Choosing the target wisely: partial tibial nerve transfer to extensor digitorum motor branches with simultaneous posterior tibial tendon transfer. Could this be a way to improve functional outcome and gait biomechanics?

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OBJECTIVE

The objective of this study was clinical assessment of the reduction of pathological motor phenomena with the recovery of long toe extensors, and evaluation of functional outcome with simultaneous nerve and tendon transfer in cases of common peroneal nerve (CPN) injuries.

METHODS

Seven male patients (mean age 26.4 years) received a partial tibial nerve transfer to the extensor hallucis longus muscle (MEHL) and extensor digitorum longus muscle (MEDL) motor branches, after a mean of 2.7 months following a traction-type injury to the CPN. Tibialis posterior muscle (MTP) tendon transfer through the interosseous route was performed on the same day. The follow-up period included a clinical neurological examination, a modified Stanmore System questionnaire (MSSQ), electromyographic examination of the interference pattern, and a video-based analysis of the gait biomechanics in the 3rd and 12th months. Video analysis of the gait investigated the presence or reduction of “stair-climbing maneuver” (SCM), foot slap (FS), and foot stability during the gait cycle.

RESULTS

The average range of active dorsiflexion in the 3rd month was 0.85°. SCM accompanied walking in 6 patients (86%). FS accompanied walking in 3 patients (43%) and 3 patients (43%) avoided FS by planting the entire foot on the ground. All patients required orthopedic support (shoe inserts) to compensate for mediolateral foot instability. The average MSSQ score was 80.4 points. The average duration for the effective recovery of function (≥ 4 points on the Medical Research Council grading system) of long toe extensors was 11.2 months. The average range of active dorsiflexion in the 12th month increased to 4.4°. A reduction of FS was observed in 5 patients (71%). Excessive foot eversion was reduced in 4 patients (57%). Another 3 patients (43%) required no specific orthopedic shoe inserts. Reduction of pathological motor phenomena with recovery of the long toe extensors resulted in an increase of functional outcome. The average MSSQ score after 12 months was 92.4 points.

CONCLUSIONS

Partial tibial nerve transfer to the motor branches of the extensor hallucis longus and the long toe extensors along with the simultaneous tibialis posterior tendon transfer produce the reduction of FS and bring mediolateral stability to the foot, i.e., improved gait biomechanics. The reduction of pathological motor phenomena at the time of recovery of the long toe extensors is reflected in an increase in patients’ functional perception of the injured lower extremity during daily walking.

ABBREVIATIONS CPN = common peroneal nerve; EMG = electromyography; FFL = forefoot loading; FS = foot slap; HO = heel off; HS = heel strike; MEDL = extensor digitorum longus muscle; MEHL = extensor hallucis longus muscle; MRC = Medical Research Council; MSSQ = modified Stanmore System questionnaire; MTP = tibialis posterior muscle; SCM = stair-climbing maneuver; TB = terminal branch; TO = toe off.

Article Information

Correspondence Alexander A. Gatskiy: Romodanov Neurosurgery Institute, National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine. drgatskiy@mail.ru.

INCLUDE WHEN CITING Published online June 7, 2019; DOI: 10.3171/2019.3.JNS182866.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Graphic representation of pathological motor phenomena during the corresponding phases of the gait cycle after MTP transfer (A) and partial tibial nerve transfer to the motor branch of the tibialis anterior muscle (B). EDL = extensor digitorum longus muscle; EHL = extensor hallucis longus muscle; NT = nerve transfer; PM = peroneus longus and brevis muscles; TA = tibialis anterior muscle; TP = tibialis posterior muscle. Figure is available in color online only.

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    Schematic representation of the partial tibial nerve transfer to the MEHL and MEDL motor branches via the direct repair technique (patients 1 and 4, see Table 1). 1 = motor branch of the tibial nerve to the lateral head of the gastrocnemius muscle; 2 = healthy-appearing fascicles to the MEHL and MEDL dissected within the CPN trunk; Art = articular branch; CF = caput fibulae; DPN = deep peroneal nerve; EDL = fascicles to MEDL; EHL = fascicles to MEHL; Sci = sciatic; SPN = superficial peroneal nerve; Sur = sural nerve; TA = fascicles to tibialis anterior muscle; TN = tibial nerve. Orientation: A = anterior; P = posterior; Ca = caudal; Cr = cranial. Figure is available in color online only.

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    Schematic representation of the partial tibial nerve transfer to the MEHL and MEDL motor branches with graft interposition: scenario 1.1, patients 3 and 7; scenario 1.2, patients 2, 5, and 6 (see Table 1). 1 = motor branch of the tibial nerve to the lateral head of the gastrocnemius muscle; 2 = healthy-appearing fascicles to the MEHL and MEDL dissected within the CPN trunk. Figure is available in color online only.

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    Graphic representation of pathological motor phenomena during the corresponding phases of the gait cycle: 3 months (A) and 12 months (B) after surgery (at the time of MEHL and MEDL recovery). Figure is available in color online only.

