexor pollicis longus tendon lacerations, no patient obtained the normal 40 degrees of hyperextension [130], and two patients had no interphalangeal motion [130]. In a review of 95 patients treated for flexor tendon injuries, end-to-end repairs were possible in only five of the late referrals [121]. In a series of 3 patients with late reconstruction of intratendinous ruptures of the flexor digitorum profundus tendon, none obtained excellent results [72]. Conversely, in a series of 10 patients using a new technique for flexor profundus repair in the distal part of zone I, no ruptures or infections occurred [243].

Nerve Repair and Reconstruction

Perineural Scarring: Chronic compression caused by adherent perineural scar is an important aetiological factor in further fibroblastic proliferation and fibrosis around peripheral nerves previously subjected to traumatic lesions [212]. The formation of fibrous scar around and inside peripheral nerves may significantly hamper axonal regeneration [212]. In a review of 107 endoscopic carpal tunnel releases, two cases of postoperative perineural scarring clinically manifested 3 months after surgery [212]; both cases required open re-exposure of the carpal tunnel and neurolysis [212].

Graft and Conduit Complications: In a preliminary report on the first ten human cases of "cell surgery" for nerve repair, no complications were observed either at the time of operation or later [63]. In a study of immediate and delayed nerve repair using freeze-thawed muscle autografts in animals, there were no immediate or long-term complications of the surgery [127]. However, the presence of an arterial injury repaired with a vein autograft consistently produced the lowest values for all variables compared to simple repair [127], and indices of recovery were all worse after delayed repair when compared to immediate repair [127].

End-to-Side Suture Limitations: In a study of 11 patients with traumatic brachial plexus injuries treated with end-to-side nerve suture, end-to-side neurotisations were unsuccessful in the remaining cases where shoulder abduction recovery was not observed [214]. The study did not demonstrate a reliable role for end-to-side nerve suture in brachial plexus surgery [214], and it must not be a substitute for standard reconstructive techniques [214].

Wrist Nerve Repair Outcomes: In a study of 9 young adult patients with thirteen nerve lesions at the wrist level, results have been better after ulnar-nerve repair than after repair of the median nerve [42]. Sensation returned to the distal phalanx of the little finger within six months in five and after six months in three of the eight ulnar repairs [42], whereas a similar return in the distal phalanx of the index finger occurred within six months in only one of the five median repairs [42]. The final quality of sensibility was rated at S3 or better in half of the eight patients with ulnar-nerve lesions [42], compared to two of the five patients with severance of the median nerve [42]. Tendon injuries requiring repair were present in seven of the nine patients [42], with injury to one artery in five patients and both arteries cut in two others [42]; the ulnar artery was repaired in each of the two patients where both arteries had been cut [42]. Regeneration began within a month of repair as indicated by Tinel’s sign distal to the wound in all patients [42]. After the eight ulnar-nerve repairs, advancement of Tinel’s sign or the point of sensibility was at the rate of five millimeters per week or more in six patients [42], and less than five millimeters per week in two patients [42]. After the median-nerve repairs, sensory return progressed more slowly [42], with regeneration progressing at the rate of five millimeters per week in only two of the five patients [42]. The amount of nerve substance resected from a stump to reach undamaged tissue never exceeded three millimeters [42], with an average total for both stumps of four millimeters [42]. In all patients, the nerve division was caused by a relatively sharp instrument and there was no tissue loss [42]. Recovery of motor function was determined by disappearance of denervation [42]. The trial series included nine young adult patients with thirteen nerve lesions—eight ulnar and five median, all at the wrist level [42].

