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Tibial to Peroneal Nerve Transfer for Treatment of Severe Peroneal Palsy
Description:
Tibial to Peroneal Nerve Transfer for Treatment of Severe Peroneal Palsy
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T00H33M42S
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Upload Date:
2025-04-26T13:38:31.8779114Z
Transcript:
Language: EN.
Segment:0 .
DURETTI FUFA: Today, I'm going to be taking you through a case of a 51-year-old patient who sustained a traumatic laceration to his common peroneal nerve on the right side. He underwent immediate direct repair of the common peroneal nerve. And we've been following him with electrodiagnostic studies now, at month six from the repair and injury, with no clinical or electrodiagnostic signs of return.
DURETTI FUFA: And as a result, we've offered him a tibial to peroneal nerve transfer in an end to side supercharged fashion. Next, we'll go through some of the superficial subcu with Bovie to lift those edges up for me. May I have a forcep, please? Just being careful once we get a little bit deep to the area where the peroneal nerve will be. We'll take a lap.
DURETTI FUFA: Looks like we have the most native tissue plane here to maybe follow. Where's his fibular head? We're using as a landmark here. Just lifting the tissues away from the peroneal nerve given that we know we're operating in an area of dense scar tissue, I feel like it might be right here.
DURETTI FUFA: The nerve actually is right here. I'm going to cut this with scissors, since we're getting a little closer to the nerve. We're a little distal right? His fibular head is kind of up here. So here we're coming over the lateral compartment. Peroneal nerve. Tendons, excuse me.
DURETTI FUFA: And it looks like the nerve is here entrapped in some scar tissue. OK, so this is our peroneal nerve here coming into view. I'm going to spread above it and below it to start to identify it. And Raul will use a big vessel loop in order to loop this in a moment.
DURETTI FUFA: We are not to where there'd be any meaningful branches of the perineal nerve yet, just to make sure I'm not going into any axilla, you know? OK, so in this setting, given that we see that the perineal nerve repair has failed, this is the proximal nerve stump and this is the distal nerve stump, and they're not in continuity. Our nerve transfer is going to be a complete nerve transfer and to target the anterior tibial
DURETTI FUFA: and I would expect that he's going to need a tendon transfer in the future. OK so neurolysis wise this, I think we should just make sure to bury in muscle. Let me do. Can we have an army? Navy? Thank you.
DURETTI FUFA: Sort of bulbous portion here. That's the nerve neuroma bridge in but we're not going to sacrifice his own tissue because of the unlikelihood that it's going to come back to bring motor. We're going to give motor, by the way, of the nerve transfer, and we're going to bridge this so that there's a chance for sensation to recover.
DURETTI FUFA: OK so we're going to follow the peroneal nerve into the lateral and anterior compartments. Fibulas here. Peroneal longus there. So now we've got anterior tibial coming up to you And we need to be able to decipher out the branches here.
DURETTI FUFA: So we're isolating the superficial peroneal nerve. Fascial peroneal nerve branches running posterior and our deep peroneal nerve branches anterior. In the interval between the peroneal musculature here and the anterior tibial musculature here.
DURETTI FUFA: Just one of the more direct that we go into the branches to the anterior tibial obviously, the more we're going to just focus the transfer there. OK so we're developing the interval between the peroneal muscles and the anterior compartment to see the branching of the deep peroneal nerve to the anterior tibial.
DURETTI FUFA: OK. So superficial peroneal nerve. Do you have Raytex also Raul? Yeah. Thank you.
DURETTI FUFA: You see a membrane there, which, actually, ultimately we need to open up for our transfer anyways. See all this? The superficial branch with, with branches going to the perineal and sensory.
DURETTI FUFA: So we're showing the proximal nerve stump. Here, the deep motor branch, deep peroneal nerve and the superficial peroneal nerve. Distally on the deep peroneal nerve we see multiple branches. First branch is going to the tib/fib joint. Next we're going to target these to go to the anterior tibial musculature and leave the longitudinally oriented EHL
DURETTI FUFA: without a target. OK, great. Thank you. Do you have those nerve cutting? This is neuroma. Got it. Got it. Thanks, Raul.
