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Fascicular nerve transfers for foot drop: Proposed surgical algorithm and outcomes assessment
Mitchel Seruya, MD1; Robin Babadjouni, MD1; Brianne Mitchell, MD1; Julie Werner, PhD2
1Cedars-Sinai Medical Center, Los Angeles, CA; 2Children's Hospital of Los Angeles, Los Angeles, CA

Introduction: Patients suffering from foot drop face a lifetime of poor gait and dependence on an ankle foot orthosis (AFO) for ambulation. While tibialis posterior tendon transfer remains a popular orthopedic technique for restoring dorsiflexion, functional relearning can be challenging and the restored range of motion limited. Past endeavors at addressing the injured common peroneal nerve, either with neurolysis or with nerve grafts, have been largely met with failure. The purpose of this study was to present a surgical algorithm for treating foot drop with fascicular nerve transfers and report outcomes thus far.
Materials and Methods: A prospective review was carried out for all patients presenting to a single-surgeon with foot drop between 2020 and 2022. The surgical algorithm consisted of targeting both dorsiflexion and eversion to provide a balanced ankle and doing so with tibial fascicular nerve transfers or peroneal, where able. Inclusion criteria included patients presenting within 12 months from the onset of injury and undergoing nerve transfer reconstruction. Exclusion criteria consisted of patients with less than 12 months of postoperative follow-up and those suffering from concomitant musculotendinous injury. Patient demographics, time from onset of injury to surgery, the specific donor and target nerves for transfer, and functional scores per the British Medical Research Council (MRC) were recorded.
Results: Nine patients met inclusion criteria, with one patient subsequently excluded due to concomitant musculotendinous injury. Of the eight patients, four were male, four were female, and the average age was 34.8 years-old. Preoperative dorsiflexion was M0 (N=7) and M2 (N=1) , while preoperative eversion was M0 (N=5), M1 (N=1), and M3 (N=2). Mean time from injury to surgery was 8.4 months. Donor nerves included flexor hallucis longus/flexor digitorum longus (N=7), flexor hallucis brevis/flexor digitorum brevis (N=2), and extensor hallucis longus (N=1). Target nerves included tibialis anterior (N=8), peroneus longus (N=5), peroneus brevis (N=2), and extensor hallucis longus (N=1). With a mean follow-up of 12.6 months, postoperative dorsiflexion was M5 (N=1), M4 (N=4), M3 (N=2), and M1 (N=1) while eversion was M5 (N=1) and M4 (N=7). Six of eight patients no longer required an AFO, with one additional patient weaning off their AFO.
Conclusions: This prospective series demonstrates that fascicular nerve transfers show promise in restoring ankle dorsiflexion and eversion and eliminating the need for an AFO in patients suffering from foot drop. Additional studies are necessary to optimize patient and donor site selection.


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