Long-Term and Technical Considerations: The results 3 years after nerve repair are summarized in Table 1 [101]. The results of nerve repair today are far better than they were 50 years ago, largely due to the control of wound infection and the recognition of the complex internal structure of nerves [36]. Michon concluded that primary repair gave better results at the wrist than secondary repair of nerves [56]. The timing of repair, the overall management of the wound, and the technical performance of nerve suture are the only ways in which a surgeon can directly affect the outcome of the treatment of a transected nerve [13]. Both studies show that young patients are likely to do well both functionally and as regards the regaining of two-point discrimination after nerve suture [31]. Evidence for good nerve recovery or improved function following nerve repair is poor, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels [23]. Follow-up time and age significantly influence the outcome following nerve repair, with significant improvements in the total score seen throughout the follow-up period [245]. Delay in repair of less than 6 months, defect length of less than 5 cm, or grafting with three or more donor nerve cables achieved better recovery [22]. Even for large gaps, within 8 months, an attempt at nerve reconstruction before proceeding to tendon transfers appears to be indicated [5]. End-to-end repair of fascicular groups provides better results than repair using nerve grafts [64]. The technique is mainly indicated in high peripheral nerve injury or secondary cases when recovery of the intrinsic muscle of the hand is not expected after end-to-end repair or graft [10]. The results of a limited case series for this rare condition indicate that simultaneous nerve repair and tendon transfer showed no detrimental results and may provide improved function over tendon transfer alone [3]. Tendon or tissue transfers in combined nerve palsies require longer follow-up than isolated nerve palsies to make a valid assessment of the outcome [2]. Therapy evaluation and treatment protocols for patients with peripheral nerve repairs with nerve conduits are detailed [1].

Conduit Usage: Proper planning begins with having the appropriate nerve tube available in the operating room [60]. Commercially available conduits range from 1.5 mm to 10.0 mm in diameter [60], and the chosen conduit should be slightly larger than the diameter of the nerve [60]. The surgeon should be aware of the cost, biomechanical properties, and contraindications of available conduits [60]. An assessment of the soft tissues is mandatory to determine whether reconstruction should be performed before or concomitant with the nerve repair [60]. An incision slightly off the expected course of the nerve can be helpful to avoid the skin suture line lying directly over the foreign body [60]. The proximal and distal ends of the nerve are located and cut back to healthy fascicles [60]. A helpful first maneuver is to stabilize the nerve tube to the soft tissues with several interrupted sutures, sewn in a U-shaped fashion over the tube [60]. Once secured, the freshened nerve endings are then inserted 2 mm into the ends of the tube under adequate magnification [60], and an 8-0 nylon, interrupted horizontal mattress suture is then used to secure the outer epineurium [60].

Advanced Techniques and Timing: The author notes that to date there are no published outcomes studies on the clinical use of the supercharged end-to-side nerve repair [24]. The end-to-side repair can be primarily indicated in cases of complex trauma, such as extensive nerve substance loss at a single or multiple sites along the same nerve [30]. Patients with sharp major nerve injuries required grafting more frequently after several days from injury [240], although primary repair of common and proper digital nerves could be achieved up to two weeks or greater after injury [240]. The study showed that excellent results could be obtained for nerve repair even after 24 months delay [57]. There was no difference in outcomes between nerve transfer and nerve graft groups at 1 or 2 or more years follow-up [112]. Outcomes from processed nerve allografts are comparable to nerve autograft and exceed those for nerve conduit in historical controls [244]. Muscle-in-vein conduits can be considered for primary and secondary reconstruction of digital nerves [236]. Nerve grafting remains indicated in case of failure or in case of more severe defects [216]. These findings suggest that the procedure described for repair of nerve may be appropriate for routine surgical repair of large and small nerves which require the interposition of grafts [40].

