Tendon transfers for drop foot correction: long-term results including quality of life assessment, and dynamometric and pedobarographic measurements

Tibial nerve branching pattern and compatibility of branches for the deep fibular nerve

PURPOSE

In individuals who develop drop foot due to nerve loss, several methods such as foot-leg orthosis, tendon transfer, and nerve grafting are used. Nerve transfer, on the other hand, has been explored in recent years. The purpose of this study was to look at the tibial nerve's branching pattern and the features of its branches in order to determine the suitability of the tibial nerve motor branches, particularly the plantaris muscle motor nerve, for deep fibular nerve transfer.

METHODS

There were 36 fixed cadavers used. Tibial nerve motor branches were observed and measured, as were the lengths, distributions, and thicknesses of the common fibular nerve and its branches at the bifurcation region.

RESULT

The motor branches of the tibial nerve that supply the soleus muscle, lateral head, and medial head of the gastrocnemius were studied, and three distinct forms of distribution were discovered. The motor branch of the gastrocnemius medial head was commonly observed as the first branch to divide, and it appeared as a single root. The nerve of the plantaris muscle was shown to be split from many origins. When the thickness and length of the motor branches measured were compared, the nerve of the soleus muscle was determined to be the most physically suited for neurotization.

CONCLUSION

In today drop foot is very common. Traditional methods of treatment are insufficient. Nerve transfer is viewed as an application that can both improve patient outcomes and hasten the patient's return to society. The nerve of the soleus muscle was shown to be the best candidate for transfer in our investigation.

[Secondary surgical procedures following motor nerve injuries]

BACKGROUND

The functional deficits that develop after a peripheral nerve injury mean a considerable reduction in the quality of life for the affected patients. However, interventions on the injured nerve are not always possible or effective. In this case, secondary procedures, e.g. tendon transfers, are a feasible option for functional reconstruction.

OBJECTIVES

An overview of the most common secondary surgical procedures for functional reconstruction after peripheral nerve injuries.

METHODS

Presentation and discussion of the most common secondary surgical procedures with emphasis on tendon transfers. Illustration of the primary functions that need to be reconstructed depending on the respective nerve lesion.

RESULTS

The basic principle of secondary surgical procedures after nerve injuries is the transposition of a healthy tendomuscular unit to replace a lost function following a loss of muscle or tendon or if an intervention on the nerve is not promising. For example, by transferring flexor forearm muscles, wrist, finger and thumb extension can be reconstructed after radial nerve injury. By transposing the tibialis posterior muscle, dorsiflexion in the talocrural joint can be restored to enable the affected patient to walk safely without an orthosis.

CONCLUSIONS

Secondary surgical procedures are a valuable option for functional reconstruction after nerve injury.

Tendon transfer in foot drop: a systematic review

INTRODUCTION

Foot drop is a disorder that impairs walking and leads to tripping and falling. Tendon transfer (e.g., tibialis posterior tendon) is a typical secondary procedure in foot drop treatment. The purpose of this systematic review was to identify the most common tendon transfer techniques for treating foot drop and to analyze the reported functional outcomes. Furthermore, it was of interest if the type of surgical technique affects the functional outcome.

METHODS

A PubMed and MEDLINE literature search was performed according to PRISMA guidelines. The search terms used were ("tendon transfer" OR "tendon transposition") AND ("foot drop" OR "peroneal neuropathies"). Any study published before January 2020 was considered for inclusion. No case reports or reviews were included. Common outcome measures (Stanmore score, AOFAS, FAAM, AFO use, patient satisfaction and active ankle dorsiflexion) were evaluated. The quality of the included studies was assessed using the Coleman Methodology Score.

RESULTS

Of the 125 reviewed publications, 37 met the inclusion criteria. 42 cohorts were analyzed. The frequently reported tendon transfer technique was the tibialis posterior tendon transfer through the interosseus membrane. The most used fixation technique was tendon on tendon fixation; however in recent years, a tendon to bone fixation has gained popularity. There was an increase in Stanmore scores and AOFAS postoperatively and a decrease of AFO use postoperatively observed.

CONCLUSIONS

Due to various outcome measures and lack of preoperative assessment in the included studies, a meta-analysis of the pooled results was not possible. Nevertheless, the findings of this study show that tendon transfer increases mobility and self-independency leading to patient satisfaction. The choice of the surgical technique does not affect the outcome. A prospective collection of patient data and standardized outcome measures will be important to further analyze the efficacy of tendon transfer techniques.

Conservative versus surgical treatment of foot drop in peroneal nerve entrapment: rationale and design of a prospective, multi-centre, randomized parallel-group controlled trial

BACKGROUND

High-quality evidence is lacking to support one treatment strategy over another in patients with foot drop due to peroneal nerve entrapment. This leads to strong variation in daily practice.

