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Han Y, Zheng Q, Zuo T. A commentary on 'Could nerve transplantation be the future of this field: a bibliometric analysis about lumbosacral plexus injury'. Int J Surg 2024; 110:5210-5211. [PMID: 38716899 PMCID: PMC11326003 DOI: 10.1097/js9.0000000000001501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 04/14/2024] [Indexed: 08/16/2024]
Affiliation(s)
- Yiyan Han
- Liaoning University of Traditional Chinese Medicine
| | - Qu Zheng
- Liaoning University of Traditional Chinese Medicine
- Acupuncture Biology Key Laboratory of the Education Department of Liaoning Province, Liaoning 110847, People's Republic of China
| | - Tao Zuo
- Liaoning University of Traditional Chinese Medicine
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Yilmaz M, Gungor Y, Salman N, Comert A, Esmer TS, Esmer AF. Tibial nerve branching pattern and compatibility of branches for the deep fibular nerve. Surg Radiol Anat 2024; 46:413-424. [PMID: 38480593 DOI: 10.1007/s00276-024-03329-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/22/2024] [Indexed: 04/05/2024]
Abstract
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.
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Affiliation(s)
- Mehmet Yilmaz
- School of Medicine, Department of Anatomy, Ankara University, Sihhiye, Ankara, 06100, Turkey.
| | - Yigit Gungor
- School of Medicine, Department of Anatomy, Ankara University, Sihhiye, Ankara, 06100, Turkey
| | - Necati Salman
- Gulhane Faculty of Medicine, Department of Anatomy, University of Health Sciences Turkey, Ankara, Turkey
| | - Ayhan Comert
- School of Medicine, Department of Anatomy, Ankara University, Sihhiye, Ankara, 06100, Turkey
| | - Tulin Sen Esmer
- School of Medicine, Department of Anatomy, Ankara University, Sihhiye, Ankara, 06100, Turkey
| | - Ali Firat Esmer
- School of Medicine, Department of Anatomy, Ankara University, Sihhiye, Ankara, 06100, Turkey
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3
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Miller TA, Ross DC. Sciatic and tibial neuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:165-181. [PMID: 38697738 DOI: 10.1016/b978-0-323-90108-6.00003-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
The sciatic nerve is the body's largest peripheral nerve. Along with their two terminal divisions (tibial and fibular), their anatomic location makes them particularly vulnerable to trauma and iatrogenic injuries. A thorough understanding of the functional anatomy is required to adequately localize lesions in this lengthy neural pathway. Proximal disorders of the nerve can be challenging to precisely localize among a range of possibilities including lumbosacral pathology, radiculopathy, or piriformis syndrome. A correct diagnosis is based upon a thorough history and physical examination, which will then appropriately direct adjunctive investigations such as imaging and electrodiagnostic testing. Disorders of the sciatic nerve and its terminal branches are disabling for patients, and expert assessment by rehabilitation professionals is important in limiting their impact. Applying techniques established in the upper extremity, surgical reconstruction of lower extremity nerve dysfunction is rapidly improving and evolving. These new techniques, such as nerve transfers, require electrodiagnostic assessment of both the injured nerve(s) as well as healthy, potential donor nerves as part of a complete neurophysiological examination.
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Affiliation(s)
- Thomas A Miller
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, St. Joseph's Health Care, Parkwood Institute, London, ON, Canada.