DURETTI FUFA: Great. That's 6 with his knee extended The idea is that we're going to put a graft from the common peroneal to the superficial peroneal nerve, and we had a large neuroma that was not giving any meaningful signal distally so we're going to do a direct end to end nerve transfer from the tibial nerve branches into the anterior tibial branches here.
DURETTI FUFA: Third just posterior to the palpable posterior aspect of the tibia bone. OK? Same kinds of retractors with the Gelpi and the sharps. Thank you. We'll have a saphenous vein potentially here to reconcile with. So this is gastroc. So actually we will probably want to make the window a little bit on the anterior side of this Bovie into the corner.
DURETTI FUFA: What is this nerve? We won't cut it. But what is it? It's a superficial. I guess it's just off of the saphenous, right? All right, so we're on the posterior crural fascia here, and we're going to incise the gastroc muscle. We feel the posterior border of the tibia.
DURETTI FUFA: Here, I'll make a little nick and then we can incise this fascia. It's not vascular. The back of the tibia there. Gastroc, there.
DURETTI FUFA: OK so here's the gastroc muscle and posterior tibial there. You can take the Bovie and run that interval maybe. Posterior. Army Navy, please. No nerves in this interval that we need to worry about.
DURETTI FUFA: It's behind my index finger soleus muscle between my index and the tibia. And then our tibialis posterior and our neurovascular bundle is deep in here. If you take a look down, you can kind of see it there. Anthony. OK. So now we can keep taking the soleus down so that we have a better view of the posterior tibial neurovascular bundle.
DURETTI FUFA: Structures here. This is the posterior tibial neurovascular bundle which is our target for the nerve transfer. Maybe that can kind of be down there. OK, great. So I'm going to open up the posterior tibial neurovascular bundle specifically with attention to our nerve, which is more lateral.
DURETTI FUFA: So first thing I'm going to use Sherwin is a large vessel loop cut in half. We can keep it full length since this is sort of deep right now. [BACKGROUND VOICES}
DURETTI FUFA: Tibial nerve. OK, so the topography of the nerve, right? We don't want to go to soleus. We don't want to go to posterior tib. Right. We, I mean, we don't want to donate from it. Excuse me. I want to get to his toe flexors, which are starting to branch off here
DURETTI FUFA: I believe. The more distal that we take the donor, the more swing distance that we have to bring it up to our recipient. Now, it's a little trickier quite honestly. See, like this could be a branch that we could use. Yeah it's trickier when you go into side because you don't have any excursion from the recipient nerve
DURETTI FUFA: but here we actually have it cut so we can swing that really down to meet us partway so we will not have to chase this quite as far distal. We can look at this and see what this is doing. This small nerve branch here. May I have that nerve stimulator, please? Unified and we're going to use the nerve stimulator to see what its function is.
DURETTI FUFA: So here we're going to be watching for the toes to flex in response to our stimulation. OK so it seems strong to FHL right. Yeah. Yeah, for sure. OK more so than FDL. All right. So I mean, this looks like a very nice target, though I'm not sure we can neuralise a little bit more
DURETTI FUFA: to see, but I don't really see unless it could have been coming off more proximal. That's all the same one that we have there. Such a nice long course. Now, there could be two bundles in there. Yeah, it does almost look like there's two bundles. I mean, I'm going to take probably both, but.
DURETTI FUFA: So we have our tibial nerve and that little branch, maybe I can do a small vessel loop cut in half to, to tag that so that we have it now with these tiny nerve branches once we start manipulating them and everything, we can kind of make them go into a palsy so I'm cautious. And even once you stimulate it too much, it can go into a little bit of a palsy
DURETTI FUFA: so I'm not going to electrocute it. I used a pretty small amplitude and frequency there. I'll use the Hemoclip now please. OK, so we have one nerve branch there. We have tibial, full tibial nerve here, and I can just look a little bit more distal to see if anything else is branching off. May I have those long scissors, I have them.
DURETTI FUFA: Thank you. Thanks, Anthony. That's our same nerve branch there. You know, or I could go into this nerve to see if there's anything else
DURETTI FUFA: but this is just so good. Is there anything more proximal that was coming off? A big old vein right there, going to the soleus, soleus nerve branch there. So we're pretty proximal at this point. Yeah. I think we're going to take this FHL branch. It's got tons of swing length. Yeah. The only thing would be if I internal neurolised to bring something that's not just his.