Recovery

Nerve Repair Outcomes and Prognostic Factors: End-to-end nerve repair was performed in 10% of brachial plexus injury cases in war victims, with 35% achieving excellent results [4]. In high radial nerve injuries, better recovery is associated with a delay in repair of less than 6 months, a defect length of less than 5 cm, or grafting with three or more donor nerve cables [22]. Conversely, delay of nerve repair and the presence of a complicating injury, both alone and together, contribute to poorer outcomes in the recovery of nerve function and maturation [26]. Despite these factors, excellent results can be obtained for nerve repair even after a 24-month delay [57]. Primary repair of nerves at the wrist yielded better results than secondary repair according to Michon [56]. Evidence for good nerve recovery or improved function following single digital nerve repair in adults is poor, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels [23]. Associated injuries to adjacent structures had no impact on ulnar nerve recovery in children undergoing primary epineural repair [71]. Median nerve injury cases have shown impressive recovery of thenar motor function [233]. Adequate sensory recovery without any nerve repair had occurred by the 2-year follow-up in artery-only fingertip replantations [237]. Suture pull-out with failure of nerve repairs occurred at more than 15% elongation for all nerves in a rat model of immediate and delayed repairs [58].

Tendon Transfer Outcomes and Indications: Tendon transfer is a useful option to restore function after nerve injury to the radial, median, or ulnar nerve when surgical repair does not result in useful function or is not possible [15]. Tendon transfers remain the primary reconstructive procedure for paralytic injuries of the upper limb until sufficiently powered studies of nerve transfer outcomes are published [154]. Tendon transfer offers an important alternative, possibly the procedure of choice, to microsurgical nerve reconstruction, particularly when early professional and social reintegration is important [25, 28]. Patients who present early and can tolerate longer time to functional recovery are optimal candidates for nerve transfers rather than tendon transfers [33]. Simultaneous nerve repair and tendon transfer showed no detrimental results and may provide improved function over tendon transfer alone in peroneal nerve injuries [3]. Patients who had early direct repair of the tendon had better functional results than those treated with tendon grafting or tendon transfer for intratendinous rupture of the flexor digitorum profundus [219]. Heterodigital flexor digitorum profundus hemi-tendon transfer restores good function in most patients with zone 1 and 2 flexor tendon injuries where primary repair was not performed or was unsuccessful and pulley reconstruction is not required [223]. The improvement of primary flexor tendon repair has limited the indications of secondary repairs to neglected initial wound care and deficiencies in surgical technique or rehabilitation [27].

Rehabilitation and Recovery Protocols: Therapy evaluation and treatment protocols for patients with peripheral nerve repairs using nerve conduits are detailed [1]. A rehabilitative protocol individualized to fit each patient's tendon pathology and surgery is essential following extensor mechanism surgery [160]. Findings suggest the benefit of early rehabilitation after hand tendon repair [164]. The combination of repair and early active mobilization for primary repair of flexor pollicis longus tendons compares favorably with previous methods of treatment [166]. More homogeneous follow-up protocols are needed for strength measurement and patient-reported outcome measures for both nerve and tendon transfers after cervical spinal cord injury [11]. More participants with a longer follow-up are needed to fully demonstrate the superiority of combined nerve and tendon procedures in tetraplegia [7]. An increased need is foreseen for studies addressing combined nerve and tendon transfer reconstructions alongside patient-perceived outcome investigations in tetraplegia [6].

Technical Considerations Affecting Recovery: Tubular repair may not be superior to conventional techniques in terms of functional recovery but represents a simple biological approach to nerve repair [8]. Leaving an intentional distance between nerve ends and enclosing the injury site in a "biological chamber" is a physiological approach that may allow neurotrophic and neurotropic mechanisms to act [8]. The median-ulnar end-to-side bridge nerve graft technique is mainly indicated in high peripheral nerve injury or secondary cases when recovery of the intrinsic muscle of the hand is not expected after end-to-end repair or graft [10]. Supercharged end-to-side anterior interosseous to ulnar motor nerve transfer has broad clinical utility for augmenting partial recovery and preserving motor end plates in second- and third-degree axonotmetic nerve injuries [238]. PEG fusion techniques may drastically improve the long-term recovery of more proximal nerve injuries where poor outcomes are more common [234]. Functional return from repair of spinal nerve roots would have considerable clinical potential for the management of brachial plexus injuries [150]. Early efforts to improve nerve regeneration centered on improvements in technical or surgical repairs, with only modest gains [159].

