Use of ultrasound and targeted physiotherapy in the management of a nerve suture performed under joint flexion

Background In 1915, when Delorme described three general requirements for successful nerve repair—(1) resecting scar until a healthy bed is secured, (2) excising damaged nerve until healthy stumps are reached, and (3) placing tension-free sutures, either by adequately mobilizing adjacent joints or nerve grafting—his work was heavily criticized. One century later, history has vindicated all but one of these claims. Flexing adjacent joints to avoid nerve grafts remains controversial, though this practice has increased in recent years. Methods An 11-year-old male suffered a penetrating domestic accident that resulted in complete foot drop. At surgery, a 6-cm gap was treated with direct nerve sutures, for which the knee was maintained in 60° flexion in a cast. To avoid damage to the nerve sutures, ultrasound and an intense, though cautious physiotherapy program were employed to guide the progression of knee extension. Results The patient started to show clear signs of peroneal motor function recovery within 3 months of surgical repair, and almost complete recovery by 4 months postoperatively. Conclusions Using physiotherapy and ultrasound might validate the classic joint-flexion technique in select patients with lower-limb nerve injuries.