Skeletal muscle reinnervation by reduced axonal numbers results in whole muscle force deficits

Patients sustaining a peripheral nerve injury will frequently experience residual muscle weakness after muscle reinnervation, even if the nerve repair is performed under optimal circumstances to allow rapid muscle reinnervation. The mechanisms responsible for this contractile dysfunction remain unclear. It is hypothesized that after peripheral nerve injury and repair, a reduced number of axons are available for skeletal muscle reinnervation that results in whole muscle force and specific force deficits. A rat model of peroneal nerve injury and repair was designed so that the number of axons available for reinnervation could be systematically reduced. In adult rats, the peroneal nerve to the extensor digitorum longus muscle was either left intact (sham group, n = 8) or divided and repaired with either 50 percent (R50 group, n = 7) or 100 percent (R100 group, n = 8) of the axons in the proximal stump included in the repair. Four months after surgery, maximal tetanic isometric force was measured and specific force was calculated for each animal. Mean tetanic isometric force for extensor digitorum longus muscles from R50 rats (2765.7 +/- 767.6 mN) was significantly lower than sham (4082.8 +/- 196.5 mN) and R100 (3729.0 +/-370.2 mN) rats (p < 0.003). Mean specific force calculations revealed significant deficits in both the R100 (242.1 +/- 30 kN/m2) and R50 (190.6 +/- 51.8 kN/m2) rats compared with the sham animals (295.9 +/- 14 kN/m2) (p < 0.0005). These data support our hypothesis that after peripheral nerve injury and repair, reinnervation of skeletal muscle by a reduced number of axons results in a reduction in tetanic isometric force and specific force. The greater relative reduction in specific force compared with absolute force production after partial nerve repair may indicate that a population of residual denervated muscle fibers is responsible for this deficit.     

Denervated muscle fibers explain the deficit in specific force following reinnervation of the rat extensor digitorum longus muscle

The authors tested the hypothesis that, after denervation and reinnervation of skeletal muscle, observed deficits in specific force can be completely attributed to the presence of denervated muscle fibers. The peroneal nerve innervating the extensor digitorum longus muscle in rats was sectioned and the distal stump was coapted to the proximal stump, allowing either a large number of motor axons (nonreduced, n = 12) or a drastically reduced number of axons access to the distal nerve stump (drastically reduced, n = 18). A control group of rats underwent exposure of the peroneal nerve, without transection, followed by wound closure (control, n = 9). Four months after the operation, the maximum tetanic isometric force (Fo) of the extensor digitorum longus muscle was measured in situ and the specific force (sFo) was calculated. Cross-sections of the muscles were labeled for neural cell adhesion molecule (NCAM) protein to distinguish between innervated and denervated muscle fibers. Compared with extensor digitorum longus muscles from rats in the control (295 +/- 11 kN/m2) and nonreduced (276 +/- 12 kN/m2) groups, sFo of the extensor digitorum longus muscles from animals in the drastically reduced group was decreased (227 +/- 15 kN/m2, p < 0.05). The percentage of denervated muscle fibers in the extensor digitorum longus muscles from animals in the drastically reduced group (18 +/- 3 percent) was significantly higher than in the control (3 +/- 1 percent) group, but not compared with the nonreduced (9 +/- 2 percent) group. After exclusion of the denervated fibers, sFo did not differ between extensor digitorum longus muscles from animals in the drastically reduced (270 +/- 20 kN/m2), nonreduced (301 +/- 13 kN/m2), or control (303 +/- 10 kN/m2) groups. The authors conclude that, under circumstances of denervation and rapid reinnervation, the decrease in sFo of muscle can be attributed to the presence of denervated muscle fibers.     