DURETTI FUFA: Do you think his lesser toes are moving also? I'd love it if they were both in there sort of. Can I have the nerve stimulator back, please? [They were flexing, but not as strong] as the FHL. Yeah, Yeah, Yeah. Just one up. Thank you. So if I do this down here, I'm going to do the full tibial nerve.
DURETTI FUFA: Interesting. When I do the full tibial nerve, I'm not even getting the toes right? So it must be that FDL is in there, you know? Yeah. OK. Yeah I mean, it's flexing the first to third toes. OK. Thank you. All right. We'll take that branch there. There's going to be more innervation to it as it goes distal
DURETTI FUFA: so we'll take that branch. OK? So this is our target nerve. Let's give you a nice view of it there. If our main tibial nerve here and a single branch that we've stimulated and identified that it gives motor to the greater and lesser toes. So this is going to be our nerve target and we're just going to find the appropriate swing length to reach our nerve coaptation site, which will be in the lateral incision.
DURETTI FUFA: OK? And in our other incision here. Anterior. Tibia is anterior. There's fibula there. May I have a freer, please? Thank you.
DURETTI FUFA: Come on. Fibula arteries there, nerve is with you. Bluntly tunneling from the medial incision to the lateral incision so that we can get a pathway through the interosseous membrane, through which we'll transfer our tibial nerve branch.
DURETTI FUFA: And no major blood. That's good. Yeah go ahead. Thank you.
DURETTI FUFA: OK, so that gives us a sense of how far we need to transfer it so that we can decide how far distal to cut our target nerve. Now, I'll get you not on pressure on the tibial nerve. What can I use as a sponge? A Raytec? Thank you.
DURETTI FUFA: OK, so we're going to go through up there. This little branch, I wonder. It's so small though. We'll leave that actually it's going to come with us when we take this. Oh actually it'll still be giving to that. Can I have the nerve stimulator? Let's see if there's anything in it.
DURETTI FUFA: Thank you. Really imperceptibly different. Both are pretty strong in the great toe. Yeah. Hard to believe this tiny little thing is going to. Thank you.
DURETTI FUFA: The foot. You know, if you weaken the flexor side, you don't need as much strength in the anterior side. Oh that's good. That's good for him. Right since we know he's going to be compromised but I also want to consider what they're going to use for tendon transfers because he's like going to almost guaranteed need a tendon transfer.
DURETTI FUFA: OK so I'm just now neurolising this thing backwards. Flexor nerve as distally as we can, and we've separated one single fascicle that gives a nice strong motor signal, which we're going to take for our transfer.
DURETTI FUFA: One, two, three. Another micro forcep, please? Thank you. And I'm going to get rid of this vessel loop. May I have a blue background? So here
DURETTI FUFA: is our donor nerve. I don't know if that's a good view. All right. And that's 90. Thank you. I'm going to carry this to the other side. Black scissors?
DURETTI FUFA: Now it looks a little bit like a longer distance. OK. Thank you. Let's see the pathway from both sides now. Keep that there. Give you that room.
DURETTI FUFA: We can nestle it inside there and then try to pull it through. Just feel it with my finger also and then we'll receive it on the other. We'll check how it looks on the other side. Let's make heads or tails of all this stuff. This is our anterior tibial. Could I have a stapler, please? Stapler? Yes.
DURETTI FUFA: Oh do we have one or no? Can I have a moist, moist on here, please? I'll clean up this blood. This is deep. We said we're probably targeting this guy. Thank you. This is our superficial perineal.
DURETTI FUFA: We'll keep down here out of the way. And this is sort of the other branch of our deep. OK so our tunnel now. May I have a langenbach, please? Thank you.
DURETTI FUFA: And a snap. Going underneath. Thank you. Are you able to take that from me, please? So our two options are. I can just pass a forcep through and you try to hand me it.
DURETTI FUFA: Yeah. Let's see what happens if I send a micro forcep. Can you see the nerve there? OK, good. Can I have just a drizzle? Some irrigation on that nerve, please. So I'll send this micro forcep through and you see if you can see it reliably enough that you could hand me it in a micro forcep. Got it.