Key Evidence

• [L4] Therapy evaluation and treatment protocols for patients with peripheral nerve repairs with nerve conduits are detailed. [1] (10.1197/j.jht.2005.02.012)
• [L5] Tendon or tissue transfers in combined nerve palsies require longer follow-up than isolated nerve palsies to make a valid assessment of the outcome. [2] (10.1016/0266-7681(92)90183-3)
• [L4] The results of our limited case series for this rare condition indicate that simultaneous nerve repair and tendon transfer showed no detrimental results and may provide improved function over tendon transfer alone. [3] (10.1186/s13018-014-0067-6)
• [L4] End to end nerve repair was performed in 10% of cases and 35% had excellent results. [4] (10.1016/s0363-5023(03)80320-9)
• [L4] Even for large gaps, within 8 months, an attempt at nerve reconstruction before proceeding to tendon transfers appears to be indicated. [5] (10.1016/j.jhsa.2007.10.004)
• [L5] They foresee an increased need for studies addressing combined nerve and tendon transfer reconstructions alongside patient-perceived outcome investigations. [6] (10.1177/1753193419827814)
• [L3] More participants with a longer follow-up are needed to fully demonstrate the superiority of combined nerve and tendon procedures. [7] (10.1177/17531934251381202)
• [L1] [8] (10.1097/00130911-199706000-00008)
• [Case_report] The technique is mainly indicated in high peripheral nerve injury or secondary cases when recovery of the intrinsic muscle of the hand is not expected after end-to-end repair or graft. [10] (10.1016/j.jhsa.2009.10.033)
• [L4] More homogeneous follow-up protocols are needed for strength measurement and patient-reported outcome measures for both nerve and tendon transfers. [11] (10.1016/j.jhsg.2026.101116)
• [L5] Techniques for clinical approximation of severed nerve ends have reached an optimal technical refinement and new concepts are needed to further increase the results from nerve repair. [12] (10.1053/jhsu.2000.4165)
• [L5] The timing of repair, the overall management of the wound, and the technical performance of nerve suture are the only ways in which a surgeon can directly affect the outcome of the treatment of a transected nerve. [13] (10.1016/0266-7681(84)90006-8)
• [L4] Resection of a nerve as a tendon graft is a serious surgical complication which may be avoided by the very knowledge of the possibility. [14] (10.1016/0266-7681(87)90010-6)
• [L5] The management of the patient with painful sequelae of nerve injury is the most challenging of all peripheral nerve reconstructions. [16] (10.1097/00130911-199709000-00007)
• [L4] The presence of fractures is associated with a higher incidence of nerve and tendon injuries, and involvement of these structures is linked to an increased risk of long-term disability. [17] (10.1177/15589447221092111)
• [L4] Nerve grafting is indicated especially in young patients with nerve loss or associated lesions that do not allow immediate repair. [18] (10.1016/j.hansur.2018.10.181)
• [L4] Overall, we observed better outcomes in those who underwent nerve transfer versus tendon transfer procedures. [20] (10.1016/j.jhsa.2019.12.009)
• [L4] Delay in repair of less than 6 months, defect length of less than 5 cm, or grafting with three or more donor nerve cables achieved better recovery. [22] (10.1177/17531934221147651)
• [L2] Evidence for good nerve recovery or improved function following nerve repair is poor, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels. [23] (10.1177/1753193419846761)
• [L4] The tendon transfer offers an important alternative—possibly the procedure of choice—to microsurgical nerve reconstruction, particularly when early professional and social reintegration is important. [25] (10.1016/j.jhsa.2008.11.012)
• [Paper] It was found that delay of the nerve repair and the presence of a complicating injury, both alone and together, contributed to a poorer outcome in recovery of nerve function and maturation. [26] (10.1016/s0266-7681(97)80273-2)