| | - Douglas C Ross
- Division of Plastic Surgery, Schulich School of Medicine and Dentistry, Western University, St. Joseph's Health Care, Roth McFarlane Hand and Upper Limb Centre, London, ON, Canada
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Duraku LS, Buijnsters ZA, Power DM, George S, Walbeehm ET, de Jong T. Motor and sensory nerve transfers in the lower extremity: Systematic review of current reconstructive possibilities. J Plast Reconstr Aesthet Surg 2023; 84:323-333. [PMID: 37390541 DOI: 10.1016/j.bjps.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 05/24/2023] [Accepted: 06/03/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Peripheral nerve injuries (PNI) are predominantly treated by anatomical repair or reconstruction with autologous nerve grafts or allografts. Motor nerve transfers for PNI in the upper extremity are well established; however, this technique is not yet widely used in the lower extremity. This literature review presents an overview of the current options and postoperative results for nerve transfers as a treatment for nerve injury in the lower extremity. METHODS A systematic search in PubMed and Embase databases was performed. Full-text English articles describing surgical procedures and postoperative outcomes of nerve transfers in the lower extremity were included. The primary outcome was postoperative muscle strength measured using the British Medical Research Council (MRC) scale, with MRC> 3 considered good and postoperative return of sensation reported according to the modified Highet classification. RESULTS A total of 36 articles for motor nerve transfer and 7 for sensory nerve transfer were included. Sixteen articles described motor nerve transfers for treating peroneal nerve injury, 17 for femoral nerve injury, 2 for tibial nerve injury, and one for obturator nerve injury. Transfers of multiple branches to restore deep peroneal nerve function led to a good outcome in 58% of patients and 43% when a single branch was used as a donor. The transfer of multiple branches for femoral nerve or obturator nerve repair was performed in all reported patients with a good outcome. CONCLUSIONS The transfer of motor nerves for the recovery of PNI is a feasible technique with relatively low risks and great benefits. The correct indication, timing, and surgical technique are essential for optimizing results.
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Affiliation(s)
- Liron S Duraku
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Zoë A Buijnsters
- Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Dominic M Power
- Department of Hand and Peripheral Nerve Surgery, Birmingham University Hospital, Birmingham, United Kingdom
| | - Samuel George
- Department of Hand and Peripheral Nerve Surgery, Birmingham University Hospital, Birmingham, United Kingdom
| | - Erik T Walbeehm
- Department of Plastic, Reconstructive and Hand Surgery, HAGA Hospital, Den Hague, the Netherlands
| | - Tim de Jong
- Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Nijmegen, the Netherlands.
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Surgical Interventions for Lumbosacral Plexus Injuries: A Systematic Review. Plast Reconstr Surg Glob Open 2022; 10:e4436. [PMID: 36032367 PMCID: PMC9400934 DOI: 10.1097/gox.0000000000004436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/23/2022] [Indexed: 11/26/2022]
Abstract
Background: Nerve reconstruction techniques for lumbosacral plexus (LSP) injuries vary. There are no clear treatment guidelines available, and summative evaluations of the literature discussing these surgeries are lacking. For these reasons, this investigation aimed to systematically review and consolidate all available literature discussing surgical interventions for LSP injuries and cohesively present patient-reported and objective postoperative outcomes. Methods: The authors conducted a systematic review using PubMed, Embase, Web of Science, ProQuest Dissertations and Theses Global (via Proquest.com), and ClinicalTrials.gov databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. After title and abstract screening, identified articles were read in full and selected for inclusion based on prespecified criteria. Results: Our literature search identified 8683 potential citations, and after duplicate removal, abstract screening, and full-text review, 62 studies remained meeting inclusion and exclusion criteria. Outcomes were extracted according to the location of injury and type of surgical repair. Injuries were classified into isolated femoral nerve injuries, isolated obturator nerve injuries, isolated sciatic nerve injuries, and multilevel LSP injuries. Surgical treatment was further classified into exploration with neurolysis, direct repair, nerve grafting, and nerve transfer surgery. Conclusions: Although results vary based on the location of the injury and the surgical technique used, nerve grafts and transfers demonstrated reasonable success in improving functional and pain outcomes. Overall, isolated femoral and obturator nerve injuries had the best outcomes reported with surgical treatment. Furthermore, incomplete sciatic nerve and multilevel LSP injuries had more reported surgical options and better outcomes than complete sciatic nerve injuries.
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A Systematic Review of Muscle Synergies during a Walking Gait to Define Optimal Donor-Recipient Pairings for Lower Extremity Functional Reconstruction. Plast Reconstr Surg Glob Open 2022; 10:e4438. [PMID: 35983544 PMCID: PMC9377677 DOI: 10.1097/gox.0000000000004438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/24/2022] [Indexed: 11/25/2022]
Abstract
Functional lower extremity reconstruction primarily aims to restore independent ambulation. We sought to define the synergies recruited during a walking gait to inform donor selection for various motor deficits. With these findings, we discuss the functional neuromuscular components of independent gait with the goal of informing lower extremity reconstruction.
