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Foot reanimation via nerve transfer to the peroneal nerve using the nerve branch to the lateral gastrocnemius: Case report
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 1380e1382
CASE REPORT
Foot reanimation via nerve transfer to the peroneal nerve using the nerve branch to the lateral gastrocnemius: Case report Robert Strazar a, Colin P. White b, James Bain c,* a
Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada Division of Plastic Surgery, Department of Surgery, Faculty of Medicine, McMaster University, Hamilton, Ontario, Canada c Division of Plastic Surgery, Department of Surgery, HSC Rm 4E16, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada b
Received 5 February 2011; accepted 23 February 2011
KEYWORDS Peroneal nerve injury; Fibular nerve; Foot drop; Mononeuropathy; Nerve transfer; Nerve repair
Summary Injury to the peroneal nerve can be devastating to a patient’s daily function. By paralyzing the ankle dorsiflexors, peroneal neuropathy results in foot drop. Gait difficulties and other functional limitations impede these patients on a daily basis. Knee and ankle injuries, lacerations, and compression are only a few of many etiologies which make peroneal nerve palsy the most common neuropathy of the lower limb. We present a case of peroneal nerve palsy secondary to an ACL and lateral collateral ligament tears. This 18 year old male underwent foot reanimation via nerve transfer to the peroneal nerve using the branch from the lateral gastrocenus to tibalias anterior muscle branch. The patient was followed and assessed for function during the subsequent two years. This case reports provides a synopsis of this patient’s surgical treatment, as well as a glance into the literature surrounding peroneal nerve transfer. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Peroneal nerve damage can deinnervate the ankle and toe dorsiflexing muscles, producing a foot drop. Nerve grafting procedures for reconstruction of nerve deficits is the gold standard of treatment; however, nerve transfer offers * Corresponding author. E-mail address: [email protected] (J. Bain).
significant advantages. Mainly, the donor nerve recovers while the harvested motor fibers grow into the previously deinnervated muscle, shortening the period of denervation.
Case report An 18 year old male was seen for evaluation of a right sided peroneal nerve palsy. The injury occurred three weeks prior when he stepped awkwardly on a soccer ball and rolled his
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.02.025
Case report right ankle medially. He immediately experienced numbness and tingling and was unable to weight bear on his right leg. He was unable to dorsiflex or evert his right foot. The patient was diagnosed torn anterior cruciate and lateral collateral ligaments of the right knee. On examination, the patient was unable to dorsiflex and weight bear on his right foot but did have normal plantar flexion. The patient could invert but was unable to evert the right foot. He had decreased sensation to the lateral leg and lateral foot and to the first toes dorsal web space. The lower leg displayed a negative Tinel’s sign. An EMG showed conduction delay at the fibular head. The patient was taken to the operating room and had combined procedure by orthopaedics and plastics. The orthopaedics team performed a repair of the lateral collateral ligament and reconstruction anterior cruciate ligament. The plastics team performed an exploration of the peroneal nerve, a sural nerve transfer for protective sensation, and lateral gastrocnemius nerve transfer to reanimate the foot.
Description of nerve transfer Exposure of the peroneal nerve and the popliteal fossa was obtained using a zigzag incision over the fibular head. The peroneal nerve was identified in the distal popliteal fossa. A significant neuroma in continuity was found and extended from the bifurcation of the sciatic nerve to approximately 5 cm proximal to the fibular neck. The peroneal nerve was cleaned from the surrounding scar tissue and a healthy distal stump was identified in the anterior compartment. The sural nerve was identified in the popliteal fossa and dissected distally down to the lateral malleous to protect and mobilize the nerve. Motor nerve transfer was performed by identifying and dissecting the branch to the lateral gastrocenus. This branch was transected off its muscle attachment distally. The component of the peroneal nerve which was servicing the tibalis anterior muscle was identified (Figure 1).
Figure 1 Intraoperative photo highlighting the dissected branches of the tibial nerve.
1381 Under the microscope these two motor branches were coapted using 9-0 nylon and sural nerve grafts. The entire repair was augmented with tisseel. The patient was splinted after skin closure.
Follow up The patient was followed post operatively during the next 2 years (Table 1). By 4 months, the patient was completely pain free and Tinel’s sign was 10 cm distal to the scar. Tinel’s sign reached the ankle by 12 months and disappeared fully by 18 months. Dorsiflexion power was nonexistent until the 12th month post op, at which point the patient stopped wearing his ankle foot othrotic and was squatting 200 lbs. By 18 months, his power was 3e4/5 and he was squatting 450 lbs. The final follow up visit at 24 months post op showed a maximum power for the extensor hallicus longus of 4/5 and peroneal muscles of 2/5. There was limited sensation along the common peroneal nerve distribution. At this time, the patient was now playing basketball, jogging for 3 km, and squatting over 450 lbs.
