Common peroneal nerve injuries: results with one-stage nerve repair and tendon transfer

The authors report their experience in the treatment of common peroneal nerve (CPN) injuries using a one-stage procedure of nerve repair and tibialis posterior tendon transfer. A series of 45 patients with traumatic injury and graft repair of the CPN is presented. From 1988 to 1991, the six patients elected for surgery had only nerve repair: five ultimately did not recover, while muscle contraction in the remaining patient was graded M1-2. Since 1991, nerve surgery in our clinic was associated with tendon transfer procedures (39 cases) which were followed by a satisfactory reinnervation rate. Nerve transection and iatrogenic injuries, torsion/dislocation of the knee, complex biosseous fractures of the leg, and gunshot wounds showed excellent to fair results in decreasing order: in nerve sections, muscle recovery scored M3 or M4+ in all the patients, and in nerve ruptures due to severe dislocation of the knee, it was M3 or M4+ in 85% of cases. The association of microsurgical nerve repair and tendon transfer has changed the course of CPN injuries.     

Common peroneal nerve injuries in knee dislocations: results with one-stage nerve repair and tibialis posterior tendon transfer

We report our experience in the treatment of common peroneal nerve (CPN) palsy following knee dislocations: a twelve-year surgical series of 26 patients presenting with a traumatic injury of the lateral sciatic nerve and no spontaneous recovery is reviewed. From 1988 to 1991, we performed nerve surgery alone on 3 patients. Their results were highly disappointing and in none did we observe muscle recovery. Since 1991 nerve surgery was associated with a palliative procedure for 23 patients. Although at surgical exploration, severe nerve damage was found in 87% of these patients (thereby indicating the need for graft repair), the overall outcome was good, with a score of M3 on the BMRC scale in about 75% of the cases. These results suggest that the one-stage association of microsurgical nerve repair and tibialis posterior tendon transfer changed the destiny of these injuries. Received: 10 December 2001/Accepted: 14 February 2002     

Surgical treatment of common peroneal nerve injuries: indications and results. A series of 62 cases

AIM: Common peroneal nerve (CPN) injuries represent the most common nerve lesions of the lower limb and can be due to several causative mechanisms. Although in most cases they recover spontaneously, an irreversible damage of the nerve is also likely to occur. Nerve regeneration following CPN repair is poorer if compared to other peripheral nerves and this can explain the reluctant attitude of many physicians towards the surgical treatment of these patients. Among the several factors advocated to explain the poor outcome following surgery, it has been suggested that reinnervation might be obstacled by the force imbalance between the functioning flexors and the paralysed extensors that eventually results in the fixed equinism of the foot, due to the excessive contracture of the active muscles and the shortening of the heel cord. Therefore the early correction of these forces might favour nerve regeneration. Following such hypothesis, the authors treat irreversible CPN injuries performing a one-stage procedure of nerve repair and tibialis tendon transfer. We report our experience, describing the indications to surgical treatment, the operative technique and the postoperative clinical outcome correlated with the causative mechanisms of the injuries. METHODS: A 62-patient series controlled over a period of 15 years with a post-traumatic palsy of the CPN is reported. All the patients underwent surgery. In open wounds, when a nerve transection was suspected, surgery was performed at emergency (2 cases). In closed injuries, operative treatment was advised when no spontaneous regeneration occurred 3-4 months after the injury. From 1988 till 1991, 9 patients were elected for surgery : in 6 cases treatment consisted of neuroma resection and nerve repair by means of a graft. In 3 patients it was performed only a CPN decompression at the fibular neck. Since 1991, surgical treatment has always consisted of nerve repair associated with a tendon transfer during the same procedure. Fifty-three patients were elected for surgery. Nerve repair was achieved by direct suture in 1 case and by means of a graft in 46 patients. Decompression of the CPN at the fibular neck was performed in 6 patients where nerve continuity was demonstrated. RESULTS: In the first group of patients, nerve repair outcome was highly disapponting: no recovery in 5 cases, reinnervation occurred in 1 patient only (M1-2). CPN decompression was followed by complete recovery in 2 cases, no improvement was observed in 1 case. Nerve repair associated with tibialis tendon transfer dramatically improved the postoperative outcome: at 2 year follow-up, neural regeneration was demonstrated in 90% of the patients. Surgical outcome depends on the causative mechanisms of the lesion: sharp injuries and severe dislocations of the knee had an excellent recovery, while in crush injuries and gunshot wounds good recovery was less common. CONCLUSION: Surgical treatment of CPN injuries can nowadays be highly rewarding. CPN palsies in open wounds should undergo surgical exploration at emergency. In close injuries with no spontaneous recovery within 4 months after the injury, patients should be advised to seek surgical treatment regardless the causative mechanism of the lesion. According to our experience, the association of a transfer procedure to nerve repair enhances neural regeneration, dramatically improving the surgical outcome of these injuries.     

