Background: Femoral nerve palsy can cause gait deficits and knee instability. For its treatment, nerve transfers are preferred. However, this approach is only applicable for a limited window of time. For patients outside of this window or when nerve transfers are not technically feasible, musculotendinous transfers represent a viable alternative. 

Case Presentation: A 39 years-old female suffered a complete transection of the femoral nerve within the pelvis during proximal thigh schwannoma resection. Three years postoperatively she presented with antalgic gait, atrophy of the quadriceps, 0/5 strength in knee extension, and loss of thigh sensation. EMG revealed complete femoral nerve palsy with no recruitment of the quadriceps, sartorius, and iliopsoas muscles. 
The patient elected to undergo an adductor magnus, gracilis, and TFL musculotendinous transfer to the quadriceps tendon. This approach aimed to balance forces by harvesting a hip flexor and hip adductor while preserving hip adductor function by leaving the adductor longus muscle intact. 
Intraoperatively, the gracilis tendon was weaved into the vastus medialis and medial quadriceps tendon. The adductor magnus was weaved into the rectus femoris and vastus intermedius tendons. The IT band was weaved into the vastus lateralis and rectus femoris. By 11 months post-op she had 4/5 in right knee extension and hip flexion strength. Gait analysis revealed active recruitment of the gracilis, TFL, and adductors with improved walking speed and gait symmetry without requiring assistive devices.

Discussion: 
Given the extent, proximal location, and chronicity of her femoral nerve injury, nerve transfers were not feasible for this patient. Therefore, we opted for a musculotendinous transfer. We used multiple leg muscles to attain sufficient knee extension strength. To simplify surgery and recovery we selected easily mobilized muscles with long tendons innervated by her healthy obturator nerve. This technique also had a shorter recovery time as reinnervation is not needed. 
Nonetheless, to relearn basic motor patterns with a new set of muscles and innervations, the patient underwent rehabilitation involving six weeks of immobilization followed by passive rage-of-motion movements and active strength-building exercises. Our subject’s EMG findings, lack of falls, and functional gait improvements further demonstrate these rehabilitation methods’ efficacy.

Adductor Magnus, Gracilis, and Tensor Fascia Latae Transfer Restores Knee Extension and Stability after Femoral Nerve Palsy

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Adductor Magnus, Gracilis, and Tensor Fascia Latae Transfer Restores Knee Extension and Stability after Femoral Nerve Palsy

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