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Miranda SP, Zager EL. Commentary: Clinical Application of Saphenous Nerve Transfer for Sensory Reconstruction of the Sole After Sciatic Nerve Injury: A Case Series. Oper Neurosurg (Hagerstown) 2022; 22:e239-e240. [DOI: 10.1227/ons.0000000000000202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 01/27/2022] [Indexed: 11/19/2022] Open
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Emamhadi M, Haghani Dogahe M. Clinical Application of Saphenous Nerve Transfer for Sensory Reconstruction of the Sole After Sciatic Nerve Injury: A Case Series. Oper Neurosurg (Hagerstown) 2022; 22:373-379. [DOI: 10.1227/ons.0000000000000152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 12/15/2021] [Indexed: 11/19/2022] Open
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Plasticity of the Central Nervous System Involving Peripheral Nerve Transfer. Neural Plast 2022; 2022:5345269. [PMID: 35342394 PMCID: PMC8956439 DOI: 10.1155/2022/5345269] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/09/2022] [Accepted: 02/28/2022] [Indexed: 11/22/2022] Open
Abstract
Peripheral nerve injury can lead to partial or complete loss of limb function, and nerve transfer is an effective surgical salvage for patients with these injuries. The inability of deprived cortical regions representing damaged nerves to overcome corresponding maladaptive plasticity after the reinnervation of muscle fibers and sensory receptors is thought to be correlated with lasting and unfavorable functional recovery. However, the concept of central nervous system plasticity is rarely elucidated in classical textbooks involving peripheral nerve injury, let alone peripheral nerve transfer. This article is aimed at providing a comprehensive understanding of central nervous system plasticity involving peripheral nerve injury by reviewing studies mainly in human or nonhuman primate and by highlighting the functional and structural modifications in the central nervous system after peripheral nerve transfer. Hopefully, it will help surgeons perform successful nerve transfer under the guidance of modern concepts in neuroplasticity.
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Bjorklund KA, West JM, Nopkhun W, Moore AM. Surgical Innovations to Restore Function in Pediatric Peripheral Nerve Conditions. Pediatrics 2021; 148:183394. [PMID: 34851416 DOI: 10.1542/peds.2021-052556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 11/24/2022] Open
Abstract
Peripheral nerve injuries in children can result in devastating lifelong deficits. Because of the time-sensitive nature of muscle viability and the limited speed of nerve regeneration, early recognition and treatment of nerve injuries are essential to restore function. Innovative surgical techniques have been developed to combat the regenerative length and speed; these include nerve transfers. Nerve transfers involve transferring a healthy, expendable donor nerve to an injured nerve to restore movement and sensation. Nerve transfers are frequently used to treat children affected by conditions, including UE trauma, brachial plexus birth injury, and acute flaccid myelitis. Pediatricians play an important role in the outcomes of children with these conditions through early diagnosis and timely referrals. With this review, we aim to provide awareness of state-of-the-art surgical treatment options that significantly improve the function of children with traumatic nerve injuries, brachial plexus birth injury, and acute flaccid myelitis.