METHODS/DESIGN

The FOOTDROP (Follow-up and Outcome of Operative Treatment with Decompressive Release Of The Peroneal nerve) trial is a randomized, multi-centre study in which patients with peroneal nerve entrapment and persistent foot drop, despite initial conservative treatment, will be randomized 10 (± 4) weeks after onset between non-invasive treatment and surgical decompression. The primary endpoint is the difference in distance covered during the 6-min walk test between randomization and 9 months later. Time to recovery is the key secondary endpoint. Other secondary outcome measures encompass ankle dorsiflexion strength (MRC score and isometric dynamometry), gait assessment (10-m walk test, functional ambulation categories, Stanmore questionnaire), patient-reported outcome measures (EQ5D-5L), surgical complications, neurological deficits (sensory changes, motor scores for ankle eversion and hallux extension), health economic assessment (WPAI) and electrodiagnostic assessment.

DISCUSSION

The results of this randomized trial may elucidate the role of surgical decompression of the peroneal nerve and aid in clinical decision-making.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04695834. Registered on 4 January 2021.

Evaluation and Management of Cavus Foot in Adults: A Narrative Review

Objective: Cavus foot is a deformity defined by the abnormal elevation of the medial arch of the foot and is a common but challenging occurrence for foot and ankle surgeons. In this review, we mainly aim to provide a comprehensive evaluation of the treatment options available for cavus foot correction based on the current research and our experience and to highlight new technologies and future research directions. Methods: Searches on the PubMed and Scopus databases were conducted using the search terms cavus foot, CMT (Charcot–Marie–Tooth), tendon-transfer, osteotomy, and adult. The studies were screened according to the inclusion and exclusion criteria, and the correction of cavus foot was analyzed based on the current research and our own experience. At the same time, 3D models were used to simulate different surgical methods for cavus foot correction. Results: A total of 575 papers were identified and subsequently evaluated based on the title, abstract, and full text. A total of 84 articles were finally included in the review. The deformities involved in cavus foot are complex. Neuromuscular disorders are the main etiologies of cavus foot. Clinical evaluations including biomechanics, etiology, classification, pathophysiology and physical and radiological examinations should be conducted carefully in order to acquire a full understanding of cavus deformities. Soft-tissue release, tendon-transfer, and bony reconstruction are commonly used to correct cavus foot. Surgical plans need to be customized for different patients and usually involve a combination of multiple surgical procedures. A 3D simulation is helpful in that it allows us to gain a more intuitive understanding of various osteotomy methods. Conclusion: The treatment of cavus foot requires us to make personalized operation plans according to different patients based on the comprehensive evaluation of their deformities. A combination of soft-tissue and bony procedures is required. Bony procedures are indispensable for cavus correction. With the promotion of digital orthopedics around the world, we can use computer technology to design and implement cavus foot operations in the future.

Posterior Tibial Tendon Transfer for Central Foot Drop: A Case Report

INTRODUCTION: Peripheral causes of foot drop are widely known. However, causes stemming from the central nervous system are rare. Posterior tibial tendon (PTT) transfer has been widely used for treating peripheral causes of foot drop but not central causes. We report a case of central foot drop (CFD) that was corrected with PTT transfer. CASE REPORT: A 68-year-old female presented with progressive weakness and numbness of both feet due to old compression fracture of the 12th thoracic spine. She also had Parkinson disease with gait rigidity. The patient was diagnosed with central foot drop. The left foot PTT transfer was done through the interosseous membrane and fixed to the navicular bone with an interference screw. Three months after the procedure, there is an improvement on the gait, and the foot drop is corrected. PTT transfer has a good outcome in peripheral foot drop. However, it is still questionable for the CFD case. In our case, PTT transfer was considered because it is less invasive, and tenodesis or ankle fusion still could be performed later if the PTT transfer outcome is not favorable. CONCLUSION: PTT transfer is a possible option to correct CFD. It is less invasive and has a good outcome.

CORRELATION BETWEEN QUALITY OF LIFE AND THE CLINICAL RESULTS OF PATIENTS WITH LEPROSY WITH DROP FOOT AFTER TENDON TRANSFER

Objective

To evaluate the functional results of surgically correcting drop foot in patients with leprosy and compare their SALSA, Social Participation, and AOFAS score.

Methods

Overall, 22 patients were subjected to posterior tibial tendon transfer via the subcutaneous route to the foot dorsum with an average follow-up of 56 months (min 12, max 70). In our sample, 15 of the enrolled patients were men and seven, women, aged between 20 and 73 years old who were operated on from January 2014 to December 2017. The Pearson's correlation test (r) was used to measure the correlation among those scales. A p < 0.05 was considered significant between the pre- and pos-operative AOFAS scale scores.

Results

Pre-operative average AOFAS score was 59.6 (min 35, max 74) and 77.2 postoperative (min 36, max 97) (p < 0.0001), postoperative Salsa and Social Participation scale, 30.6 and 22.5, respectively. Statistical analysis suggests a strong positive correlation between AOFAS and Salsa scales (r = -0.83) and AOFAS and social participation (r = -0.78). Average dorsiflexion was 5.4 degrees.