DURETTI FUFA: And if not, we will try the passing it that way. I need to not stab anything while I'm doing this. This is sharp. OK you got it. Yep trying not to mash it, but control it. If you can do anything to guide it, I'll take the Army Navy back.
DURETTI FUFA: Got it? Just see that it's kind of going smoothly through our track there. Everything looks good still over on your side? Yep so that. No time to see you now. Tips are by me. So good.
DURETTI FUFA: We have a little nerve there. Good. Let me give you that. Can I have the micro forcep, please? I got it. Yep. Yep. OK so it came through. Is there anything that you can see to do to actually, maybe I'll just have you come to this side and mind the nerve on this side.
DURETTI FUFA: Yeah, I can do it. Thank you. OK you can let go. OK, so this is for our other. We'll do this guy first so we don't lose him. And what can we coapt to it?
DURETTI FUFA: Can I have a scalpel, please and it adds in with teeth. You need to find something that looks like good nerve. Yeah to anterior tibial. Like just one of these good fascicles here. Black scissors, please.
DURETTI FUFA: That doesn't look very good. This looks like it's going right into muscle. OK, I like that one. Micro forceps, please and it looks like our distance will be great. Yeah how much time do we have before two hours. 10 minutes.
DURETTI FUFA: All right. Can you see that little trifurcation there? So here we have our donor nerve from the tibial and branching of the deep peroneal nerve.
DURETTI FUFA: This nerve is one of the most healthy looking branches that's going anterior towards the anterior tibial so this will be our recipient. So next we're going to transect the recipient nerve so that we can coapt end to end here. Can I have mixture and vessel loop, the small micro one if you have.
DURETTI FUFA: Yeah it's OK. It probably it's a little delicate so we'll just do this. Is that far enough is all I want to know. Micro forcep please. Thank you.
DURETTI FUFA: So the closer I can get it to the muscle, the better. You know, in terms of its speed to recovery. However, I need this to not be on tension. I'm going to cut the nerve now. So we're going to cut our donor, our recipient excuse me, nerve here.
DURETTI FUFA: Debakey? Would be much better to do this under the microscope. Again, I just want to get him approximated and I'm going to keep the blue background so that we can find it. I may even paint it blue so that we can see it when we come back. Although it's going to be increasingly hard because the tourniquet is going to go down. That's true.
DURETTI FUFA: So maybe I just need to buy it now. Raul. I mean, Sherwin, can you drape the microscope, please? And do we have the Versa wrap ready? Yeah. OK.
DURETTI FUFA: Thanks. Microscope? Generally in my career, I try not to have anybody have to hold anything because you kind of like, inevitably muscles will fire and stuff, but we're in a little hole.
DURETTI FUFA: The Versa wrap is open as well? OK, I'll take the 10-0. Thank you. Scissors curved.
DURETTI FUFA: I'll take it. Thank you. OK, that's our transfer now. Thank goodness. OK that's it right here. This guy. OK, good.
DURETTI FUFA: Where do we go from here? I think it might be over there. OK. OK. Major bleeding over there. That's good. And you have the other half of background that we gave back to you. Yeah. Thank you.
DURETTI FUFA: We have more than enough, so that's great. Nerve coaptation from the nerve transfer complete anteriorly here. What's remaining is that we're going to graft from the common peroneal nerve to the superficial peroneal nerve with a nerve allograft in order to give the patient sensory recovery and we will rely on our nerve transfer and plan for tendon transfers for his motor recovery.
DURETTI FUFA: Our nerve gap here is 6 centimeters. So in this case of a common peroneal nerve palsy, after sharp laceration, the inspection of the peroneal nerve repair demonstrated large neuroma barely in continuity. So our plan was modified from an end to side supercharge of the anterior tibial branch of the peroneal nerve to a direct end to end transfer given that there was no sign that there was going to be any motor recovery across that repair at the, and that nerve transfer went well.
DURETTI FUFA: We identified a fascicle from the posterior tibial going largely to the digital flexors, and co-apted that to the anterior to branch up of the anterior tibial nerve with a very nice size match 10-0 nylon under the microscope. The second portion then of the procedure was for the sensory nerve recovery performed with a nerve allograft again under microscope for end to end repair
DURETTI FUFA: with a nerve graft measuring six centimeters. The patient will be placed in a boot that's going to block ankle range of motion postoperatively and begin nerve rehabilitation about four weeks down the line. [VIDEO ENDS]
Segment:0 .