"Donor" muscle structure and function after end-to-side neurorrhaphy

End-to-end nerve coaptation is the preferred surgical technique for peripheral nerve reconstruction after injury or tumor extirpation. However, if the proximal nerve stump is not available for primary repair, then end-to-side neurorrhaphy may be a reasonable alternative. Numerous studies have demonstrated the effectiveness of this technique for muscle reinnervation. However, very little information is available regarding the potential adverse sequelae of end-to-side neurorrhaphy on the innervation and function of muscles innervated by the "donor" nerve. End-to-side neurorrhaphy is hypothesized to (1) acutely produce partial donor muscle denervation and (2) chronically produce no structural or functional deficits in muscles innervated by the donor nerve. Adult Lewis rats were allocated to one of two studies to determine the acute (2 weeks) and chronic (6 months) effects of end-to-side neurorrhaphy on donor muscle structure and function. In the acute study, animals underwent either sham exposure of the peroneal nerve (n = 13) or end-to-side neurorrhaphy between the end of the tibial nerve and the side of the peroneal nerve (n = 7). After a 2-week recovery period, isometric force (F(0) was measured, and specific force (sF(0) was calculated for the extensor digitorum longus muscle ("donor" muscle) for each animal. Immunohistochemical staining for neural cell adhesion molecule (NCAM) was performed to identify populations of denervated muscle fibers. In the chronic study, animals underwent either end-to-side neurorrhaphy between the end of the peroneal nerve and the side of the tibial nerve (n = 6) or sham exposure of the tibial nerve with performance of a peroneal nerve end-to-end nerve coaptation approximately 6), to match the period of anterior compartment muscle denervation in the end-to-side neurorrhaphy group. After a 6-month recovery period, contractile properties of the medial gastrocnemius muscle ("donor" muscle) were measured. Acutely, a fivefold increase in the percentage of denervated muscle fibers (1 +/0 0.7 percent to 5.4 +/-2.7 percent) was identified in the donor muscles of the animals with end-to-side neurorrhaphy (p < 0.001). However, no skeletal muscle force deficits were identified in these donor muscles. Chronically, the contractile properties of the medial gastrocnemius muscles were identical in the sham and end-to-side neurorrhaphy groups. These data support our two hypotheses that end-to-side neurorrhaphy causes acute donor muscle denervation, suggesting that there is physical disruption of axons at the time of nerve coaptation. However, end-to-side neurorrhaphy does not affect the long-term structure or function of muscles innervated by the donor nerve.     

Influence of tenotomy on posttetanic responses of the rat fast and slow muscle

The effect of two weeks of tenotomy on posttetanic isometric contractile responses of the rat fast: Extensor digitorum longus and slow: soleus muscles was studied in experiments on isolated muscle preparations. Direct tetanic stimulation (100 impulses, 50 Hz) increased the force of contractions by 20-25% (p < 0.05) of both, control and tenotomized fast muscles. Identical to above tetanic stimulation of control, slow muscle resulted in posttetanic depression, a decrease in the amplitude of contractile responses. Tenotomized slow muscles did not develop posttetanic depression. Caffeine (4 mM) increased and dandrolene (10 microM) decreased the force of unitary and tetanic contractions of control and tenotomized muscles. Neither drug, however, affected development of posttetanic phenomena in ether fast or slow muscles. The fact that in extensor digitorum longus, posttetanic potentiation is preserved for at least forty days of tenotomy but disappears after only 2 weeks of denervation suggests important role of neurotrophic influences in regulation of posttetanic responses of fast muscles.     

Functional deficits in skeletal muscle grafts

Individual skeletal muscle fibers degenerate and regenerate with minimal functional deficits. When whole skeletal muscles are grafted in rats or cats by standard grafting techniques, revascularization and reinnervation must occur spontaneously. Under these circumstances, contraction times and maximum velocities of shortening eventually return to control values, but a significant deficit is observed in maximum tetanic tension. Grafts made with anastomosis of nerves or with nerves left intact have smaller deficits in tension development than do standard grafts made without nerve repair. The measurement of contractile properties of single motor units in extensor digitorum longus (EDL) muscles and in EDL grafts in rats indicates that the decreased maximum tetanic tension of whole grafts is due to a 10-20% decrease in the maximum tetanic tension of individual motor units, whereas standard grafts also show a 40-45% decrease in the number of motor units. Compared with control values, the fatigability of 100-mg grafts in rats is decreased, whereas larger 3-g grafts in cats show an increased fatigability. The deficits observed in large grafts can be reduced, but not eliminated, by grafting with neurovascular anastomoses.     

