Clinical Orthopaedics and Related Research®

, Volume 472, Issue 9, pp 2637–2643 | Cite as

Posterior Tibial Tendon Transfer Improves Function for Foot Drop After Knee Dislocation

  • Marius Molund
  • Lars EngebretsenEmail author
  • Kjetil Hvaal
  • Jan Hellesnes
  • Elisabeth Ellingsen Husebye
Symposium: Management of the Dislocated Knee



Knee dislocation may be associated with an injury to the common peroneal nerve with a subsequent foot drop. Previous studies have demonstrated good functional results after posterior tibial tendon transfer in patients with foot drop. No studies, to our knowledge, have focused exclusively on knee dislocation as the cause of common peroneal nerve injury leading to foot drop.


We determined the percentage of patients developing common peroneal nerve paresis after knee dislocation, the symptom improvement rate in these patients, and patient-reported outcomes (American Orthopaedic Foot and Ankle Society [AOFAS] ankle-hindfoot score), ankle dorsiflexion strength, and ROM in patients with no symptom improvement treated with posterior tibial tendon transfer.


Two hundred forty-seven patients with knee dislocation, defined as an injury to both the ACL and PCL with an additional injury to the lateral and/or medial ligaments (Schenck Classification II to IV), were registered in a single institution’s database between 1996 and 2011. The database was queried for the frequency of documented injuries to the common peroneal nerve and, among those, the frequency of spontaneous resolution after this injury. Patients demonstrating no active dorsiflexion 12 months after injury generally were offered posterior tibial tendon transfer. Postoperatively, patients were evaluated for AOFAS score, ankle dorsiflexion strength, and ROM.


Forty-three patients (17%) had a common peroneal nerve paresis at admission. At 1-year followup, 15 of 43 patients (35%) had experienced symptom improvement. One patient experienced spontaneous improvement later than 1 year after injury. One patient was lost to followup. A below-knee amputation was performed in one patient due to the initial trauma. Seven patients were satisfied with their function using a brace or had medical contraindications to surgical treatment, while four patients refused the proposed operation with a tendon transfer, leaving 14 patients treated with posterior tibial tendon transfer. In the 12 patients available for evaluation, mean AOFAS score was 91 of 100. Mean (± SD) dorsiflexion strength was 118 (± 55) Nm on the operated side and 284 (± 94) Nm on the unaffected side (p < 0.001). Mean ROM was 67° (± 15°) on the operated side and 93° (± 14°) on the unaffected side (p < 0.001).


Based on these findings, we recommend posterior tibial tendon transfer for treatment of foot drop that persists at least 1 year after knee dislocation.

Level of Evidence

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.


Common Peroneal Nerve Tendon Transfer Knee Dislocation Posterior Tibial Tendon Symptom Improvement Rate 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors thank Tore Fjalestad MD, PhD for help with the statistical analysis.


