Thomas J. Francel and A. Lee Dellon
FUNCTIONAL LIMB SALVAGE COMBINING GASTROCNEMIUS NEUROTIZATION AND POSTERIOR Downloaded by: National University of Singapore. Copyrighted material.
TIBIAL NERVE GRAFTING: A CASE REPORT ABSTRACT Functional limb salvage requires motor and sensory reconstruction of the extremity. An avulsion of the tibial nerve in the popliteal fossa after arthroscopy is presented. Functional limb recovery necessitated intraoperative nerve mapping by awake stimulation, neurotization of the gastrocnemius muscle bellies, and interfascicular posterior tibial nerve grafting. Eighteen-month follow-up demonstrated good gastrocnemius motor function and protective sensation on the plantar surface. The patient is ambulatory without the need of an assistive device.
Traumatic loss of posterior tibial nerve sensibility is considered by some authors to be an indication for amputation.1 In the lower extremity, the distance from the nerve-cell bodies results in slow regeneration and, therefore, nerve reconstruction done proximal to the knee may not achieve functional limb salvage. Nevertheless, there has been increasing support for nerve reconstruction, even in the distal leg where interfascicular nerve grafting of the posterior tibial nerve has not only given good relief of painful in-continuity neuromas, but has also restored functional sensibility.2 With complete disruption of the distal nerve from muscle, reconstruction is still possible by "neurotization" of the muscle itself with a nerve graft. Function after neurotization is not as good as with primary neurorrhaphy or nerve grafting.3-5 We present a patient in whom a strategy for limb salvage was successful after complete disruption of the tibial nerve proximal to the knee and compression of the common peroneal nerve at the knee.
CASE REPORT E.Y. was a 17-year-old female who underwent arthroscopic right-knee surgery after a skiing accident. After the arthroscopic procedure, the limb showed severe vascular compromise. Exploration via a posterior popliteal approach revealed complete disruption of the popliteal vessels, necessitating restoration of the popliteal artery and vein by saphenous vein grafting. At the time of exploration, the tibial nerve was found completely transected proximally and no distal nerve was noted. A secondary nerve reconstruction was carried out and the wound was closed. Electrodiagnostic studies documented complete absence of tibial and common peroneal nerve function. Although Doppler studies showed the venous channels to be patent, the lower extremity below the knee was markedly edematous. Three months later, there was no electrodiagnostic evidence of reinnervation of com-
Division of Plastic Surgery, Washington University, Saint Louis, Missouri and Division of Plastic Surgery, Department of Neurological Surgery, Johns Hopkins Hospital, Baltimore, Maryland Reprint requests-. Dr. Dellon, Suite 104, 3901 Greenspring Ave., Baltimore, MD 21211 Accepted for publication January 2, 1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
209
mon peroneal or posterior tibial nerve-innervated muscles. The leg and foot remained edematous. In order to reconstruct the limb's neural function, the patient was placed in the prone position and the popliteal region explored under local anesthesia. This allowed mapping of the proximal tibial nerve stump by direct electrical stimulation (Xomed-Thrace disposable nerve stimulator) (Fig. 1). Stimulation of the gastrocnemius motor fascicles was interpreted by the patient as a crampy sensation in the calf, in contrast to stimulation of the sensory fascicles which was interpreted as an intense, painful sensation localized to the toes and bottom of the foot. After successful mapping and separation of the gastrocnemius motor fascicles from the sensory fascicles, the patient was placed under general anesthesia. The common peroneal nerve was found to be intact. The contralateral sural nerve was harvested, including the peroneal communicating branch, i.e., lateral sural nerve (Fig. 2). The motor branches to the medial and lateral gastrocnemius muscle bellies had been avulsed. The right posterior tibial nerve was identified at the mid-calf level. Two 15-cm interfascicular interposition sural nerve grafts were sutured to the proximal tibial sensory fascicles and distal to the entire posterior tibial nerve, with the goal of restoring protective sensation to the foot. Segments of the har-
210
Figure 1. Intraoperative view at time of "awake" electrical stimulation. Stimulator (Xomed-Thrace disposable nerve stimulator) touching a motor fascicle of posterior tibial nerve. Vessel loops about medial sural nerve, lateral sural nerve, and common peroneal nerve. Proximal is toward top of photograph. Sutures mark two primarily motor fascicles (to gastrocnemius) and larger central fascicle to plantar aspect of foot.