Literature review Nerve transfer is a potential treatment option to correct foot drop caused by a proximal lesion to the common or deep peroneal nerve. Nerve transfer has been well documented in repairing peripheral nerve lesions of the upper limb with relatively consistent and good success.1 Although the reconstruction principles and strategies are similar for the damaged nerves in the lower limb,1 nerve transfer for the lower extremity has not been well studied. Nerve repair with grafts has variable results. Graft length is a determining factor in functional outcomes, with longer grafts being associated with poorer outcomes.2 The axon regeneration must transverse iatrogenic lesions at either end of the graph.3 Nerve transfers offer certain benefits over nerve grafting. Nerve transfer of the tibial nerve provides a direct coaptation from the donor nerve to the distal stump, minimizing the number coaptation lesions which the axon must transverse.2 Previous studies examining nerve transfer to the peroneal nerve have produced acceptable results, showing adequate return functional outcomes without severely disrupting plantar flexion strength.1,2 Given that only a third of the donor nerve is dissected, there was normally no apparent clinical weakness in foot eversion or plantar flexion following peroneal nerve transfer.1 The feasibility of using the tibial nerve has been assessed in cadaver studies.4 Nearly all the mobilized tibial nerve fascicles provided sufficient length for tensionless coaptation with the peroneal nerve around the fibular head.3 If the fascicle is of insufficient length, an approach through the interosseus membrane between the fibula and tibula has been proposed.5 This shortens both the length to reach the peroneal nerve and the length of axon regeneration. Timely surgical correction appears to favor nerve recovery.1,2 Skeletal muscles without innervations for greater than a year can become refractory and develop a permanent paralysis. Since the rate of peripheral nerve
1382 Table 1
R. Strazar et al. Patient’s progress documented from post operative follow up visits ranging from 2 to 24 months.
Post-Op
2 months
4 months
8 months
12 months
18 months
24 months
Tinel’s sign (cm from scar) Dorsiflexionc
Nil
10 cm
12.5 cm
Level of ankle
Nil
Nil
0/5
0/5
0/5
1/5
3e4/5
Foot Eversionc Orthotics
0/5 Ankle foot orthotic
0/5 Ankle foot orthotic
1/5 Ankle foot orthotic
EHLa 4/5 TAb 4/5 Peroneal 2/5 Knee orthotic (only for sports) Jog 3 km
Activity a b c
Stopped using orthotics Squat (200 lbs)
3/5 No orthotic Squat (450 lbs)
EHL Z Extensor Hallicus Longus. TA Z Tibialis Anterior. MRC grading system.
regeneration is about 1 mm per day or approximately 1 inch per month, surgical correction should occur no later than 8e12 months to allow time for the muscles to become innervated.1 A potential benefit to nerve transfer repair lies in the fact that the muscular anatomy remains native, and planter flexion is only sub clinically disrupted. The donor nerve recovers using the peripheral nervous system’s capability to regenerate following a partial denervation, while the harvested motor fibers grow into the previously deinnervated muscle. If the nerve transfer unfortunately fails, the patient still maintains the ability to undergo other surgical options (tendon transfer). More research is needed to elicit the answers to several questions including which is the best donor nerve and also to look at long term functional outcomes. We believe that nerve transfers should be included in the armamentarium for lower extremity re-innervation as it is in the upper limb.
Conflict of interest None.
Funding None.
References 1. Nath RK, Lyons AB, Paizi M. Successful Management of foot drop by nerve transfers to the deep peroneal nerve. J Recon Microsurg 2008;24(6):419e27. 2. Kim D, Murovic J, Tiel R, Kline D. Management and outcomes in 318 operative common peroneal nerve lesions at Louisiana State University Health Sciences Center. Neurosurg 2004;54(6):1421e9. 3. Bodily KD, Spinner RJ, Bishop AT. Restoration of motor function of the deep fibular (Peroneal) nerve by direct nerve transfer of branches from the tibial nerve: an Anatomical study. Clin Anat 2004;17:201e5. 4. Flores LP. Proximal motor branches from the tibial nerve as direct donors to restore function of the deep fibular nerve for treatment of high sciatic nerve injuries: a cadaveric feasibility study. Neurosurg 2009;65(6):218e25. 5. Pirela-Cruz MA, Hansen U, Terreros DA, Rossum A, West P. Interosseous nerve transfers for tibialis anterior muscle paralysis (foot drop): a human cadaver-based feasibility study. J Recon Microsurg 2009;25(3):203e11.
