Obturator nerve transfer for femoral nerve reconstruction: Anatomic study and clinical application

Background: Femoral nerve lesion causes significant disability. In many cases, the availability of the proximal stump is in question and further complicates surgical management by severely limiting reconstructive options and precluding nerve graft reconstruction. The purpose of this report is to describe the successful restoration of quadriceps function by distal nerve transfer at the level of the thigh without functional donor morbidity and the findings of cadaveric dissections of the obturator and femoral nerve branches. Methods: Eight fresh frozen cadaveric lower limbs were dissected at the region of the groin and thigh. Two patients were referred to us with complete femoral nerve palsy and unavailability of the proximal femoral nerve for reconstruction by conventional methods. Distal nerve transfers were performed using the anterior branch of the obturator nerve and in one case, the motor branch to the tensor fasciae latae to reinnervate the rectus femoris and vastus medialis muscles. Results: As measured in cadaveric specimens, the transferable lengths of each donor nerve branch when used to innervate any combination of quadriceps muscles provide plenty of length for tension-free end-to-end coaptations. One patient recovered 3 to 4/5 Medical Research Council grade knee extension and the other 4+/5 knee extension. The latter patient is able to walk, run, and use stairs normally, whereas the former still has difficulty with fast ambulation, running, and stairs. Conclusion: The authors present a novel reconstructive approach that yields good clinical outcomes, as well as an anatomic study that demonstrates the feasibility of this technique.