Commentary on Long-term clinical outcome after epineural coaptation of digital nerves. R. M. Fakin, M. Calcagni, H. J. Klein and P. Giovanoli. J Hand Surg. 2016, 41: 148–154

In this article the authors highlight the lack of consensus regarding the optimal method of digital nerve repair. Although not quoted in their article, a large meta-analysis in 2013 from a group of surgeons in Munich reviewed 87 publications, which included the outcomes of 2997 nerve repairs, all with a minimum follow-up of 1 year (Paprottka et al., 2013). The study by Fakin et al. is a retrospective series of 155 patients, but only 83 patients (54%) were willing to participate in their analysis. These results can be added to the Munich meta-analysis led by Paprottka et al. as the outcomes from both articles are similar. It seems agreed that if a clean nerve transection has occurred, end to end coaptation is the surgical technique of choice as long as a tension free repair can be performed. Children and adolescents should have good to excellent surgical outcomes, but the recovery after nerve repair in adults is variable, incomplete and declining age is named as one of the major predictors for nerve recovery in the meta-analysis from Paprottka et al. Other factors known to influence nerve regeneration following surgical repair include the surgeon’s experience, the mechanism of injury and timing of repair. If nerve repair is to be performed, as part of the consent to surgery patients should be advised of their expected outcome; persistent sensory deficit, paraesthesia and the possibility of painful neuroma. Due to a paucity of evidence in the medical literature, it is unclear however whether an adult with an isolated digital nerve injury achieves a consistently better functional outcome with surgery compared with a patient who does not have surgery, leaving their digital nerve unexplored and unrepaired? In the prospective study by Chow and Ng (1993) they assessed 108 digital nerve injuries analysing the outcomes of those patients who underwent digital nerve repair compared with those nerves left unrepaired. Injuries to the thumb, radial border of the index finger and ulnar side of the little finger were excluded from their study. The repaired nerve group had superior two-point discrimination at 2 years follow-up, but 94% of patients with unrepaired nerves regained some protective sensibility and declined future surgery. However, in the unrepaired group 2/36 (5%) nerves developed painful neuroma (and underwent surgery to relieve pain), while 0/72 in the surgical group developed pain, although there was no statistical analysis comparing these two patient groups. If the prevention of painful neuroma is a prime indication for nerve repair, further studies are needed to answer this question more conclusively. Should nerve repair in adults be restricted only to those nerves involved with tri-digital grip and the ulnar border of the hand? Inevitably every surgeon will have their own opinions on the management of these injuries based upon their personal experience and their knowledge of the medical evidence. I have personal experience of a number of medical colleagues who have sustained accidental digital nerve injury; some have had nerve repair and others chose to avoid surgery, facilitating an earlier return to their work. As normality was never regained in any of these cases, I believe further studies should be made to examine outcomes after digital nerve repair, compared with those patients who choose not to undergo surgery. This type of analysis may show there are times when a digital nerve injury is reasonable to be left alone, e.g. non-border digits or iatrogenic nerve injury after Dupuytren’s fasciectomy in the older person perhaps? Surgery for a patient often involves additional absence from work and extra costs to the patient’s healthcare, so the statement in the discussion given by Fakin et al.: ‘All patients with a digital nerve injury, regardless of their age, mechanism and extent of trauma, and anatomical site should be encouraged to undergo a prompt microsurgical repair’, is certainly a reasonable 622729 JHS0010.1177/1753193415622729Journal of Hand Surgery (European Volume)Commentary research-article2015