MAY 1992
Figure 2. The harvested sural nerve. Note that dissection of the lateral sural component to the (common) sural nerve permits harvesting enough extra nerve to use for the fourth long interfascicular graft. Proximal is toward top of photograph.
vested sural nerve were used to neurotize directly the medial and lateral gastrocnemius muscle bellies from the proximal motor fascicles. A decompression of the common peroneal nerve at the fibular head was done with internal neurolysis along the 8-cm segment proximal to this part of entrapment (Fig. 3). The patient began to exhibit gastrocnemius and anterior tibial compartment contractions approximately six months after release of the peroneal nerve and neurotization of the gastrocnemius muscle bellies. Along with early muscle contraction came resolution of the lower extremity edema. One-year follow-up showed early return of plantar and dorsal foot sensation, no peripheral edema, and EMG studies revealing successful neurotization of the lateral and medial gastrocnemius muscle bellies, with active plantar flexion and increasing recruitment. At 16 months, active range of ankle flexion was approximately 45 degrees, while standing. Vibratory perception to 30 Hz had returned to the level of the metacarpal head. Unmyelinated fiber-mediated perception, such as pain, had almost progressed to the big toe. Excellent toe extension and dorsiflexion of the ankle had recovered (Fig. 4).
DISCUSSION An extremity injury involving a proximal nerve with motor and sensory components presents diffi-
Downloaded by: National University of Singapore. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 3
FUNCTIONAL LIMB SALVAGE/FRANCEL, DELLON
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Figure 3. Intraoperative view after neurolysis of common peroneal nerve (left) and after interfascicular nerve grafting (right) with two fascicles to the posterior tibial nerve and neurotization of the medial and lateral gastrocnemius muscle bellies.
culty in nerve reconstruction. In order to achieve good results, intraoperative nerve mapping has been established.67 The work by Sunderland has been expanded by intraoperative nerve staining techniques 8 - 10 and nerve stimulation under local anesthesia.11-13 It is generally stated that stimulation of the sensory fascicle will evoke sensation, while stimulation of the motor fascicle is "silent". In this patient, we found that the sensation was perceived as cramping in the calf, we presume secondary to the impulses generated via the stretch receptors within the muscle. This "muscle sense"14 is usually not emphasized, but would be valuable to suggest to the patient in preoperative counseling, to facilitate the patient's correct intraoperative response. Avulsion of a motor nerve from the motor endplates cannot be reconstructed by classic nerve repair or grafting. If neurotization is performed, experimental response has been shown to occur, but is severely diminished.5 Others have shown good clinical function after direct neurotization, especially of upper extremity injuries.3 How many fascicles are needed to restore complete neurotization is not established. In this patient, a minimal number of fascicles, one per muscle belly, reestablished the motor control of the gastrocnemius muscle. Successful restoration of sensation to the sole of the foot after posterior tibial nerve injury is required to
prevent recurrent injury to an insensate foot. Disruption of the posterior tibial nerve has been compared with ulnar and median nerve injury in the upper extremity. Most of the early nerve grafting was performed with "cabled" or trunk grafts15 with variable success. Cable grafts have an ischemic component because the center is not well vascularized. In contrast, interfascicular nerve grafting with multiple, separated fascicles, allows all the nerve grafts to be surrounded by vascularized tissue at the recipient site. 216 We present a case of disruption of the motor and sensory nerve fascicles to the distal leg. Nerve reconstruction in this case revealed the importance of: 1) direct intraoperative electrical nerve stimulation to isolate motor from sensory fascicles; 2) harvesting of the peroneal communicating branch of the sural nerve to maximize the length of the nerve graft available; 3) using non-cabled nerve grafts to minimize ischemia of the nerve grafts; 4) neurotization with minimal fascicles to restore motor function to the extremity and resist edema; and 5) the important role of sensibility testing and sensory reeducation in the lower extremity. While serial EMGs documented recovery of muscle function after neurotization, sensibility evaluation documented recovery of neural regeneration into the surface of the foot. For both the peroneal nerve, which must have sustained a Sunderland class III injury and the posterior tibial, which sustained a Sunderland
211
MAY 1992
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 3
Figure 4. Sixteen months after a nerve graft in the distal thigh, the patient can contract the gastrocnemius sufficiently to produce ankle flexion against resistance (top), and has recovered smallfiber sensory perception to the proximal phalanx of the big toe on the plantar surface and large-fiber sensory perception (vibration and touch) to the level of the metatarsal (bottom).