Force deficits in skeletal muscle after delayed reinnervation

Using a rat hindlimb model, the authors tested the hypothesis that, in muscles reinnervated after long-term denervation, atrophy-dependent and atrophy-independent mechanisms operate independently to produce force deficits. In adult rats, gastrocnemius muscles were subjected to denervation via tibial nerve transection. Reconstruction of the nerve lesion was delayed for periods ranging from 2 weeks to 1 year. After a minimum recovery period of 6 months after nerve repair, muscle mass and maximum isometric tetanic force were measured and specific force was calculated for each muscle (n = 40 muscles from 23 animals). After recovery, observed deficits in muscle mass and maximum tetanic force were directly proportional to the denervation interval. On the other hand, the deficit in specific force was not proportional to the denervation interval; all groups in which the nerve reconstruction was delayed for a month or longer demonstrated a deficit of 30 percent to 50 percent. These data support our hypothesis that, after prolonged denervation followed by reinnervation, the magnitude of the deficit in whole muscle force does not parallel the deficit in specific force. These data support the idea that mechanisms governing muscle atrophy are independent of those resulting in specific force deficits.     

Muscle reinnervation and IGF-I synthesis are affected by exposure to heparin: an effect partially antagonized by anti-growth hormone-releasing hormone

Sciatic nerve crush was performed in 2-day-old rats, then reinnervation of the extensor digitorum longus muscle, motor neuron survival, and muscle IGF-I production were monitored. In saline-treated rats, the extent of reinnervation was around 50% and the number of EDL reinnervating motor neurons was significantly reduced. In heparin-treated rats the extent of muscle reinnervation, the recovery of nerve-evoked muscle twitch tension, and the number of motor neurons reinnervating the extensor digitorum longus muscle were greatly enhanced compared to saline-treated rats. In addition, treatment with heparin increased markedly insulin-like growth factor-I levels in denervated muscles. The concomitant exposure to anti-growth hormone releasing hormone partially abolished the stimulatory action of heparin on muscle reinnervation and prevented the increase of insulin-like growth factor-I muscle levels.     

Independence of changes in contraction properties and myofibrillar ATPase activity of denervated mammalian muscle on length of nerve stump.

1. Contractile properties of the fast extensor digitorum longus of one-month-old rats and of the fast peroneus longus muscles of adult rabbits were studied in vitro at 36 degrees C after nerve section close to the muscle. Changes in contraction properties (prolongation) are not observed until 48 hours after denervation in the rat and 14-30 days in the rabbit. 2. At no period after denervation are differences in twitch isometric contraction properties dependent on the length of the sectioned nerve stump. This lack of dependence of contractile behavior after denervation is in contrast to many metabolic changes which show a clear dependence on the length of the nerve stump. 3. It is concluded that the onset of denervation changes in contractile behavior are related to the loss of nerve-impulse activity, while the transient early metabolic changes are related to changes of fast axoplasmic flow, initiated after nerve section and therefore dependent on length of sectioned nerve stump.     

Mechanical function of muscle reinnervated by end-to-side neurorrhaphy.

End-to-side neurorrhaphy is a surgical technique for peripheral nerve reconstruction when end-to-end neurorrhaphy is not an option. To define the effectiveness of end-to-side neurorrhaphy as a method of nerve repair, the authors tested the null hypothesis: there is no difference in the mechanical function of skeletal muscle denervated and reinnervated by end-to-side versus end-to-end neurorrhaphy. Adult Lewis rats underwent either transection and end-to-end epineurial repair of the left peroneal nerve (n = 9) or end-to-side repair of the distal stump of the peroneal nerve to the side of the tibial nerve (n = 8). After a 6-month recovery period, isometric force (Fo) was measured, and specific force (sFo) was calculated for the extensor digitorum longus muscle of each animal. Immunohistochemical staining for neural cell adhesion molecule (NCAM) was performed to identify populations of denervated muscle fibers. The mean extensor digitorum longus muscle mass in the end-to-end group (195 +/- 32 g) was significantly greater than that of the end-to-side group (146 +/- 55 g) (p < 0.05). A significantly greater percentage of denervated fibers was identified in the extensor digitorum longus muscles of animals in the end-to-side group (9.4 +/- 3.2 percent) than in those in the end-to-end group (3.8 +/- 1.0 percent) (p < 0.05). Despite a lower muscle mass and a higher percentage of denervated fibers, neither Fo nor sFo was significantly different in the two groups. These data support the null hypothesis that, under appropriate circumstances, there is no difference in the recovery of whole muscle force and specific force production in muscles reinnervated by end-to-side versus end-to-end neurorrhaphy.     