• [L5] The improvement of primary flexor tendon repair has limited the indications of secondary repairs to neglected initial wound care and deficiencies in the surgical technique or rehabilitation. [27] (10.1016/j.main.2014.05.007)
• [L4] Accordingly, the tendon transfer offers an important alternative – possibly the procedure of choice – to microsurgical nerve reconstruction, particularly when early professional and social reintegration is important. [28] (10.1016/s0363-5023(09)60108-8)
• [L4] We feel that the end-to-side repair can be primarily indicated in cases of complex trauma, such as extensive nerve substance loss at a single or multiple sites along the same nerve. [30] (10.1177/1753193417695177)
• [L4] Both studies show that young patients are likely to do well both functionally and as regards the regaining of two-point discrimination after nerve suture. [31] (10.1016/0266-7681(90)90043-4)
• [L4] On pooled analysis, tendon transfers had higher rates of superior clinical outcomes as compared with nerve transfers and nerve grafts. [32] (10.1177/15589447221150516)
• [L3] Patients who present early and can tolerate longer time to functional recovery would be optimal candidates for nerve transfers. [33] (10.1177/1558944720988126)
• [L5] [34] (10.2106/00004623-195941040-00001)
• [L4] This technique allows for precise repair and easy gliding, and can be easily performed by orthopedic and hand surgeons. [35] (10.1097/bth.0b013e3181ec44a0)
• [Paper] The results of nerve repair today are far better than they were 50 years ago, largely due to the control of wound infection and the recognition of the complex internal structure of nerves. [36] (10.1016/s0363-5023(84)80175-6)
• [L5] These findings suggest that the procedure described for repair of nerve may be appropriate for routine surgical repair of large and small nerves which require the interposition of grafts. [40] (10.1016/0266-7681(86)90155-5)
• [L4] Nerve transfers have become a first line reconstructive technique in the restoration of function, with fundamental principles such as donor site location, strength, safety, and efficacy introduced by Oberlin et al remaining integral to contemporary nerve surgery. [44] (10.1016/j.jhsa.2025.01.013)
• [L4] Selection of the donor nerve must be carefully weighed against other treatment alternatives, considering the risk of donor nerve impairment and the potential narrowing of future reconstructive options. [46] (10.1016/j.jhsa.2006.12.012)
• [L5] Tendon lengthening and transfer are indicated for neuromuscular disorders, nerve injuries, and congenital or traumatic lesions. [54] (10.1016/j.otsr.2014.07.033)
• [L5] We recommend immobilization of nerve repairs, although this contradicts most recent studies. [55] (10.1016/j.hansur.2016.05.001)
• [Paper] Michon concluded that primary repair gave better results at the wrist than secondary repair of nerves. [56] (10.1016/s0363-5023(85)80021-6)
• [L4] The study showed that excellent results could be obtained for nerve repair even after 24 months delay. [57] (10.1016/j.main.2012.09.001)
• [Paper] The suture pull-out with failure of the repairs occurred at more than 15% elongation for all nerves. [58] (10.1016/0363-5023(92)90316-h)
• [L4] More prospective studies using standardized outcome measures are needed to define the precise role of nerve transfers. [59] (10.1177/1753193419886443)
• [L5] [60] (10.1016/j.jhsa.2010.02.025)
• [L5] [61] (10.1016/s0894-1130(98)80007-0)
• [L5] The committee was charged to define techniques and establish scales for evaluation of the clinical result after surgical treatment of peripheral nerve injury. [62] (10.1016/s0363-5023(83)80265-2)
• [L4] [63] (10.1016/0266-7681(91)90103-u)
• [L4] End-to-end repair of fascicular groups provides better results than repair using nerve grafts. [64] (10.1016/j.jhsa.2014.01.026)
• [L4] This technique allows the tendon to be harvested with minimal scarring. [65] (10.1016/0266-7681(93)90008-4)
• [L4] The active tendon implant is a reliable, biologically acceptable temporary tendon implant, with the major advantage being the ability to use the digit for extended periods between stage I and stage II. [68] (10.1016/0363-5023(88)90259-6)