212
FUNCTIONAL LIMB SALVAGE/FRANCEL, DELLON
REFERENCES Lange RH, Bach AW, Hansen ST, et al.-. Open tibial fractures with associated injuries: Prognosis for limb salvage. J Trauma 25:203, 1985 Dellon AL, Mackinnon SE: Results of posterior tibial nerve grafting at the ankle. I Reconstr Microsurg 7:81, 1991 Brunelli G: Direct neurotization of severely damaged muscles. I Hand Surg 7:572, 1982 Frey M, Gruber H, Holle J, Freilinger G: An experimental comparison of different kinds of muscle reinnervation: Nerve suture, nerve implantation and muscle neurotization. Plast Reconstr Surg 69:659, 1982 McNamara M), Garrett WE, Seaber AV, et al: Neurorrhaphy, nerve grafting and neurotization: A functional comparison of nerve reconstruction techniques. I Hand Surg 12A:354, 1987 Sunderland S, Ray LI: The intraneural topography of the sciatic nerve and its popliteal divisions in man. Brain 71:242, 1948
7.
Sunderland S: Nerve and Nerve Injuries, 2nd ed. Edinburgh: Churchill Livingston, 1978 8. Kruber H, Zenker W: Acetylcholinesterase: Histochemical differentiation between motor and sensory nerve fibers. Brain Res 51:207, 1973 9. Engel 1, Ganel A, MelamedR, eta!.: Cholineacetyltransferasefor differentiation between human motor and sensory fibers. Ann Plast Surg 4:367, 1979 10. Ganel A, Engel I, Raymond S: Intraoperative identification of peripheral nerve fascicle: Use of a new rapid biochemical assay technique. Orthop Rev 15:85, 1986 11. Gaul IS: Electrical fascicle identification as an adjunct to nerve repair. Hand Clin 2:709, 1986 12. Williams HB, Terzis JK: Single fascicular recording: An intraoperative diagnostic tool for the management of peripheral nerve lesions. Plast Reconstr Surg 57:562, 1976 13. Hakstian RW: Funicular orientation by direct stimulation: An aid to peripheral nerve repair. I Bone Joint Surg 50:1178, 1968 14. Dellon AL: Muscle sense or non-sense. Ann Plast Surg 26:444, 1991 15. Seddon HJ: The use of autogenous grafts for the repair of large gaps in peripheral nerves. Brit I Surg 35:151, 1947 16. Millesi H, Miessl G, Berger A: The interfascicular nerve grafting of the median and ulnar nerves. I Bone Joint Surg 54A:727, 1972 17. Mackinnon SE, Dellon AL: Surgery of the Peripheral Nerve. New York: Thieme, 1988, chap 2 18. Dellon AL, Curtis RM, Edgerton MT: Evaluating recovery of sensation in the hand after nerve injury. Johns Hopkins Med J 130:235, 1972 19. Dellon AL: Evaluation of Sensibility and Re-education of Sensation in the Hand. Baltimore: Williams and Wilkins, 1981, chap 7 20. Dellon AL: Surgical treatment of the symptoms of diabetic neuropathy. Plast Reconstr Surg 89:689, 1992
Downloaded by: National University of Singapore. Copyrighted material.
class V injury17 recovery of sensibility occurred in the order of pain first, closely followed by temperature perception, then touch manifested by perception of 30 Hz, then 256 Hz. Moving touch perception recovered about the same time as 30 Hz, as previously observed.1819 This pattern has been observed generally during neural regeneration after nerve grafting in the lower extremity2 and also in the lower extremity of diabetics following neurolysis of the posterior tibial nerve.20
213
FUNCTIONAL LIMB SALVAGE COMBINING GASTROCNEMIUS NEUROTIZATION AND POSTERIOR Downloaded by: National University of Singapore. Copyrighted material.
