| Backgrounds:With the development of the era, the incidence of hip fracture and dislocation caused by high-energy damage is increasing, often along with sciatic nerve injury, most of which turn out to be simple fibular nerve injury (48.3%). Others occur combined with different degrees of tibial nerve damage (51.61%), which provide a significant clinical background for surgeons to treat high fibular nerve injury. Additionally, in view of the long-term recovery after high sciatic nerve injury, the function of ventral calf muscles is poor. Many studies reported poor surgical recoveries when the fibular nerve bundle was damaged around the hip area or the proximal thigh. In addition, for the majority of patients with closed sciatic nerve injuries, early recovery of the tibial component can be obtained by conservative treatment, yet with fibular composition, hardly ever(1). Therefore, such a injured character provides a valuable clinical context for surgeons to cure high common fibular nerve injuries with the advantage of branch transposition of TN (here we define the high common fibular nerve as the part from the point where sciatic nerve through the piriformis to the point above the popliteal fossa). Current treatments to CPN injuries mainly cover neurolysis of CPN, tendon transposition surgery, autologous nerve grafting, specific nerve grafting and etc[31、78、256、298]. But efficacy without exception is poor. In recent years, some scholars, inspired by Yu-dong Gu’s treatment of upper limb nerve injury[41、7], started to study and cure CPN injuries by branch transposition of TN. Comparing the branches of tibial nerves and CPN (primarily refer to branch of anterior tibialis) by means of autopsy gives Colin P White a significant consideration to axon count and CSA matching[9], because the axon matching is a key factor to choose an ideal nerve donor. Previously, Mackinnon and the team had proved the matched nerve is the hinge of recovery [10]. The paper will provide a sound basis for surgical treatment for high common fibular nerve injuries through detailed anatomy and Slice observation research of popliteal fossa nerve of cadaveric lower limbs, and discussing the feasibility to recover deep fibular nerve by the soleus nerve transposition.Objectives:To explore some appropriate motor branches from the Tibial Nerve (TN) as direct donors to suture the Deep Peroneal Nerve (DPN) by anatomical and immunohistochemical methods as well as clinical therapies, thus providing basis for surgical treatment of high fibular nerve injuries.Methods and results:An anatomic study was performed that included the dissection of the popliteal fossa in total 20 lower limbs, four of which came from amputations, the others come from 9 fresh frozen adult cadavers, then cut out part of the nervous tissue for slice observation and also, count the number of fibers in these nerves. We found that the branches of the TN found to the medial and lateral head of the gastrocnemius and the soleus muscle had a mean length of 31.25± 2.00 mm,38.73 ±2.27 mm and 59.50±2.59 mm and a mean diameter of 1.72±0.08 mm,1.88±0.08 mm,2.10±0.10 mm respectively. When the epineurium of the common peroneal nerve (CPN) was split, we separated the deep and superficial bundles toward to the proximal end until cross-link of two nerves is occurred, such a separation segment is called damage-free separated tract (DFST), which had a mean length of 66.80 ±2.69mm and a mean diameter of 2.15±0.12 mm. Thus a tensionless direct suture to the DPN bundle was made possible by using the three donors in all specimens. Slice observation showed that the three donors and the deep fibular nerve bundle had a mean motor fiber number of 2035±58,2187±25,3106±86,3521±112 respectively. Statistic evaluation demonstrated that Soleus nerve had an similar diameter and number of motor fibers to DPN bundles (P>0.05), those of Medial and Lateral gastrocnemius were inferior to DPN bundles (P>0.05). Additionally, we gathered 5 clinical cases of foot drop caused by common peroneal nerve injury, these patients experienced nerve transposition as we designed in the anatomical experiment in our hospital. Then we observed the myodynamia of dorsiflexion from pre-op to post-op (3 months,6 months,12 months) to evaluate the therapeutic effects in the 5 cases. Consequenty we find that all the 5 patients have gained conspicuous advancements of dorsiflexional function in varying dgrees.Conclusion:All of the proximal motor branches from the tibial nerve can serve as direct donors to suture the DPN. We recommend the nerve to the Lateral gastrocnemius as the first choice for a donor in the proposed transfer for its adequate length and considerable motor fiber number. In addition, the therapy of this nverve transposition have been verificated effective and safe by clinical applications. |
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