Conclusion

The surgical correction of drop foot positively affects the quality of life and social participation of patients with leprosy. Level of Evidence III, Retrospective Study.

Foot Reanimation Using Double Nerve Transfer to Deep Peroneal Nerve: A Novel Technique for Treatment of Neurologic Foot Drop

BACKGROUND

Our primary objective was to assess the efficacy of a new technique for foot reanimation in patients with neurologic foot drop using double nerve transfer from the tibial to the deep peroneal nerve. Our secondary objective was to document the technical nuances of our technique.

METHODS

Thirty-one patients with common peroneal nerve injury between October 2015 and March 2019 were prospectively enrolled in the study. Patients underwent a transfer of the tibial nerve branches to flexor digitorum longus and lateral head of gastrocnemius to the deep peroneal nerve. Motor recovery, range of ankle dorsiflexion, pain, leg girth, and complications were examined as outcome measures. The modified Medical Research Council (MRC) scale was adopted to assess the motor power recovery. All patients were followed up for a minimum of 1 year.

RESULTS

Motor recovery of M3 or M4 grade of tibialis anterior, extensor hallucis longus, and extensor digitorum longus was achieved in 15 of 31, 13 of 31, and 12 of 31 patients, respectively. Those patients could discontinue use of orthosis. Most patients with high-energy traumas or knee-level injuries failed to recover antigravity function. Only 2 patients reported weak postoperative toe plantarflexion. Our patients achieved significant improvement of the pain perception and range of active ankle motion at the final follow-up.

CONCLUSION

The double nerve transfer technique represented a feasible and safe surgical option. It has been shown to improve function in some patients with neurologic foot drop resulting from a less than 12-month injury of the deep peroneal nerve.

LEVEL OF EVIDENCE

Level IV, therapeutic.

Tendon Transfers and Their Role in Cavus Foot Deformity

Management of the cavus foot is a difficult task for the foot and ankle surgeon. Tendon transfers have been a longstanding accepted treatment for the flexible cavus foot. Performing tendon transfers requires an in-depth understanding of the patient's medical history, factors leading to the development of deformity, as well as the deforming forces contributing to the deformity. Evaluation of the patient for rigid, progressive, and/or spastic deformities is critical to avoid postoperative complications. Educating the patient on postoperative rehabilitation, potential complications, and postoperative expectations is essential to ensure appropriate surgical outcomes.

Adductor magnus muscle transfer to restore knee extension: Anatomical studies and clinical applications

BACKGROUND

Loss of knee extension causes significant impairment. Though nerve-based reconstruction is preferable in cases of femoral nerve palsy or injury, these surgeries are not always appropriate if the pathology involves the quadriceps muscles or presentation too late for muscle reinnervation. Muscle transfers are another option that has been underutilized in the lower extremity. We describe the successful restoration of knee extension by adductor magnus muscle transfer without functional donor morbidity, along with anatomical considerations.

METHODS

Ten fresh frozen cadaveric lower limbs were dissected at the groin and thigh. In addition, three patients presented with femoral nerve palsy for which nerve-based reconstruction was not appropriate because of late presentation. In these patients, adductor magnus muscle transfers were performed, along with sartorius, gracilis, and tensor fasciae latae transfers if available and healthy.

RESULTS

In cadavers, the pedicle for the adductor magnus is at the level of the gracilis and adequate for muscle transfer, with sufficient weavable tendon length. The only major structure at risk is the femoral neurovascular bundle, which is in a reliable anatomic position. Two patients recovered 4/5 active knee extension and ambulation without assistive devices. A third required reoperation for a loosened tendon weave, after which the noted improved stability and strength with ambulation but did not regain strong active knee extension and continued to require a cane.

CONCLUSIONS

We present a novel reconstructive approach for loss of quadriceps function in patients, which yields good clinical outcomes, with anatomic and technical details to demonstrate the utility of this technique. Ongoing evaluation of optimal technique and rehabilitation to maximize functional outcomes is still needed.

The Interdisciplinary Management of Foot Drop

BACKGROUND

Foot drop can be caused by a variety of diseases and injuries. Although it is a common condition, its overall incidence has not been reported to date. Foot drop markedly restricts the everyday activities of persons suffering from it. There is, therefore, a need for an optimized strategy for its diagnosis and treatment that would be standardized across the medical specialties encountering patients with this problem.

METHODS

This article consists of a review on the basis of pertinent publications re- trieved by a search in the Pubmed/MEDLINE and Cochrane databases, as well as a description of the authors' proposed strategy for the diagnosis and treatment of foot drop.

RESULTS

Foot drop can be due to a disturbance at any central or peripheral location along the motor neural pathway that terminates in the dorsiflexor muscles of the foot, or at multiple locations in series. Optimal localization of the lesion(s) is a pre- requisite for appropriate treatment and a successful outcome. The most common causes are L5 radiculopathy and peroneal nerve injury. An operation by a neuro- surgeon or spinal surgeon is a reasonable option whenever there is a realistic chance that the nerve will recover. In our opinion, any patient with a subjectively disturbing foot drop and a clinically suspected compressive neuropathy of the peroneal nerve should be informed about the option of surgical decompression of the nerve at the fibular head, which can be performed with little risk. In case of a permanent foot drop, some patients can benefit from muscle-transfer surgery. For spastic foot drop, the option of botulinum toxin injections should be evaluated.