TIBIAL NERVE GRAFTING: A CASE REPORT ABSTRACT Functional limb salvage requires motor and sensory reconstruction of the extremity. An avulsion of the tibial nerve in the popliteal fossa after arthroscopy is presented. Functional limb recovery necessitated intraoperative nerve mapping by awake stimulation, neurotization of the gastrocnemius muscle bellies, and interfascicular posterior tibial nerve grafting. Eighteen-month follow-up demonstrated good gastrocnemius motor function and protective sensation on the plantar surface. The patient is ambulatory without the need of an assistive device.
Traumatic loss of posterior tibial nerve sensibility is considered by some authors to be an indication for amputation.1 In the lower extremity, the distance from the nerve-cell bodies results in slow regeneration and, therefore, nerve reconstruction done proximal to the knee may not achieve functional limb salvage. Nevertheless, there has been increasing support for nerve reconstruction, even in the distal leg where interfascicular nerve grafting of the posterior tibial nerve has not only given good relief of painful in-continuity neuromas, but has also restored functional sensibility.2 With complete disruption of the distal nerve from muscle, reconstruction is still possible by "neurotization" of the muscle itself with a nerve graft. Function after neurotization is not as good as with primary neurorrhaphy or nerve grafting.3-5 We present a patient in whom a strategy for limb salvage was successful after complete disruption of the tibial nerve proximal to the knee and compression of the common peroneal nerve at the knee.
CASE REPORT E.Y. was a 17-year-old female who underwent arthroscopic right-knee surgery after a skiing accident. After the arthroscopic procedure, the limb showed severe vascular compromise. Exploration via a posterior popliteal approach revealed complete disruption of the popliteal vessels, necessitating restoration of the popliteal artery and vein by saphenous vein grafting. At the time of exploration, the tibial nerve was found completely transected proximally and no distal nerve was noted. A secondary nerve reconstruction was carried out and the wound was closed. Electrodiagnostic studies documented complete absence of tibial and common peroneal nerve function. Although Doppler studies showed the venous channels to be patent, the lower extremity below the knee was markedly edematous. Three months later, there was no electrodiagnostic evidence of reinnervation of com-
Division of Plastic Surgery, Washington University, Saint Louis, Missouri and Division of Plastic Surgery, Department of Neurological Surgery, Johns Hopkins Hospital, Baltimore, Maryland Reprint requests-. Dr. Dellon, Suite 104, 3901 Greenspring Ave., Baltimore, MD 21211 Accepted for publication January 2, 1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
209
mon peroneal or posterior tibial nerve-innervated muscles. The leg and foot remained edematous. In order to reconstruct the limb's neural function, the patient was placed in the prone position and the popliteal region explored under local anesthesia. This allowed mapping of the proximal tibial nerve stump by direct electrical stimulation (Xomed-Thrace disposable nerve stimulator) (Fig. 1). Stimulation of the gastrocnemius motor fascicles was interpreted by the patient as a crampy sensation in the calf, in contrast to stimulation of the sensory fascicles which was interpreted as an intense, painful sensation localized to the toes and bottom of the foot. After successful mapping and separation of the gastrocnemius motor fascicles from the sensory fascicles, the patient was placed under general anesthesia. The common peroneal nerve was found to be intact. The contralateral sural nerve was harvested, including the peroneal communicating branch, i.e., lateral sural nerve (Fig. 2). The motor branches to the medial and lateral gastrocnemius muscle bellies had been avulsed. The right posterior tibial nerve was identified at the mid-calf level. Two 15-cm interfascicular interposition sural nerve grafts were sutured to the proximal tibial sensory fascicles and distal to the entire posterior tibial nerve, with the goal of restoring protective sensation to the foot. Segments of the har-
210
Figure 1. Intraoperative view at time of "awake" electrical stimulation. Stimulator (Xomed-Thrace disposable nerve stimulator) touching a motor fascicle of posterior tibial nerve. Vessel loops about medial sural nerve, lateral sural nerve, and common peroneal nerve. Proximal is toward top of photograph. Sutures mark two primarily motor fascicles (to gastrocnemius) and larger central fascicle to plantar aspect of foot.
