A. Lee Dellon and Susan E. Mackinnon
RESULTS OF POSTERIOR TIBIAL NERVE GRAFTING AT THE ANKLE ABSTRACT
The results of lower extremity nerve repair and grafting have been recently reviewed.1 There has not been a report of microsurgical interposition interfascicular nerve grafting, by Millesi's technique,2"3 to the posterior tibial nerve. Isolated case reports or small series of nerve grafts to the more proximal posterior tibial nerve4-9 have uniformly indicated recovery of at least protective sensation to the sole of the foot, but have revealed some postoperative "hyperesthesia" that has sounded a note of caution. 510 Injury to the posterior tibial nerve is associated with significant patient morbidity. Sensory loss to the weight-bearing sole of the foot will predictably result in ulceration and eventual amputation. In some patients, in continuity injuries to this nerve are associated with pain severe enough for the patient to request amputation of the foot. When injury to the posterior tibial nerve at the ankle results in pain that can no longer be managed by local physiotherapy modalities, such as desensitization or steroid iontophoresis, the resulting chronic pain may lead to narcotic abuse, impaired ambulation, loss of work, and a request by the patient for amputation of the extremity. Neurosurgical options have been reviewed recently11—implantable neurostimulators, intrathecal opiate infusion, sympathectomy, neurectomy, dorsal rhizotomy and
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The results of interfascicular interposition nerve grafting for posterior tibial nerve deficit at the ankle are reported for eight patients. The sural nerve was the donor nerve in all cases. Mean age at injury was 36.3 years (range 22 to 50 years). Mean postoperative follow-up is 5.0 years (range 2.25 to 8.0 years). In five of the patients, the primary indication for nerve grafting was pain or numbness in degree sufficient to consider amputation. Mean graft length was 9.8 cm (range 4 to 18 cm). After grafting, all eight patients ambulate without assistive devices and are productively employed or have resumed pre-injury household activities. All patients received postoperative sensory re-education. Sensory recovery has been to S4 level in two, to S3+ in four, and to S3 in two. There have been no foot ulcerations. It is concluded that grafting the posterior tibial nerve is indicated for the treatment of pain and recovery of sensation in carefully selected patients, and is capable of predictably restoring at least some touch sensibility.
"various neurolyses and neural repair procedures." The present report gives our long-term experience with distal posterior tibial nerve grafting, emphasizing its indications in the treatment of post-traumatic painful neuropathy.
METHODS AND MATERIALS PATIENT POPULATION.
Between October 1981 and
January of 1988, eight patients were operated on for defects in the distal posterior tibial nerve. There were three women and five men. Their mean age was 36.3 years (range 22 to 50 years). Cause for the nerve deficit was trauma in seven patients and tumor in one patient. Trauma was due to a fall with ankle fracture in three, laceration with soft tissue loss in one, glass laceration in one, chain saw injury in one, and gunshot wound in one. One patient suffered an iatrogenic injury to the posterior tibial nerve when a benign Schwannoma was excised. One patient was a Type I diabetic. Six patients had had at least one operative procedure prior to the nerve grafting. Two patients had four, and three patients had two operative procedures prior to nerve grafting. These operations included tarsal
Divisions of Plastic Surgery and Department of Neurological Surgery, lohns Hopkins University, Baltimore, Maryland, and Division of Plastic Surgery, University of Toronto, Toronto General Hospital, Toronto, Canada Reprint requests: Dr. Dellon, Suite 104, 3901 Greenspring Ave., Baltimore, MD 21211 Accepted for publication January 7,1991 Copyright© 1991 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 7, NUMBER 2
tunnel releases in four patients, single or multiple neurolyses in four patients, lumbar sympathectomy in two patients, and nerve repair in one patient. SURGICAL PROCEDURE. The nerve injury in the patients whose primary complaint was pain was an in continuity nerve injury while in the remaining patients, the initial injury resulted in a nerve deficit. The nerve deficit at the time of nerve grafting was a mean of 9.8 cm (4 to 18 cm range). From two to four interposition interfascicular sural nerve grafts were placed, depending upon the nerve gap and the availability of distal branches. Where possible, grafts were placed to the medial and to the lateral plantar nerves, as well as to the calcaneal nerve. In the patient with the tumor excision, grafts were required only to the medial plantar nerve. Millesi's nerve grafting technique was used.2-3
APRIL 1991
All eight patients ambulated without assistance and without assistive devices. All patients wore normal shoes. No patient had hyperpathia or dysesthesia. All five patients who had preoperative pain severe enough to request extremity amputation were pain-free. All patients had perception of hot, cold, and pain. All patients could localize a moving-touch stimulus correctly to the big toe. Two patients had recovered static two-point discrimination (s2PD) of 8 mm (S4), four patients had recovered s2PD between 9 and 15 mm (S3 + ), and two patients had no s2PD. (One of these was the poorly controlled diabetic.) No patient had foot ulcerations (Figs. 1, 2).