Contralateral motor rootlets and ipsilateral nerve transfers in brachial plexus reconstruction

OBJECT: The goal of this study was to evaluate outcomes in patients with brachial plexus avulsion injuries who underwent contralateral motor rootlet and ipsilateral nerve transfers to reconstruct shoulder abduction/external rotation and elbow flexion. METHODS: Within 6 months after the injury, 24 patients with a mean age of 21 years underwent surgery in which the contralateral C-7 motor rootlet was transferred to the suprascapular nerve by using sural nerve grafts. The biceps motor branch or the musculocutaneous nerve was repaired either by an ulnar nerve fascicular transfer or by transfer of the 11th cranial nerve or the phrenic nerve. The mean recovery in abduction was 90 degrees and 92 degrees in external rotation. In cases of total palsy, only two patients recovered external rotation and in those cases mean external rotation was 70 degrees. Elbow flexion was achieved in all cases. In cases of ulnar nerve transfer, the muscle scores were M5 in one patient, M4 in six patients, and M3+ in five patients. Elbow flexion repair involving the use of the 11th cranial nerve resulted in a score of M3+ in five patients and M4 in two patients. After surgery involving the phrenic nerve, two patients received a score of M3 + and two a score of M4. Results were clearly better in patients with partial lesions and in those who were shorter than 170 cm (p < 0.01). The length of the graft used in motor rootlet transfers affected only the recovery of external rotation. There was no permanent injury at the donor sites. CONCLUSIONS: Motor rootlet transfer represents a reliable and potent neurotizer that allows the reconstruction of abduction and external rotation in partial injuries.     

Functional results after posterior interosseous nerve microsurgical repair

Background

The posterior interosseous nerve is one of the terminal branches of the radial nerve, and its motor function is very important for finger extension. Its repair success can be ascertained by the recovery of this motor function. Early surgical exploration is advocated in open injuries, and there is still some controversy regarding the appropriate approach in closed injuries. Tendon transfer is only performed in neglected cases and in cases with poor functional outcome after nerve repair.

Patients and methods

Consent was taken from 23 patients suffering from posterior interosseous nerve injury from January 2005 to December 2012. Eighteen patients had undergone end-to-end repair of the posterior interosseous nerve by epineurial repair, and five patients were treated by sural nerve graft using an operating microscope.

Results

There were 19 males and 4 females. The mean age was 25 years old with a range of 16–45 years; there were 16 injuries on the right side and 7 on the left side. The mean follow-up period was 12 months with range from 10 to 36 months. All patients had satisfactory results except for two cases that necessitated tendon transfer surgery. In 21 of the 23 patients, the British Medical Research Council (BMRC) metacarpophalangeal joint (MCP) extension power was measured at M4–M5. The thumb opening angle was measured between 55° and 70° in 19 patients. According to the modified Verga classification scores, there were 19 excellent cases, 2 good and 2 poor results. The primarily repaired posterior interosseous nerve (PIN) injuries had better muscle recovery than the grafted nerves.

Conclusions

The posterior interosseous nerve repairs, if done using end-to-end anastomosis or a nerve graft and with the appropriate technique, may result to nearly full recovery in young patients. Nerve repair is suggested until the 6th month after the injury using end-to-end anastomosis or grafting methods.

Level of clinical evidence

Level 4, case series study     

Surgical outcomes following nerve transfers in upper brachial plexus injuries

Background:

Brachial plexus injuries represent devastating injuries with a poor prognosis. Neurolysis, nerve repair, nerve grafts, nerve transfer, functioning free-muscle transfer and pedicle muscle transfer are the main surgical procedures for treating these injuries. Among these, nerve transfer or neurotization is mainly indicated in root avulsion injury.