• [L4] [70] (10.1016/0266-7681(86)90154-3)
• [L4] Similarly, associated injuries to adjacent structures had no impact on ulnar nerve recovery. [71] (10.1053/jhsu.1999.jhsu25a0016)
• [L4] The three patients who had late reconstruction of the tendon mechanism improved, but none obtained excellent results. [72] (10.1016/s0363-5023(87)80095-3)
• [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. [88] (10.1016/s0363-5023(76)80006-8)
• [L4] The anterior approach yields similar results to the posterior approach and has the advantage of allowing easier access for simultaneously performing nerve or tendon transfers to reconstruct grasp and pinch. [90] (10.1177/1753193421996987)
• [L4] The TWZL technique offers an alternative treatment option for patients with tendon deficiency and nerve injuries, avoiding donor site morbidity associated with autograft harvest. [91] (10.1016/j.jhsa.2022.12.016)
• [L5] The use of the ASSI nerve and tendon cutting instrumentation will almost assuredly simplify the complex task of tendon repair, regardless of the suture technique used. [93] (10.1016/0363-5023(89)90076-2)
• [Paper] Modern nerve-to-nerve transfers represent one of the greatest advances in peripheral nerve surgery. [96] (10.1097/bth.0b013e31812714f3)
• [L4] [101] (10.1016/0266-7681(94)90068-x)
• [L4] The existence of nerve contusion and a high number of tendon injuries were factors associated with a poorer prognosis. [102] (10.1016/j.main.2009.01.001)
• [Case_report] This case contributes further to our understanding of the clinical presentation of hand function following high median nerve transection. [105] (10.1186/s12891-025-08469-3)
• [L3] Patients with an injury pattern that may lead to nerve injury warrant prompt referral to an upper extremity specialist in an effort to optimize outcomes. [107] (10.1177/1558944719866865)
• [L5] [108] (10.5435/jaaos-d-17-00325)
• [L4] There was no difference in outcomes between nerve transfer and nerve graft groups at 1 or 2 or more years follow-up. [112] (10.1016/j.jhsa.2019.10.036)
• [L3] [113] (10.1177/17531934221074514)
• [L4] These three patients demonstrate that partial laceration of a flexor tendon can result in morbidity at varying times after injury, including entrapment, delayed rupture, and triggering. [117] (10.1016/s0363-5023(81)80051-2)
• [L5] The painful neuroma is a debilitating sequela of nerve injury with poorly understood pathophysiology involving fascicular escape and scarring; treatment must be tailored to the individual patient as there are a number of approaches available. [118] (10.1016/j.jhsa.2009.12.019)
• [L4] [121] (10.1016/0266-7681(87)90181-1)
• [Paper] [127] (10.1016/s0266-7681(98)80057-0)
• [L4] [130] (10.1016/0363-5023(92)90126-a)
• [Paper] I would recommend it to anyone who does a significant number of tendon transfers. [145] (10.1016/s0363-5023(84)80122-7)
• [L5] Functional return from repair of spinal nerve roots would have a considerable clinical potential for instance in the management of brachial plexus injuries. [150] (10.1016/s0266-7681(96)80239-7)
• [L5] The panel recommends adapting a simpler classification system resembling that for flexor tendons and outlines specific treatment approaches for acute extensor tendon injuries in each zone to facilitate surgical decision-making and rehabilitation. [151] (10.1177/17531934251363138)
• [L5] Tendon transfers remain the primary reconstructive procedure for paralytic injuries of the upper limb until sufficiently powered studies of nerve transfer outcomes are published. [154] (10.1177/1753193419864838)
• [L5] Early efforts to improve nerve regeneration centered on improvements in technical or surgical repairs, with only modest gains. [159] (10.1016/s0894-1130(12)80289-4)
• [L5] A rehabilitative protocol that is individualized to fit each patient's tendon pathology and surgery is essential. [160] (10.1016/j.jhsa.2015.04.043)
• [L4] Our findings suggest the benefit of early rehabilitation after hand tendon repair. [164] (10.1016/j.jht.2014.09.005)
