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Continue Ankle-foot orthosis (AFO) and physical therapy
8%
400/5011
Repeat neurolysis with possible nerve repair
1%
42/5011
Peroneus tertius transfer
4%
221/5011
Peroneus tertius transfer with achilles tendon lengthening
7%
345/5011
Posterior tibial tendon transfer to dorsum of foot
79%
3983/5011
Select Answer to see Preferred Response
A peroneal nerve palsy (with intact posterior tibial tendon strength) that has failed conservative management is best treated with a posterior tibial tendon transfer to the dorsum of the foot. Peroneal nerve palsy following total knee arthroplasty or knee dislocation is a potentially devastating complication that may lead to lack of active dorsiflexion and a compensatory steppage gait pattern. Initial management consists of an ankle-foot orthosis (AFO) and physical therapy to maintain passive ankle dorsiflexion. If nerve function fails to return during the course of conservative management and the patient demonstrates intact posterior tibialis muscle strength, posterior tibial tendon transfer to the dorsum of the foot has been shown to improve functional outcomes and eliminate the need for continued bracing. The most common procedure for posterior tibial tendon transfer involves transferring the tendon through the interosseous membrane and inserting the tendon onto the lateral cuneiform. Prahinski et al. review the results of 10 patients at 61 months' follow-up who underwent the Bridle transfer (posterior tibialis transfer through interosseous membrane and peroneus longus to front of lateral malleolus) for peroneal nerve palsies. They conclude the Bridle procedure is adequate for return to function in low-demand individuals, but may fail over time in those who return to vigorous physical activity. Rodriguez et al. review the results of 10 patients who underwent the Bridle procedure for peroneal nerve palsy in an attempt to balance their foot and provide dorsiflexion. All of their patients were brace free at an average follow-up of 6.8 years. Video V shows the clinical results 10 weeks after transfer of the tibialis posterior tendon for a drop foot. Incorrect Answers: Answer 1: An AFO and physical therapy is appropriate for initial management while awaiting potential nerve recovery. Answer 2: Repeat neurolysis is unlikely to achieve clinical improvement after initial failure. Answer 3: The peroneus tertius is also located within the anterior compartment and is likely to be involved in her nerve injury pattern. Answer 4: The peroneus tertius is also located within the anterior compartment and is likely to be involved in her nerve injury pattern.
4.0
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