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Affiliation(s)
| | | | - Wilawan Nopkhun
- Department of Physical Medicine and Rehabilitation, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Amy M Moore
- Section of Plastic and Reconstructive Surgery
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Garg SP, Hassan AM, Patel AA, Perez MM, Stoehr JR, Ketheeswaran S, Chappell AG, Galiano RD, Ko JH. Outcomes of Tibial Nerve Repair and Transfer: A Structured Evidence-Based Systematic Review and Meta-Analysis. J Foot Ankle Surg 2021; 60:1280-1289. [PMID: 34366221 DOI: 10.1053/j.jfas.2021.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/29/2021] [Accepted: 07/01/2021] [Indexed: 02/03/2023]
Abstract
Although nerve transfer and repair are well-established for treatment of nerve injury in the upper extremity, there are no established parameters for when or which treatment modalities to utilize for tibial nerve injuries. The objective of our study is to conduct a systematic review of the effectiveness of end-to-end repair, neurolysis, nerve grafting, and nerve transfer in improving motor function after tibial nerve injury. PubMed, Cochrane, Medline, and Embase libraries were queried according to the PRISMA guidelines for articles that present functional outcomes after tibial nerve injury in humans treated with nerve transfer or repair. The final selection included Nineteen studies with 677 patients treated with neurolysis (373), grafting (178), end-to-end repair (90), and nerve transfer (30), from 1985 to 2018. The mean age of all patients was 27.0 ± 10.8 years, with a mean preoperative interval of 7.4 ± 10.5 months, and follow-up period of 82.9 ± 25.4 months. The mean graft repair length for nerve transfer and grafting patients was 10.0 ± 5.8 cm, and the most common donor nerve was the sural nerve. The most common mechanism of injury was gunshot wound, and the mean MRC of all patients was 3.7 ± 0.6. Good outcomes were defined as MRC ≥ 3. End-to-end repair treatment had the greatest number of good outcomes, followed by neurolysis. Patients with preoperative intervals less than 7 months were more likely to have good outcomes than those greater than 7 months. Patients with sport injuries had the highest percentage of good outcomes in contrast to patients with transections and who were in MVAs. We found no statistically significant difference in good outcomes between the use of sural and peroneal donor nerve grafts, nor between age, graft length, and MRC score.
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Affiliation(s)
- Stuti P Garg
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Abbas M Hassan
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Anooj A Patel
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Megan M Perez
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jenna R Stoehr
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Ava G Chappell
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Robert D Galiano
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jason H Ko
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
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McInnes CW, Ha AY, Power HA, Tung TH, Moore AM. Femoral nerve decompression and sartorius-to-quadriceps nerve transfers for partial femoral nerve injury: a cadaveric study and early case series. J Neurosurg 2021; 135:904-911. [PMID: 33157531 DOI: 10.3171/2020.6.jns20251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 06/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Partial femoral nerve injuries cause significant disability with ambulation. Due to their more proximal and superficial location, sartorius branches are often spared in femoral nerve injuries. In this article, the authors report the benefits of femoral nerve decompression, demonstrate the feasibility of sartorius-to-quadriceps nerve transfers in a cadaveric study, describe the surgical technique, and report clinical results. METHODS Four fresh-frozen cadaveric lower limbs were dissected for anatomical analysis of the sartorius nerve. In addition, a retrospective review of patients with partial femoral nerve injuries treated with femoral nerve decompression and sartorius-to-quadriceps nerve transfers was conducted. Pre- and postoperative knee extension Medical Research Council (MRC) grades and pain scores (visual analog scale) were collected. RESULTS Up to 6 superficial femoral branches innervate the sartorius muscle just distal to the inguinal ligament. Each branch yielded an average of 672 nerve fibers (range 99-1850). Six patients underwent femoral nerve decompression and sartorius-to-quadriceps nerve transfers. Four patients also had concomitant obturator-to-quadriceps nerve transfers. At final follow-up (average 13.4 months), all patients achieved MRC grade 4-/5 or greater knee extension. The average preoperative pain score was 5.2, which decreased to 2.2 postoperatively (p = 0.03). CONCLUSIONS Femoral nerve decompression and nerve transfer using sartorius branches are a viable tool for restoring function in partial femoral nerve injuries. Sartorius branches serve as ideal donors in quadriceps nerve transfers because they are expendable, are close to their recipients, and have an adequate supply of nerve fibers.