CONCLUSION

The care of patients with foot drop could be optimized by interdisciplin- ary foot-drop clinics involving all of the relevant specialists. The goals of treatment should always be improved mobility in everyday life and the prevention of falls, pain, and abnormal postures.

[Effectiveness of tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy]

Objective

To investigate the effectiveness of tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy.

Methods

The clinical data of 21 patients with unilateral foot drop secondary to peroneal nerve palsy between October 2009 and September 2016 was retrospectively analyzed. There were 12 males and 9 females with an average age of 32.1 years (range, 23-47 years). The causes of peroneal nerve injury were iatrogenic injury in 7 cases, tibiofibular fractures combined with compartment syndrome in 5 cases, nerve exploration surgery after stab or cut injury in 3 cases, direct violence in 4 cases, and the fibular head fracture in 2 cases. The average time from injury to operation was 5.6 years (range, 2-8 years). There was 1 case of hallux valgus and 5 cases of toe flexion contracture. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, Foot and Ankle Ability Measure (FAAM) scores, range of motion (ROM), and dorsiflexion strength of ankle joint were used to evaluated the ankle function. Radiographic evaluation for the changes of postoperative foot alignment included Meary angle, calcaneal pitch angle, and hindfoot alignment angle.

Results

All incisions healed by first intention. All patients were followed up 18-42 months (mean, 30.2 months). The dorsiflexion strength of ankle joint recovered from grade 0 to grade 3-4 after operation. There was no patient with a postoperative flat foot deformity and claw toe during follow-up. There was no significant difference in Meary angle, calcaneal pitch angle, and hindfoot alignment angle between pre- and post-operation ( P>0.05). The AOFAS score, FAAM score, and ROM of dorsiflexion significantly improved at last follow-up when compared with preoperative values ( P<0.05); while there was no significant difference in ROM of plantar-flexion between pre- and post-operation ( t=4.239, P=0.158). There were significant differences in AOFAS score, FAAM score, and ROM of dorsiflexion between affected and healthy sides ( P<0.05); but no significant difference in ROM of plantar-flexion was found ( t=2.319, P=0.538).

Conclusion

Tibialis posterior tendon transfer is an effective surgical option for foot drop secondary to peroneal nerve palsy. And no postoperative flat foot deformity occurred at short-term follow-up.

Modified bridle tendon transfer procedure following a complete musculature loss of the anterior leg compartment: Case report and literature review

The complete musculature loss of the anterior compartment of the leg is a rare complication that occurs as a result of local tissue damage, intracompartmental bleeding and ischemia-reperfusion events. It causes foot drop and equinovarus deformity that negatively impact the quality of life of affected patients. This report describes a modified bridle tendon transfer procedure to correct this defect in a case of extensive muscle necrosis secondary to local hemorrhage.

A review of the literature was carried out to elucidate the benefits and risks associated to this technique.

Failure of Surgical Treatment in Patients with Cavovarus Deformity: Why Does This Happen and How Do We Approach Treatment?

Recurrent deformity after surgical treatment of the cavus foot occurs because a procedure is not performed at the apex of the deformity. In many instances there are multiple apices and, in addition to hindfoot osteotomy or arthrodesis, the midfoot must be corrected. There is not much of a role for the Coleman block test to determine flexibility of the foot, and this has led to many failures where the foot was believed flexible and an osteotomy was insufficient treatment. Skeletal correction, even if perfect, does not last unless the foot is balanced with appropriate tendon transfers.

[Bilateral well-leg compartment syndrome in a child after abdominal trauma : A review of the literature and treatment recommendations illustrated by a case study]

This article reports a case of a bilateral well leg compartment syndrome (WLCS) in a 9-year-old girl who presented to the emergency room 24 h after blunt abdominal trauma and liver laceration. The abdomen was already packed on presentation. The patient presented a manifest compartment syndrome of both lower legs 48 h after the second look surgery and removal of the packing. Both tibial anterior and peroneal compartments had to be partially resected. In an analysis of literature only five cases of WLCS after surgery in a supine position were found. The young age of the patient and the intra-abdominal packing were identified as risk factors for increased intra-abdominal pressure and reperfusion was suspected to be the cause of the lower leg compartment syndrome.

Transferring of femoral nerve motor branches for high-level sciatic nerve injury: a cadaver feasibility study

BACKGROUND

Sciatic nerve injuries cause significant disability. We propose here a novel reconstructive procedure of transferring the motor branches of the femoral nerve as donor nerves to reconstruct both the peroneal and tibial nerve function as a novel approach to treat high sciatic nerve injury.