Muscle reinnervation in rats treated with vitamin E]

During muscle reinnervation, a transitory phase of polyinnervation occurs. In reinnervated muscles of vitamin E deficient rats, sprouting and polyinnervation are increased with respect to reinnervated controls. In this work, polyinnervation was observed in reinnervated extensor digitorum longus (edl) muscle of rats treated with pharmacological doses of vitamin E. Sciatic nerve was crushed and edl muscle was examined electrophysiologically at 30, 40 and 60 days after denervation. The percentage of polyinnervated cells in controls peaked at 30 days and thus it decreased. In muscles of vitamin E treated rats, the time course of percentage of polyinnervated muscle cells was qualitatively the same, but it was decreased at all times.     

Hyperbaric oxygen improves contractile function of regenerating rat skeletal muscle after myotoxic injury.

There is growing interest in hyperbaric oxygen (HBO) as an adjunctive treatment for muscle injuries. This experiment tested the hypothesis that periodic inhalation of HBO hastens the functional recovery and myofiber regeneration of skeletal muscle after myotoxic injury. Injection of the rat extensor digitorum longus (EDL) muscle with bupivacaine hydrochloride causes muscle degeneration. After injection, rats breathed air with or without periodic HBO [100% O(2) at either 2 or 3 atmospheres absolute (ATA)]. In vitro maximum isometric tetanic force of injured EDL muscles and regenerating myofiber size were unchanged between 2 ATA HBO-treated and untreated rats at 14 days postinjury but were approximately 11 and approximately 19% greater, respectively, in HBO-treated rats at 25 days postinjury. Maximum isometric tetanic force of injured muscles was approximately 27% greater, and regenerating myofibers were approximately 41% larger, in 3 ATA HBO-treated rats compared with untreated rats at 14 days postinjury. These findings demonstrate that periodic HBO inhalation increases maximum force-producing capacity and enhances myofiber growth in regenerating skeletal muscle after myotoxic injury with greater effect at 3 than at 2 ATA.     

Chronic hypobaric hypoxia increases isolated rat fast-twitch and slow-twitch limb muscle force and fatigue

Chronic hypoxia alters respiratory muscle force and fatigue, effects that could be attributed to hypoxia and/or increased activation due to hyperventilation. We hypothesized that chronic hypoxia is associated with phenotypic change in non-respiratory muscles and therefore we tested the hypothesis that chronic hypobaric hypoxia increases limb muscle force and fatigue. Adult male Wistar rats were exposed to normoxia or hypobaric hypoxia (PB=450 mm Hg) for 6 weeks. At the end of the treatment period, soleus (SOL) and extensor digitorum longus (EDL) muscles were removed under pentobarbitone anaesthesia and strips were mounted for isometric force determination in Krebs solution in standard water-jacketed organ baths at 25 °C. Isometric twitch and tetanic force, contractile kinetics, force-frequency relationship and fatigue characteristics were determined in response to electrical field stimulation. Chronic hypoxia increased specific force in SOL and EDL compared to age-matched normoxic controls. Furthermore, chronic hypoxia decreased endurance in both limb muscles. We conclude that hypoxia elicits functional plasticity in limb muscles perhaps due to oxidative stress. Our results may have implications for respiratory disorders that are characterized by prolonged hypoxia such as chronic obstructive pulmonary disease (COPD).     

Exogenous Pleiotrophin Applied to Lesioned Nerve Impairs Muscle Reinnervation

Pleiotrophin (PTN) is a heparin-binding growth factor involved in nerve regeneration after peripheral nerve injury. After crush injury, PTN is found in distal nerve segments in several non-neural cell types, including Schwann cells, macrophages, and endothelial cells, but not in axons. To further clarify the role for PTN in nerve regeneration, we investigated the effects of PTN applied to lesioned peripheral nerve in vivo. PTN in a dose of 1 mg/kg impaired muscle reinnervation. Thus, gastrocnemius muscle failed to recover its contractile properties as assessed by in situ maximal isometric tetanic force. PTN also decreased non-neural cell densities and delayed macrophage recruitment in the distal crushed nerve. These results are discussed in the light of recent evidence that PTN is a multifunctional polypeptide.     