  1. 1.
    Breukink SO, Spronk CA, Dijkstra PU, Heybroek E, Marck KW. [Transposition of the tendon of M. tibialis posterior an effective treatment of drop foot; retrospective study with follow-up in 12 patients] [in Dutch]. Ned Tijdschr Geneeskd. 2000;144:604–608.PubMedGoogle Scholar
  2. 2.
    Cho D, Saetia K, Lee S, Kline DG, Kim DH. Peroneal nerve injury associated with sports-related knee injury. Neurosurg Focus. 2011;31:E11.PubMedCrossRefGoogle Scholar
  3. 3.
    Engebretsen L, Risberg MA, Robertson B, Ludvigsen TC, Johansen S. Outcome after knee dislocations: a 2–9 years follow-up of 85 consecutive patients. Knee Surg Sports Traumatol Arthrosc. 2009;17:1013–1026.PubMedCrossRefGoogle Scholar
  4. 4.
    Gasq D, Molinier F, Reina N, Dupui P, Chiron P, Marque P. Posterior tibial tendon transfer in the spastic brain-damaged adult does not lead to valgus flatfoot. Foot Ankle Surg. 2013;19:182–187.PubMedCrossRefGoogle Scholar
  5. 5.
    Goitz RJ, Tomaino MM. Management of peroneal nerve injuries associated with knee dislocations. Am J Orthop. 2003;32:14–16.PubMedGoogle Scholar
  6. 6.
    Green NE, Allen BL. Vascular injuries associated with dislocation of the knee. J Bone Joint Surg Am. 1977;59:236–239.PubMedGoogle Scholar
  7. 7.
    Hove LM, Nilsen PT. Posterior tibial tendon transfer for drop-foot. 20 cases followed for 1–5 years. Acta Orthop Scand. 1998;69:608–610.PubMedCrossRefGoogle Scholar
  8. 8.
    Janssen JC, Le-Ngoc L. Intratester reliability and validity of concentric measurements using a new hand-held dynamometer. Arch Phys Med Rehabil. 2009;90:1541–1547.PubMedCrossRefGoogle Scholar
  9. 9.
    Johnson ME, Foster L, DeLee JC. Neurologic and vascular injuries associated with knee ligament injuries. Am Sports Med. 2008;36:2448–2462.CrossRefGoogle Scholar
  10. 10.
    Kilic A, Parmaksizoglu AS, Kabukcuoglu Y, Bilgili F, Sokucu S. [Extramembranous transfer of the tibialis posterior tendon for the correction of drop foot deformity] [in Turkish]. Acta Orthop Traumatol Turc. 2008;42:310–315.PubMedCrossRefGoogle Scholar
  11. 11.
    Kim DH, Murovic JA, Tiel RL, Kline DG. Management and outcomes in 318 operative common peroneal nerve lesions at the Louisiana State University Health Sciences Center. Neurosurgery. 2004;54:1421–1428; discussion 1428–1429.Google Scholar
  12. 12.
    Klimkiewicz JJ, Petrie RS, Harner CD. Surgical treatment of combined injury to anterior cruciate ligament, posterior cruciate ligament, and medial structures. Clin Sports Med. 2000;19:479–492, vii.Google Scholar
  13. 13.
    Malizos KN, Xenakis T, Mavrodontidis AN, Xanthis A, Korobilias AB, Soucacos PN. Knee dislocations and their management: a report of 16 cases. Acta Orthop Scand Suppl. 1997;275:80–83.PubMedGoogle Scholar
  14. 14.
    Meyers MH, Harvey JP Jr. Traumatic dislocation of the knee joint: a study of eighteen cases. J Bone Joint Surg Am. 1971;53:16–29.PubMedGoogle Scholar
  15. 15.
    Motion-online. Available at: Accessed January 30, 2014.
  16. 16.
    Niall DM, Nutton RW, Keating JF. Palsy of the common peroneal nerve after traumatic dislocation of the knee. J Bone Joint Surg Br. 2005;87:664–667.PubMedCrossRefGoogle Scholar
  17. 17.
    Omid R, Thordarson DB, Charlton TP. Adult-acquired flatfoot deformity following posterior tibialis to dorsum transfer: a case report. Foot Ankle Int. 2008;29:351–353.PubMedCrossRefGoogle Scholar
  18. 18.
    Ozkan T, Tuncer S, Ozturk K, Aydin A, Ozkan S. Tibialis posterior tendon transfer for persistent drop foot after peroneal nerve repair. J Reconstr Microsurg. 2009;25:157–164.PubMedCrossRefGoogle Scholar
  19. 19.
    Rihn JA, Groff YJ, Harner CD, Cha PS. The acutely dislocated knee: evaluation and management. J Am Acad Orthop Surg. 2004;12:334–346.PubMedGoogle Scholar
  20. 20.
    Robertson A, Nutton RW, Keating JF. Dislocation of the knee. J Bone Joint Surg Br. 2006;88:706–711.PubMedCrossRefGoogle Scholar
  21. 21.
    Shields L, Mital M, Cave EF. Complete dislocation of the knee: experience at the Massachusetts General Hospital. J Trauma. 1969;9:192–215.PubMedCrossRefGoogle Scholar
  22. 22.
    Sisto DJ, Warren RF. Complete knee dislocation: a follow-up study of operative treatment. Clin Orthop Relat Res. 1985;198:94–101.PubMedGoogle Scholar
  23. 23.
    Stayner LR, Coen MJ. Historic perspectives of treatment algorithms in knee dislocation. Clin Sports Med. 2000;19:399–413.PubMedCrossRefGoogle Scholar
  24. 24.
    Sullivan SJ, Chesley A, Hebert G, McFaull S, Scullion D. The validity and reliability of hand-held dynamometry in assessing isometric external rotator performance. J Orthop Sports Phys Ther. 1988;10:213–217.PubMedCrossRefGoogle Scholar
  25. 25.
    Tomaino M, Day C, Papageorgiou C, Harner C, Fu FH. Peroneal nerve palsy following knee dislocation: pathoanatomy and implications for treatment. Knee Surg Sports Traumatol Arthrosc. 2000;8:163–165.PubMedCrossRefGoogle Scholar
  26. 26.
    Treiman GS, Yellin AE, Weaver FA, Wang S, Ghalambor N, Barlow W, Snyder B, Pentecost MJ. Examination of the patient with a knee dislocation: the case for selective arteriography. Arch Surg. 1992;127:1056–1062; discussion 1062–1053.Google Scholar
  27. 27.
    Vigasio A, Marcoccio I, Patelli A, Mattiuzzo V, Prestini G. New tendon transfer for correction of drop-foot in common peroneal nerve palsy. Clin Orthop Relat Res. 2008;466:1454–1466.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Wascher DC. High-velocity knee dislocation with vascular injury: treatment principles. Clin Sports Med. 2000;19:457–477.PubMedCrossRefGoogle Scholar
  29. 29.
    Wascher DC, Dvirnak PC, DeCoster TA. Knee dislocation: initial assessment and implications for treatment. J Orthop Trauma. 1997;11:525–529.PubMedCrossRefGoogle Scholar
  30. 30.
    Welling RE, Kakkasseril J, Cranley JJ. Complete dislocations of the knee with popliteal vascular injury. J Trauma. 1981;21:450–453.PubMedGoogle Scholar
  31. 31.
    Wood MB. Peroneal nerve repair: surgical results. Clin Orthop Relat Res. 1991;267:206–210.PubMedGoogle Scholar
  32. 32.
    Yeap JS, Birch R, Singh D. Long-term results of tibialis posterior tendon transfer for drop-foot. Int Orthop. 2001;25:114–118.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2014

Authors and Affiliations

  • Marius Molund
    • 1
  • Lars Engebretsen
    • 1
    Email author
  • Kjetil Hvaal
    • 1
  • Jan Hellesnes
    • 1
  • Elisabeth Ellingsen Husebye
    • 1
  1. 1.Department of Orthopaedic SurgeryOslo University HospitalOsloNorway

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