DURETTI FUFA: Today, I'm going to be taking you through a case of a 51-year-old patient who sustained a traumatic laceration to his common peroneal nerve on the right side. He underwent immediate direct repair of the common peroneal nerve. And we've been following him with electrodiagnostic studies now, at month six from the repair and injury, with no clinical or electrodiagnostic signs of return.
DURETTI FUFA: And as a result, we've offered him a tibial to peroneal nerve transfer in an end to side supercharged fashion. Next, we'll go through some of the superficial subcu with Bovie to lift those edges up for me. May I have a forcep, please? Just being careful once we get a little bit deep to the area where the peroneal nerve will be. We'll take a lap.
DURETTI FUFA: Looks like we have the most native tissue plane here to maybe follow. Where's his fibular head? We're using as a landmark here. Just lifting the tissues away from the peroneal nerve given that we know we're operating in an area of dense scar tissue, I feel like it might be right here.
DURETTI FUFA: The nerve actually is right here. I'm going to cut this with scissors, since we're getting a little closer to the nerve. We're a little distal right? His fibular head is kind of up here. So here we're coming over the lateral compartment. Peroneal nerve. Tendons, excuse me.
DURETTI FUFA: And it looks like the nerve is here entrapped in some scar tissue. OK, so this is our peroneal nerve here coming into view. I'm going to spread above it and below it to start to identify it. And Raul will use a big vessel loop in order to loop this in a moment.
DURETTI FUFA: We are not to where there'd be any meaningful branches of the perineal nerve yet, just to make sure I'm not going into any axilla, you know? OK, so in this setting, given that we see that the perineal nerve repair has failed, this is the proximal nerve stump and this is the distal nerve stump, and they're not in continuity. Our nerve transfer is going to be a complete nerve transfer and to target the anterior tibial
DURETTI FUFA: and I would expect that he's going to need a tendon transfer in the future. OK so neurolysis wise this, I think we should just make sure to bury in muscle. Let me do. Can we have an army? Navy? Thank you.
DURETTI FUFA: Sort of bulbous portion here. That's the nerve neuroma bridge in but we're not going to sacrifice his own tissue because of the unlikelihood that it's going to come back to bring motor. We're going to give motor, by the way, of the nerve transfer, and we're going to bridge this so that there's a chance for sensation to recover.
DURETTI FUFA: OK so we're going to follow the peroneal nerve into the lateral and anterior compartments. Fibulas here. Peroneal longus there. So now we've got anterior tibial coming up to you And we need to be able to decipher out the branches here.
DURETTI FUFA: So we're isolating the superficial peroneal nerve. Fascial peroneal nerve branches running posterior and our deep peroneal nerve branches anterior. In the interval between the peroneal musculature here and the anterior tibial musculature here.
DURETTI FUFA: Just one of the more direct that we go into the branches to the anterior tibial obviously, the more we're going to just focus the transfer there. OK so we're developing the interval between the peroneal muscles and the anterior compartment to see the branching of the deep peroneal nerve to the anterior tibial.
DURETTI FUFA: OK. So superficial peroneal nerve. Do you have Raytex also Raul? Yeah. Thank you.
DURETTI FUFA: You see a membrane there, which, actually, ultimately we need to open up for our transfer anyways. See all this? The superficial branch with, with branches going to the perineal and sensory.
DURETTI FUFA: So we're showing the proximal nerve stump. Here, the deep motor branch, deep peroneal nerve and the superficial peroneal nerve. Distally on the deep peroneal nerve we see multiple branches. First branch is going to the tib/fib joint. Next we're going to target these to go to the anterior tibial musculature and leave the longitudinally oriented EHL
DURETTI FUFA: without a target. OK, great. Thank you. Do you have those nerve cutting? This is neuroma. Got it. Got it. Thanks, Raul.
DURETTI FUFA: Great. That's 6 with his knee extended The idea is that we're going to put a graft from the common peroneal to the superficial peroneal nerve, and we had a large neuroma that was not giving any meaningful signal distally so we're going to do a direct end to end nerve transfer from the tibial nerve branches into the anterior tibial branches here.