METHODS

The autopsies of donor nerves (vastus lateralis nerve branch (VLN), vastus medialis nerve branch (VMN), saphenous nerve (SAN)) and respective recipient nerves (deep peroneal nerve branch (DPN), medial gastrocnemius nerve branch (MGN), sural nerve (SN)) were conducted in six fresh-frozen lower limbs. The distance between the origin or bifurcation points of the nerves to the head of fibula and the diameter of the end at the coaptation site were measured. The feasibility of tensionless direct suturing or grafting between the donor nerves and the recipient was evaluated. Finally, the nerve end at the coaptation site was harvested for observation with toluidine blue staining and nerve fiber count.

RESULTS

The mean diameter of the VMN, VLN, MGN, DPN, SAN, and SN nerves were 1.5 ± 0.1, 1.4 ± 0.1, 1.3 ± 0.1, 2.3 ± 0.1, 2.1 ± 0.3, and 1.3 ± 0.2 mm, respectively. Histological observation showed that the abovementioned six nerve bundles had a respective nerve fiber number of 392 ± 27, 205 ± 520, 219 ± 67, 394 ± 50, 308 ± 77, and 335 ± 49. A total of 5/6 specimens needed grafting for a length ranging from 5 to 15 cm to bridge the VMN-MGN, 6/6 needed a graft length of 10-20 cm for VLN-DPN bridging, and 2/6 needed a graft length of 0-4 cm for SAN-SN bridging.

CONCLUSION

The study demonstrated the feasibility of the transferring femoral nerve branches to sciatic nerve branches to restore the function for sciatic injury.

Translocation of the soleus muscular branch of the tibial nerve to repair high common peroneal nerve injury

BACKGROUND

This study was performed to evaluate the clinical effect of translocating the soleus muscular branch of the tibial nerve to repair the deep peroneal nerve.

METHODS

Eight patients were treated for high common peroneal nerve injury. The deep peroneal nerve was separated out from the common peroneal nerve if no injury occurred upon opening the epineurium of the common peroneal nerve. The soleus muscular branch of the tibial nerve was then translocated to the deep peroneal nerve.

RESULTS

The average follow-up duration was 21.75 months. Electromyography revealed newly appearing electric potentials in the tibialis anterior, extensor hallucis longus, and extensor toe longus muscle at 8 to 10 months postoperatively. Four patients showed good functional recovery after surgery; functional recovery was poor in other patients.

CONCLUSIONS

Translocation of the soleus muscle branch is a feasible method to treat high common peroneal nerve injuries. A full understanding of the indications for this operation is required.

[Soft tissue sarcomas: limb salvage using reconstructive plastic surgery techniques]

The treatment of choice for soft tissue sarcomas with local involvement is still the complete surgical removal into healthy tissue. The aim of surgery is to achieve tumor-free resection margins in the sense of a R0 resection. No other treatment option can equally replace this important oncological condition. The enormous development in the field of reconstructive plastic surgery and in particular the advances in flap techniques and microsurgery enable limb salvage and the functional reconstruction even in the case of extensive tumors.

Peroneal Nerve Dysfunction due to Multiligament Knee Injury: Patient Characteristics and Comparative Outcomes After Posterior Tibial Tendon Transfer

OBJECTIVE

To objectively compare outcomes of nonoperative management and posterior tibial tendon (PTT) transfer for peroneal nerve injury due to multiligament knee injury (MLI).

DESIGN

Retrospective cohort study with prospective follow-up.

SETTING

Tertiary care institution.

PATIENTS

Ten patients with peroneal nerve injury due to MLI (5 managed nonoperatively, 5 with PTT transfer) were evaluated and a control group of 4 patients without peroneal nerve injury.

INTERVENTIONS

Clinical examination, subjective questionnaires, and 3-D motion capture gait analysis during flat-ground walking and stair descent.

MAIN OUTCOME MEASURES

The primary outcome measure was the result of gait analysis. The results of subjective questionnaires were a secondary outcome measure.

RESULTS

Dorsiflexion was significantly reduced at initial contact and mid-late swing phase in the nonoperative cohort. The PTT transfer cohort demonstrated increased dorsiflexion at each of these time intervals compared with patients managed nonoperatively, restoring symmetry between limbs. The PTT transfer cohort demonstrated similar gait patterns to controls but tended to be more everted. Ground reaction force was increased in the uninvolved limb in the PTT transfer group during gait and step down. There were no statistically significant differences in AOFAS, FAAM, IKDC, or Lysholm results.

CONCLUSIONS

Posterior tibial tendon transfer is an option to restore dorsiflexion and eliminate the need for an orthosis in patients with foot drop due to MLI. Gait analysis demonstrates a significant improvement in sagittal plane ankle kinematics after PTT transfer. The trade-off is subtle instability, highlighting the dynamic stability that the PTT provides.

Interosseous membrane window size for tibialis posterior tendon transfer-Geometrical and MRI analysis

BACKGROUND

Tibialis posterior (TP) tendon transfer through the interosseous membrane is commonly performed in Charcot-Marie-Tooth disease. In order to avoid entrapment of this tendon, no clear recommendation relative to the interosseous membrane (IOM) incision size has been made.