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Affiliation(s)
- Colin W McInnes
- 1Department of Surgery, Division of Plastic Surgery, Fraser Health Authority/University of British Columbia, New Westminster, British Columbia, Canada
| | - Austin Y Ha
- 2Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - Hollie A Power
- 3Department of Surgery, Division of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada; and
| | - Thomas H Tung
- 2Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - Amy M Moore
- 4Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Peters BR, Ha AY, Moore AM, Tung TH. Nerve transfers for femoral nerve palsy: an updated approach and surgical technique. J Neurosurg 2021; 136:856-866. [PMID: 34416726 DOI: 10.3171/2021.2.jns203463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 02/10/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Femoral nerve palsy results in significant impairment of lower extremity function due to the loss of quadriceps muscle function. The authors have previously described their techniques utilizing the anterior obturator and sartorius nerves for transfer in cases of femoral nerve palsy presenting within 1 year of injury. In the current study, the authors discuss their updated techniques, results, and approach to partial and complete femoral nerve palsies using femoral nerve decompression and nerve transfers. METHODS They conducted a retrospective review of patients with femoral nerve palsies treated with their technique at the Washington University School of Medicine in 2008-2019. Primary outcomes were active knee extension Medical Research Council (MRC) grades and visual analog scale (VAS) pain scores. RESULTS Fourteen patients with femoral nerve palsy were treated with femoral nerve decompression and nerve transfer: 4 with end-to-end (ETE) nerve transfers, 6 with supercharged end-to-side (SETS) transfers, and 4 with ETE and SETS transfers, using the anterior branch of the obturator nerve, the sartorius branches, or a combination of both. The median preoperative knee extension MRC grade was 2 (range 0-3). The average preoperative VAS pain score was 5.2 (range 1-9). Postoperatively, all patients attained an MRC grade 4 or greater and subjectively noted improved strength and muscle bulk and more natural gait. The average postoperative pain score was 2.3 (range 0-6), a statistically significant improvement (p = 0.001). CONCLUSIONS Until recently, few treatments were available for high femoral nerve palsy. A treatment strategy involving femoral nerve decompression and nerve transfers allows for meaningful functional recovery and pain relief in cases of partial and total femoral nerve palsy. An algorithm for the management of partial and complete femoral nerve palsies and a detailed description of surgical techniques are presented.
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Affiliation(s)
- Blair R Peters
- 1Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; and
| | - Austin Y Ha
- 1Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; and
| | - Amy M Moore
- 2Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Thomas H Tung
- 1Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri; and
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Robinson LR, Binhammer P. Role of electrodiagnosis in nerve transfers for focal neuropathies and brachial plexopathies. Muscle Nerve 2021; 65:137-146. [PMID: 34331718 DOI: 10.1002/mus.27376] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 07/13/2021] [Accepted: 07/18/2021] [Indexed: 12/16/2022]
Abstract
Over the past 2 decades, the surgical treatment of brachial plexus and peripheral nerve injuries has advanced considerably. Nerve transfers have become an important surgical tool in addition to nerve repair and grafting. Electrodiagnosis has traditionally played a role in the diagnosis and localization of peripheral nervous system injuries, but a different approach is needed for surgical decision-making and monitoring recovery. When patients have complete or severe injuries they should be referred to surgical colleagues early after injury, as outcomes are best when nerve transfers are performed within the first 3 to 6 mo after onset. Patients with minimal recovery of voluntary activity are particularly challenging, and the presence of a few motor unit action potentials in these individuals should be interpreted on the basis of timing and evidence of ongoing reinnervation. Evaluation of potential recipient and donor muscles, as well as redundant muscles, for nerve transfers requires an individualized approach to optimize the chances of a successful surgical intervention. Anomalous innervation takes on new importance in these patients. Communication between surgeons and electrodiagnostic medicine specialists (EMSs) is best facilitated by a joint collaborative clinic. Ongoing monitoring of recovery post-operatively is critical to allow for decision making for continued surgical and rehabilitation treatments. Different electrodiagnostic findings are expected with resolution of neurapraxia, distal axon sprouting, and axonal regrowth. As new surgical techniques become available, EMSs will play an important role in the assessment and treatment of these patients with severe nerve injuries.
