Advances in peripheral nerve reconstruction: Current clinical conduits, comparative outcomes, limitations, and future technological perspectives.

Introduction: Peripheral nerve injuries remain a major clinical challenge, often resulting in persistent motor deficits, sensory loss, and neuropathic pain. When direct tension-free repair is not feasible, nerve reconstruction relies on autografts, processed allografts, or conduit-based strategies. Despite decades of innovation, outcomes remain inconsistent, particularly in motor nerves, long-gap defects, and complex traumatic environments. Research question: What are the relative clinical performances and limitations of currently available nerve repair strategies, and which emerging technologies may address their unmet biological shortcomings? Material and methods: This narrative review synthesizes clinical, experimental, and comparative evidence on autologous nerve grafts, processed nerve allografts, and biological or synthetic nerve conduits. Emphasis is placed on reported functional recovery, gap-length tolerance, complication profiles, and the influence of the injury microenvironment. Results: Autologous nerve grafting remains the benchmark for reliable regeneration but is limited by donor-site morbidity and graft availability. Processed nerve allografts preserve extracellular matrix architecture and demonstrate outcomes comparable to autografts for moderate-length defects, while avoiding harvest-related complications. In contrast, hollow biological and synthetic conduits show acceptable performance primarily in short sensory gaps, with declining efficacy in motor nerves, long defects, and inflammatory or scar-prone injuries. Discussion and conclusion: Current nerve repair technologies are fundamentally constrained by their passive structural design and limited ability to modulate the inhibitory post-injury microenvironment. Future progress is likely to depend on integrative platforms that combine structural guidance with active biological modulation, including bioactive and hydrogel-based strategies, to enhance regeneration in complex peripheral nerve injuries.