MAY 1992
Figure 2. The harvested sural nerve. Note that dissection of the lateral sural component to the (common) sural nerve permits harvesting enough extra nerve to use for the fourth long interfascicular graft. Proximal is toward top of photograph.
vested sural nerve were used to neurotize directly the medial and lateral gastrocnemius muscle bellies from the proximal motor fascicles. A decompression of the common peroneal nerve at the fibular head was done with internal neurolysis along the 8-cm segment proximal to this part of entrapment (Fig. 3). The patient began to exhibit gastrocnemius and anterior tibial compartment contractions approximately six months after release of the peroneal nerve and neurotization of the gastrocnemius muscle bellies. Along with early muscle contraction came resolution of the lower extremity edema. One-year follow-up showed early return of plantar and dorsal foot sensation, no peripheral edema, and EMG studies revealing successful neurotization of the lateral and medial gastrocnemius muscle bellies, with active plantar flexion and increasing recruitment. At 16 months, active range of ankle flexion was approximately 45 degrees, while standing. Vibratory perception to 30 Hz had returned to the level of the metacarpal head. Unmyelinated fiber-mediated perception, such as pain, had almost progressed to the big toe. Excellent toe extension and dorsiflexion of the ankle had recovered (Fig. 4).
DISCUSSION An extremity injury involving a proximal nerve with motor and sensory components presents diffi-
Downloaded by: National University of Singapore. Copyrighted material.
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 3
FUNCTIONAL LIMB SALVAGE/FRANCEL, DELLON
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Figure 3. Intraoperative view after neurolysis of common peroneal nerve (left) and after interfascicular nerve grafting (right) with two fascicles to the posterior tibial nerve and neurotization of the medial and lateral gastrocnemius muscle bellies.
culty in nerve reconstruction. In order to achieve good results, intraoperative nerve mapping has been established.67 The work by Sunderland has been expanded by intraoperative nerve staining techniques 8 - 10 and nerve stimulation under local anesthesia.11-13 It is generally stated that stimulation of the sensory fascicle will evoke sensation, while stimulation of the motor fascicle is "silent". In this patient, we found that the sensation was perceived as cramping in the calf, we presume secondary to the impulses generated via the stretch receptors within the muscle. This "muscle sense"14 is usually not emphasized, but would be valuable to suggest to the patient in preoperative counseling, to facilitate the patient's correct intraoperative response. Avulsion of a motor nerve from the motor endplates cannot be reconstructed by classic nerve repair or grafting. If neurotization is performed, experimental response has been shown to occur, but is severely diminished.5 Others have shown good clinical function after direct neurotization, especially of upper extremity injuries.3 How many fascicles are needed to restore complete neurotization is not established. In this patient, a minimal number of fascicles, one per muscle belly, reestablished the motor control of the gastrocnemius muscle. Successful restoration of sensation to the sole of the foot after posterior tibial nerve injury is required to
prevent recurrent injury to an insensate foot. Disruption of the posterior tibial nerve has been compared with ulnar and median nerve injury in the upper extremity. Most of the early nerve grafting was performed with "cabled" or trunk grafts15 with variable success. Cable grafts have an ischemic component because the center is not well vascularized. In contrast, interfascicular nerve grafting with multiple, separated fascicles, allows all the nerve grafts to be surrounded by vascularized tissue at the recipient site. 216 We present a case of disruption of the motor and sensory nerve fascicles to the distal leg. Nerve reconstruction in this case revealed the importance of: 1) direct intraoperative electrical nerve stimulation to isolate motor from sensory fascicles; 2) harvesting of the peroneal communicating branch of the sural nerve to maximize the length of the nerve graft available; 3) using non-cabled nerve grafts to minimize ischemia of the nerve grafts; 4) neurotization with minimal fascicles to restore motor function to the extremity and resist edema; and 5) the important role of sensibility testing and sensory reeducation in the lower extremity. While serial EMGs documented recovery of muscle function after neurotization, sensibility evaluation documented recovery of neural regeneration into the surface of the foot. For both the peroneal nerve, which must have sustained a Sunderland class III injury and the posterior tibial, which sustained a Sunderland
211
MAY 1992
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 3
Figure 4. Sixteen months after a nerve graft in the distal thigh, the patient can contract the gastrocnemius sufficiently to produce ankle flexion against resistance (top), and has recovered smallfiber sensory perception to the proximal phalanx of the big toe on the plantar surface and large-fiber sensory perception (vibration and touch) to the level of the metatarsal (bottom).
