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Page 6 of 16 Garbuzov et al. Plast Aesthet Res 2023;10:9 https://dx.doi.org/10.20517/2347-9264.2022.51

[30]
disturbance and can lead to falls . In cases where conservative management fails to improve nerve function
after 4 months, surgical treatment may be required with nerve decompressions, direct nerve repair, nerve or
[30]
tendon transfers, or ankle fusion .

Nerve transfers can restore function for patients with peroneal nerve palsy. Ferris et al. demonstrated
improvement in active dorsiflexion in patients with traumatic common peroneal nerve injuries who
[31]
underwent partial tibial nerve transfer to the motor branches of tibialis anterior . Another study reports
successful outcomes in patients with foot drop who undergo superficial peroneal nerve or tibial nerve
fascicles transfer to the motor branch of the tibialis anterior and the deep peroneal nerve [Figure 1].
[32]
Feasible nerve transfers have been reported in cadaver studies by transferring the vastus lateralis nerve
[33]
branch to the deep peroneal nerve branch . While there is potential for nerve transfers to help patients, not
all nerve transfers have excellent outcomes. Poor outcomes have been reported in the nerve of the soleus
muscle to the deep peroneal nerve transfer .
[34]

These novel techniques demonstrate the innovation required to treat patients with PNI in the lower
extremity. Nerve transfers have the potential to restore function in cases where other treatments, such as
nerve grafting, are not feasible. To optimize outcomes in nerve transfers, the donor activation focused
rehabilitation approach has been suggested in upper extremity nerve transfers . Given the success of these
[35]
interventions in the upper extremity, advances in the lower extremity are promising.

SURGICAL NEUROLYSIS
Neurolysis is another therapeutic option for patients with intractable pain that are not responsive to
conventional treatments. Surgical neurolysis refers to the procedure of releasing the entrapped nerves from
the adjacent tissues enabling them to decompress and repair. Pess et al. in 1987, described a case of femoral
nerve compression following a total hip replacement that was successfully treated with surgical nerve
decompression and neurolysis . Since then, the implications of neurolysis for the treatment of lower
[36]
extremity neuropathic pain have been discussed in the literature with favorable patient outcomes [Table 2].
The main role of neurolysis for lower extremity neuropathic pain is for patients with nerve entrapment.
Decompressing the affected nerve from the adjacent fibrous tissues would lead to better functional recovery,
symptom relief, and axonal regeneration. Surgical neurolysis is considered a safe and feasible option for
nerve decompression [Figure 2]. Complications of surgical neurolysis have been reported rarely, and it
mainly depends on surgical technique and the degree of nerve adhesions to the surrounding structures.

STEM CELL THERAPY FOR NERVE REGENERATION
Nerve transfers may provide a definitive surgical resolution to many cases of lower extremity PNI.
Alternative therapies to promote axonal regeneration and improve nerve function may be required in cases
where nerve transfers are not possible. Stem cells have been investigated as a therapy for PNI due to their
potential to regenerate neurons, support glial cells, and release factors to promote nerve regeneration .
[4]
Schwann cells, in particular, play a vital role in the regenerative response, although there are challenges
associated with harvesting autologous Schwann cells . Schwann cells are procured by harvesting donor
[37]
[37]
nerves and cell culturing, requiring the loss of a functional nerve . For this reason, there have been
significant advances in lower extremity nerve regeneration using stem cells and the results have been
satisfactory.

Embryonic stem cells
Embryonic stem cells (ESC) are pluripotent cells and can be extracted from the inner embryonic blastocyte
layer. They can actively differentiate into almost all cell lineages including neurons and glial cells, which