OBJECTIVE

Analyze the TP size at the transfer level and therefore determine the most adequate IOM window size to avoid muscle entrapment.

METHODS

Eleven lower extremity magnetic resonances were analyzed. TP muscle measurements were made in axial views, obtaining the medial-lateral and antero-posterior diameter at various distances from the medial malleolus tip. The distance from the posterior to anterior compartment was also measured. These measurements were applied to a mathematical model to predict the IOM window size necessary to allow an ample TP passage in an oblique direction.

RESULTS

The average tendon diameter (confidence-interval) at 15cm proximal to the medial malleolus tip was 19.47mm (17.47-21.48). The deep posterior compartment to anterior compartment distance was 10.97mm (9.03-12.90). Using a mathematical model, the estimated IOM window size ranges from 4.2 to 4.9cm.

CONCLUSION

The IOM window size is of utmost importance in trans-membrane TP transfers, given that if equal or smaller than the transposed tendon oblique diameter, a high entrapment risk exists. A membrane window of 5cm or 2.5 times the size of the tendon diameter should be performed in order to theoretically diminish this complication.

Reconstruction of Soft-Tissue Defects at the Foot and Ankle after Oncological Resection

Introduction

Solid malignancies at the foot and ankle region are rare and include mainly soft-tissue sarcomas, bone sarcomas, and skin malignancies. Complete surgical resection with clear margins still remains the mainstay of therapy in these malignancies. However, attainment of negative surgical margins in patients with locally advanced tumors of the foot and ankle region may require extensive surgery and could result in loss of extremity function. In these circumstances, plastic surgical techniques can frequently reduce functional impairment and cover soft-tissue defects, particularly in cases of large tumor size or localization adjacent to critical anatomic structures, thereby improving the quality of life for these patients. The aim of this article is to illustrate the various treatment options of plastic surgery in the multimodal therapy of patients with malignant tumors of the foot and ankle region.

Materials and methods

This article is based on the review of the current literature and the evaluation of the author’s own patient database.

Results

The local treatment of malignant extremity tumors has undergone major changes over the last few decades. Primary amputations have been increasingly replaced by limb-sparing techniques, preserving extremity function as much as possible. Although defect coverage at the foot and ankle region is demanding due to complex anatomical features and functional requirements, several plastic surgical treatment options can be implemented in the curative treatment of patients with malignant solid tumors in this area. Soft-tissue defects after tumor resection can be covered by a variety of local flaps. If local flaps are not applicable, free flap transfers, such as the anterolateral thigh flap, parascapular flap, or latissimus dorsi flap, can be utilized to cover nearly all kinds of defects in the foot and ankle region.

Conclusion

Soft-tissue reconstruction in the foot and ankle region is a vital component of limb-sparing surgery. It enables complete resection of locally advanced tumors and subsequent adjuvant radiotherapy. Modern plastic surgical techniques should, therefore, be integrated in the multimodal treatment concept of malignancies in the foot and ankle region.

Motor Nerve Transfers

Brachial plexus and peripheral nerve injuries are exceedingly common. Traditional nerve grafting reconstruction strategies and techniques have not changed significantly over the last 3 decades. Increased experience and wider adoption of nerve transfers as part of the reconstructive strategy have resulted in a marked improvement in clinical outcomes. We review the options, outcomes, and indications for nerve transfers to treat brachial plexus and upper- and lower-extremity peripheral nerve injuries, and we explore the increasing use of nerve transfers for facial nerve and spinal cord injuries. Each section provides an overview of donor and recipient options for nerve transfer and of the relevant anatomy specific to the desired function.

Bridle procedure combined with a subtalar implant: a case series and review of the literature

BACKGROUND

The bridle procedure is a tritendon anastomosis between the tibialis posterior, peroneus longus, and tibialis anterior, utilized in the treatment of drop foot. Concerned about the potential for acquired flatfoot deformity following the bridle procedure, the authors hypothesized that placing a sinus tarsi implant would prevent this potential sequela.

MATERIALS AND METHODS

Over a 10-year period, 15 patients (16 feet) were treated with a bridle procedure for drop foot, and 9 of these feet also had a subtalar arthroereisis implanted; 8 patients (9 feet) positively responded to requests for long-term follow-up evaluation and returned for subjective evaluation with the American Orthopaedic Foot and Ankle Society (AOFAS) Hindfoot Scale and Short Form (SF)-36 forms and objective clinical and radiographic measurements.

RESULTS

At an average follow-up of 61 months, the 8 patients (9 feet) who returned for long-term evaluation maintained a plantigrade foot, were able to dorsiflex above neutral both actively and passively, and did not develop a flatfoot deformity at long-term follow-up. There were no significant differences between those who had a sinus tarsi implant (6 feet) and those who did not (3 feet). Although 7 of the 9 feet evaluated in this study wore a brace preoperatively, none continued to use a brace after surgery. The major complaints were occasional pain at the subtalar arthroereisis site and a feeling that the great toe was dragging.