• [Paper] [165] (10.1016/j.jhse.2007.03.005)
• [L4] The final combination of repair and early active mobilization for primary repair of FPL tendons compares favourably with previous methods of treatment. [166] (10.1054/jhsb.1999.0230)
• [L3] Our new classification scheme of FDP tendon avulsion appeared to be comprehensive and useful in guiding the surgeon for the best treatment option. [168] (10.1142/s0218810417500083)
• [L4] The authors propose an additional category (Type 3) to the Türker classification system to encompass rare findings of two radial-sided accessory extensor tendons in the same individual, which were not previously represented in existing classifications. [173] (10.1016/j.jhsg.2023.10.005)
• [L4] Based on the results of this survey, a revisit of the popular extensor tendon zone classifications systems may be necessary for future clinical practice and communication among surgeons. [176] (10.1177/17531934241253137)
• [L4] MRI provides important preoperative information for surgical decision-making and planning in patients who present late with closed flexor tendon injuries of the hand. [180] (10.1054/jhsb.1999.0306)
• [L4] Surgical reconstruction of degenerate abductor tendons should be considered in the presence of an MRI confirmed separation where clinical findings are consistent with the known tendon disruption. [182] (10.1016/j.arth.2019.11.012)
• [L4] Surgical treatment consisting of flexor tendon sheath release is effective in restoring motion with minimal risks of recurrence and neurovascular complication, although the optimal age for surgical treatment is unclear. [183] (10.1016/j.jhsa.2008.04.017)
• [L4] Unless patients, their caregivers, and nonsurgical health care providers have baseline knowledge of tendon and/or nerve transfers, they are unlikely to obtain de novo awareness of surgical options with self-initiated searches. [184] (10.1177/1558944719878835)
• [L3] [185] (10.1016/j.jhsa.2014.06.140)
• [L4] With modern anesthesia techniques, tendon lacerations in a healthy neonate can be managed in a timely and safe manner. [187] (10.1016/j.jhsa.2010.09.015)
• [L5] In the absence of a space-occupying lesion, a trial of nonoperative management is advisable, but exploration of the nerve is recommended if there is no sign of muscle recovery after 6 weeks of observation or if there is progressive weakness. [188] (10.1016/j.jhsa.2017.07.026)
• [L5] [189] (10.5435/jaaos-22-12-791)
• [L4] Non-repair of partially divided flexor tendons produces excellent results with none of the complications reported by Kleinert and Schlenker. [190] (10.1016/0266-7681(92)90083-e)
• [L5] [191] (10.1097/bth.0000000000000167)
• [L4] [192] (10.1016/s0266-7681(98)80020-x)
• [L3] The study notes that while non-randomised, the technique appears better without an increased rate of rupture but with a shorter rehabilitation period. [194] (10.1177/1753193408091570)
• [L5] The use of interference screws for fixation of tendon grafts to bone for hand ligament reconstructions is a promising new surgical technique. [195] (10.1016/j.jhsa.2004.12.013)
• [L5] Wrapping the nerve with fibrin sealant before division and immediate fixation resulted in less protrusion of the nerve end. [197] (10.1054/jhsb.1999.0250)
• [L5] This work may inform future improvements in surgical techniques for tendon-to-bone fixation. [198] (10.1016/j.jisako.2023.03.418)
• [L4] The method allows for the early evaluation of the success of nerve repair by demonstrating conduction across the repair site through the localization of tingling sensations in the area of sensory loss. [199] (10.1016/0266-7681(93)90249-f)
• [L4] [200] (10.1016/j.jhsa.2009.05.015)
• [L5] The use of type I collagen conduit is a reliable alternative to nerve grafting for gaps up to 10 mm in length. [203] (10.1016/j.jhsa.2007.07.015)
• [L4] This study confirms that collagen conduits reliably provide a repair that restores nerve function for nerve gaps measuring less than 2 cm. [204] (10.1016/j.jhsa.2011.06.009)
