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Outcomes with microsurgery of common peroneal nerve lesions
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Journal of Plastic, Reconstructive & Aesthetic Surgery (2019) 000, 1–9
Outcomes with microsurgery of common peroneal nerve lesions Julia K Terzis a,∗, Ioannis Kostas b a
Adjunct Professor, Department of Plastic Surgery, New York University Medical Center, NYU School of Medicine, and International Institute of Reconstructive Microsurgery, 27/28 Thomson Avenue, Suite 620, LIC, 11101, New York b Orthopaedic Surgeon, Senior Consultant, University Hospital of Ioannina, Greece Received 26 April 2018; accepted 12 February 2019 Available online xxx
KEYWORDS ommon peroneal nerve; Nerve graft repair; Microneurolysis
Summary Objectives: The purpose of this retrospective study is to present our results with peroneal nerve lesions, to examine the relative significance of various factors, to assess their effect on outcome, and to establish guidelines of treatment for the microsurgical management of these difficult lesions. Methods: Over a 33-year period, a total of 62 patients were treated at McGill University and the Microsurgical Research Center, Eastern Virginia Medical School. The clinical records of all patients treated for peroneal nerve lesions were reviewed for retrospective analysis. Results: Of 62 patients, 35 had microneurolysis and nerve decompression of the common peroneal nerve (CPn) as the only surgical procedure while 27 required reconstruction with nerve grafting. Postoperatively muscle power was graded from M + 4 to M − 5 in 27 patients, from M − 4 to M4 in 26 patients, from M − 3 to M + 3 in 8 patients, and from M − 2 to M + 2 in 1 patient. The behavioral video data showed a mean preoperative ankle dorsiflexion of 6.79° ± 5.6 and postoperative ankle dorsiflexion of 37.9° ± 9.3. Overall, excellent functional results were achieved in 27 of 62 patients (43%) with peroneal palsy who underwent microsurgical reconstruction, and good results were observed in 25 patients (40%). Conclusions: Despite previous widespread pessimism, the surgical repair of CPn lesion is worthwhile, yielding good to excellent results in the majority of patients, after a careful preoperative consultation, establishment of a sound strategy of reconstruction and using aggressive and atraumatic microsurgery. © 2019 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Introduction
∗ Corresponding
author. E-mail address: [email protected] (J.K. Terzis).
Peroneal nerve palsy is the most frequent nerve injury of the lower extremity and accounts for about 15–20% of all peripheral nerve lesions.1 Vulnerability of the common peroneal nerve (CPn) has been attributed to various
https://doi.org/10.1016/j.bjps.2019.02.031 1748-6815/© 2019 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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J.K. Terzis and I. Kostas
Table 1
Evaluation system for the common peroneal nerve lesions.
Score
Classification
Description
0 1
None Poor
2
Fair
3
Good
4
Excellent
There is no palpable muscle contraction. The muscle power cannot bring the foot at 90° dorsiflexion with the gravity eliminated. This score corresponds to M2 for TA, EDB, and EDL muscles. The muscle power can bring the foot at 90° dorsiflexion, but cannot overcome this point against gravity. This score corresponds from M + 2 to +3 for TA, EDB, and EDL muscles. The muscle power moves the ankle joint through a useful range of motion overcoming the 90° of dorsiflexion against an applied load. This score corresponds from M − 4 to 4 for TA, EDB, and EDL, and at least M − 3 EHL muscle. Near normal function of the lower extremity. This score corresponds from M + 4 to −5 for TA, EDB, and EDL, and M + 3 or stronger for the EHL muscle.
TA: tibialis anterior muscle. EDB: extensor digitorum brevis muscle. EDL: extensor digitorum longus muscle. EHL: extensor hallucis longus muscle.
factors, including its internal organization, blood supply, superficial topography over the fibular head, and its course among others.2 Because of its location, the peroneal nerve seems particularly prone to injury from iatrogenic accidents,3–5 motor vehicle accidents,6–8 sport injuries,9–11 and gunshot wounds.12 Compression and entrapment lesions are probably the most frequent causes of peroneal neuropathy.13–15 The CPn may be compressed by a ganglion cyst, cysts of lateral meniscus, or a tumor of the head of the fibula.16–20 While previously published papers showed pessimistic results with CPn lesions,21 , 22 more recent studies have shown more encouraging results.23–26 Better understanding of fascicular topography, the use of improved microsurgical techniques such as vascularized nerve grafts (VNG) along with the knowledge that tension plays a detrimental role at the repair site, have allowed for optimal alignment at the fascicular level.27–31 The aims of this study are as follows: 1) To present our 33-year experience with CPn lesions. 2) To examine the relative significance of various factors including the type of injury, denervation time, and the length of nerve graft to assess their effect on the outcome. 3) To establish principles of treatment of these difficult lesions.
Materials/patients and methods The patient population for this study consists of 62 consecutive patients (43 male and 19 female) treated for peroneal nerve lesions at McGill University and at the Microsurgical Research Center of Eastern Virginia Medical School between 1978 and 2011. The inclusion criteria were 12 months or longer follow up for patients who underwent microneurolysis, and 24 months or longer for patients who had repair with nonvascularized nerve grafts (NNG) or VNG. Video and photographic documentation were obtained for each patient prior to and after the surgery as part of a routine workup and follow-up. The preoperative and post-
operative videotapes were assessed by five independent reviewers who separately graded the function of each patient. Motor strength grading was performed for each muscle innervated from the deep and superficial peroneal nerve preoperatively, as well as postoperatively at six months intervals. Our modified British Medical Research Council Grading System (grading from 0 to −5 with grade −5 being excellent) was used to assess the functional results after nerve microreconstruction, Table 1. Tinel’s sign was documented for each patient.32 Preoperative and postoperative electromyography (EMG) and nerve conduction velocity (NCV) studies were performed on all patients. All operative procedures were carried out by the senior surgeon (JKT). In all cases, the indication for surgical exploration was complete paralysis of the CPn that failed to show any evidence of clinical or electrophysiological recovery by three months or longer after injury. In the present series, the peroneal nerve was often explored at much later periods because of delayed referral of the patient. An algorithm for our strategy of reconstruction of common peroneal lesions is depicted, Figure 1. Intraoperative electrical stimulation and nerve action potential (NAP) recording were performed on each nerve and branches, particularly in lesions in continuity, in which a decision had to be made whether to proceed with microneurolysis (in cases with NAP preserved), or to resect the bundle and proceed with nerve grafting (in cases with absent NAP).32 The patients were evaluated at 3 months, 6 months, 9 months, and 12 months postoperatively and yearly thereafter. All variables of interest were analyzed by using the Mann–Whitney test. The results include mean values ± SD. The p values are reported, and any value <0.05 is considered statistically significant.
