The patient came to the clinic 21-January-2009 complaining of complete loss of function of the left peroneal nerve and partial impairment of the left tibial nerve territory after gun shot 7 months ago.

Electrophysiological studies performed several days ago confirmed the presence of complete denervation of the peroneal division with partial damage to the tibial division of the left sciatic nerve.

On examination: the patient has drop left foot 0/5 and weak planterflexion left foot 3/5. There is analgesia of the left L5 territory.

The left sciatic nerve was exposed at its superior third and followed downward. The part with injury level was dissected off scars. There was neuroma in continuity felt at the peroneal side of the nerve. Using the Inomed  IIS with EMG and DNS, the nerve was studied and the non-functioning fascicles were identified and splitting of the sciatic nerve was performed into 2 divisions. During this process some fascicles were isolated from the non-functioning part, because they were studied and showed slight activity with stimulation of 4-7 mA. They were preserved. The non-functioning part was studied and even with 10 and higher mA stimulation there was no response. The scarrous part of the damaged segment was removed and the sharp section of this part of the nerve was cut until good fibers were obtained proximally and distally. The gap between these stumps was 55 mm. In order to perform cross-anastamosis, it was necessary to release the proximal and distal parts of the nerve to regain some extra-length and the cross anastamosis was performed with the knee flexion about 40 degrees. Good coaptation of the stumps and routine closure of the wound and back slap was applied.

Smooth postoperative recovery.

Without using the Inomed IIS, it was impossible to perform such surgery with good information about the morphological and functional status of the bundles.  Some of the bundles were included first with the planned to to be sacrificed, but studying them, exclude them from that group. The remaining fibers were all ending in scar and no fibers were seen in the cut part of the damaged nerve.

With a gap of 55 mm it was better to have direct anastamosis of the peroneal part, than to get sural nerve graft, because the end result will be inferior in the case of putting neural bridge.