CASE REPORT
Foot reanimation via nerve transfer to the peroneal nerve using the nerve branch to the lateral gastrocnemius: Case report Robert Strazar a, Colin P. White b, James Bain c,* a
Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada Division of Plastic Surgery, Department of Surgery, Faculty of Medicine, McMaster University, Hamilton, Ontario, Canada c Division of Plastic Surgery, Department of Surgery, HSC Rm 4E16, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada b
Received 5 February 2011; accepted 23 February 2011
KEYWORDS Peroneal nerve injury; Fibular nerve; Foot drop; Mononeuropathy; Nerve transfer; Nerve repair
Summary Injury to the peroneal nerve can be devastating to a patient’s daily function. By paralyzing the ankle dorsiflexors, peroneal neuropathy results in foot drop. Gait difficulties and other functional limitations impede these patients on a daily basis. Knee and ankle injuries, lacerations, and compression are only a few of many etiologies which make peroneal nerve palsy the most common neuropathy of the lower limb. We present a case of peroneal nerve palsy secondary to an ACL and lateral collateral ligament tears. This 18 year old male underwent foot reanimation via nerve transfer to the peroneal nerve using the branch from the lateral gastrocenus to tibalias anterior muscle branch. The patient was followed and assessed for function during the subsequent two years. This case reports provides a synopsis of this patient’s surgical treatment, as well as a glance into the literature surrounding peroneal nerve transfer. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Peroneal nerve damage can deinnervate the ankle and toe dorsiflexing muscles, producing a foot drop. Nerve grafting procedures for reconstruction of nerve deficits is the gold standard of treatment; however, nerve transfer offers * Corresponding author. E-mail address: [email protected] (J. Bain).
significant advantages. Mainly, the donor nerve recovers while the harvested motor fibers grow into the previously deinnervated muscle, shortening the period of denervation.
Case report An 18 year old male was seen for evaluation of a right sided peroneal nerve palsy. The injury occurred three weeks prior when he stepped awkwardly on a soccer ball and rolled his
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.02.025
Case report right ankle medially. He immediately experienced numbness and tingling and was unable to weight bear on his right leg. He was unable to dorsiflex or evert his right foot. The patient was diagnosed torn anterior cruciate and lateral collateral ligaments of the right knee. On examination, the patient was unable to dorsiflex and weight bear on his right foot but did have normal plantar flexion. The patient could invert but was unable to evert the right foot. He had decreased sensation to the lateral leg and lateral foot and to the first toes dorsal web space. The lower leg displayed a negative Tinel’s sign. An EMG showed conduction delay at the fibular head. The patient was taken to the operating room and had combined procedure by orthopaedics and plastics. The orthopaedics team performed a repair of the lateral collateral ligament and reconstruction anterior cruciate ligament. The plastics team performed an exploration of the peroneal nerve, a sural nerve transfer for protective sensation, and lateral gastrocnemius nerve transfer to reanimate the foot.
Description of nerve transfer Exposure of the peroneal nerve and the popliteal fossa was obtained using a zigzag incision over the fibular head. The peroneal nerve was identified in the distal popliteal fossa. A significant neuroma in continuity was found and extended from the bifurcation of the sciatic nerve to approximately 5 cm proximal to the fibular neck. The peroneal nerve was cleaned from the surrounding scar tissue and a healthy distal stump was identified in the anterior compartment. The sural nerve was identified in the popliteal fossa and dissected distally down to the lateral malleous to protect and mobilize the nerve. Motor nerve transfer was performed by identifying and dissecting the branch to the lateral gastrocenus. This branch was transected off its muscle attachment distally. The component of the peroneal nerve which was servicing the tibalis anterior muscle was identified (Figure 1).
Figure 1 Intraoperative photo highlighting the dissected branches of the tibial nerve.
1381 Under the microscope these two motor branches were coapted using 9-0 nylon and sural nerve grafts. The entire repair was augmented with tisseel. The patient was splinted after skin closure.
Follow up The patient was followed post operatively during the next 2 years (Table 1). By 4 months, the patient was completely pain free and Tinel’s sign was 10 cm distal to the scar. Tinel’s sign reached the ankle by 12 months and disappeared fully by 18 months. Dorsiflexion power was nonexistent until the 12th month post op, at which point the patient stopped wearing his ankle foot othrotic and was squatting 200 lbs. By 18 months, his power was 3e4/5 and he was squatting 450 lbs. The final follow up visit at 24 months post op showed a maximum power for the extensor hallicus longus of 4/5 and peroneal muscles of 2/5. There was limited sensation along the common peroneal nerve distribution. At this time, the patient was now playing basketball, jogging for 3 km, and squatting over 450 lbs.