Results Of the 62 operated patients 43 were male and 19 female, with ages ranging from 4 to 64 years (mean age, 30.2 years) at the time of surgery. In 40 patients, the lesion was in the right side, in 20 patients the left peroneal nerve was involved while two patients had bilateral lesions.
Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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Outcomes with microsurgery
Figure 1
3
Represents a surgical decision-making algorithm for common peroneal nerve lesions.
The average time from initial injury to microreconstruction was 15.8 months (range, 1–71 months). Mean follow-up for patients who had undergone surgery was 32 months, range 9–117 months. A motor vehicle accident was the cause of injury in 20 patients, sports-related trauma in 10 patients, and 9 patients had iatrogenic injury, (osteotomy of the tibia, cast placement, skeletal traction placement, tourniquet placement, and surgery to remove an exostosis on the lateral side of the femur). The CPn lesion was associated with a fracture in 14 patients (22.5%). In 10 patients (16.2%) the nerve lesion was associated with knee dislocation. In 10 patients (16.2%) there was associated vascular injury. Thirty-one patients (50%) had microneurolysis and nerve decompression of the CPn as the only surgical procedure. Of 62 patients who underwent surgery, 27 patients (43.5%) required reconstruction with interposition nerve grafts. Of these, 15 patients (24.1%) had NNG, 5 patients (8%) had a combination of VNG and NNG (Figure 2(a)–(d)), while 7 patients (11.3%) with severe traction injuries had a combination of VNG, NNG, and vascularized posterior calf fascia flap (VPCF) to embrace the nerve reconstruction, Figure 3(a)–(d), Table 2.
Transfer of tendons was performed in our patients only in selected cases and only as a secondary procedure. Data from secondary reconstruction are not considered in this study.
Traction-avulsion lesions Twenty-five patients had severe traction-avulsion lesions (41% of the total operated population). Intraoperative findings indicated perineurial discontinuity in 7 patients, neuroma in continuity with NAP propagation in 10 patients, while 8 patients had severe nerve lesions in continuity with no NAP transmittal. Ten of 25 patients (40%) had extensive microneurolysis. In 14 of the 25 patients (56%), the placement of interfascicular nerve grafts was necessary because of nerve tissue loss. In this subgroup, 6 patients underwent repair with NNG and 2 others had a combination of NNG and VNG. In the latter, extensive nerve grafting was necessary. In six patients a combination of NNG, VNG, and VPCF was used to optimize nerve regeneration, Table 3. One patient had a graft length of 6 cm and the final result was excellent. Three of the 6 patients with graft length from 7 to 13 cm had excellent results and 2 of 7 patients with
Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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a
b
c
d
Figure 2 Represents a case of common peroneal nerve lesion in which conventional and vascularized sural nerve grafts were used to bridge the nerve defect. (a–b). A 43-year-old male patient sustained a deep laceration on the posterolateral aspect of the right knee secondary to a boat propeller accident. Nine months after the injury, the patient was presented to our center with a complete drop foot. Surgical exploration showed a complete common peroneal nerve transection at the head of the fibula. Upon exploration and proximal and distal stump preparation, a 10 cm gap was created, which was repaired with a combination of 5 × 10 cm conventional sural nerve grafts and 2 × 10 cm vascularized sural nerve grafts. (c–d). An excellent result was seen 3 years after surgery. The patient is able to dorsiflex the right foot and heel walk.
graft lengths longer than 13 cm also had excellent results, Table 4. Of the patients operated early (less than 6 months), 6 of them (75%) had excellent recovery, while only 2 of the 6 patients (33.3%) with a denervation time from 7 to 13 months regained excellent function. When the delay in treatment ranged from 14 to 20 months, only 1 of 4 patients (25%) had excellent recovery. No patient with denervation time greater than 20 months had excellent functional recovery, Table 5.
Table 2 Surgical procedures vs no. of patients for 62 operated patients with CPn lesion. Procedures
No. of patients %
Microneurolysis NNG Combination of NNG and VNG NNG, VNG, and VPCF Neuroma excision & loop coaptation
31 15 5 7 4
50 24.1 8 11.3 6.4
NNG (nonvascularized nerve graft). VNG (vascularized nerve graft). VPCF (vascularized posterior calf fascia).
Laceration/stab lesions All 13 patients with laceration/stab lesions were diagnosed intraoperatively with complete nerve transection.
NNGs were used in 9 patients, a combination of NNG and VNG was used in 3 patients, while VPCF in combination with VNG was used in one patient, Table 6.
Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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5
a
b
c
d
Figure 3 Represents a case with common peroneal nerve lesion in which conventional and vascularized sural nerve grafts were used to bridge the nerve defect and vascularized posterior calf fascia was used to create a healthy vascularized bed around the nerve reconstruction. (a–b). A 23-year-old male patient sustained posterior dislocation of the right knee and right common peroneal nerve palsy secondary to a MVA. Three months after the accident, the patient presented to our center with complete foot drop. An EMG-NCV study showed findings compatible with complete common peroneal nerve transection. Surgical exploration at 4 months showed a large defect at the common peroneal nerve. The proximal and distal stumps of the common peroneal nerve were excised till healthy fascicles were seen. Because of a severe amount of scar at the nerve lesion site, a VPCF was elevated and was used to envelop the nerve reconstruction. The nerve defect was repaired by using a 2 × 20 cm conventional sural, 2 × 20 cm vascularized sural nerve grafts, and the vascularized posterior calf fascia flap around nerve reconstruction. (c–d). Five years after the nerve microreconstruction, the patient recovered near normal right foot dorsiflexion and right heel walking.