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Affiliation(s)
- Lawrence R Robinson
- Physical Medicine & Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Paul Binhammer
- Plastic & Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada
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O'Brien AL, West JM, Zewdu A, Grignol VP, Scharschmidt TJ, Moore AM. Nerve transfers to restore femoral nerve function following oncologic nerve resection. J Surg Oncol 2021; 124:33-40. [PMID: 33831232 DOI: 10.1002/jso.26487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Advances in the care of soft-tissue tumors, including imaging capabilities and adjuvant radiation therapy, have broadened the indications and opportunities to pursue surgical limb salvage. However, peripheral nerve involvement and femoral nerve resection can still result in devastating functional outcomes. Nerve transfers offer a versatile solution to restore nerve function following tumor resection. METHODS Two cases were identified by retrospective review. Patient and disease characteristics were gathered. Preoperative and postoperative motor function were assessed using the Medical Research Council Muscle Scale. Patient-reported pain levels were assessed using the numeric rating scale. RESULTS Nerve transfers from the obturator and sciatic nerve were employed to restore knee extension. Follow up for Case 1 was 24 months, 8 months for Case 2. In both patients, knee extension and stabilization of gait without bracing was restored. Patient also demonstrated 0/10 pain (an average improvement of 5 points) with decreased neuromodulator and pain medication use. CONCLUSION Nerve transfers can restore function and provide pain control benefits and ideally are performed at the time of tumor extirpation. This collaboration between oncologic and nerve surgeons will ultimately result in improved functional recovery and patient outcomes.
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Affiliation(s)
- Andrew L O'Brien
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Julie M West
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Abbie Zewdu
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Valerie P Grignol
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Thomas J Scharschmidt
- Department of Orthopaedic Surgery, The Ohio State University James Wexner Medical Center, Columbus, Ohio, USA
| | - Amy M Moore
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Impacts of Rehabilitation Gait Training on Functional Outcomes after Tibial Nerve Transfer for Patients with Peroneal Nerve Injury: A Nonrandomized Controlled Trial. Plast Reconstr Surg 2021; 147:1202-1207. [PMID: 33835089 DOI: 10.1097/prs.0000000000007896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although there was initial success using tibial nerve transfer to restore ankle dorsiflexion following peroneal nerve injury, results from later series were less promising. A potential reason is coactivation of the much stronger antagonistic muscles during gait. The purpose of this study was to test the hypothesis that gait training would improve functional performance following tibial nerve transfer. METHODS Using a prospective, nonrandomized, controlled study design, patients were divided into two groups: surgery only or surgery plus gait training. Of the 20 patients who showed reinnervation in the tibialis anterior muscle, 10 were assigned to the gait training group, and an equal number were in the control group. Those in the treatment group began training once reinnervation in the tibialis anterior muscle was detected, whereas those in the control group continued to use their ankle-foot orthosis full time. Differences in ankle dorsiflexion were measured using the Medical Research Council scale, and quantitative force measurement and functional disability was measured using the Stanmore Scale. RESULTS Patients in the gait training group attained significantly better functional recovery as measured by the Stanmore Scale (79.5 ± 14.3) (mean ± SD) versus (37.2 ± 3.5) in the control group (p = 0.02). Medical Research Council grades were 3.8 ± 0.6 in the training group versus 2.5 ± 1.2 in the surgery only group (p < 0.05). Average dorsiflexion force from patients with above antigravity strength (all from the training group) was 31 percent of the contralateral side. CONCLUSION In patients with successful reinnervation following tibial nerve transfers, rehabilitation training significantly improved dorsiflexion strength and function. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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McGillivray MK, Haldane C, Doherty C, Berger MJ. Evaluation of muscle strength following peripheral nerve surgery: A scoping review. PM R 2021; 14:383-394. [PMID: 33751851 DOI: 10.1002/pmrj.12586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 02/24/2021] [Accepted: 03/07/2021] [Indexed: 12/14/2022]
Abstract
Peripheral nerve injury (PNI) can result in devastating loss of function, often with poor long-term prognosis. Increased use of peripheral nerve surgical techniques (eg, nerve transfer, nerve grafting, and nerve repair) has resulted in improved muscle strength and other functional outcomes in patients with PNI. Muscle strength has largely been evaluated with the British Medical Research Council (MRC) scale. MRC is convenient to use in clinical settings, but more robust measures of muscle function are necessary to fully elucidate patient recovery. This scoping review aims to examine alternative instruments used to assess muscle function in studies of peripheral nerve surgery for PNI of the upper and lower limbs. A scoping review was conducted using Ovid MEDLINE, CINAHL, EMBASE, and PubMed databases in May and December of 2020, yielding a total of 20 studies pertaining to the review question. Studies pertaining to handheld dynamometry, grip and pinch dynamometry, Rotterdam Intrinsic Hand Myometers, isokinetic dynamometry, ultrasonography, and electromyography were reviewed. We provide a synopsis of each method and current clinical applications and discuss potential benefits, disadvantages, and areas of future research.