Materials and Methods:

We analysed the results of various neurotization techniques in 20 patients (age group 20-41 years, mean 25.7 years) in terms of denervation time, recovery time and functional results. The inclusion criteria for the study included irreparable injuries to the upper roots of brachial plexus (C5, C6 and C7 roots in various combinations), surgery within 10 months of injury and a minimum follow-up period of 18 months. The average denervation period was 4.2 months. Shoulder functions were restored by transfer of spinal accessory nerve to suprascapular nerve (19 patients), and phrenic nerve to suprascapular nerve (1 patient). In 11 patients, axillary nerve was also neurotized using different donors - radial nerve branch to the long head triceps (7 patients), intercostal nerves (2 patients), and phrenic nerve with nerve graft (2 patients). Elbow flexion was restored by transfer of ulnar nerve motor fascicle to the motor branch of biceps (4 patients), both ulnar and median nerve motor fascicles to the biceps and brachialis motor nerves (10 patients), spinal accessory nerve to musculocutaneous nerve with an intervening sural nerve graft (1 patient), intercostal nerves (3rd, 4th and 5th) to musculocutaneous nerve (4 patients) and phrenic nerve to musculocutaneous nerve with an intervening graft (1 patient).

Results:

Motor and sensory recovery was assessed according to Medical Research Council (MRC) Scoring system. In shoulder abduction, five patients scored M4 and three patients M3+. Fair results were obtained in remaining 12 patients. The achieved abduction averaged 95 degrees (range, 50 - 170 degrees). Eight patients scored M4 power in elbow flexion and assessed as excellent results. Good results (M3+) were obtained in seven patients. Five patients had fair results (M2+ to M3).     

儿童习惯性髌骨脱位的手术治疗

目的 探讨治疗儿童习惯性髌骨脱位的手术方法。方法 习惯性髌骨脱位患者３６例,平均年龄９．１岁;采用复合性软组织手术的方法对其中４５个髌骨脱位进行治疗;手术方法包括膝外侧软组织广泛松解,股外侧肌止点上移,膝内仙软组织紧缩,股内侧肌移位和半侧髌腱内移术;平均随访时间４年４个月。结果 ２８例患者获得满意的功能和稳定的膝关节。运动能力明显提高;７例随访时间４年４个月。结果 ２８例患者获得满意的功能和稳定的膝关节。运动能力明显提高;７例患者虽然对膝关节功能很满意,但在进行剧烈体育运动时手术侧膝关节有力弱感,与术前相比改善不明显;１例患者术后发生再脱位,所有患者均无伤口感染和膝关节活动受限。结论 采用复合性软组织手术的方法治疗儿童习惯性髌骨脱位患者,不损伤骨骺,易于操作,可取得明显疗效。     

儿童桡神经损伤78例分析

目的讨论儿童桡神经损伤的临床特点和治疗方法。方法对７８例儿童桡神经损伤的临床资料进行总结和分析。伤因：６６例为上肢骨折或脱位时合并神经损伤，其中肱骨下段骨折７例，肱骨髁上骨折３７例，孟氏骨折或单纯桡骨头脱位１８例，尺骨和／或桡骨骨折４例。１２例为单纯神经损伤。采用手法复位、石膏固定或牵引１８例，神经松解术３８例，神经吻合术２０例，肌腱转移功能重建术２例。结果４２例随访２个月～２６年，平均４年２个月。用Ｈｉｇｈｅｔ运动评定法评定，疗效为优者３４例，优良率达８１％。伤后３个月内治疗者优良率占９６．５％，明显优于伤后６个月处理者的５０％。结论儿童上肢骨折脱位易合并桡神经损伤，对开放性骨折合并桡神经损伤者应尽快手术治疗。闭合性损伤在保守治疗１～３个月后功能无恢复时应考虑手术治疗     

Axillary nerve repair by triceps motor branch transfer through an axillary access: anatomical basis and clinical results