Motor and sensory reinnervation of fast and slow mammalian muscles

Summary 1. The formation of endplates outside the original endplate region of a muscle fibre was studied in slow and fast rat muscles. It was found that such new endplates are readily formed on the soleus muscle, whereas hardly at all in the fast extensor digitorum longus. Most new endplates appear to be morphologically normal within 2 months after nerve implantation.2. The time course of recovery of slow and fast cat muscles was followed after crushing the sciatic nerve. It was found that the slow soleus muscle recovers more rapidly than the fast flexor hallucis longus muscle.3. The endplates of reinnervated cat muscles are more complicated than those of the control muscles, but have nevertheless fewer nerve terminals per endplate. Reinnervated muscles are more sensitive to curare and it is suggested that this is due to a decrease in transmitter release, for it was found that less acetylcholine is released from reinnervated rat hemidiaphragms than from control ones.4. Motor and sensory reinnervation of spindles and tendon organs was studied. At the time when motor reinnervation is almost completed the sensory endings from spindles and tendon organs are highly abnormal. Thus sensory reinnervation proceeds much more slowly than motor.     

Nerve Cross-Bridging to Enhance Nerve Regeneration in a Rat Model of Delayed Nerve Repair

There are currently no available options to promote nerve regeneration through chronically denervated distal nerve stumps. Here we used a rat model of delayed nerve repair asking of prior insertion of side-to-side cross-bridges between a donor tibial (TIB) nerve and a recipient denervated common peroneal (CP) nerve stump ameliorates poor nerve regeneration. First, numbers of retrogradely-labelled TIB neurons that grew axons into the nerve stump within three months, increased with the size of the perineurial windows opened in the TIB and CP nerves. Equal numbers of donor TIB axons regenerated into CP stumps either side of the cross-bridges, not being affected by target neurotrophic effects, or by removing the perineurium to insert 5-9 cross-bridges. Second, CP nerve stumps were coapted three months after inserting 0-9 cross-bridges and the number of 1) CP neurons that regenerated their axons within three months or 2) CP motor nerves that reinnervated the extensor digitorum longus (EDL) muscle within five months was determined by counting and motor unit number estimation (MUNE), respectively. We found that three but not more cross-bridges promoted the regeneration of axons and reinnervation of EDL muscle by all the CP motoneurons as compared to only 33% regenerating their axons when no cross-bridges were inserted. The same 3-fold increase in sensory nerve regeneration was found. In conclusion, side-to-side cross-bridges ameliorate poor regeneration after delayed nerve repair possibly by sustaining the growth-permissive state of denervated nerve stumps. Such autografts may be used in human repair surgery to improve outcomes after unavoidable delays.     

Ischemia reperfusion injury of the skeletal muscle after selective deafferentation

The present study analyzes the effect of selective deafferentation on the reperfusion injury of the skeletal muscle when nociceptive sensory fibers of the left sciatic nerve are selectively damaged by capsaicin pretreatment in a rat model following tourniquet ischemia (ISC) applied for 30 min, 1 h, and 2 h on the left hind limb. The isometric tetanic contractile force of the extensor digitorum longus (EDL) muscle was measured after 1 h, and 1, 3, or 7 days of reperfusion. Contractile force of the damaged muscle was compared to the intact contralateral muscle. In another group, ISC was used without capsaicin pre-treatment. After 30 min of ISC, there was no difference between deafferented and non-pretreated groups. Following 1 h ISC, with the exception of 1 h reperfusion, the non-pretreated group produced stronger contractions than the deafferented group. After 2 h ISC, the contractile force of the deafferented muscle was significantly stronger compared to the non-deafferented muscle force at all reperfusion times. In conclusions, it was found that the absence of peptidergic sensory fibers after long-lasting (2 h) ischemia is beneficial in reperfusion injury, whereas the absence of vasodilator peptides has unfavorable effects if tissue damage is milder (after 1 h ischemia).     

Restoration of muscle contractile properties after partial and complete denervation

The subject of this experimental study was the isometric contractile properties of rat tibialis anterior muscle, number and average size of the motor units as well as type content and type-grouping of muscle fibres according to SDH activity in the same muscle after total and partial denervation (crushing the sciatic nerve and L4). It has been shown that in the process of reinnervation after total and partial denervation, quantitative differences with the general tendency in the dynamics of restoration of contractile properties of the whole muscle are found at different dynamics of restoration of electromyographic and muscle histochemical characteristics of motor units.     