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Affiliation(s)
- Meghan K McGillivray
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Chloe Haldane
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher Doherty
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael J Berger
- International Collaboration on Repair Discoveries, Vancouver, British Columbia, Canada.,Division of Physical Medicine & Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,School of Kinesiology, Faculty of Education, University of British Columbia, Vancouver, British Columbia, Canada
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Agarwal P, Sharma D. Our experience of reinnervation of sole in diabetic sensorimotor polyneuropathy: A chance to change the natural history of disease. J Clin Orthop Trauma 2021; 17:25-29. [PMID: 33717968 PMCID: PMC7920140 DOI: 10.1016/j.jcot.2021.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/05/2021] [Accepted: 01/19/2021] [Indexed: 12/23/2022] Open
Abstract
Diabetic sensorimotor polyneuropathy (DSPN) is the commonest form of neuropathy which leads to insensate sole, diabetic foot ulcers (DFU) and its complications. We share our experience in recovery of sensation in the sole after prophylactic surgery such as nerve decompression (ND) or sensory neurotization by nerve transfer (NT) in patients having Diabetic sensorimotor polyneuropathy DSPN. 32 patients (46 feet) were selected for either nerve decompression or sensory neurotization depending upon presence or absence of Tinel's sign at tarsal tunnel. At 6 month post-operatively perception of touch and pain recovered in all feet; temperature and pressure perception recovered in ∼95% feet; average vibration perception threshold returned to normal range and 2-Point Discrimination came down significantly. There were no ulcers or amputation in operated limbs during follow up period of 6 months. Prophylactic surgery in the form of ND and NT can be offered with minimal complications which significantly improve sensations in the sole in selected cases of DSPN. These have the potential to improve the quality of life of patient and change the natural course of disease.
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Affiliation(s)
- Pawan Agarwal
- Professor, and in Charge Plastic Surgery Unit, NSCB Government Medical College, Jabalpur MP, 482003, India
- Corresponding author. 292/293, Napier Town, Jabalpur, 482001, MP, India.
| | - Dhananjaya Sharma
- Professor and Head, Department of Surgery, NSCB Government Medical College, Jabalpur, MP, 482003, India
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Martin E, Dullaart MJ, Verhoef C, Coert JH. A systematic review of functional outcomes after nerve reconstruction in extremity soft tissue sarcomas: A need for general implementation in the armamentarium. J Plast Reconstr Aesthet Surg 2020; 73:621-632. [PMID: 32088187 DOI: 10.1016/j.bjps.2019.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/16/2019] [Accepted: 12/31/2019] [Indexed: 11/17/2022]
Abstract
Resection of nerves in extremity soft tissue sarcomas (STS) can lead to large functional deficits. Nerve reconstructions are rarely performed and little is known on their outcomes and indications for their use, even though they are essential in restoring sensation in limb salvage procedures. This study investigated current knowledge on functional outcomes and considerations to be taken before performing such reconstructions after sarcoma resection. A systematic search was performed in July 2018 in PubMed and Embase databases according to PRISMA guidelines. Search terms related to "soft tissue sarcoma" and "nerve reconstruction" were used. Studies evaluating functional outcomes after nerve grafting or nerve transfers in extremity STS were included. Qualitative synthesis was performed on all studies. Nineteen studies were included after full-text screening, describing 26 patients. The majority of patients had a nerve reconstruction in the upper extremity (65%). Perioperative radiotherapy was administered in 67% and perioperative chemotherapy in 29% of patients. Nerve grafting was most commonly performed (n = 23) and nerve transfers were performed in six patients. A wide variety of outcome measures were used. Most patients recovered at least some motor function and sensation, but success rates were higher after upper than lower extremity defects. Multimodal treatment did not preclude successful reconstructions. Nerve reconstructions in extremity STS allow the restoration of sensation in limb salvation, even motor nerve function can be restored with satisfactory function. The use of multimodal therapy does not seem to interfere with success. Nerve reconstructions should therefore be considered in STS patients.