OBJECT: Grafting or nerve transfers to the axillary nerve have been performed using a deltopectoral approach and/or a posterior arm approach. In this report, the surgical anatomy of the axillary nerve was studied with the goal of repairing the nerve through an axillary access. METHODS: The axillary nerve was bilaterally dissected in 10 embalmed cadavers to study its variations. Three patients with axillary nerve injuries then underwent surgical repair through an axillary access; the axillary nerve was repaired by transfer of the triceps long head motor branch. RESULTS: At the lateral margin of the subscapularis muscle, the axillary nerve was found in the center of a triangle bounded medially by the subscapular artery, laterally by the latissimus dorsi tendon, and cephalad by the posterior circumflex humeral artery. At the entrance of the quadrangular space, the axillary nerve divisions were loosely connected to each other, and could be clearly separated and correctly identified. Surgery for the axillary nerve repair through the axillary access was straightforward. Eighteen months after surgery, all three patients had recovered deltoid strength to a score of M4 on the Medical Research Council scale and had improved abduction strength by 50%. No deficit was evident in elbow extension. CONCLUSIONS: The axillary nerve and its branches can be safely dissected and repaired by triceps motor nerve transfer through an axillary access.     

Reconstruction of the Achilles tendon region by free microvascular flaps. 9 cases followed for 1-9 years.

In 1981-89, 9 patients underwent reconstruction for complex injuries in the Achilles tendon region. 10 free microvascular flaps were used: 5 fasciocutaneous and 5 muscle or musculocutaneous flaps. In addition, 4 Achilles tendons and 1 tibial posterior nerve were reconstructed, 1 femoropopliteal bypass was performed, and 6 tibial fractures were treated. The patients were re-examined on an average 3.5 years after the reconstruction. The stability of soft tissues was good in all patients. Good contour was achieved in superficial defects with fasciocutaneous and in deep injuries with latissimus dorsi free flaps. The calcaneal tendon function was good in 5, fair in 2 and poor in 2 patients, depending on the severity of the underlying skeletal injury. We conclude that free microvascular transfer offers one-stage reconstruction of complex, infected wounds in the Achilles tendon region, promotes fracture healing, and allows simultaneous tendon or nerve repair.     

不可逆桡神经损伤的手功能重建

目的评估不可逆桡神经损伤后肌腱移位重建伸腕、伸拇及伸指功能的效果。方法1987年1月～2005年2月，用Riordan肌腱移位术治疗不可逆桡神经损伤25例。其中桡神经主干损伤19例，桡神经深支损伤6例；均伴伸拇及伸指功能障碍，肌力0～1级，前臂肌萎缩。肌腱移位术距神经损伤或修复时间为4个月～8年。结果术后23例经3～60个月随访，根据陈德松等制定的桡神经损伤后肌腱移位术疗效判定标准，优10例，良9例，手功能恢复基本满意；可2例，差2例，其中1例为移位肌腱张力不足，3例为移位肌腱粘连所致。结论Riordan肌腱移位术可作为不可逆桡神经损伤功能重建的首选方法。     

Brachial plexus reconstruction based on the new definition of level of injury

SUMMARY: Although brachial plexus reconstruction remains a challenge to microsurgeons, especially when attempting to reconstruct cases with total root avulsion, much improvement in results has been recently achieved by a better understanding of various new methods of reconstruction, such as nerve transfer, functioning free muscle transplantation and prolonged postoperative rehabilitation. To better understand these improved results, we classified our patients into four levels of injury: (1) preganglionic root; (2) postganglionic spinal nerve; (3) pre- and retro-clavicular; (4) infraclavicular brachial plexus injury. Nerve transfer, functioning free muscle transplantation or local muscle transfer are the only possible solutions for the level 1 injury. Nerve transfers include extraplexus, intraplexus, close-target and end-to-side neurotisation. Neurolysis, nerve repair, nerve grafts, C-loop vascularised ulnar nerve grafts, nerve transfer and functioning free muscle transplantation are options for levels 2, 3 and 4 injuries. Tendon transfer, functioning or functional muscle transfer, arthrodesis or orthotics can be used for late palliative reconstruction. Taken together, these options can make brachial plexus surgery a worthy pursuit and make a useless limb useful.     