Analysis of miniature potentials in reinnervated rat muscle]

Miniature endplate potentials (MEPPs) are regarded as the expression of release of a single quantum of acetylcholine by motor nerve endings in the muscle. Mepp frequency is dependent on the presynaptic mechanism, but MEPP amplitudes and time courses are the result of the characteristics of pre- and postsynaptic structures and of the interaction between them. After post-traumatic reinnervation of skeletal muscles, MEPP frequency increases, reaching slowly normal values. Two groups of male, Sprague Dawley rats were used: in the first group left sciatic nerve was crushed and nerve fibres were allowed to regenerate, whereas the others were regarded as controls. MEPPs were intracellularly recorded in end plates of normal and reinnervated left extensor digitorum longus muscle. MEPPs were sampled and recorded on a personal computer, and, subsequently, amplitude, rise time and half decay time were computed. At early stage after reinnervation, MEPPs showed rise times and decay times longer than normal. Afterwards, we did not find differences between mepp time courses by normal and reinnervated end plates. The possible relationships between the results and changes in acetylcholine receptor number and type, and in acetylcholinesterase activity occurring during denervation and reinnervation are discussed.     

Functional Recovery of Denervated Skeletal Muscle with Sensory or Mixed Nerve Protection: A Pilot Study

Functional recovery is usually poor following peripheral nerve injury when reinnervation is delayed. Early innervation by sensory nerve has been indicated to prevent atrophy of the denervated muscle. It is hypothesized that early protection with sensory axons is adequate to improve functional recovery of skeletal muscle following prolonged denervation of mixed nerve injury. In this study, four groups of rats received surgical denervation of the tibial nerve. The proximal and distal stumps of the tibial nerve were ligated in all animals except for those in the immediate repair group. The experimental groups underwent denervation with nerve protection of peroneal nerve (mixed protection) or sural nerve (sensory protection). The experimental and unprotected groups had a stage II surgery in which the trimmed proximal and distal tibial nerve stumps were sutured together. After 3 months of recovery, electrophysiological, histological and morphometric parameters were assessed. It was detected that the significant muscle atrophy and a good preserved structure of the muscle were observed in the unprotected and protective experimental groups, respectively. Significantly fewer numbers of regenerated myelinated axons were observed in the sensory-protected group. Enhanced recovery in the mixed protection group was indicated by the results of the muscle contraction force tests, regenerated myelinated fiber, and the results of the histological analysis. Our results suggest that early axons protection by mixed nerve may complement sensory axons which are required for promoting functional recovery of the denervated muscle natively innervated by mixed nerve.     

Functional and morphometric evaluation of end-to-side neurorrhaphy for muscle reinnervation

This study was undertaken to quantify the effect of motor collateral sprouting in an end-to-side repair model allowing end organ contact. Besides documentation of the functional outcome of muscle reinnervation by end-to-side neurorrhaphy, this experimental work was performed to determine possible downgrading effects to the donor nerve at end organ level. In 24 female New Zealand White rabbits, the motor nerve branch to the rectus femoris muscle of the right hindlimb was dissected, cut, and sutured end-to-side to the motor branch to the vastus medialis muscle after creating an epineural window. The 24 rabbits were divided into two groups of 12 each, with the second group receiving additional crush injury of the vastus branch. After a period of 8 months, maximum tetanic tension in the reinnervated rectus femoris and the vastus medialis muscles was determined. The contralateral healthy side served as control. The reinnervated rectus femoris muscle showed an average maximum tetanic force of 24.9 N (control 26.2 N, p = 0.7827), and the donor- vastus medialis muscle 11.0 N (control 7.3 N, p = 0.0223). There were no statistically significant differences between the two experimental groups (p = 0.9914). The average number of regenerated myelinated nerve fibers in the rectus femoris motor branch was 1,185 +/- 342 (control, 806 +/- 166), and the mean diameter was 4.6 +/- 0.6 microm (control, 9.4 +/- 1.0 microm). In the motor branch to the vastus medialis muscle, the mean fiber number proximal to the coaptation site was 1227 (+/-441), and decreased distal to the coaptation site to 795 (+/-270). The average difference of axon counts in the donor nerve proximal to distal regarding the repair site was 483.7 +/- 264.2. In the contralateral motor branch to the vastus medialis muscle, 540 (+/- 175) myelinated nerve fibers were counted. In nearly all cross-section specimens of the motor branch to the vastus medialis muscle, altered nerve fibers could be identified in one fascicle distal and proximal to the repair site. The results show a relevant functional reinnervation by end-to-side neurorrhaphy without functional impairment of the donor muscle. It seems to be evident that most axons in the attached segment were derived from collateral sprouts. Nonetheless, the present study confirms that end-to-side neurorrhaphy is a reliable method of reconstruction for damaged nerves, which should be applied clinically in a more extended manner.