DURETTI FUFA: Third just posterior to the palpable posterior aspect of the tibia bone. OK? Same kinds of retractors with the Gelpi and the sharps. Thank you. We'll have a saphenous vein potentially here to reconcile with. So this is gastroc. So actually we will probably want to make the window a little bit on the anterior side of this Bovie into the corner.
DURETTI FUFA: What is this nerve? We won't cut it. But what is it? It's a superficial. I guess it's just off of the saphenous, right? All right, so we're on the posterior crural fascia here, and we're going to incise the gastroc muscle. We feel the posterior border of the tibia.
DURETTI FUFA: Here, I'll make a little nick and then we can incise this fascia. It's not vascular. The back of the tibia there. Gastroc, there.
DURETTI FUFA: OK so here's the gastroc muscle and posterior tibial there. You can take the Bovie and run that interval maybe. Posterior. Army Navy, please. No nerves in this interval that we need to worry about.
DURETTI FUFA: It's behind my index finger soleus muscle between my index and the tibia. And then our tibialis posterior and our neurovascular bundle is deep in here. If you take a look down, you can kind of see it there. Anthony. OK. So now we can keep taking the soleus down so that we have a better view of the posterior tibial neurovascular bundle.
DURETTI FUFA: Structures here. This is the posterior tibial neurovascular bundle which is our target for the nerve transfer. Maybe that can kind of be down there. OK, great. So I'm going to open up the posterior tibial neurovascular bundle specifically with attention to our nerve, which is more lateral.
DURETTI FUFA: So first thing I'm going to use Sherwin is a large vessel loop cut in half. We can keep it full length since this is sort of deep right now. [BACKGROUND VOICES}
DURETTI FUFA: Tibial nerve. OK, so the topography of the nerve, right? We don't want to go to soleus. We don't want to go to posterior tib. Right. We, I mean, we don't want to donate from it. Excuse me. I want to get to his toe flexors, which are starting to branch off here
DURETTI FUFA: I believe. The more distal that we take the donor, the more swing distance that we have to bring it up to our recipient. Now, it's a little trickier quite honestly. See, like this could be a branch that we could use. Yeah it's trickier when you go into side because you don't have any excursion from the recipient nerve
DURETTI FUFA: but here we actually have it cut so we can swing that really down to meet us partway so we will not have to chase this quite as far distal. We can look at this and see what this is doing. This small nerve branch here. May I have that nerve stimulator, please? Unified and we're going to use the nerve stimulator to see what its function is.
DURETTI FUFA: So here we're going to be watching for the toes to flex in response to our stimulation. OK so it seems strong to FHL right. Yeah. Yeah, for sure. OK more so than FDL. All right. So I mean, this looks like a very nice target, though I'm not sure we can neuralise a little bit more
DURETTI FUFA: to see, but I don't really see unless it could have been coming off more proximal. That's all the same one that we have there. Such a nice long course. Now, there could be two bundles in there. Yeah, it does almost look like there's two bundles. I mean, I'm going to take probably both, but.
DURETTI FUFA: So we have our tibial nerve and that little branch, maybe I can do a small vessel loop cut in half to, to tag that so that we have it now with these tiny nerve branches once we start manipulating them and everything, we can kind of make them go into a palsy so I'm cautious. And even once you stimulate it too much, it can go into a little bit of a palsy
DURETTI FUFA: so I'm not going to electrocute it. I used a pretty small amplitude and frequency there. I'll use the Hemoclip now please. OK, so we have one nerve branch there. We have tibial, full tibial nerve here, and I can just look a little bit more distal to see if anything else is branching off. May I have those long scissors, I have them.
DURETTI FUFA: Thank you. Thanks, Anthony. That's our same nerve branch there. You know, or I could go into this nerve to see if there's anything else
DURETTI FUFA: but this is just so good. Is there anything more proximal that was coming off? A big old vein right there, going to the soleus, soleus nerve branch there. So we're pretty proximal at this point. Yeah. I think we're going to take this FHL branch. It's got tons of swing length. Yeah. The only thing would be if I internal neurolised to bring something that's not just his.
