Page 41 - Read Online

Garbuzov et al. Plast Aesthet Res 2023;10:9 https://dx.doi.org/10.20517/2347-9264.2022.51 Page 5 of 16

transfer [13,14] . This approach has also successfully restored knee extension in a pediatric patient with acute
[15]
flaccid myelitis . In cases of femoral nerve injury accompanied by bilateral obturator nerve damage, a
cadaveric study by Chen et al. suggested the muscle branches of the sciatic nerve may be a reasonable
[21]
candidate for femoral nerve repair . Lubelski et al. demonstrated sciatic-to-femoral nerve transfer using a
fascicle of the proximal tibial nerve as the donor for pediatric patients with acute flaccid paralysis .
[16]
However, the clinical implications and functional outcomes of this nerve transfer remain unclear.

Other proposed donors in cases of femoral nerve injury include the nerve to semitendinosus and the S1
[21]
[22]
[23]
nerve root , as well as the intercostal, ilioinguinal, and iliohypogastric nerves . Overall, the main
indication of nerve transfer for repair of a high femoral nerve injury is reserved for patients for whom direct
nerve repair or nerve graft surgery is not plausible.

Obturator nerve injury
The obturator nerve originates from the L2-L4 nerve roots and innervates the medial compartment of the
thigh, which are responsible for adduction and external rotation of the thigh, as well as sensory processing
of medial thigh. It enters the thigh after passing across the pelvis and through the obturator foramen.
Obturator nerve injuries are rare and occur most commonly from complications during pelvic surgery.
Injury to the obturator nerve results in weakness in thigh adduction and external rotation and sensory loss
in the medial thigh. Given the surgical setting of these injuries, nerve repair is often performed
intraoperatively with direct repair or nerve grafting [24-26] . Nerve transfers are less common interventions in
obturator nerve injuries presenting postoperatively, with a conservative approach being preferred. However,
one study reported full restoration of hip adduction and medial thigh sensation after nerve transfer of a
branch of the femoral nerve to the obturator nerve .
[27]

Tibial nerve repair
The tibial nerve is a distal branch of the sciatic nerve (L4-S3 nerve roots) and is responsible for motor and
sensory innervations to the posterior leg compartment, as well as foot and toe flexor muscles. Injuries to the
tibial nerve may result in significant gait disturbance, impaired foot plantar flexion, and sensory losses. In
cases of sciatic nerve injury, repair of the tibial nerve is given priority to ensure plantarflexion strength for
walking and protective plantar sensation . The first description of nerve transfer for repair of the tibial
[17]
[28]
nerve was in the study by Koshima et al. in 2003 . They successfully used the deep peroneal nerve to
restore sensory functions of the injured tibial nerve. Moore et al. described a novel approach for performing
nerve transfer of the terminal branches of the femoral nerve supplying vastus medialis and vastus lateralis to
the medial and lateral branches of the tibial nerve in cases of tibial and common peroneal nerve palsies after
[17]
sciatic nerve injury . Obturator nerve transfer to the tibial nerve to the medial head of the gastrocnemius
has also been successful in restoring knee and ankle flexion . One cadaver study found feasible targets for
[27]
restoring tibial nerve function using transfers of the vastus medialis nerve branch to the medial
[29]
gastrocnemius nerve branch . There is a paucity of data on the utilization of nerve transfer for tibial nerve
repair in the current literature. Nevertheless, all published articles reported significant improvements in
functional outcomes. Nerve transfer should be taken into consideration as an alternative option, particularly
for proximal sciatic nerve injuries.

Peroneal nerve repair
The common peroneal nerve is another major branch of the sciatic nerve, and it provides the motor and
sensory processing of anterolateral compartment of legs to the dorsal aspect of feet and toes. The common
peroneal nerve is at high risk of injury due to its superficial anatomical course, and it is the most common
[30]
source of mononeuropathy in the lower extremity . Peroneal nerve palsies arise from trauma,
compression, or iatrogenic causes and are classically associated with “foot drop”, which results in gait