Table 3 Surgical procedures vs functional recovery for 25 operated patients in the avulsion/traction group. Procedures
Excellent Good Fair Poor None
Microneurolysis and nerve decompression NNG NNG and VNG NNG, VNG, and VPCF Neuroma excision & loop coaptation Total
3
3
3
0
1
2 1 3 0
2 1 3 1
2 0 0 0
0 0 0 0
0 0 0 0
9
10
5
0
1
Table 4 Graft length vs functional recovery for 14 patients treated with grafting in the avulsion/traction group. Graft length
Excellent
Good
Fair
Poor
None
2.5–6 cm 7–13 cm >13 cm
1 3 2
0 3 3
0 0 2
0 0 0
0 0 0
In 6 patients, the nerve grafts had a length from 2.5 to 6 cm. Of these, 3 patients (50%) had an excellent functional result. Among the 6 patients with nerve grafts ranging from 7 to 13 cm in length, 2 of them (33.3%) had excellent results, and 2 had good recovery. One patient required a nerve
Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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J.K. Terzis and I. Kostas Table 5 Denervation time vs functional recovery for 25 patients in the avulsion/traction group.
Table 8 Type of treatment vs functional results for 62 operated patients with CPn lesion.
Denervation time
Excellent
Good
Fair
Poor
None
Procedures
Excellent
Good
Fair
Poor
1–6 months 7–13 months 14–20 months >20 months
6 2 1 0
1 3 2 4
1 1 1 2
0 0 0 0
0 0 0 1
Microneurolysis and Nerve Decompression NNG NNG and VNG NNG, VNG, and PFF Neuroma excision and Loop coaptation
16
11
3
1
4 3 4
7 1 3 4
4 0
0 0 0 0
Table 6 Surgical procedures vs functional recovery for 13 patients in the laceration/stab group. Procedures
0
Excellent Good Fair Poor None
NNG 2 NNG and VNG 2 NNG, VNG, and VPCF 1
5 0 0
2 1 0
0 0 0
0 0 0
Table 7 Graft length vs functional recovery for 13 patients in the laceration/stab group treated with nerve grafts. Graft length
Excellent
Good
Fair
Poor
None
2.5–6 cm 7–13 cm >13 Total
3 2 0 5
2 2 1 5
1 2 0 3
0 0 0 0
0 0 0 0
Figure 4 Represents nerve graft length versus functional recovery for 27 operated patients treated with nerve grafts.
graft longer than 13 cm and postoperatively he had a good result, Table 7. Three of 7 patients with denervation time from 1 to 6 months had excellent functional recovery. From the patients with denervation time more than 20 months, 1 patient had a good result and 2 patients had a fair result.
Crush/compression lesions Twenty-four patients had crush-compression lesions. The intraoperative findings in all patients in this group were epineurial fibrosis and fibrous constricting bands. Most of them presented with causalgic pain, and persistent hyperesthesia or dysesthesia secondary to compression. Surgery consisted of microneurolysis in 21 patients while 3 had neuroma excision and loop coaptation. Thirteen patients had excellent recovery, had no pain, paresthesia, or dysesthesia, and 11 had good recovery with significant pain relief, having intermittent discomfort, which did not require analgesic treatment. Excellent results were observed in 5 of 7 patients (71.4%) with denervation time of 1–6 months, in 5 of 8 patients (62.5%) with denervation time of 7–13 months, and in 3 of 6 patients (50%) with more than 20 months denervation time.
Overall results Overall, excellent functional results were achieved in 27 of 62 patients (43%), good results were observed in 25 patients (40%), satisfactory results in 7 (11%), and only 1 patient (1.6%) showed a poor result, Table 8.
Figure 5 Represents denervation time and functional results for 62 operated patients with common peroneal nerve lesions.
There were statistically significant differences in the functional outcomes between the group of patients with nerve graft length less than 6 cm and those who received a longer than 13 cm nerve graft length (p < 0.001), Figure 4. Statistically significant differences (p = 0.007) were also seen between the group of patients with less than 13 months denervation time and those with longer delays before surgery, Figure 5. The behavioral video data as graded by 5 independent reviewers showed a mean preoperative ankle dorsiflexion of 6.79° ± 5.6 and postoperative ankle dorsiflexion of 37.9° ± 9.3, (p < 0.001), Figure 6. Muscle power was graded from M + 4 to M − 5 in 27 patients, from M − 4 to M4 in 26 patients, from M − 3 to M + 3 in 8 patients and from M − 2 to M + 2 in 1 patient (p < 0.001), Figure 7.
Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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Figure 6 Represents preoperative and postoperative video evaluations as far as foot dorsiflexion for 62 operated patients with common peroneal nerve lesions.
Figure 7 Represents preoperative and postoperative muscle grading for 62 operated patients with common peroneal nerve lesions.