DURETTI FUFA: Do you think his lesser toes are moving also? I'd love it if they were both in there sort of. Can I have the nerve stimulator back, please? [They were flexing, but not as strong] as the FHL. Yeah, Yeah, Yeah. Just one up. Thank you. So if I do this down here, I'm going to do the full tibial nerve.
DURETTI FUFA: Interesting. When I do the full tibial nerve, I'm not even getting the toes right? So it must be that FDL is in there, you know? Yeah. OK. Yeah I mean, it's flexing the first to third toes. OK. Thank you. All right. We'll take that branch there. There's going to be more innervation to it as it goes distal
DURETTI FUFA: so we'll take that branch. OK? So this is our target nerve. Let's give you a nice view of it there. If our main tibial nerve here and a single branch that we've stimulated and identified that it gives motor to the greater and lesser toes. So this is going to be our nerve target and we're just going to find the appropriate swing length to reach our nerve coaptation site, which will be in the lateral incision.
DURETTI FUFA: OK? And in our other incision here. Anterior. Tibia is anterior. There's fibula there. May I have a freer, please? Thank you.
DURETTI FUFA: Come on. Fibula arteries there, nerve is with you. Bluntly tunneling from the medial incision to the lateral incision so that we can get a pathway through the interosseous membrane, through which we'll transfer our tibial nerve branch.
DURETTI FUFA: And no major blood. That's good. Yeah go ahead. Thank you.
DURETTI FUFA: OK, so that gives us a sense of how far we need to transfer it so that we can decide how far distal to cut our target nerve. Now, I'll get you not on pressure on the tibial nerve. What can I use as a sponge? A Raytec? Thank you.
DURETTI FUFA: OK, so we're going to go through up there. This little branch, I wonder. It's so small though. We'll leave that actually it's going to come with us when we take this. Oh actually it'll still be giving to that. Can I have the nerve stimulator? Let's see if there's anything in it.
DURETTI FUFA: Thank you. Really imperceptibly different. Both are pretty strong in the great toe. Yeah. Hard to believe this tiny little thing is going to. Thank you.
DURETTI FUFA: The foot. You know, if you weaken the flexor side, you don't need as much strength in the anterior side. Oh that's good. That's good for him. Right since we know he's going to be compromised but I also want to consider what they're going to use for tendon transfers because he's like going to almost guaranteed need a tendon transfer.
DURETTI FUFA: OK so I'm just now neurolising this thing backwards. Flexor nerve as distally as we can, and we've separated one single fascicle that gives a nice strong motor signal, which we're going to take for our transfer.
DURETTI FUFA: One, two, three. Another micro forcep, please? Thank you. And I'm going to get rid of this vessel loop. May I have a blue background? So here
DURETTI FUFA: is our donor nerve. I don't know if that's a good view. All right. And that's 90. Thank you. I'm going to carry this to the other side. Black scissors?
DURETTI FUFA: Now it looks a little bit like a longer distance. OK. Thank you. Let's see the pathway from both sides now. Keep that there. Give you that room.
DURETTI FUFA: We can nestle it inside there and then try to pull it through. Just feel it with my finger also and then we'll receive it on the other. We'll check how it looks on the other side. Let's make heads or tails of all this stuff. This is our anterior tibial. Could I have a stapler, please? Stapler? Yes.
DURETTI FUFA: Oh do we have one or no? Can I have a moist, moist on here, please? I'll clean up this blood. This is deep. We said we're probably targeting this guy. Thank you. This is our superficial perineal.
DURETTI FUFA: We'll keep down here out of the way. And this is sort of the other branch of our deep. OK so our tunnel now. May I have a langenbach, please? Thank you.
DURETTI FUFA: And a snap. Going underneath. Thank you. Are you able to take that from me, please? So our two options are. I can just pass a forcep through and you try to hand me it.
DURETTI FUFA: Yeah. Let's see what happens if I send a micro forcep. Can you see the nerve there? OK, good. Can I have just a drizzle? Some irrigation on that nerve, please. So I'll send this micro forcep through and you see if you can see it reliably enough that you could hand me it in a micro forcep. Got it.
DURETTI FUFA: And if not, we will try the passing it that way. I need to not stab anything while I'm doing this. This is sharp. OK you got it. Yep trying not to mash it, but control it. If you can do anything to guide it, I'll take the Army Navy back.