Transfer of the accessory nerve to the suprascapular nerve in brachial plexus reconstruction

PURPOSE: Transfer of the accessory nerve to the suprascapular nerve is a common procedure, performed to reestablish shoulder motion in patients with brachial plexus palsy. We propose dissecting both nerves via a distal oblique supraclavicular incision, which can be prolonged up to the scapular notch. The results of the transfer to the suprascapular nerve are compared with those of the combined repair of the suprascapular and axillary nerves. METHODS: Thirty men between the ages of 18 and 37 years with brachial plexus trauma had reparative surgery within 3 to 10 months of their injuries. In partial injuries with a normal triceps, a triceps motor branch transfer to the axillary nerve was performed. The suprascapular and accessory nerves were dissected via an oblique incision, extending from the point at which the plexus crosses the clavicle to the anterior border of the trapezius muscle. In 10 patients with fractures or dislocations of the clavicle, the trapezius muscle was partially elevated to expose the suprascapular nerve at the suprascapular notch. RESULTS: In all cases, transfer of the accessory to the suprascapular nerve was performed without the need for nerve grafts. A double lesion of the suprascapular nerve was identified in 1 patient with clavicular dislocation. In those with total palsy, the average improvement in range of abduction was 45 degrees , but none of the patients with total palsy recovered any active external rotation. Patients with upper-type injury recovered an average of 105 degrees of abduction and external rotation. If only patients with C5-C6 injuries were considered, the range of abduction and external rotation increased to 122 degrees and 118 degrees , respectively. CONCLUSIONS: Use of the accessory nerve for transfer to the suprascapular nerve ensured adequate return of shoulder function, especially when combined with a triceps motor branch transfer to the axillary nerve. The supraclavicular exposure proposed here for the suprascapular and accessory nerves is advantageous and can be extended easily to explore the suprascapular nerve at the scapular notch.     

Posterolateral dislocation of the knee joints:analysis of 9 cases

Posterolateraldislocationofthekneejointisrare .Till 1981,only 2 7caseswerereportedinEnglishliteratures1andnocaseswerereportedafterwards.2 ,3Thiskindofinjuryislikelymisdiagnosedasligamentdisruptionorirreducibledislocationdueto”buttonholing”ofthe jointmedially4 (Fig .1 1)Between 1979and 2 0 0 19casesofposterolateraldislocationofkneejointsweretreatedinourhospital.The pathologicalcharacteristics ,complicationsandtreatmentareanalyzedanddescribedinthispaper .Fig .1 1.Buttonholingoffemoralmedialc…     

Reconstruction of the Achilles tendon region by free microvascular flaps 9

In 1981–89, 9 patients underwent reconstruction for complex injuries in the Achilles tendon region. 10 free microvascular flaps were used: 5 fasciocutaneous and 5 muscle or musculocutaneous flaps. In addition, 4 Achilles tendons and 1 tibial posterior nerve were reconstructed, 1 femoropopiiteal bypass was performed, and 6 tibial fractures were treated. The patients were re–examined on an average 3.5 years after the reconstruction. The stability of soft tissues was good in all patients. Good contour was achieved in superficial defects with fasciocutaneous and in deep injuries with latissimus dorsi free flaps. The calcaneal tendon function was good in 5, fair in 2 and poor in 2 patients, depending on the severity of the underlying skeletal injury.

We conclude that free microvascular transfer offers one–stage reconstruction of complex, infected wounds in the Achilles tendon region, promotes fracture healing, and allows simultaneous tendon or nerve repair.     

Posterolateral dislocation of the knee joints：analysis of 9 case

Objective:To analyze the rtraumatie pathologieal characteristics of posterolateral dislocation of knee joins and its treatment.Methods:Mine cases of posterolateral dislocation of knee joint,5 cases of fresh injuries(the fresh injury group)and 4 cases of old injuries (the old injury group)were reviewed and analyzed.In the fresh injury group 4 cases failed in close reduction due to “buttonholing”through the medial joint,among them 3 case underwent repair of the damaged ligantents.In the old injury group 2 cases underwant ACL and MCL repair only in acuts stage,but re-dislocated.Of the rest 2 case 1 was associated with peroneal nerve injury and the other was not treated of the tibiul condyle and popllteal artery injury.Open reduction was performed in 3 enses.One case was fixed with 2-crossed pin and another was fixed with one pin through the tibial and femoral condyle and second pin with olecranization fixation.Plester immobilization for 6.8 weeks respectively was required.In the old injury group in 1 case ACL and PCL repair(Augustine method) and posterolateral structure were performed and olecranization fixation and plaster immobilization for 6 weeks was needed.Arthrodesis of the knee was done for the patient with comminuted fracture of the tibial condyte and popliteal artery injury.Results:All the cases were followed up for 1-23 years(average 6 years).Knee stabllity in 4 cases with repair of the ligaments was improved,although PDT showed ( ) with different was improved,although the patients treated with ligamentous reconstruction were much better than those of the patients without any repair. Conclusions:Well understanding of the tranmatic pathological characteristics,repair of the damaged postoperative immobilization for 6 weeks are the key points of successful treatment.     