Discussion A complex array of tightly interrelated prognostic factors including those associated with the patient, such as associated fractures and/or vascular injury, the mechanism and type of injury, denervation time, nerve gap length, and nerve graft length, as well as the surgical strategy, all have a profound impact on the functional outcomes. In this series, surgical exploration was carried out in all patients who failed to show any clinical or electrophysiological recovery within 3 months from injury. Because of delayed referral to our center, many patients had exploration much later than this period. It is known that functional recovery decreases with increased denervation time. Birch showed that M4 muscle power can be achieved in 47% of patients with less than 6 months delay in treatment and in only 8% of patients with delay of more than 12 months.33 In our series, excellent results were seen in 63.6% of patients with a delay in treatment of 1 to 6 months, in 50% of patients with delay of 7–13 months, and in only 18% of the patients with denervation time of more than 20 months. There were statistically significant differences (p = 0.007) between the group of patients with less than 13 months denervation time and those who had surgery after this period. The mechanism of injury is another factor with impact on the functional recovery. This is because surgical strategy is usually dictated by the severity of trauma and the neural defect. Trumble reports that laceration injuries appear
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7 to regenerate better than crush injuries.34 Because of the longitudinal extent of the nerve damage and the presence of associated vascular lesions, Clawson and Seddon advocated no surgery for severe traction injuries.21 High velocity trauma is responsible for most traction-avulsion injuries, which most likely require interpositional nerve grafting and in many cases an improved vascularized bed, in contrast to crush/compression injuries, which require only microneurolysis in the majority of cases. Thus, the results in our series with crush/compression lesions treated only with microneurolysis (mean muscle grading; 3.77 ± 0.4) tended to be superior to those from traction-avulsion injury where interpositional nerve grafts were used (3.06 ± 0.90). There is an agreement that the results of nerve grafting are influenced by the length of the defect to be reconstructed, with shorter nerve grafts having better prognosis. Wood reported that good results (M + 3 muscle grading) are expected only with nerve grafts shorter than 6 cm.35 Kim stated that good functional recovery could not be expected with a graft length of more than 12 cm.8 Others have reported muscle grading of M + 4 even with nerve grafts of up to 20 cm.36 Our data showed that when dealing with CPn lesions, regardless of the type of nerve injury, 4 patients (57%) with nerve grafts length of up to 6 cm achieved excellent function. In patients with a nerve graft length of 7–13 cm, 5 patients (41%) had excellent results and five patients had good results. However, only 2 of 8 patients (25%) with a nerve graft longer than 13 cm had excellent results. In cases when nerve lesions are associated with fractures and/or vascular injury, the resulting ischemia worsens the nerve tissue injury. Additionally, the vascular or orthopedic procedures done before nerve microreconstruction alters the anatomy, which has a negative impact in the final outcome. In our series, the overall functional result in patients with no vascular injuries or fractures was 3.31 ± 1.7, while in the patients with associated fractures/dislocations and/or vascular injury was 3.08 ± 0.9, (p = 0.671). The VPCF that carries the ipsilateral sural nerve and lesser saphenous vein is an intelligent strategy for severe peroneal nerve lesions, as it minimizes the negative effects of scarred bed and/or exceedingly long grafts. In our series, this procedure was used in 7 patients.37 Five patients had severe knee dislocations and 4 required immediate posterior tibialis artery repairs with a saphenous vein graft. Excellent functional results were seen in 6 patients and a good result in 1. In this series, no significant correlation with age was noted, 3.7 ± 0.48 was muscle grading for patients under 25 years of age and 3.15 ± 1.14 for the patients older than 40 years of age, (p = 0.204). This may reflect the fact that in this study, very few patients were under 18 years of age, which may lead to the weakening of any association between age and functional result. It has been stated that reinnervation of CPn could be impaired by the force imbalance between active plantar flexors and denervated foot extensors.38 For late cases of CPn lesion, Millesi suggests performing both nerve repair and tibialis tendon transfer in the same surgical procedure.38 Garozzo et al. after obtaining disappointing results when only CPn repair was done (in 5 out of 6 cases no muscle recovery was seen), advocates nerve repair and tendon transfer in one single surgical procedure.36 We do not adhere to
Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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this strategy. Our experience shows that patients with CPn lesion are usually young active people who are involved in sports and do not easily accept an immediate posterior tibialis tendon transfer. To prevent muscle atrophy, we strongly recommend slow-pulse stimulation for 5–6 h a day. We use secondary tendon transfers to enhance the functional outcomes in selected late cases at a later date. Thus, our strategy is to address the nerve lesion first and if the recovery is inadequate, then enhance the results with tendon transfer. Tendon transfers were performed in our series only in 7 cases. Three patients improved from fair to good and 4 patients went from good to excellent after the secondary procedure. In the case of CPn lesions, motor recovery is more important than sensory recovery. Protective sensation was restored in all our patients after surgery, and none of them had causalgia. Motor recovery is useful only if it enables the patient to dorsiflex the foot against gravity. Postoperative electrophysiological studies at 12 months after surgery showed complete reinnervation in 44 patients, partial reinnervation in 16 patients, and no improvement in one patient. The results reported in this series advocate that peroneal nerve reconstruction is worthwhile in at least 83.5% of the cases. The use of modern principles of nerve grafting and transfer39 , 40 can indeed yield worthwhile outcomes in these often ignored lesions.
Conclusions 1. In CPn lesions, early surgical exploration and repair are recommended. 2. The goal of treatment is to achieve useful motor function, and at least protective sensibility. 3. Implementation of principles that optimize nerve regeneration. 4. In cases with highly unfavorable scarred beds and large nerve gaps, the use of VNG in combination with the transfer of VPCF is strongly advocated.
Declaration of Conflict of Interest Dr. Julia K Terzis and Dr. Ioannis Kostas report no biomedical financial interests or potential conflicts of interest.
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Outcomes with microsurgery 30. Terzis JK, Breidenbach WC. The anatomy of free vascularized nerve grafts. In: Terzis J, editor. Microreconstruction of nerve injuries. Philadelphia: W.B.Saunders Co.; 1987. p. 101–16. 31. Terzis JK, Kostopoulos VK. Vascularized nerve grafts; a review. Atlas of the Hand Clinics 2005;10:101–3. 32. Williams HB, Terzis JK. Single fascicular recordings: an intraoperative diagnostic tool for the management of peripheral nerve lesions. Plast Reconstr Surg 1976;57:562–9. 33. Birch R, Booney G, Wynn CB. Surgical disorders of the peripheral nerves. London: Churchill Livingstone; 1988. p. 235– 243. 34. Trumble T, Vanderhooft E. Nerve grafting for lower extremity injuries. J Pediatr Orthop 1994;14:161–5. 35. Wood MB. Peroneal nerve repair, surgical results. Clin Orthop Relat Res 1991;267:206–10.