CONCLUSION

The bridle procedure provided excellent outcomes in patients with drop foot, with patients achieving long-term success in being free from brace wear. The ability to actively dorsiflex the foot during gait was also restored, reestablishing a normal heel-to-toe gait pattern.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case series.

Plastic surgery for the oncological patient

The therapy of oncological patients has seen tremendous progress in the last decades. For most entities, it has been possible to improve the survival as well as the quality of life of the affected patients. To supply optimal cancer care, a multidisciplinary approach is vital. Together with oncologists, radiotherapists and other physicians, plastic surgeons can contribute to providing such care in all stages of treatment. From biopsies to the resection of advanced tumors, the coverage of the resulting defects and even palliative care, plastic surgery techniques can help to improve survival and quality of life as well as mitigate negative effects of radiation or the problems arising from exulcerating tumors in a palliative setting. This article aims to present the mentioned possibilities by illustrating selected cases and reviewing the literature. Especially in oncological patients, restoring their quality of life with the highest patient safety possible is of utmost importance.

Posterior tibialis tendon transfer via the circumtibial route: a cadaveric limb analysis

Background

Studies have yet to determine the optimal height at which the posterior tibial tendon (PTT) can be re-routed and the tendon length discrepancy at different height levels in terms of PTT transfer via the circumtibial route. This cadaveric study was conducted to determine the optimal height of PTT subcutaneous transfer and to compare tendon length discrepancies at different heights.

Materials and methods

Twenty-five fresh normal cadaveric lower legs were used for measurements. PTT was exposed and then isolated. An incision along the calf was made to re-route PTT outside the fascia. The upper edge of the incision was classified as point “a.” The distal tip of the tendon was classified as point “b.” The midpoints of the intermediate cuneiform, the lateral cuneiform, and the cuboid were defined as points “c,” “d,” and “e,” respectively. The lengths of “ab,” “ac,” “ad,” and “ae” were measured and compared at different height levels above the distal tip of the medial malleolus. Angles α, β, and γ between the tendon outside the fascia connecting to different bones and the tendon inside the fascia were also measured as tendons were transferred at different bones and different height levels. Experimental data were collected and analyzed.

Results

At a height of ≥5 cm, all of the PTTs could reach the midpoints of the three bones. The lengths of ac, ad, and ae were significantly less than the length of ab (p < 0.05). At a height of 10 cm, angles α, β, and γ were 177° ± 2.1°, 170° ± 3.1°, and 164° ± 3.7°, respectively. These angles were not significantly different from those at a height of 11 cm (p >0.05).

Conclusions

PTT transfer via the subcutaneous route could achieve an adequate length to be transferred to the intermediate cuneiform, the lateral cuneiform, and the cuboid from a height of 5 cm above the distal tip of the medial malleolus. A height of 10 cm could be optimal for PTT transfer in the three bones via the subcutaneous route.

[Long-term functional results after sarcoma resection]

Multimodal treatment of malignant tumors of the musculoskeletal system with R0 in sano resection plays a key role in prevention of local recurrence in soft tissue and bone sarcoma. In cases of unavoidable neuromuscular or osseous defects, current plastic and orthoplastic reconstruction techniques avoid limb amputation in the majority of patients. Clinical long-term results demonstrate that large resection defects do not necessarily result in impaired limb function if multidisciplinary procedures are integrated. In oncologically necessary major limb amputation, segmental resection and replantation of distal limb parts should be considered which provide end-bearing long stump formation. The functional conditions of long-term surviving elderly patients should be integrated into surgical decision-making and rehabilitation efforts.

Clinical Results of Transferring a Motor Branch of the Tibial Nerve to the Deep Peroneal Nerve for Treatment of Foot Drop

BACKGROUND:

Foot drop is a very debilitating condition affecting patients' daily activities, and its treatment has been a challenge for neurosurgeons. Grafting the peroneal or sciatic nerve usually results in poor outcomes. Our previous anatomic study demonstrated the feasibility of transferring a motor branch of the tibial nerve to the deep peroneal nerve at the level of the popliteal fossa.

OBJECTIVE:

To demonstrate the outcomes obtained after the transfer of a branch of the tibial nerve to the peroneal nerve for recovery of foot drop.

METHODS:

A retrospective review of 13 patients with foot drop caused by injuries to a lumbar root or the sciatic or peroneal nerve, who underwent a transfer of the nerve of the soleus muscle to the deep peroneal nerve. The results were evaluated using the British Medical Research Council grading system.

RESULTS:

Three patients were lost to follow-up. Of the remaining 10 patients, the outcomes were considered good (Medical Research Council grade M3 or M4) in 2 patients (20%) concerning ankle dorsiflexion and in 2 patients concerning toe extension (20%). One patient reported a reduced calf circumference.

CONCLUSION:

The transfer of the nerve of the soleus muscle to the deep peroneal nerve demonstrated poor results in most of the patients, although favorable outcomes were observed in a few subjects. Due to the inconsistency of the results, we do not favor the routine use of this technique for the treatment of foot drop.