Literature review Nerve transfer is a potential treatment option to correct foot drop caused by a proximal lesion to the common or deep peroneal nerve. Nerve transfer has been well documented in repairing peripheral nerve lesions of the upper limb with relatively consistent and good success.1 Although the reconstruction principles and strategies are similar for the damaged nerves in the lower limb,1 nerve transfer for the lower extremity has not been well studied. Nerve repair with grafts has variable results. Graft length is a determining factor in functional outcomes, with longer grafts being associated with poorer outcomes.2 The axon regeneration must transverse iatrogenic lesions at either end of the graph.3 Nerve transfers offer certain benefits over nerve grafting. Nerve transfer of the tibial nerve provides a direct coaptation from the donor nerve to the distal stump, minimizing the number coaptation lesions which the axon must transverse.2 Previous studies examining nerve transfer to the peroneal nerve have produced acceptable results, showing adequate return functional outcomes without severely disrupting plantar flexion strength.1,2 Given that only a third of the donor nerve is dissected, there was normally no apparent clinical weakness in foot eversion or plantar flexion following peroneal nerve transfer.1 The feasibility of using the tibial nerve has been assessed in cadaver studies.4 Nearly all the mobilized tibial nerve fascicles provided sufficient length for tensionless coaptation with the peroneal nerve around the fibular head.3 If the fascicle is of insufficient length, an approach through the interosseus membrane between the fibula and tibula has been proposed.5 This shortens both the length to reach the peroneal nerve and the length of axon regeneration. Timely surgical correction appears to favor nerve recovery.1,2 Skeletal muscles without innervations for greater than a year can become refractory and develop a permanent paralysis. Since the rate of peripheral nerve
1382 Table 1
R. Strazar et al. Patient’s progress documented from post operative follow up visits ranging from 2 to 24 months.
Post-Op
2 months
4 months
8 months
12 months
18 months
24 months
Tinel’s sign (cm from scar) Dorsiflexionc
Nil
10 cm
12.5 cm
Level of ankle
Nil
Nil
0/5
0/5
0/5
1/5
3e4/5
Foot Eversionc Orthotics
0/5 Ankle foot orthotic
0/5 Ankle foot orthotic
1/5 Ankle foot orthotic
EHLa 4/5 TAb 4/5 Peroneal 2/5 Knee orthotic (only for sports) Jog 3 km
Activity a b c
Stopped using orthotics Squat (200 lbs)
3/5 No orthotic Squat (450 lbs)
EHL Z Extensor Hallicus Longus. TA Z Tibialis Anterior. MRC grading system.
regeneration is about 1 mm per day or approximately 1 inch per month, surgical correction should occur no later than 8e12 months to allow time for the muscles to become innervated.1 A potential benefit to nerve transfer repair lies in the fact that the muscular anatomy remains native, and planter flexion is only sub clinically disrupted. The donor nerve recovers using the peripheral nervous system’s capability to regenerate following a partial denervation, while the harvested motor fibers grow into the previously deinnervated muscle. If the nerve transfer unfortunately fails, the patient still maintains the ability to undergo other surgical options (tendon transfer). More research is needed to elicit the answers to several questions including which is the best donor nerve and also to look at long term functional outcomes. We believe that nerve transfers should be included in the armamentarium for lower extremity re-innervation as it is in the upper limb.
Conflict of interest None.
Funding None.
References 1. Nath RK, Lyons AB, Paizi M. Successful Management of foot drop by nerve transfers to the deep peroneal nerve. J Recon Microsurg 2008;24(6):419e27. 2. Kim D, Murovic J, Tiel R, Kline D. Management and outcomes in 318 operative common peroneal nerve lesions at Louisiana State University Health Sciences Center. Neurosurg 2004;54(6):1421e9. 3. Bodily KD, Spinner RJ, Bishop AT. Restoration of motor function of the deep fibular (Peroneal) nerve by direct nerve transfer of branches from the tibial nerve: an Anatomical study. Clin Anat 2004;17:201e5. 4. Flores LP. Proximal motor branches from the tibial nerve as direct donors to restore function of the deep fibular nerve for treatment of high sciatic nerve injuries: a cadaveric feasibility study. Neurosurg 2009;65(6):218e25. 5. Pirela-Cruz MA, Hansen U, Terreros DA, Rossum A, West P. Interosseous nerve transfers for tibialis anterior muscle paralysis (foot drop): a human cadaver-based feasibility study. J Recon Microsurg 2009;25(3):203e11.