212
FUNCTIONAL LIMB SALVAGE/FRANCEL, DELLON
REFERENCES Lange RH, Bach AW, Hansen ST, et al.-. Open tibial fractures with associated injuries: Prognosis for limb salvage. J Trauma 25:203, 1985 Dellon AL, Mackinnon SE: Results of posterior tibial nerve grafting at the ankle. I Reconstr Microsurg 7:81, 1991 Brunelli G: Direct neurotization of severely damaged muscles. I Hand Surg 7:572, 1982 Frey M, Gruber H, Holle J, Freilinger G: An experimental comparison of different kinds of muscle reinnervation: Nerve suture, nerve implantation and muscle neurotization. Plast Reconstr Surg 69:659, 1982 McNamara M), Garrett WE, Seaber AV, et al: Neurorrhaphy, nerve grafting and neurotization: A functional comparison of nerve reconstruction techniques. I Hand Surg 12A:354, 1987 Sunderland S, Ray LI: The intraneural topography of the sciatic nerve and its popliteal divisions in man. Brain 71:242, 1948
7.
Sunderland S: Nerve and Nerve Injuries, 2nd ed. Edinburgh: Churchill Livingston, 1978 8. Kruber H, Zenker W: Acetylcholinesterase: Histochemical differentiation between motor and sensory nerve fibers. Brain Res 51:207, 1973 9. Engel 1, Ganel A, MelamedR, eta!.: Cholineacetyltransferasefor differentiation between human motor and sensory fibers. Ann Plast Surg 4:367, 1979 10. Ganel A, Engel I, Raymond S: Intraoperative identification of peripheral nerve fascicle: Use of a new rapid biochemical assay technique. Orthop Rev 15:85, 1986 11. Gaul IS: Electrical fascicle identification as an adjunct to nerve repair. Hand Clin 2:709, 1986 12. Williams HB, Terzis JK: Single fascicular recording: An intraoperative diagnostic tool for the management of peripheral nerve lesions. Plast Reconstr Surg 57:562, 1976 13. Hakstian RW: Funicular orientation by direct stimulation: An aid to peripheral nerve repair. I Bone Joint Surg 50:1178, 1968 14. Dellon AL: Muscle sense or non-sense. Ann Plast Surg 26:444, 1991 15. Seddon HJ: The use of autogenous grafts for the repair of large gaps in peripheral nerves. Brit I Surg 35:151, 1947 16. Millesi H, Miessl G, Berger A: The interfascicular nerve grafting of the median and ulnar nerves. I Bone Joint Surg 54A:727, 1972 17. Mackinnon SE, Dellon AL: Surgery of the Peripheral Nerve. New York: Thieme, 1988, chap 2 18. Dellon AL, Curtis RM, Edgerton MT: Evaluating recovery of sensation in the hand after nerve injury. Johns Hopkins Med J 130:235, 1972 19. Dellon AL: Evaluation of Sensibility and Re-education of Sensation in the Hand. Baltimore: Williams and Wilkins, 1981, chap 7 20. Dellon AL: Surgical treatment of the symptoms of diabetic neuropathy. Plast Reconstr Surg 89:689, 1992
Downloaded by: National University of Singapore. Copyrighted material.
class V injury17 recovery of sensibility occurred in the order of pain first, closely followed by temperature perception, then touch manifested by perception of 30 Hz, then 256 Hz. Moving touch perception recovered about the same time as 30 Hz, as previously observed.1819 This pattern has been observed generally during neural regeneration after nerve grafting in the lower extremity2 and also in the lower extremity of diabetics following neurolysis of the posterior tibial nerve.20
213