RESULTS The patients were evaluated postoperatively at a mean of 5.0 years (range 2.25 to 8.0 years).
82
The results of this clinical study demonstrate that microsurgical interfascicular interposition nerve grafting of the posterior tibial nerve at the ankle level can reliably relieve post-traumatic neuropathic pain and restore better than just "protective" sensation to the
Figure 1. This 41-year-old man received a laceration to the leg, resulting in division of the posterior tibial nerve which was repaired primarily. One year later, because of pain and failure of an advancing Tinel's sign, the nerve was explored and neurolysed. After two years of progressive pain, the patient requested amputation of his foot. A, At exploration in April of 1984, he had an in continuity neuroma densely adherent to all surrounding structures. B, Deficit after neuroma excision. C, Four interposition interfascicular sural nerve grafts of 8 cm in length were placed D, more than six years later, the patient ambulates without pain, without assistive devices, and has made an S4 level of sensory recovery.
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DISCUSSION
POSTERIOR TIBIAL NERVE GRAFTING/DELLON, MACKINNON
ously reported.12 A vascularized nerve graft would provide another alternative to extra-anatomic routing.13 It is concluded that, for carefully chosen patients, microneurosurgical grafting into the distal lower extremities is indicated.
REFERENCES 1. Mackinnon SE, Dellon AL, Surgery of the Peripheral Nerve, NY: Thieme Medical Publishers, 1988, chap 4 2. Millesi H: Microsurgery of peripheral nerves, Hand 5:157, 1973 3. Millesi H: The nerve gap: Theory and practice. HandClin 2:651,
Figure 2. A 36-year-old man sustained ankle fracture after a fall. He subsequently had a tarsal tunnel release, then a posterior tibial neurolysis. Because of continuing persisting pain, he subsequently had a lumbar sympathectomy. For persistent pain, his posterior tibial nerve was divided and implanted into the tibia, but his pain persisted. Four years after nerve grafting, he now ambulates without pain.
1987
4.
Bateman JE: Trauma to Nerves in Limbs, Philadelphia: WB Saunders, 1962 5. Seddon HI: Surgical Disorders of the Peripheral Nerve, Baltimore: Williams & Wilkins, 1972 6. Kline DG: Operative management of major nerve lesions of the lower extremity. Surg Clin N Amer 52:1247, 1982 7. Aldea PA, Shaw WW: Lower extremity nerve injuries. Clin Plast Surg 13:691, 1986
sole of the foot. Considering the age of the patients, the length of the nerve deficit, the long interval between nerve injury and nerve grafting in this series of patients, the results achieved are comparable to those possible in the upper extremity.1 In three patients, the soft tissue was sufficiently injured and the medial malleolar region so scarred that an extra-anatomic route was chosen for placement of the nerve grafts. One of these patients has been previ-
Millesi H: Lower extremity nerve lesions. In Terzis JK (ed): Microreconstruction of Nerve Injuries, Philadelphia: WB Saunders, 1987, chap 19 9. Sedel L: Surgical management of lower extremity nerve lesions. In Terzis JK (ed): Microreconstruction of Nerve Injuries. Philadelphia: WB Saunders, 1987, chap 20 10 Kline DG, Kahn EA: The surgery of peripheral nerve injuries. In Schneider RC, Kahn EA (eds): Correlative Neurosurgery, 3rd ed, Vol I, Springfield, IL: CC Thomas, 1982, p 506 11. Tasker RR: Management of nociceptive, deafferentation and central pain by surgical intervention. In HL Fields (ed): Pain Syndromes in Neurology-. London: Butterworths, 1990, chap 7 12. Mackinnon SE, Dellon AL, Daneshvar A: Tarsal tunnel syndrome: Histopathologic examination of a human posterior tibial nerve. Contemp Orthoped 9:43, 1984 13. Breidenbach W, Terzis |K: The anatomy of free vascularized nerve grafts. Clin Plast Surg 11:65, 1984
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RESULTS OF POSTERIOR TIBIAL NERVE GRAFTING AT THE ANKLE ABSTRACT
The results of lower extremity nerve repair and grafting have been recently reviewed.1 There has not been a report of microsurgical interposition interfascicular nerve grafting, by Millesi's technique,2"3 to the posterior tibial nerve. Isolated case reports or small series of nerve grafts to the more proximal posterior tibial nerve4-9 have uniformly indicated recovery of at least protective sensation to the sole of the foot, but have revealed some postoperative "hyperesthesia" that has sounded a note of caution. 510 Injury to the posterior tibial nerve is associated with significant patient morbidity. Sensory loss to the weight-bearing sole of the foot will predictably result in ulceration and eventual amputation. In some patients, in continuity injuries to this nerve are associated with pain severe enough for the patient to request amputation of the foot. When injury to the posterior tibial nerve at the ankle results in pain that can no longer be managed by local physiotherapy modalities, such as desensitization or steroid iontophoresis, the resulting chronic pain may lead to narcotic abuse, impaired ambulation, loss of work, and a request by the patient for amputation of the extremity. Neurosurgical options have been reviewed recently11—implantable neurostimulators, intrathecal opiate infusion, sympathectomy, neurectomy, dorsal rhizotomy and
Downloaded by: NYU. Copyrighted material.