Kinetics and kinematics after the Bridle procedure for treatment of traumatic foot drop

BACKGROUND

The Bridle procedure restores active ankle dorsiflexion through a tri-tendon anastomosis of the tibialis posterior, transferred to the dorsum of the foot, with the peroneus longus and tibialis anterior tendon. Inter-segmental foot motion after the Bridle procedure has not been measured. The purpose of this study is to report kinetic and kinematic variables during walking and heel rise in patients after the Bridle procedure.

METHODS

18 Bridle and 10 control participants were studied. Walking and heel rise kinetic and kinematic variables were collected and compared using an ANOVA.

FINDINGS

During walking the Bridle group, compared with controls, had reduced ankle power at push-off [2.3 (SD 0.7) W/kg, 3.4 (SD 0.6) W/kg, respectively, P<.01], less hallux extension during swing [-13 (SD 7)°, 15 (SD 6)°, respectively, P<.01] and slightly less ankle dorsiflexion during swing [6 (SD 4)°, 9 (SD 2)°, respectively, P=.03]. During heel rise the Bridle group had 4 (SD 6)° of forefoot on hindfoot dorsiflexion compared to 8 (SD 3)° of plantarflexion in the controls (P<.01).

INTERPRETATION

This study provides evidence that the Bridle procedure restores the majority of dorsiflexion motion during swing. However, plantarflexor function during push-off and hallux extension during swing were reduced during walking in the Bridle group. Abnormal mid-tarsal joint motion, forefoot on hindfoot dorsiflexion instead of plantarflexion, was identified in the Bridle group during the more challenging heel rise task. Intervention after the Bridle procedure must maximize ankle plantarflexor function and midfoot motion should be examined during challenging tasks.

Lateral meniscal cyst causing irreversible peroneal nerve palsy

We report an unusual case of irreversible foot drop occurring secondary to a large lateral meniscal cyst. We discuss the presentation and management of this rare case and highlight some of the less common causes of foot drop.

Cadaveric limb analysis of tendon length discrepancy of posterior tibial tendon transfer through the interosseous membrane

The posterior tibial tendon transfer through the interosseous membrane, as popularized by Watkins in 1954, is a procedure for treating reducible eversion and dorsiflexory paresis used by lower extremity foot and ankle surgeons. The posterior tibial tendon has been transferred to various locations on the midfoot for equinus and equinovarus deformities. Dorsiflexory paresis is a common symptom in equinovarus deformity, clubfoot deformity, Charcot-Marie-Tooth disease, leprosy, mononeuropathy, trauma to the common peroneal nerve, cerebrovascular accident, and Duchenne's muscular dystrophy. The main difficulty with this procedure, often discussed by surgeons, is inadequate tendon length, making anchoring to the cuneiforms or cuboid difficult. The goal of our cadaveric study was threefold. First, we sought to determine whether the tendon length is sufficient when transferring the posterior tibial tendon to the dorsum of the foot through the interosseous membrane for a dynamic or a static transfer. Second, we wished to describe the surgical technique designed to obtain the maximal length. Finally, we sought to discuss the strategies used when the tendon length for transfer is insufficient.

Functional neuro-vascularized muscle transfer for oncological reconstruction of extremity sarcoma

The strategy of limb salvage following surgical resection of skeletal tumor has led to an increased demand for more complex reconstructive options in order to achieve better functional outcomes. Functional neuro-vascularized muscle transfer (FMT) is a beneficial tool for restoring joint movement involving the reconstruction of "movement" in the affected extremity. Until now, however, the clinical application of FMT was mainly limited to trauma cases and to date, very few studies have focused on musculoskeletal oncology. In this study, we reviewed patients who underwent wide resection for extremity sarcoma and functional reconstruction using FMT and discussed the advantages, indications and complications of the procedure.

A method used to access the functional outcome of tibial posterior tendon transfer for foot drop in leprosy

OBJECTIVES

The aim of this study was to access the postoperative functional results of posterior tibial tendon transfer for foot drop as a consequence of nerve palsy in leprosy.

MATERIAL AND METHODS

Thirteen patients (9 males and 4 females) with ages ranging from 9 to 69 years were submitted to posterior tibial tendon transfer by the circumtibial route to correct foot drop in leprosy. The length of postoperative follow-up ranged from 1 to 5 years. The Stanmore system was used as a method for evaluating the functional results of postoperative posterior tibial tendon transfer. This system is made up of 7 different categories and the total score is 100.

RESULTS

According to the Stanmore system, the results were poor in 1 patient (7.6%), moderate in 2 feet (15.3%), good in 5 feet (38.4%), and excellent in 5 feet (38.4%). All the patients were satisfied with the final outcome.

CONCLUSION

The posterior tibial tendon transfer for foot drop in leprosy was efficient in restoring normal function of the foot and gait without changing foot posture. In the absence of a standardized method for assessing the results of posterior tibial tendon transfer, the Stanmore system seems to be a good tool for an objective evaluation.