Treatment approach to isolated common peroneal nerve palsy by mechanism of injury: Systematic review and meta-analysis of individual participants’ data

BackgroundWe reviewed the individual participant data of patients who sustained isolated common peroneal nerve (CPN) injuries resulting in foot drop. Functional results were compared between eight interventions for CPN palsies to determine step-wise treatment approaches for the underlying mechanisms of nerve injury.MethodsPubMed, Embase, Cochrane Library, Web of Science, Scopus, and CINAHL databases were searched. PRISMA-IPD and Cochrane guidelines were followed in the data search. Eligible patients sustained isolated CPN injuries resulting in their foot drop. Patients were stratified by mechanisms of nerve injury, ages, duration of motor symptoms, and nerve defect/zone of injury sizes, and were compared by functional results (poor = 0, fair = 1, good = 2, excellent = 3), using meta-regression between interventions. Interventions evaluated were primary neurorrhaphy, neurolysis, nerve grafts, partial nerve transfer, neuromusculotendinous transfer, tendon transfer, ankle-foot orthosis (AFO), and arthrodesis.ResultsOne hundred and forty-four studies included 1284 patients published from 1985 through 2020. Transection/Cut: Excellent functional results following tendon transfer (OR: 126, 95%CI: 6.9, 2279.7, p=0.001), compared to AFO. Rupture/Avulsion: Excellent functional results following tendon transfer (OR: 73985359, 95%CI: 73985359, 73985359, p<0.001), nerve graft (OR: 4465917, 95%CI: 1288542, 15478276, p<0.001), and neuromusculotendinous transfer (OR: 42277348, 95%CI: 3001397, 595514030, p<0.001), compared to AFO. Traction/Stretch: Good functional results following tendon transfer (OR: 4.1, 95%CI: 1.17, 14.38, p=0.028), compared to AFO. Entrapment: Excellent functional results following neurolysis (OR: 4.6, 95%CI: 1.3, 16.6, p=0.019), compared to AFO.ConclusionsFunctional results may be optimized for treatments by the mechanism of nerve injury. Transection/Cut and Traction/Stretch had the best functional results following tendon transfer. Rupture/Avulsion had the best functional results following tendon transfer, nerve graft, or neuromusculotendinous transfer. Entrapment had the best functional results following neurolysis.     

Therapiestandards nach Beugesehnen- und Nervenverletzungen der Hand

Background

There is little evidence for the ideal aftercare of combined nerve and flexor tendon injuries of the hand. The aim of this study was to elicit whether concomitant nerve injuries are changing the individual treatment plans after flexor tendon repair in a survey of German centres for hand surgery.

Methods

A questionnaire about aftercare of isolated and combined nerve and flexor tendon injuries of the hand was distributed to members of three German Societies of hand, trauma and plastic surgery.

Results

Isolated flexor tendon injuries in zones II to IV are treated by early mobilization in all centres, whereas isolated digital nerve repair is usually followed by immobilization (10% no immobilization, 22.5% up to 1 week, 52.5% for 2 weeks and 15% for 3 weeks). The duration of immobilization increases with lesions of the median or ulnar nerves by about 1 week. In 55% of cases concomitant nerve injury does not influence the early onset of dynamic splinting and mobilization after flexor tendon injuries.

Conclusion

There seem to be no uniform treatment guidelines for flexor tendon repair if concomitant nerve injury is present. Against the background of the current literature early controlled mobilization after tendon and nerve repair seems to be justified.