The results of interfascicular interposition nerve grafting for posterior tibial nerve deficit at the ankle are reported for eight patients. The sural nerve was the donor nerve in all cases. Mean age at injury was 36.3 years (range 22 to 50 years). Mean postoperative follow-up is 5.0 years (range 2.25 to 8.0 years). In five of the patients, the primary indication for nerve grafting was pain or numbness in degree sufficient to consider amputation. Mean graft length was 9.8 cm (range 4 to 18 cm). After grafting, all eight patients ambulate without assistive devices and are productively employed or have resumed pre-injury household activities. All patients received postoperative sensory re-education. Sensory recovery has been to S4 level in two, to S3+ in four, and to S3 in two. There have been no foot ulcerations. It is concluded that grafting the posterior tibial nerve is indicated for the treatment of pain and recovery of sensation in carefully selected patients, and is capable of predictably restoring at least some touch sensibility.
"various neurolyses and neural repair procedures." The present report gives our long-term experience with distal posterior tibial nerve grafting, emphasizing its indications in the treatment of post-traumatic painful neuropathy.
METHODS AND MATERIALS PATIENT POPULATION.
Between October 1981 and
January of 1988, eight patients were operated on for defects in the distal posterior tibial nerve. There were three women and five men. Their mean age was 36.3 years (range 22 to 50 years). Cause for the nerve deficit was trauma in seven patients and tumor in one patient. Trauma was due to a fall with ankle fracture in three, laceration with soft tissue loss in one, glass laceration in one, chain saw injury in one, and gunshot wound in one. One patient suffered an iatrogenic injury to the posterior tibial nerve when a benign Schwannoma was excised. One patient was a Type I diabetic. Six patients had had at least one operative procedure prior to the nerve grafting. Two patients had four, and three patients had two operative procedures prior to nerve grafting. These operations included tarsal
Divisions of Plastic Surgery and Department of Neurological Surgery, lohns Hopkins University, Baltimore, Maryland, and Division of Plastic Surgery, University of Toronto, Toronto General Hospital, Toronto, Canada Reprint requests: Dr. Dellon, Suite 104, 3901 Greenspring Ave., Baltimore, MD 21211 Accepted for publication January 7,1991 Copyright© 1991 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
81
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 7, NUMBER 2
tunnel releases in four patients, single or multiple neurolyses in four patients, lumbar sympathectomy in two patients, and nerve repair in one patient. SURGICAL PROCEDURE. The nerve injury in the patients whose primary complaint was pain was an in continuity nerve injury while in the remaining patients, the initial injury resulted in a nerve deficit. The nerve deficit at the time of nerve grafting was a mean of 9.8 cm (4 to 18 cm range). From two to four interposition interfascicular sural nerve grafts were placed, depending upon the nerve gap and the availability of distal branches. Where possible, grafts were placed to the medial and to the lateral plantar nerves, as well as to the calcaneal nerve. In the patient with the tumor excision, grafts were required only to the medial plantar nerve. Millesi's nerve grafting technique was used.2-3
APRIL 1991
All eight patients ambulated without assistance and without assistive devices. All patients wore normal shoes. No patient had hyperpathia or dysesthesia. All five patients who had preoperative pain severe enough to request extremity amputation were pain-free. All patients had perception of hot, cold, and pain. All patients could localize a moving-touch stimulus correctly to the big toe. Two patients had recovered static two-point discrimination (s2PD) of 8 mm (S4), four patients had recovered s2PD between 9 and 15 mm (S3 + ), and two patients had no s2PD. (One of these was the poorly controlled diabetic.) No patient had foot ulcerations (Figs. 1, 2).