DURETTI FUFA: Got it? Just see that it's kind of going smoothly through our track there. Everything looks good still over on your side? Yep so that. No time to see you now. Tips are by me. So good.
DURETTI FUFA: We have a little nerve there. Good. Let me give you that. Can I have the micro forcep, please? I got it. Yep. Yep. OK so it came through. Is there anything that you can see to do to actually, maybe I'll just have you come to this side and mind the nerve on this side.
DURETTI FUFA: Yeah, I can do it. Thank you. OK you can let go. OK, so this is for our other. We'll do this guy first so we don't lose him. And what can we coapt to it?
DURETTI FUFA: Can I have a scalpel, please and it adds in with teeth. You need to find something that looks like good nerve. Yeah to anterior tibial. Like just one of these good fascicles here. Black scissors, please.
DURETTI FUFA: That doesn't look very good. This looks like it's going right into muscle. OK, I like that one. Micro forceps, please and it looks like our distance will be great. Yeah how much time do we have before two hours. 10 minutes.
DURETTI FUFA: All right. Can you see that little trifurcation there? So here we have our donor nerve from the tibial and branching of the deep peroneal nerve.
DURETTI FUFA: This nerve is one of the most healthy looking branches that's going anterior towards the anterior tibial so this will be our recipient. So next we're going to transect the recipient nerve so that we can coapt end to end here. Can I have mixture and vessel loop, the small micro one if you have.
DURETTI FUFA: Yeah it's OK. It probably it's a little delicate so we'll just do this. Is that far enough is all I want to know. Micro forcep please. Thank you.
DURETTI FUFA: So the closer I can get it to the muscle, the better. You know, in terms of its speed to recovery. However, I need this to not be on tension. I'm going to cut the nerve now. So we're going to cut our donor, our recipient excuse me, nerve here.
DURETTI FUFA: Debakey? Would be much better to do this under the microscope. Again, I just want to get him approximated and I'm going to keep the blue background so that we can find it. I may even paint it blue so that we can see it when we come back. Although it's going to be increasingly hard because the tourniquet is going to go down. That's true.
DURETTI FUFA: So maybe I just need to buy it now. Raul. I mean, Sherwin, can you drape the microscope, please? And do we have the Versa wrap ready? Yeah. OK.
DURETTI FUFA: Thanks. Microscope? Generally in my career, I try not to have anybody have to hold anything because you kind of like, inevitably muscles will fire and stuff, but we're in a little hole.
DURETTI FUFA: The Versa wrap is open as well? OK, I'll take the 10-0. Thank you. Scissors curved.
DURETTI FUFA: I'll take it. Thank you. OK, that's our transfer now. Thank goodness. OK that's it right here. This guy. OK, good.
DURETTI FUFA: Where do we go from here? I think it might be over there. OK. OK. Major bleeding over there. That's good. And you have the other half of background that we gave back to you. Yeah. Thank you.
DURETTI FUFA: We have more than enough, so that's great. Nerve coaptation from the nerve transfer complete anteriorly here. What's remaining is that we're going to graft from the common peroneal nerve to the superficial peroneal nerve with a nerve allograft in order to give the patient sensory recovery and we will rely on our nerve transfer and plan for tendon transfers for his motor recovery.
DURETTI FUFA: Our nerve gap here is 6 centimeters. So in this case of a common peroneal nerve palsy, after sharp laceration, the inspection of the peroneal nerve repair demonstrated large neuroma barely in continuity. So our plan was modified from an end to side supercharge of the anterior tibial branch of the peroneal nerve to a direct end to end transfer given that there was no sign that there was going to be any motor recovery across that repair at the, and that nerve transfer went well.
DURETTI FUFA: We identified a fascicle from the posterior tibial going largely to the digital flexors, and co-apted that to the anterior to branch up of the anterior tibial nerve with a very nice size match 10-0 nylon under the microscope. The second portion then of the procedure was for the sensory nerve recovery performed with a nerve allograft again under microscope for end to end repair
DURETTI FUFA: with a nerve graft measuring six centimeters. The patient will be placed in a boot that's going to block ankle range of motion postoperatively and begin nerve rehabilitation about four weeks down the line. [VIDEO ENDS]
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