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9 36. Garozzo D, Ferraresi S, Buffatti P. Surgical treatment of common peroneal nerve injuries: indications and results. A series of 62 cases. J Neurosurg Sci 2004;48:105–12. 37. Terzis JK, Kostopoulos VK. Vascularized nerve grafts for lower extremity nerve reconstruction. Ann Plast Surg 2010;64:169–76. 38. Millesi H. Lower extremity nerve lesions. In: Terzis J, editor. Microreconstruction of nerve injures. Philadelphia: W. B. Saunders Co.; 1987. p. 239–51. 39. Nath RK, Lyons AB, Paizi M. Successful management of foot drop by nerve transfers to the deep peroneal nerve. J Reconstr Microsurg 2008;24:419–27. 40. Leclère FM, Badur N, Mathys L, Vögelin E. Nerve transfers for persistent traumatic peroneal nerve palsy: the inselspital bern experience. Neurosurgery 2015;77:572–9.
Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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Journal of Plastic, Reconstructive & Aesthetic Surgery (2019) 000, 1–9
Outcomes with microsurgery of common peroneal nerve lesions Julia K Terzis a,∗, Ioannis Kostas b a
Adjunct Professor, Department of Plastic Surgery, New York University Medical Center, NYU School of Medicine, and International Institute of Reconstructive Microsurgery, 27/28 Thomson Avenue, Suite 620, LIC, 11101, New York b Orthopaedic Surgeon, Senior Consultant, University Hospital of Ioannina, Greece Received 26 April 2018; accepted 12 February 2019 Available online xxx
KEYWORDS ommon peroneal nerve; Nerve graft repair; Microneurolysis
Summary Objectives: The purpose of this retrospective study is to present our results with peroneal nerve lesions, to examine the relative significance of various factors, to assess their effect on outcome, and to establish guidelines of treatment for the microsurgical management of these difficult lesions. Methods: Over a 33-year period, a total of 62 patients were treated at McGill University and the Microsurgical Research Center, Eastern Virginia Medical School. The clinical records of all patients treated for peroneal nerve lesions were reviewed for retrospective analysis. Results: Of 62 patients, 35 had microneurolysis and nerve decompression of the common peroneal nerve (CPn) as the only surgical procedure while 27 required reconstruction with nerve grafting. Postoperatively muscle power was graded from M + 4 to M − 5 in 27 patients, from M − 4 to M4 in 26 patients, from M − 3 to M + 3 in 8 patients, and from M − 2 to M + 2 in 1 patient. The behavioral video data showed a mean preoperative ankle dorsiflexion of 6.79° ± 5.6 and postoperative ankle dorsiflexion of 37.9° ± 9.3. Overall, excellent functional results were achieved in 27 of 62 patients (43%) with peroneal palsy who underwent microsurgical reconstruction, and good results were observed in 25 patients (40%). Conclusions: Despite previous widespread pessimism, the surgical repair of CPn lesion is worthwhile, yielding good to excellent results in the majority of patients, after a careful preoperative consultation, establishment of a sound strategy of reconstruction and using aggressive and atraumatic microsurgery. © 2019 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Introduction
∗ Corresponding
author. E-mail address: [email protected] (J.K. Terzis).
Peroneal nerve palsy is the most frequent nerve injury of the lower extremity and accounts for about 15–20% of all peripheral nerve lesions.1 Vulnerability of the common peroneal nerve (CPn) has been attributed to various
https://doi.org/10.1016/j.bjps.2019.02.031 1748-6815/© 2019 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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Table 1
Evaluation system for the common peroneal nerve lesions.
Score
Classification
Description
0 1
None Poor
2
Fair
3
Good
4
Excellent
There is no palpable muscle contraction. The muscle power cannot bring the foot at 90° dorsiflexion with the gravity eliminated. This score corresponds to M2 for TA, EDB, and EDL muscles. The muscle power can bring the foot at 90° dorsiflexion, but cannot overcome this point against gravity. This score corresponds from M + 2 to +3 for TA, EDB, and EDL muscles. The muscle power moves the ankle joint through a useful range of motion overcoming the 90° of dorsiflexion against an applied load. This score corresponds from M − 4 to 4 for TA, EDB, and EDL, and at least M − 3 EHL muscle. Near normal function of the lower extremity. This score corresponds from M + 4 to −5 for TA, EDB, and EDL, and M + 3 or stronger for the EHL muscle.
TA: tibialis anterior muscle. EDB: extensor digitorum brevis muscle. EDL: extensor digitorum longus muscle. EHL: extensor hallucis longus muscle.
factors, including its internal organization, blood supply, superficial topography over the fibular head, and its course among others.2 Because of its location, the peroneal nerve seems particularly prone to injury from iatrogenic accidents,3–5 motor vehicle accidents,6–8 sport injuries,9–11 and gunshot wounds.12 Compression and entrapment lesions are probably the most frequent causes of peroneal neuropathy.13–15 The CPn may be compressed by a ganglion cyst, cysts of lateral meniscus, or a tumor of the head of the fibula.16–20 While previously published papers showed pessimistic results with CPn lesions,21 , 22 more recent studies have shown more encouraging results.23–26 Better understanding of fascicular topography, the use of improved microsurgical techniques such as vascularized nerve grafts (VNG) along with the knowledge that tension plays a detrimental role at the repair site, have allowed for optimal alignment at the fascicular level.27–31 The aims of this study are as follows: 1) To present our 33-year experience with CPn lesions. 2) To examine the relative significance of various factors including the type of injury, denervation time, and the length of nerve graft to assess their effect on the outcome. 3) To establish principles of treatment of these difficult lesions.