  • View in gallery

    Dynamics of change in the MSSQ score in all 7 patients at 3 and 12 months after surgery. Figure is available in color online only.

References

  • 1

    Abboud R: Relevant foot biomechanics. Curr Orthop 16:1651792002

  • 2

    Aldea PAShaw WW: Lower extremity nerve injuries. Plast Reconstr Surg 81:1421988 (Abstract)

  • 3

    Bonnevialle PDubrana FGalau BLustig SBarbier ONeyret P: Common peroneal nerve palsy complicating knee dislocation and bicruciate ligaments tears. Orthop Traumatol Surg Res 96:64692010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Brodsky JWZubak JJPollo FEBaum BS: Preliminary gait analysis results after posterior tibial tendon reconstruction: a prospective study. Foot Ankle Int 25:961002004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Giuffre JLBishop ATSpinner RJLevy BAShin AY: Partial tibial nerve transfer to the tibialis anterior motor branch to treat peroneal nerve injury after knee trauma. Clin Orthop Relat Res 470:7797902012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Giuseffi SABishop ATShin AYDahm DLStuart MJLevy BA: Surgical treatment of peroneal nerve palsy after knee dislocation. Knee Surg Sports Traumatol Arthrosc 18:158315862010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Goh JCHLee PYCLee EHBose K: Biomechanical study on tibialis posterior tendon transfers. Clin Orthop Relat Res (319):2973021995

    • Search Google Scholar
    • Export Citation
  • 8

    Ho BKhan ZSwitaj PJOchenjele GFuchs DDahl W: Treatment of peroneal nerve injuries with simultaneous tendon transfer and nerve exploration. J Orthop Surg Res 9:672014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Ipaktchi RRadtke CAust MBusche MVogt PM: On “Successful management of foot drop by nerve transfers to the deep peroneal nerve” (J Reconstr Microsurg 2008;24:419–428). J Reconstr Microsurg 26:4254262010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Immerman IPrice AEAlfonso IGrossman JAI: Lower extremity nerve trauma. Bull Hosp Jt Dis (2013) 72:43522014

  • 11

    Johnson MEFoster LDeLee JC: Neurologic and vascular injuries associated with knee ligament injuries. Am J Sports Med 36:244824622008

  • 12

    Kim DHKline DG: Management and results of peroneal nerve lesions. Neurosurgery 39:3123201996

  • 13

    Kim DHMurovic JATiel RLKline DG: Management and outcomes in 318 operative common peroneal nerve lesions at the Louisiana State University Health Sciences Center. Neurosurgery 54:142114292004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Kline DG: Operative management of major nerve lesions of the lower extremity. Surg Clin North Am 52:124712651972

  • 15

    Kumar IRanjan AChoudhary L: Postoperative functional results of posterior tibial tendon transfer for foot drop as a consequence of nerve palsy in leprosy. Ann Int Med Den Res 2:1181222016

    • Search Google Scholar
    • Export Citation
  • 16

    Leclère FMBadur NMathys LVögelin E: Nerve Transfers for persistent traumatic peroneal nerve palsy: The Inselspital Bern experience. Neurosurgery 77:5725802015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Mackinnon SENovak CB: Nerve transfers. New options for reconstruction following nerve injury. Hand Clin 15:643666 ix1999

  • 18

    Muro-de-la-Herran AGarcia-Zapirain BMendez-Zorrilla A: Gait analysis methods: an overview of wearable and non-wearable systems, highlighting clinical applications. Sensors (Basel) 14:336233942014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Nath RKLyons ABPaizi M: Successful management of foot drop by nerve transfers to the deep peroneal nerve. J Reconstr Microsurg 24:4194272008

  • 20

    Nath RKSomasundaram C: Gait improvements after peroneal or tibial nerve transfer in patients with foot drop: a retrospective study. Eplasty 17:e312017

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Ratanshi IClark TAGiuffre JL: Immediate nerve transfer for the treatment of peroneal nerve palsy secondary to an intraneural ganglion: case report and review. Plast Surg (Oakv) 25:54582017

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Ray WZMackinnon SE: Clinical outcomes following median to radial nerve transfers. J Hand Surg Am 36:2012082011

  • 23

    Sassu PLibberecht KNilsson A: Nerve transfers of the forearm and hand: a review of current indications. Plast Aesthet Res 2:1952012015

  • 24

    Seidel JAKoenig RAntoniadis GRichter HPKretschmer T: Surgical treatment of traumatic peroneal nerve lesions. Neurosurgery 62:6646732008

  • 25

    Senes FMCampus RBecchetti FCatena N: Lower limb nerve injuries in children. Microsurgery 27:32362007

  • 26

    Spinner RJAtkinson JLDTiel RL: Peroneal intraneural ganglia: the importance of the articular branch. A unifying theory. J Neurosurg 99:3303432003

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27

    Wagner UASchmitt OIchikawa D: Biomechanical and clinical investigations of posterior tibial tendon transfer. Foot Ankle Surg 2:13181996

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28

    Wood MB: Peroneal nerve repair. Surgical results. Clin Orthop Relat Res (267):2062101991

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