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

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.

Traumatic Peroneal Nerve Injuries: A Systematic Review

BACKGROUND

The common peroneal nerve (CPN) is the most commonly injured peripheral nerve of the lower extremity in patients with trauma. Traumatic CPN injuries have historically been associated with relatively poor outcomes and patient satisfaction, although improved surgical technique and novel procedures appear to improve outcomes. Given the variety of underlying injury modalities, treatment options, and prognostic variables, we sought to evaluate and summarize the current literature on traumatic CPN injuries and to provide recommendations from an analysis of the included studies for treatment and future research.

METHODS

A systematic review was performed using PubMed, Embase, and Cochrane databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Search terms consisted of variations of "peroneal nerve" or "fibular nerve" combined with "injury," "laceration," "entrapment," "repair," or "neurolysis." Information with regard to treatment modality, outcomes, and patient demographic characteristics was recorded and analyzed.

RESULTS

The initial search yielded 2,301 articles; 42 met eligibility criteria. Factors associated with better outcomes included a shorter preoperative interval, shorter graft length when an interposed graft was used, nerve continuity, and younger patient age. Gender or sex was not mentioned as a factor affecting outcomes in any study. Motor grades of ≥M3 on the British Medical Research Council (MRC) scale are typically considered successful outcomes. This was achieved in 81.4% of patients who underwent neurolysis, 78.8% of patients who underwent end-to-end suturing, 49.0% of patients who underwent nerve grafting, 62.9% of patients who underwent nerve transfer, 81.5% of patients who underwent isolated posterior tibial tendon transfer (PTTT), and 84.2% of patients who underwent a surgical procedure with concurrent PTTT.

CONCLUSIONS

Studies included in this review were heterogenous, complicating our ability to perform further analysis. It is not possible to uniformly advocate for the best treatment option, given diverse injury modalities and patient presentations and a variety of prognostic factors. Many studies do not show outcomes with respect to injury modality. Future studies should show preoperative muscle strengths and should clearly define outcomes based on the injury modality and surgical treatment option. This would allow for greater analysis of the most appropriate treatment option for a given mechanism of injury. Newer surgical techniques are promising and should be further explored.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Transfer of the Posterior Tibial Tendon for Chronic Peroneal Nerve Palsy

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The common peroneal nerve (CPN) is one of the most frequently injured nerves of the lower extremity.

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One-third of patients who develop CPN palsy proceed to chronic impairment without signs of recovery.

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Ankle-foot orthoses can provide improvement with respect to gait dysfunction and are useful as a nonsurgical treatment option.

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Severe cases of CPN palsy demonstrating no signs of recovery may require operative intervention with tendon transfer.

Anterior Tibial Tendon Side-to-Side Tenorrhaphy after Posterior Tibial Tendon Transfer: A Technique to Improve Reliability in Drop Foot after Common Peroneal Nerve Injury

Common peroneal nerve injury is present in 40% of knee dislocations, and foot drop is the principal complication. Posterior tibial tendon transfer is a viable solution to replace the function of the anterior tibial tendon (ATT) in the mid-foot. Several techniques for posterior tibial tendon transfer exist today, with variable results reported. However, adding augmentation with side-to-side tenorrhaphy of ATT to the transferred posterior tibial tendon (PTT) enhances anterior tissue balance and load sharing stress between native ATT enthesis and PTT tenodesis, allowing early rehabilitation and improving functional outcomes. Side-to-side tenorrhaphy is performed after PTT tenodesis in the lateral cuneiform to improve reliability in foot drop. This technique allows shorter immobilization time (from 6 to 2 weeks), earlier rehabilitation, sooner weight-bearing, and decreased risk of arthrofibrosis, scar formation, and muscle atrophy.

Posterior Tibial Tendon Transfer for Common Peroneal Nerve Injury

Common peroneal nerve dysfunction after a multiligament knee injury can be devastating. In patients with persistent foot drop, posterior tibial tendon transfer to the dorsum of the foot is a reliable and safe procedure to restore dorsiflexion. These authors favor passing the posterior tibial tendon through the interosseous membrane and docking it into the lateral/middle cuneiforms. A Strayer procedure or tendo-Achilles lengthening must be performed in patients unable to achieve at least 10° of passive dorsiflexion. Despite the operative limb having 30% to 40% of ankle dorsiflexion strength of the uninjured limb, short- and long-term functional outcomes are excellent.

Short- and long-term results of common peroneal nerve injuries treated by neurolysis, direct suture or nerve graft

INTRODUCTION

Damage to the common peroneal nerve is the most frequent nerve injury in lower limb traumas. Our objective was to assess the motor and sensory recovery levels and the functional outcomes after remedial surgery for common peroneal nerve trauma, through either neurolysis, direct suture or nerve graft.

METHODS

This is a transversal, observational study of a monocentric cohort of 20 patients who underwent surgery between January 2004 and June 2016, which included 16 men and 4 women whose median age was 35 ± 11 years. We assessed the level of sensory and motor nerve recovery and the Kitaoka score. Nine patients benefited from neurolysis, 5 had direct sutures, and 6 received a nerve graft.

RESULTS

With 48 months' average follow-up, 7 out of 9 patients underwent neurolysis and 4 out of 5 with direct sutures had good motor recovery (≥ M4), but none for the grafts. Sensory recovery (≥ S3) was satisfactory in 7 out of 9 cases in the neurolysis group, 3 out of 5 in the direct suture group, and 3 out of 6 in the nerve graft group. The average Kitaoka score was 83.7 ± 11.5 for the neurolysis group, 86.8 ± 16 for the direct suture group, and 73 ± 14 for the graft group.

CONCLUSION

Surgical treatment by neurolysis and direct suture yields good results with a motor recovery ratio nearing 80%. When a nerve graft becomes necessary, recovery is poor and resorting to palliative techniques in the shorter run is a strategy which should be evaluated.