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Treatment of peroneal paralysis with 
transposition of vastus lateralis muscle in calves
E. Kilic, S. Yayla, O. Aksoy, I. Ozaydin, C. Ş. Ermutlu
This study aimed to clinically evaluate the results achieved by using tendon transposition 
to treat postinjection peroneal paralysis in calves. The study material consisted of 23 calves 
in all of which the clinical history indicated the problem had occurred within 1–3 days of 
intramuscular injection. Each patient was administered medical treatment for three weeks. 
After that, a decision was made to perform tendon transposition in all the subjects because 
their prognosis was estimated to be poor. The owners of five of the calves did not agree to the 
operation, and so, medical treatment was continued. Following intrathecal anaesthesia, the 
vastus lateralis muscle was dissected at the insertion, and the musculus (m) extensor (ext) 
digitalis (dig) longus and m fibularis tertius were dissected at the origin in 18 calves. The 
tendon ends were joined by using the locking loop suture technique in the 18 calves. Follow-
up after two to three months revealed hind limb use in all surgically treated calves, while 
the medically treated calves had to be slaughtered because of lameness and decubitus. The 
results of the present study suggest that the peroneal paralysis of calves can be successfully 
treated by a tendon transposition technique.
Introduction
Injection of drugs can cause nerve paralysis due to direct tissue dam-
age, while injecting toxic drugs into an area near the nerve can cause 
direct and indirect damage (Keown 1956, Brown and Francisco 1972, 
Kadioglu 2004, Orken and others 2004, Forterre and others 2007, 
Kilic and others 2009). The prognosis in peroneal paralysis is con-
sidered to be guarded, although it depends on the cause, its direct 
relationship to the nerve, and the severity of the lesion (Aslanbey 
and Unsaldi 1992, Akin and Besalti 2000, Bekler and others 2007, 
Kilic and others 2009). It has been recommended that medical treat-
ment can be attempted in situations where the peripheral nerve is 
not directly affected (Casaus and others 1991, Aslanbey and Unsaldi 
1992, Williams 1993, Akin and Besalti 2000, Bekler and others 2007, 
Kilic and others 2009). For dogs and cats, it has been reported that 
arthrodesis can be applied in fetlock joint, which causes a certain 
amount of function loss in the leg (Aslanbey and Unsaldi 1992, Akin 
and Besalti 2000). In peroneal nerve injuries without other complica-
tions, tendon transposition has been claimed to be the most preferable 
surgical technique (Bennett and Vaughan 1976, Aslanbey and Unsaldi 
1992, Akin and Besalti 2000, Kilic and others 2009). Experimental 
and clinical studies have shown that tendon transpositions have been 
successful in treating peroneal paralysis in cats and dogs (Bennett and 
Vaughan 1976, Aslanbey and Unsaldi 1992, Akin and Besalti 2000, 
Forterre and others 2007, Leighton 2008). Besides, Kilic and others 
(2009) have reported successful results from treating peroneal paralysis 
in sheep with the same method.
We are not aware of any previous reports of surgical treatment of 
peroneal paralysis in calves. This study presents clinical results of the 
tendon transposition technique to treat peroneal paralysis in calves.
Material and methods
Calves
In total, 23 calves of various breed, gender, body weight (40–105 kg) 
and age (15–90 days) were brought to Kafkas University’s Veterinary 
Faculty Hospital between 2003 and 2013. They were presented, 
either following referral by a veterinarian or with the complaint of 
limping, one to three days after an intramuscular injection of various 
kinds of drugs administered by their owners.
Examination protocol
The clinical history of calves was used to determine that all the sub-
jects had developed paralysis after injection of varius kinds of inject-
able antibiotics or vitamin and mineral solutions. Palpation was used 
to evaluate local changes (swelling, increase in temperature, sensitiv-
ity, etc) at the area of the injection. The diagnosis of peroneal paralysis 
was given based on the way the animals held their legs (Figs 1 and 2), 
their gait and responses to passive motion (extensor thrust and flexor 
withdrawal reflex), proprioceptive reflex, needle pricking and electri-
cal stimulation.
Treatment protocol
All the subjects that were diagnosed with peroneal paralysis were first 
administered medical treatment with B complex vitamins (Nervit, 
Vetaş), corticosteroids (Vetakort, 2 mg, Vetaş) antibiotics (Reptopen 
S, CEVA-DIF) and protective bandage (Synthetic Plaster, PrimeCast, 
5.0 cm×3.6 m) for 21 days. After that period of time, a decision was 
made to perform tendon transposition in all the subjects because there 
was no improvement in clinical signs. The owners of five of the sub-
jects did not agree to the operation, so their medical treatment was 
continued for four more weeks.