RESULTS The patients were evaluated postoperatively at a mean of 5.0 years (range 2.25 to 8.0 years).
82
The results of this clinical study demonstrate that microsurgical interfascicular interposition nerve grafting of the posterior tibial nerve at the ankle level can reliably relieve post-traumatic neuropathic pain and restore better than just "protective" sensation to the
Figure 1. This 41-year-old man received a laceration to the leg, resulting in division of the posterior tibial nerve which was repaired primarily. One year later, because of pain and failure of an advancing Tinel's sign, the nerve was explored and neurolysed. After two years of progressive pain, the patient requested amputation of his foot. A, At exploration in April of 1984, he had an in continuity neuroma densely adherent to all surrounding structures. B, Deficit after neuroma excision. C, Four interposition interfascicular sural nerve grafts of 8 cm in length were placed D, more than six years later, the patient ambulates without pain, without assistive devices, and has made an S4 level of sensory recovery.
Downloaded by: NYU. Copyrighted material.
DISCUSSION
POSTERIOR TIBIAL NERVE GRAFTING/DELLON, MACKINNON
ously reported.12 A vascularized nerve graft would provide another alternative to extra-anatomic routing.13 It is concluded that, for carefully chosen patients, microneurosurgical grafting into the distal lower extremities is indicated.
REFERENCES 1. Mackinnon SE, Dellon AL, Surgery of the Peripheral Nerve, NY: Thieme Medical Publishers, 1988, chap 4 2. Millesi H: Microsurgery of peripheral nerves, Hand 5:157, 1973 3. Millesi H: The nerve gap: Theory and practice. HandClin 2:651,
Figure 2. A 36-year-old man sustained ankle fracture after a fall. He subsequently had a tarsal tunnel release, then a posterior tibial neurolysis. Because of continuing persisting pain, he subsequently had a lumbar sympathectomy. For persistent pain, his posterior tibial nerve was divided and implanted into the tibia, but his pain persisted. Four years after nerve grafting, he now ambulates without pain.
1987
4.
Bateman JE: Trauma to Nerves in Limbs, Philadelphia: WB Saunders, 1962 5. Seddon HI: Surgical Disorders of the Peripheral Nerve, Baltimore: Williams & Wilkins, 1972 6. Kline DG: Operative management of major nerve lesions of the lower extremity. Surg Clin N Amer 52:1247, 1982 7. Aldea PA, Shaw WW: Lower extremity nerve injuries. Clin Plast Surg 13:691, 1986
sole of the foot. Considering the age of the patients, the length of the nerve deficit, the long interval between nerve injury and nerve grafting in this series of patients, the results achieved are comparable to those possible in the upper extremity.1 In three patients, the soft tissue was sufficiently injured and the medial malleolar region so scarred that an extra-anatomic route was chosen for placement of the nerve grafts. One of these patients has been previ-
Millesi H: Lower extremity nerve lesions. In Terzis JK (ed): Microreconstruction of Nerve Injuries, Philadelphia: WB Saunders, 1987, chap 19 9. Sedel L: Surgical management of lower extremity nerve lesions. In Terzis JK (ed): Microreconstruction of Nerve Injuries. Philadelphia: WB Saunders, 1987, chap 20 10 Kline DG, Kahn EA: The surgery of peripheral nerve injuries. In Schneider RC, Kahn EA (eds): Correlative Neurosurgery, 3rd ed, Vol I, Springfield, IL: CC Thomas, 1982, p 506 11. Tasker RR: Management of nociceptive, deafferentation and central pain by surgical intervention. In HL Fields (ed): Pain Syndromes in Neurology-. London: Butterworths, 1990, chap 7 12. Mackinnon SE, Dellon AL, Daneshvar A: Tarsal tunnel syndrome: Histopathologic examination of a human posterior tibial nerve. Contemp Orthoped 9:43, 1984 13. Breidenbach W, Terzis |K: The anatomy of free vascularized nerve grafts. Clin Plast Surg 11:65, 1984
Downloaded by: NYU. Copyrighted material.
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