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Affiliation(s)
- Enrico Martin
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, PO Box 85060, 3508 AB Utrecht, the Netherlands.
| | - Max J Dullaart
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, PO Box 85060, 3508 AB Utrecht, the Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus Medical Center Cancer Institute, Molewaterplein 40, Rotterdam, the Netherlands
| | - J Henk Coert
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, PO Box 85060, 3508 AB Utrecht, the Netherlands.
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Thatte MR, Hiremath A, Goklani MS, Patel NR, Takwale AB. Peripheral Nerve Injury to the Lower Limb: Repair and Secondary Reconstruction. Indian J Plast Surg 2019; 52:93-99. [PMID: 31456617 PMCID: PMC6664834 DOI: 10.1055/s-0039-1687921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
This article is based on literature review of relevant articles as well as the authors’ own experiences in treating peripheral nerve injuries of the lower limb. The article deals with causative factors of lower limb nerve injuries, various grading systems of the injuries, approaches to such injuries, and techniques to repair lower limb nerve injuries. It also enumerates several reasons to explain the poorer prognosis of peroneal nerve injuries and the possible distal nerve transfers in lower limb albeit with poorer outcomes.
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Affiliation(s)
- Mukund R Thatte
- Department of Plastic Surgery, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Amita Hiremath
- Department of Plastic Surgery, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Mayur S Goklani
- Department of Plastic Surgery, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Neehar R Patel
- Department of Plastic Surgery, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Anupam B Takwale
- Department of Plastic Surgery, Bombay Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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21
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Meng D, Chen H, Lin Y, Lin H, Hou C. Transferring of femoral nerve motor branches for high-level sciatic nerve injury: a cadaver feasibility study. Acta Neurochir (Wien) 2019; 161:279-286. [PMID: 30483983 DOI: 10.1007/s00701-018-3746-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 11/21/2018] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Depeng Meng
- Department of Orthopedics, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, People's Republic of China
| | - Huihao Chen
- Department of Orthopedics, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, People's Republic of China
| | - Yaofa Lin
- Department of Orthopedics, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, People's Republic of China
| | - Haodong Lin
- Department of Orthopedics, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, People's Republic of China.
| | - Chunlin Hou
- Department of Orthopedics, Changzheng Hospital, Second Military Medical University, Shanghai, 200003, People's Republic of China
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Abstract
Nerve transfer surgery involves using a working, functional nerve with an expendable or duplicated function as a donor to supply axons and restore function to an injured recipient nerve. Nerve transfers were originally popularized for the restoration of motor function in patients with peripheral nerve injuries. However, more recently, novel uses of nerve transfers have been described, including nerve transfers for sensory reinnervation, nerve transfers for spinal cord injury and stroke patients, supercharge end-to-side nerve transfers, and targeted muscle reinnervation for the prevention and treatment of postamputation neuroma pain. The uses for nerve transfers and the patient populations that can benefit from nerve transfer surgery continue to expand. Awareness about these novel uses of nerve transfers among the medical community is important in order to facilitate evaluation and treatment of these patients by peripheral nerve specialists. A lack of knowledge of these techniques continues to be a major barrier to more widespread implementation.
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Affiliation(s)
- Thomas J Wilson
- Department of Neurosurgery, Stanford University, 300 Pasteur Drive, R293, Stanford, California, 94305, USA.
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