Eight months postoperatively, the patient had no recurrent synovitis and was asymptomatic.
Management of post-traumatic scarring around nerves is a challenge faced by all hand surgeons. Multiple procedures have been described for creating a barrier to epineural scarring and include adipofascial or muscle flaps, autologous vein grafts, and, recently, commercially available nerve conduits2,4,16-18. As an alternative, nerve conduits can be used to surround a nerve that has been repaired after a traumatic laceration. Like vein grafts, they are an option for preventing adhesions and scar formation around the injured nerve or one that resides in an unhealthy bed of soft tissue19,20. Two recently introduced neuro-protective barriers are porcine intestinal submucosal wrap (Axoguard) receiving FDA approval in 2003 and the collagen nerve wrap (Neuragen) receiving FDA approval in 200421. More recently, other commercially available nerve wraps have emerged, but are not FDA approved for compressive neuropathy22.
Only one study documents an adverse event from a nerve tube or wrap. Four patients undergoing explantation of collagen nerve tubes for failed digital nerve repair reported a single case of considerable scar formation and foreign body reaction. Since 2008, 3 complaints of “inflammation” with Neuragen have been reported to the FDA, though details provided are limited24. No complaints have been reported with NeuraWraps. One complaint of considerable swelling, inflammation, and scar formation without evidence of infection has been reported to the FDA with the Axoguard.
We report 3 cases of inflammatory response to the use of nerve wraps for persistent or recurrent carpal tunnel syndrome. In all cases, cultures were negative and pathology demonstrated acute and chronic inflammation. All 3 patients responded favorably following explantation of the wrap. Given the limited data involving complications with these devices, we recommend careful follow-up for adverse reactions with the routine use of nerve wraps in the setting of compressive neuropathy.
Note: We thank Lindsey Lowder, DO, George Mutema, MD, Shiyama Mudali, MD, Ady Kendler, MD, and Amanda Schroeder, MD with their assistance with the preparation of the photomicrographs for this manuscript.
1. Zieske L, Ebersole GC, Davidge K, Fox I, Mackinnon SE. Revision carpal tunnel surgery: a 10-year review of intraoperative findings and outcomes. J Hand Surg Am. 2013;38(8):1530-9.
2. Sotereanos D, Giannakopoulos P, Mitsionis G, Xu J, Herndon J. Vein-graft wrapping for the treatment of recurrent compression of the median nerve. Microsurgery. 1995;16:752-6.
3. Varitimidis S, Riano F, Vardakas D, Sotereanos D. Recurrent compressive neuropathy of the median nerve at the wrist: treatment with autogenous saphenous vein wrapping. J Hand Surg Br. 2000;25:271-5.
4. Rose E. The use of the palmaris brevis flap in recurrent carpal tunnel syndrome. Hand Clin. 1996;12(2):389-95.
5. Fusetti C, Garavaglia G, Mathoulin C, Petri J, Lucchina S. A reliable and simple solution for recalcitrant carpal tunnel syndrome: the hypothenar fat pad flap. Am J Orthop. 2009;38(4):181-6.
6. Chrysopoulo M, Greenberg J, Kleinman W. The hypothenar fat pad transposition flap: a modified surgical technique. Tech Hand Up Extrem Surg. 2006;10(3):150-6.
7. Mahmoud M, El Shafie S, Coppola E, Elfar J. Perforator-based radial forearm fascial flap for management of recurrent carpal tunnel syndrome. J Hand Surg Am. 2013;38(11):2151-8.
8. Craft R, Duncan S, Smith A. Management of recurrent carpal tunnel syndrome with microneurolysis and the hypothenar fat pad flap. Hand 2007;2:85-9.
9. Wulle C. The synovial flap as treatment of the recurrent carpal tunnel syndrome. Hand Clin. 1996;12(2):379-88.
10. Tham S, Ireland D, Riccio M, Morrison W. Reverse radial artery fascial flap: a treatment for the chronically scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg Am. 1996;21:849-54.
11. Danielsson P, Dahlin L, Povlsen B. Tubulization increases axonal outgrowth of rat sciatic nerve after crush injury. Exp Neurol. 1996;139(2):238-43.
13. Li S, Archibald S, Krarup C, Madison R. Peripheral nerve repair with collagen conduits. Clin Mater. 1992;9(3-4):195-200.
14. Boeckstyns ME, Sorensen AI, Viñeta JF, Rosén B, Navarro X, Archibald SJ, Valss-Solé J, Moldovan M, Krarup C. Collagen conduit versus microsurgical neurorrhapy: 2-year follow-up of a prospective, blinded clinical and electrophysiological multicenter randomized, controlled trial. J Hand Surg Am. 2013;38(12):2405-11.
16. Xu J, Varitimidis SE, Fisher KJ, Tomaino MM, Sotereanos DG. The effect of wrapping scarred nerves with autogenous vein graft to treat recurrent chronic nerve compression. J Hand Surg Am. 2000;25(1):93-103.
17. Papatheodorou LK, Williams BG, Sotereanos DG. Preliminary results of recurrent cubital tunnel syndrome treated with neurolysis and porcine extracellular matrix nerve wrap. J Hand Surg Am. 2015;40(5):987-92.
18. Soltani AM, Allan BJ, Best MJ, Mir HS, Panthaki ZJ. Revision decompression and collagen nerve wrap for recurrent and persistent compression neuropathies of the upper extremity. Ann Plast Surg. 2014;72(5):572-8.
19. Kim P, Hayes A, Ain F, Akelina F, Hays A, Rosenwasser M. Collagen nerve protector in rat sciatic nerve repair: a morphometric and histological analysis. Microsurgery. 2010;30(5):392-6.
20. Robert S, Strauch B. Nerve conduits: an update on tubular nerve repair and reconstruction. J Hand Surg. 2013;38(6):1252-5.
21. Kehoe S, Zhang XF, Boyd D. FDA approved guidance conduits and wraps for peripheral nerve injury: a review of materials and efficacy. Injury. 2012;43(5):553-72.
22. Dy CJ, Aunins B, Brogan DM. Barriers to epineural scarring: role in treatment of traumatic nerve injury and chronic compressive neuropathy. J Hand Surg Am. 2018;43(4):360-7.
23. Puckett B, Gaston R, Lourie E. A novel technique for the treatment of recurrent cubital tunnel syndrome: ulnar nerve wrapping with a tissue engineered bioscaffold. J Hand Surg Eur. 2011;36:130-4.
24. Catalog Number PNG620; Event Date 12/9/08. FDA U.S. Food and Drug Administration MAUDE Adverse Event Report.