Nerve Transfers in the Lower Extremity

Abstract

The utilization of nerve transfer procedures in the upper extremity following brachial plexus injury, trauma, spinal cord injury, tumors, infection, or other etiologies are well established. Nerve injuries in the lower extremity pose several additional challenges, including longer distance to target motor end plates, delayed presentation, and concomitant limb trauma. Nerve transfers in the lower extremity have the potential to provide functional (sensory or motor) recovery distally after direct surgical coaptation of a functional donor nerve to a non-functional recipient nerve. The ability to perform pure motor or sensory fascicular transfers allows for focused recovery while limiting donor morbidity. Indications for nerve transfers in the lower extremity are evolving, but transfers have been utilized for non-recovering peroneal, obturator, femoral, or tibial nerve palsies, to provide protective sensation to the plantar aspect of the foot as well as for painful neuropathies/neuromas. There is a paucity of orthopaedic literature on this topic and our review aims to highlight the current state of lower extremity nerve transfers as they relate to the practicing orthopaedist, including future directions in the field.

Key concepts: •Nerve transfers have been well-established as a treatment option for nerve injuries of the upper extremity and brachial plexus, but their use in the lower extremities is less common.•Nerve transfers may be of particular interest in the lower extremity because of the ability to cover relatively long distances as well as avoid the zone of injury, especially in far proximal injuries.•Nerve transfers of the lower extremity have been used to address motor deficit of the peroneal, femoral, obturator, and tibial nerves, as well as tibial and sural nerve sensory loss.•There is currently a paucity of orthopaedic literature on lower extremity nerve transfers and further understanding is required to better utilize these techniques to manage lower extremity peripheral nerve injury.

Figure 1

Clinical photographs of gracilis motor branch to rectus femoris motor branch transfer. A) Long oblique incision marked on skin to include both exploration of the femoral nerve and planned nerve transfer. B) Lacerated branches of the femoral nerve (yellow arrows). C) The gracilis motor branch of the obturator nerve (black arrow) is passed deep to the adductor muscles and superficial to the femoral vessels to reach the rectus femoris motor branch (yellow arrow) of the femoral nerve. D) View through the microscope after coaptation of the nerves using microsutures and fibrin glue.