Materials/patients and methods The patient population for this study consists of 62 consecutive patients (43 male and 19 female) treated for peroneal nerve lesions at McGill University and at the Microsurgical Research Center of Eastern Virginia Medical School between 1978 and 2011. The inclusion criteria were 12 months or longer follow up for patients who underwent microneurolysis, and 24 months or longer for patients who had repair with nonvascularized nerve grafts (NNG) or VNG. Video and photographic documentation were obtained for each patient prior to and after the surgery as part of a routine workup and follow-up. The preoperative and post-
operative videotapes were assessed by five independent reviewers who separately graded the function of each patient. Motor strength grading was performed for each muscle innervated from the deep and superficial peroneal nerve preoperatively, as well as postoperatively at six months intervals. Our modified British Medical Research Council Grading System (grading from 0 to −5 with grade −5 being excellent) was used to assess the functional results after nerve microreconstruction, Table 1. Tinel’s sign was documented for each patient.32 Preoperative and postoperative electromyography (EMG) and nerve conduction velocity (NCV) studies were performed on all patients. All operative procedures were carried out by the senior surgeon (JKT). In all cases, the indication for surgical exploration was complete paralysis of the CPn that failed to show any evidence of clinical or electrophysiological recovery by three months or longer after injury. In the present series, the peroneal nerve was often explored at much later periods because of delayed referral of the patient. An algorithm for our strategy of reconstruction of common peroneal lesions is depicted, Figure 1. Intraoperative electrical stimulation and nerve action potential (NAP) recording were performed on each nerve and branches, particularly in lesions in continuity, in which a decision had to be made whether to proceed with microneurolysis (in cases with NAP preserved), or to resect the bundle and proceed with nerve grafting (in cases with absent NAP).32 The patients were evaluated at 3 months, 6 months, 9 months, and 12 months postoperatively and yearly thereafter. All variables of interest were analyzed by using the Mann–Whitney test. The results include mean values ± SD. The p values are reported, and any value <0.05 is considered statistically significant.
Results Of the 62 operated patients 43 were male and 19 female, with ages ranging from 4 to 64 years (mean age, 30.2 years) at the time of surgery. In 40 patients, the lesion was in the right side, in 20 patients the left peroneal nerve was involved while two patients had bilateral lesions.
Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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Figure 1
3
Represents a surgical decision-making algorithm for common peroneal nerve lesions.
The average time from initial injury to microreconstruction was 15.8 months (range, 1–71 months). Mean follow-up for patients who had undergone surgery was 32 months, range 9–117 months. A motor vehicle accident was the cause of injury in 20 patients, sports-related trauma in 10 patients, and 9 patients had iatrogenic injury, (osteotomy of the tibia, cast placement, skeletal traction placement, tourniquet placement, and surgery to remove an exostosis on the lateral side of the femur). The CPn lesion was associated with a fracture in 14 patients (22.5%). In 10 patients (16.2%) the nerve lesion was associated with knee dislocation. In 10 patients (16.2%) there was associated vascular injury. Thirty-one patients (50%) had microneurolysis and nerve decompression of the CPn as the only surgical procedure. Of 62 patients who underwent surgery, 27 patients (43.5%) required reconstruction with interposition nerve grafts. Of these, 15 patients (24.1%) had NNG, 5 patients (8%) had a combination of VNG and NNG (Figure 2(a)–(d)), while 7 patients (11.3%) with severe traction injuries had a combination of VNG, NNG, and vascularized posterior calf fascia flap (VPCF) to embrace the nerve reconstruction, Figure 3(a)–(d), Table 2.
Transfer of tendons was performed in our patients only in selected cases and only as a secondary procedure. Data from secondary reconstruction are not considered in this study.
Traction-avulsion lesions Twenty-five patients had severe traction-avulsion lesions (41% of the total operated population). Intraoperative findings indicated perineurial discontinuity in 7 patients, neuroma in continuity with NAP propagation in 10 patients, while 8 patients had severe nerve lesions in continuity with no NAP transmittal. Ten of 25 patients (40%) had extensive microneurolysis. In 14 of the 25 patients (56%), the placement of interfascicular nerve grafts was necessary because of nerve tissue loss. In this subgroup, 6 patients underwent repair with NNG and 2 others had a combination of NNG and VNG. In the latter, extensive nerve grafting was necessary. In six patients a combination of NNG, VNG, and VPCF was used to optimize nerve regeneration, Table 3. One patient had a graft length of 6 cm and the final result was excellent. Three of the 6 patients with graft length from 7 to 13 cm had excellent results and 2 of 7 patients with
Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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a
b
c
d
Figure 2 Represents a case of common peroneal nerve lesion in which conventional and vascularized sural nerve grafts were used to bridge the nerve defect. (a–b). A 43-year-old male patient sustained a deep laceration on the posterolateral aspect of the right knee secondary to a boat propeller accident. Nine months after the injury, the patient was presented to our center with a complete drop foot. Surgical exploration showed a complete common peroneal nerve transection at the head of the fibula. Upon exploration and proximal and distal stump preparation, a 10 cm gap was created, which was repaired with a combination of 5 × 10 cm conventional sural nerve grafts and 2 × 10 cm vascularized sural nerve grafts. (c–d). An excellent result was seen 3 years after surgery. The patient is able to dorsiflex the right foot and heel walk.
graft lengths longer than 13 cm also had excellent results, Table 4. Of the patients operated early (less than 6 months), 6 of them (75%) had excellent recovery, while only 2 of the 6 patients (33.3%) with a denervation time from 7 to 13 months regained excellent function. When the delay in treatment ranged from 14 to 20 months, only 1 of 4 patients (25%) had excellent recovery. No patient with denervation time greater than 20 months had excellent functional recovery, Table 5.
Table 2 Surgical procedures vs no. of patients for 62 operated patients with CPn lesion. Procedures
No. of patients %
Microneurolysis NNG Combination of NNG and VNG NNG, VNG, and VPCF Neuroma excision & loop coaptation
31 15 5 7 4
50 24.1 8 11.3 6.4
NNG (nonvascularized nerve graft). VNG (vascularized nerve graft). VPCF (vascularized posterior calf fascia).
Laceration/stab lesions All 13 patients with laceration/stab lesions were diagnosed intraoperatively with complete nerve transection.
NNGs were used in 9 patients, a combination of NNG and VNG was used in 3 patients, while VPCF in combination with VNG was used in one patient, Table 6.
Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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5
a
b
c
d
Figure 3 Represents a case with common peroneal nerve lesion in which conventional and vascularized sural nerve grafts were used to bridge the nerve defect and vascularized posterior calf fascia was used to create a healthy vascularized bed around the nerve reconstruction. (a–b). A 23-year-old male patient sustained posterior dislocation of the right knee and right common peroneal nerve palsy secondary to a MVA. Three months after the accident, the patient presented to our center with complete foot drop. An EMG-NCV study showed findings compatible with complete common peroneal nerve transection. Surgical exploration at 4 months showed a large defect at the common peroneal nerve. The proximal and distal stumps of the common peroneal nerve were excised till healthy fascicles were seen. Because of a severe amount of scar at the nerve lesion site, a VPCF was elevated and was used to envelop the nerve reconstruction. The nerve defect was repaired by using a 2 × 20 cm conventional sural, 2 × 20 cm vascularized sural nerve grafts, and the vascularized posterior calf fascia flap around nerve reconstruction. (c–d). Five years after the nerve microreconstruction, the patient recovered near normal right foot dorsiflexion and right heel walking.
Table 3 Surgical procedures vs functional recovery for 25 operated patients in the avulsion/traction group. Procedures
Excellent Good Fair Poor None
Microneurolysis and nerve decompression NNG NNG and VNG NNG, VNG, and VPCF Neuroma excision & loop coaptation Total
3
3
3
0
1
2 1 3 0
2 1 3 1
2 0 0 0
0 0 0 0
0 0 0 0
9
10
5
0
1
Table 4 Graft length vs functional recovery for 14 patients treated with grafting in the avulsion/traction group. Graft length
Excellent
Good
Fair
Poor
None
2.5–6 cm 7–13 cm >13 cm
1 3 2
0 3 3
0 0 2
0 0 0
0 0 0
In 6 patients, the nerve grafts had a length from 2.5 to 6 cm. Of these, 3 patients (50%) had an excellent functional result. Among the 6 patients with nerve grafts ranging from 7 to 13 cm in length, 2 of them (33.3%) had excellent results, and 2 had good recovery. One patient required a nerve
Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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J.K. Terzis and I. Kostas Table 5 Denervation time vs functional recovery for 25 patients in the avulsion/traction group.
Table 8 Type of treatment vs functional results for 62 operated patients with CPn lesion.
Denervation time
Excellent
Good
Fair
Poor
None
Procedures
Excellent
Good
Fair
Poor
1–6 months 7–13 months 14–20 months >20 months
6 2 1 0
1 3 2 4
1 1 1 2
0 0 0 0
0 0 0 1
Microneurolysis and Nerve Decompression NNG NNG and VNG NNG, VNG, and PFF Neuroma excision and Loop coaptation
16
11
3
1
4 3 4
7 1 3 4
4 0
0 0 0 0
Table 6 Surgical procedures vs functional recovery for 13 patients in the laceration/stab group. Procedures
0
Excellent Good Fair Poor None
NNG 2 NNG and VNG 2 NNG, VNG, and VPCF 1
5 0 0
2 1 0
0 0 0
0 0 0
Table 7 Graft length vs functional recovery for 13 patients in the laceration/stab group treated with nerve grafts. Graft length
Excellent
Good
Fair
Poor
None
2.5–6 cm 7–13 cm >13 Total
3 2 0 5
2 2 1 5
1 2 0 3
0 0 0 0
0 0 0 0
Figure 4 Represents nerve graft length versus functional recovery for 27 operated patients treated with nerve grafts.
graft longer than 13 cm and postoperatively he had a good result, Table 7. Three of 7 patients with denervation time from 1 to 6 months had excellent functional recovery. From the patients with denervation time more than 20 months, 1 patient had a good result and 2 patients had a fair result.
Crush/compression lesions Twenty-four patients had crush-compression lesions. The intraoperative findings in all patients in this group were epineurial fibrosis and fibrous constricting bands. Most of them presented with causalgic pain, and persistent hyperesthesia or dysesthesia secondary to compression. Surgery consisted of microneurolysis in 21 patients while 3 had neuroma excision and loop coaptation. Thirteen patients had excellent recovery, had no pain, paresthesia, or dysesthesia, and 11 had good recovery with significant pain relief, having intermittent discomfort, which did not require analgesic treatment. Excellent results were observed in 5 of 7 patients (71.4%) with denervation time of 1–6 months, in 5 of 8 patients (62.5%) with denervation time of 7–13 months, and in 3 of 6 patients (50%) with more than 20 months denervation time.
Overall results Overall, excellent functional results were achieved in 27 of 62 patients (43%), good results were observed in 25 patients (40%), satisfactory results in 7 (11%), and only 1 patient (1.6%) showed a poor result, Table 8.
Figure 5 Represents denervation time and functional results for 62 operated patients with common peroneal nerve lesions.
There were statistically significant differences in the functional outcomes between the group of patients with nerve graft length less than 6 cm and those who received a longer than 13 cm nerve graft length (p < 0.001), Figure 4. Statistically significant differences (p = 0.007) were also seen between the group of patients with less than 13 months denervation time and those with longer delays before surgery, Figure 5. The behavioral video data as graded by 5 independent reviewers showed a mean preoperative ankle dorsiflexion of 6.79° ± 5.6 and postoperative ankle dorsiflexion of 37.9° ± 9.3, (p < 0.001), Figure 6. Muscle power was graded from M + 4 to M − 5 in 27 patients, from M − 4 to M4 in 26 patients, from M − 3 to M + 3 in 8 patients and from M − 2 to M + 2 in 1 patient (p < 0.001), Figure 7.
Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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Figure 6 Represents preoperative and postoperative video evaluations as far as foot dorsiflexion for 62 operated patients with common peroneal nerve lesions.
Figure 7 Represents preoperative and postoperative muscle grading for 62 operated patients with common peroneal nerve lesions.