• [L5] Tension at the site of repair is identified as one of the most frequent reasons for failure, and the application of autologous nerve grafts has become more popular to avoid suture lines with fibrosis or distraction. [205] (10.1016/0266-7681(90)90004-n)
• [Paper] A single piece of tendon does not readily fulfil both requirements for ligament reconstruction and filling the arthroplasty space. [206] (10.1016/0266-7681(90)90031-x)
• [L5] It allows a safe, tension-free approximation of severed ends of nerves or tendons. [207] (10.1016/s0363-5023(97)80143-8)
• [L3] Nerve grafting is a valuable and important technique in the management of a nerve gap in appropriate situations. [209] (10.1016/s0363-5023(80)80001-3)
• [L4] In median nerve implants, sensory recovery was obtained in 14 cases, but motor recovery was not obtained in 6 cases. [211] (10.1016/j.hansur.2018.10.010)
• [Paper] [212] (10.1016/s0266-7681(97)80397-x)
• [L4] [214] (10.1177/1753193409104673)
• [L4] Nerve grafting remains indicated in case of failure or in case of more severe defects. [216] (10.1016/j.main.2010.09.015)
• [L4] Ultrasonographic assessment may serve as a valuable complementary tool for objectively evaluating nerve recovery. [218] (10.1177/17531934231174603)
• [L4] Patients who had early direct repair of the tendon had better functional results than those who were treated with tendon grafting or tendon transfer. [219] (10.1016/s0363-5023(05)80111-x)
• [L5] These techniques provide objective information needed to assess the degree of injury and can assist the surgeon in making proper decisions regarding treatment of peripheral nerve lesions. [220] (10.1016/s0363-5023(76)80025-1)
• [L4] This technique restores good function in most patients with zone 1 and 2 flexor tendon injuries, in which primary tendon repair has not been performed or was unsuccessful, and where pulley reconstruction is not required. [223] (10.1177/1753193417737920)
• [L4] We present a previously unreported site of flexor tendon entrapment as well as the novel use of CT 3D volume rendering to diagnose the entrapment. [225] (10.1177/15589447231185857)
• [L4] Although diagnosing the cause of UCL locking may be complicated by the lack of evidence in imaging studies, open surgical treatment has traditionally been the most often used with a high success rate. [232] (10.1016/j.jhsg.2022.08.003)
• [L4] Median nerve injury cases have been most impressive with respect to recovery of thenar motor function. [233] (10.1016/s0363-5023(83)80162-2)
• [L5] PEG fusion techniques may drastically improve the long-term recovery of more proximal nerve injuries where poor outcomes are more common. [234] (10.1016/j.jhsa.2015.06.060)
• [L4] Muscle-in-vein conduits can be considered for primary and secondary reconstruction of digital nerves. [236] (10.1016/j.jhsa.2022.02.002)
• [L4] Furthermore, adequate sensory recovery without any nerve repair had occurred by the 2-year follow-up. [237] (10.1016/j.jhsa.2013.08.110)
• [L4] The authors believe the procedure has broad clinical utility for augmenting partial recovery and preserving motor end plates in second- and third-degree axonotmetic nerve injuries. [238] (10.1016/j.jhsa.2012.07.022)
• [L4] Patients with sharp major nerve injuries required grafting more frequently after several days from injury, whereas primary repair of common and proper digital nerves could be achieved up to two weeks or greater after injury. [240] (10.1016/j.jhsa.2023.11.006)
• [L4] All patients achieved an excellent or good outcome with no ruptures or infections. [243] (10.1177/1753193410365631)
• [L3] Outcomes from processed nerve allografts are comparable to nerve autograft and exceed those for nerve conduit in historical controls. [244] (10.1016/j.jhsa.2014.06.044)
• [L3] Follow-up time and age significantly influence the outcome following nerve repair, with significant improvements in the total score seen throughout the follow-up period. [245] (10.1054/jhsb.2001.0567)

See Also

• Flexor tendon repair

References

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