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Tibialis Posterior Tendon Transfer and Strayer for Peroneal Palsy Following Knee Dislocation

March 15, 2015

Contributors: Sebastiano Vasta, MD; Kevin D Martin, DO, FAAOS; Annunziato Amendola, MD; Biagio Zampogna, MD; Biagio Zampogna, MD

INTRODUCTION: The incidence of common peroneal nerve (CPN) injury associated with knee dislocation is between 4 and 50%. Forty percent or less of patients suffering CPN palsy in association with knee dislocation will experience functional recovery. The possible treatment options are neurolysis, nerve repair, nerve grafting, and tendon transfer. TP transfer compensates for the nonfunctioning tibialis anterior by providing active dorsiflexion and eliminates unopposed supinating activity, moreover normalizes walking without ankle foot orthosis (AFO). The indications for TP tendon transfer are: at least six months from injury, drop foot, normal TP tendon function, nearly normal passive motion of the midfoot-hindfoot complex (evaluate for gastroc release).

MATERIAL AND METHODS: A interosseus technique is shown in a 27 year old male patient with a CPN injury after a knee dislocation. He reported right anterior cruciate ligament (ACL) and posterolateral corner (PLC) injury, peroneal nerve injury after landing from a jump while water skiing. After a first surgery for ACL and PLC reconstruction, the knee was stable but the patient was unable to actively dorsiflex the ankle or the toes and to evert the right foot. Ten months after the injury he underwent the TP tendon transfer. The postoperative management consisted of a two-week period in a cast non weight bearing (WB), plus four more weeks in cast with WB as tolerated (WBAT) after suture removal. At six weeks postop, walking boot (WBAT) for four weeks, that was removed for ROM exercises and gentle strengthening. At 10 weeks, out of the boot, progressive increase of the strengthening exercises and task-specific PT for gait recovery.

DISCUSSION: PT tendon transfer should be considered as a primary treatment, in case of failed nerve repair or simultaneously with nerve repair to facilitate nerve recovery. Controversies exist with respect to the timing of the transfer (early vs. late); the type of fixation (bone insertion versus tendon-to-tendon fixation); where the tendon should be attached to reproduce perineal vs. tibialis anterior function.

CONCLUSION: The TP tendon transfer is a safe procedure, with a low complication rate. It reduces or prevents pes equinus and improves gait, by restoring the dorsiflexion, although with a 30 to 40% of the contralateral strength, and possible decrease of active plantarflexion; this eliminates the need for AFO and leads generally to satisfying outcomes with possible return to a high activity level.

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