Discussion A complex array of tightly interrelated prognostic factors including those associated with the patient, such as associated fractures and/or vascular injury, the mechanism and type of injury, denervation time, nerve gap length, and nerve graft length, as well as the surgical strategy, all have a profound impact on the functional outcomes. In this series, surgical exploration was carried out in all patients who failed to show any clinical or electrophysiological recovery within 3 months from injury. Because of delayed referral to our center, many patients had exploration much later than this period. It is known that functional recovery decreases with increased denervation time. Birch showed that M4 muscle power can be achieved in 47% of patients with less than 6 months delay in treatment and in only 8% of patients with delay of more than 12 months.33 In our series, excellent results were seen in 63.6% of patients with a delay in treatment of 1 to 6 months, in 50% of patients with delay of 7–13 months, and in only 18% of the patients with denervation time of more than 20 months. There were statistically significant differences (p = 0.007) between the group of patients with less than 13 months denervation time and those who had surgery after this period. The mechanism of injury is another factor with impact on the functional recovery. This is because surgical strategy is usually dictated by the severity of trauma and the neural defect. Trumble reports that laceration injuries appear
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7 to regenerate better than crush injuries.34 Because of the longitudinal extent of the nerve damage and the presence of associated vascular lesions, Clawson and Seddon advocated no surgery for severe traction injuries.21 High velocity trauma is responsible for most traction-avulsion injuries, which most likely require interpositional nerve grafting and in many cases an improved vascularized bed, in contrast to crush/compression injuries, which require only microneurolysis in the majority of cases. Thus, the results in our series with crush/compression lesions treated only with microneurolysis (mean muscle grading; 3.77 ± 0.4) tended to be superior to those from traction-avulsion injury where interpositional nerve grafts were used (3.06 ± 0.90). There is an agreement that the results of nerve grafting are influenced by the length of the defect to be reconstructed, with shorter nerve grafts having better prognosis. Wood reported that good results (M + 3 muscle grading) are expected only with nerve grafts shorter than 6 cm.35 Kim stated that good functional recovery could not be expected with a graft length of more than 12 cm.8 Others have reported muscle grading of M + 4 even with nerve grafts of up to 20 cm.36 Our data showed that when dealing with CPn lesions, regardless of the type of nerve injury, 4 patients (57%) with nerve grafts length of up to 6 cm achieved excellent function. In patients with a nerve graft length of 7–13 cm, 5 patients (41%) had excellent results and five patients had good results. However, only 2 of 8 patients (25%) with a nerve graft longer than 13 cm had excellent results. In cases when nerve lesions are associated with fractures and/or vascular injury, the resulting ischemia worsens the nerve tissue injury. Additionally, the vascular or orthopedic procedures done before nerve microreconstruction alters the anatomy, which has a negative impact in the final outcome. In our series, the overall functional result in patients with no vascular injuries or fractures was 3.31 ± 1.7, while in the patients with associated fractures/dislocations and/or vascular injury was 3.08 ± 0.9, (p = 0.671). The VPCF that carries the ipsilateral sural nerve and lesser saphenous vein is an intelligent strategy for severe peroneal nerve lesions, as it minimizes the negative effects of scarred bed and/or exceedingly long grafts. In our series, this procedure was used in 7 patients.37 Five patients had severe knee dislocations and 4 required immediate posterior tibialis artery repairs with a saphenous vein graft. Excellent functional results were seen in 6 patients and a good result in 1. In this series, no significant correlation with age was noted, 3.7 ± 0.48 was muscle grading for patients under 25 years of age and 3.15 ± 1.14 for the patients older than 40 years of age, (p = 0.204). This may reflect the fact that in this study, very few patients were under 18 years of age, which may lead to the weakening of any association between age and functional result. It has been stated that reinnervation of CPn could be impaired by the force imbalance between active plantar flexors and denervated foot extensors.38 For late cases of CPn lesion, Millesi suggests performing both nerve repair and tibialis tendon transfer in the same surgical procedure.38 Garozzo et al. after obtaining disappointing results when only CPn repair was done (in 5 out of 6 cases no muscle recovery was seen), advocates nerve repair and tendon transfer in one single surgical procedure.36 We do not adhere to
Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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this strategy. Our experience shows that patients with CPn lesion are usually young active people who are involved in sports and do not easily accept an immediate posterior tibialis tendon transfer. To prevent muscle atrophy, we strongly recommend slow-pulse stimulation for 5–6 h a day. We use secondary tendon transfers to enhance the functional outcomes in selected late cases at a later date. Thus, our strategy is to address the nerve lesion first and if the recovery is inadequate, then enhance the results with tendon transfer. Tendon transfers were performed in our series only in 7 cases. Three patients improved from fair to good and 4 patients went from good to excellent after the secondary procedure. In the case of CPn lesions, motor recovery is more important than sensory recovery. Protective sensation was restored in all our patients after surgery, and none of them had causalgia. Motor recovery is useful only if it enables the patient to dorsiflex the foot against gravity. Postoperative electrophysiological studies at 12 months after surgery showed complete reinnervation in 44 patients, partial reinnervation in 16 patients, and no improvement in one patient. The results reported in this series advocate that peroneal nerve reconstruction is worthwhile in at least 83.5% of the cases. The use of modern principles of nerve grafting and transfer39 , 40 can indeed yield worthwhile outcomes in these often ignored lesions.
Conclusions 1. In CPn lesions, early surgical exploration and repair are recommended. 2. The goal of treatment is to achieve useful motor function, and at least protective sensibility. 3. Implementation of principles that optimize nerve regeneration. 4. In cases with highly unfavorable scarred beds and large nerve gaps, the use of VNG in combination with the transfer of VPCF is strongly advocated.
Declaration of Conflict of Interest Dr. Julia K Terzis and Dr. Ioannis Kostas report no biomedical financial interests or potential conflicts of interest.
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Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031
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Please cite this article as: J.K. Terzis and I. Kostas, Outcomes with microsurgery of common peroneal nerve lesions, Journal of Plastic, Reconstructive & Aesthetic Surgery, https://doi.org/10.1016/j.bjps.2019.02.031