Dual nerve transfer of gracilis and adductor longus nerves in restoration of complete femoral nerve palsy

Abstract

Isolated permanent femoral nerve palsy is a rare pathology that causes significant disability. 1,2 A true unilateral complete proximal femoral nerve palsy will result in the wasting of the quadriceps, iliacus and sartorius, variable wasting of pectineus and a sensory deficit in the anteromedial thigh and medial aspect of the leg. This causes a well-described gait disturbance and renders the patient unable to ambulate independently without significant difficulty or the use of gait aids. 3 The aetiology of isolated permanent femoral nerve palsy is varied. The vast majority of reported permanent unilateral femoral nerve palsy cases in the modern era are from unintended iatrogenic injury, or a planned necessity for oncologic clearance. 1 Other causes include iliopsoas haematoma, iliopectineal bursitis, trauma and diffuse large B-cell lymphoma. 2,4 Regardless of aetiology, this is a complex reconstructive problem with poor intrinsic idiopathic regenerative capabilities. There are few documented cases 4-6 of various pattern obturator nerve transfers for femoral nerve deficits with good functional outcomes.Here we present a novel technique with a clinical case including long-term follow-up, for the restoration of quadriceps function with no discernible donor deficit.Mr JV is a piano mover who was involved in a high-speed motor vehicle accident (MVA) at age 49. He sustained major pelvic fractures managed non-operatively, in addition to facial, chest and abdominal injuries. He originally had a diffuse critical illness polyneuropathy, which resolved to reveal an underlying isolated right-sided femoral nerve palsy. It was at this point, 4 months postinjury, that he was referred to the senior author (SF). The right quadriceps were completely wasted with 0/5 power and absent sensation consistent with complete femoral nerve palsy. Ipsilateral hamstrings, adductors and both anterior and posterior leg compartments were at least 4/5 power. There were multiple scars consistent with the original trauma but no evidence of surgery in the region of the proximal femoral nerve. Femoral nerve surgery was performed 5 months after the original trauma.There is little data in the literature regarding expected resolution ranges for critical illness polyneuropathy resolution, if any can occur from a few weeks after onset to months. 7 In this case, the indication for surgery at this time was the persisting isolated femoral palsy despite resolution of weakness in the other muscle groups.Intraoperatively, the right femoral nerve had a flat and empty appearance at the level of the inguinal ligament. There was no proximal stump available for reconstruction. These surgical findings were in keeping with the pre-operative hypothesis that the femoral nerve palsy was in addition to the resolved critical illness polyneuropathy.The following nerve transfers were performed (Fig. 1): 1. Nerve to gracilis transfer to a common intermediate quadriceps nerve. 2. Nerve to adductor longus transfer to definitive nerve to vastus medialis. Both transfers had good si...

Reconstruction of Quadriceps Function Using a Single Functional Gracilis Muscle Transfer With an Adductor Longus Nerve to Femoral Nerve Branch of the Rectus Femoris Nerve Transfer

“…12 It remains unclear which muscle or nerve transfers are suitable to replace enough quadriceps function to achieve this end point. Improvement in knee extension function has been achieved via neurorrhaphy of the anterior branch of the obturator nerve to femoral nerve branches 6,11 ; however, the literature seems to support augmenting the nerve transfer with a second nerve transfer or nerve grafting to achieve improved function. Nguyen et al 5 reports that, in patients with a tumor resection resulting in loss of quadriceps muscles, training and physiotherapy after gracilis muscle transfer allow patients to achieve unassisted ambulation, normal to near-normal-appearing gait, and full or nearly full knee joint extension.…”

“…6,[8][9][10] A case of a dual nerve transfer in which the obturator nerve branches to the gracilis and adductor longus muscles are transferred into the vastus intermedius nerve branch and vastus medialis nerve branch has also been reported. 11 Tung et al 6 reported 2 cases of obturator nerve transfer for complete femoral nerve injury. One patient had incomplete femoral nerve recovery after the nerve transfer, which resulted in an inability to climb stairs, whereas the second patient's reconstruction was augmented with a superior gluteal nerve transfer, which resulted in improved function.…”

Surgical applied anatomy: alive and kicking

“…Even with novel descriptions of anatomical anomalies and anatomical variation found on imaging and intraoperatively, the main innovations appear to be in how this is clinically applied. For example, Karagiannis and Ferris 17 use of collateral nerve supply to inform the selection of the gracilis and adductor longus nerves in repairing a femoral nerve palsy reflects the innovative use of anatomical function and partial redundancy. Such an understanding and appreciation of normal anatomical arrangements and the potential flexibility afforded that can be exploited to restore function is just one example of a case study to inspire students of anatomy and demonstrate that discipline of clinical surgical anatomy is alive and kicking.…”

Advances in lower extremity peripheral nerve surgery

“…While some patients were reported to have improved sensory and motor function recovery, this study was limited by its design, and further studies are needed to confirm the benefits of ES [51] . Notably, one concern with implantable neuroprosthesis is an induced foreign body reaction, which can compromise benefits by provoking an inflammatory response [52] . However, systemic dexamethasone treatment for 2 weeks in rats was found to significantly attenuate the inflammatory response, demonstrating a potential adjuvant therapy to improve the function of neuroprostheses [52] .…”

“…Notably, one concern with implantable neuroprosthesis is an induced foreign body reaction, which can compromise benefits by provoking an inflammatory response [52] . However, systemic dexamethasone treatment for 2 weeks in rats was found to significantly attenuate the inflammatory response, demonstrating a potential adjuvant therapy to improve the function of neuroprostheses [52] .…”