The addition of a nerve transfer to the treatment of peroneal neuropathy secondary to intraneural ganglion: Case Series
Jessica M Winter, MD1, Yiyang Zhang, MD, FRCSC2, Jennifer Giuffre, MD, FRCSC1 and Tod Clark, MD, FRCSC3, (1)University of Manitoba, Winnipeg, MB, Canada, (2)University of Western Ontario, London, ON, Canada, (3)Department of Orthopedics, University of Manitoba, Pan Am Clinic, Winnipeg, MB, Canada
Introduction
The management of peroneal intraneural ganglia is controversial. Presently the accepted treatment of intraneural ganglia is decompression and ligation of the articular nerve branch. Although this treatment prevents recurrence of the ganglia, it does not always resolve the motor deficit of foot drop if present. Foot drop is classically treated with splinting or tendon transfers. This study aims to further investigate whether the addition of a nerve transfer is an appropriate adjunct to intraneural ganglion cyst decompression and articular nerve branch ligation in symptomatic peroneal nerve intraneural ganglia causing foot drop.
Materials & Methods
In our case series of five patients, all had symptomatic peroneal intraneural ganglion cysts causing foot drop. All were treated with cyst decompression, articular nerve branch ligation and nerve transfer of the motor branch to flexor hallucis longus (FHL) into motor nerve branch of tibialis anterior muscle. Measured outcomes included, demographics, time to surgery from the onset of symptoms, pre and post BMRC muscle grade of tibialis anterior and FHL, cyst recurrence, use of ambulatory aid at final follow up, donor site deficits and surgical complications.
Results
At the one year follow up, three of the five patients did not require the use an ankle foot arthrosis (AFO). Two of these three patients had grade M5 and one patient had grade M4 ankle dorsiflexion strength. Two patients did not recover ankle dorsiflexion. One patient underwent tendon transfers, while the other patient continued to use an AFO. The two patients that did not regain motor function following the nerve transfer had had a recurrence of their peroneal intraneural ganglia previously treated with decompression alone. No post-operative complications such as infection, hematoma, seroma, or dehiscence were not seen in any of the patients. No evidence of cyst recurrence was seen at one year follow up. All patients retained grade M5 ankle plantar flexion, inversion, and toe flexion at the last postoperative follow up.
Conclusions
In the setting of intraneural ganglia of the common peroneal nerve, decompression and ligation of the articular nerve branch can decrease the recurrence rate and improve pain; however, it does not always result in motor recovery. Adding a nerve transfer of the motor nerve of FHL into a motor nerve branch of anterior tibialis should be considered in the setting of foot drop as it aids in dorsiflexion recovery while offering negligible donor site morbidity. Recurrent ganglia may be critical in affecting prognosis.
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