Veterinary Record (2014) doi: 10.1136/vr.102004
E. Kilic, PhD, DVM,
S. Yayla, PhD, DVM,
O. Aksoy, PhD, DVM,
I. Ozaydin, PhD, DVM,
C. Ş. Ermutlu, PhD, DVM,
Department of Surgery, Faculty of 
Veterinary Medicine, University of 
Kafkas, Kars 36100, Turkey
E-mail for correspondence: 
sadikyayla@gmail.com
Some of the peroneal paralysis subjects 
in this study were presented in a 
report to the 10th Veterinary Surgery 
Congress. (The treatment with muscle 
transposition of fibular paralysis in calves. 
pp 16–17, 2006; Istanbul, Turkey)
Accepted May 1, 2014
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2 of 4 | Veterinary Record | 10.1136/vr.102004
Sedation with xylazin HCl (Rompun, 2 per cent, Bayer S/A) 
was administered followed by intrathecal anaesthesia with bupi-
vacaine HCl in the dose of 20 mg (Marcaine, 0.5 per cent, Astra 
Zeneca) in 18 calves, after which a 10–12 cm-long lateral parapa-
tellar skin incision was made to open up the area in question (Fig 
3a, b). The musculus (m) vastus lateralis was dissected at the tran-
sition of the muscle into the tendon, while the m extensor (ext) 
digitalis (dig) longus was dissected at the origin (Fig 3c). The freed 
ends of the insertion point of the m vastus lateralis and the origin 
point of m ext dig longus with m fibularis tertius, were brought 
together dorsal to the m tensor fascia lata and joined with the 
locking loop suture technique (Fig 3d). Number 1 polyglactin 910 
(Vicryl, Ethicon) was chosen for anastomosis. A bandage, keeping 
the fetlock joint at the normal position, was applied to the extrem-
ity for three weeks, from the distal 1/3 of the tibia down to the 
hoof. Flunixin meglumin (Fulinaljin, Topkim) of 2.2 mg/kg for 
three days, 10,000 IU benzilpenicillin prokain, 10 mg dihidrostrep-
tomycin sulphate (Reptopen S, CEVA-DIF) kg/WA for five days 
were administered after the operation. The calves were monitored 
for one year either by clinical examination (6 calves) and telephone 
questionnaire (12 calves) with regard to their posture. Also, the five 
animals whose owners did not accept the recommendation to per-
form surgery were clinically monitored by the first author of study 
for two months at the farm.
Results
A clinical examination identified local temperature increase, hard-
ness and sensitivity in all the subjects when the region containing 
the semimembranosus and semitendinosus muscles was palpated. 
When placed in a flexed position, stiffness was observed starting from 
the phalanges of the extremities in question (Fig 1). There was no 
response to deep pin pricks or electrical stimulation applied to the 
region from the front surface of the tarsal joint to the edge of the coro-
nary corium. Extensor thrust and flexor withdrawal reflex examina-
tions did not produce positive findings (Table 1). An excessive extension 
(180–220°) in the tarsal joint (n=10), and a hyperflexion in the fetlock 
joint (n=23) in calves with peroneal paralysis were found (Fig 2 and 
Table 1).
The differential diagnosis between the ischiadicparalysis and per-
oneal paralysis were examined by observing the skin sensivity from 
the cranial site of the tarsal joint, and distally to the coronary corium 
to needle pricking and electrical stimulation. Furthermore, the pres-
ence of normal flexion in the stifle joint supported the diagnosis. The 
sensitivity of the skin of the plantar site and the correct position of the 
calcaneus provided the differential diagnosis from tibial nerve damage 
(Table 1).
Intraoperative dissection of the vastus lateralis and peroneus ter-
tius/extensor tendon was without difficulties. It was easy to bring the 
freed ends of the tendons together and it was possible to apply the 
suitable tension (providing adequate extension for the fetlock joint).
Postoperatively, no complications such as wound swelling, suture 
dehiscence, and failure of the tendon anastomosis were seen.
Three weeks after the operation, the calves were allowed to move 
freely without bandages. The calves put weight on the leg correctly, 
albeit with a slight limp by pressing the complete surface of solea 
ungula on the ground and pulling up the foot from the ground.
All cases were checked clinically after 2–3 months, and the treat-
ment was termed to be successful in animals that walked nearly as 
well as uninjured animals (Fig 4). Six cases were followed by telephone 
communication with patient owners through three years. According 
to statements of owners, the calves could be used for breeding.
On the other hand, in the medically treated five calves, muscle 
atrophy, decubitus ulcers and lameness were observed. In addition, 
the treated twelve animals were followed clinically for one year. 
According to physical appearance of operated calves, there was no 
remarkable weight loss compared with sound animals.
Discussion
It has been reported that peroneal paralysis usually develops when 
traumas occur in the region where the peroneal nerve passes lateral to 
the stifle joint, when an erroneous injection is administered, or when 
toxic drugs are injected close to the nerve (Tate 1988, Akin and Besalti 
2000, Kadioglu 2004, Yilmaz and others 2004, Kilic and others 2009). 
When the information obtained from the clinical history of calves 
was combined with the evidence of local temperature increase, thicker 
tissue and higher sensitivity identified in most of the subjects during 
palpation of the caudo-lateral site of the stifle joint, it was clear that 
the primary cause was most probably related to either erroneous loca-
tion of the injection, or the injected drug.
Akin and Besalti (2000) reported that the calves with peroneal 
paralysis had an excessive extension from 180 to 220° increase in the 
tarsal joint, and a hyperflexion in the fetlock joint. In this study, it was 
observed that an excessive extension in the tarsal joint of 10 calves, 
and a hyperflexion in the fetlock joint in all the calves with peroneal 
paralysis have occurred (Fig 2). Hence, observation of tarsal extension 
and hyperflexion in the fetlock joint in the cases with peroneal paraly-
sis might possibly be seen.
FIG 1: General appearance of calf prior to surgery. Hyperflexion of 
fetlock joint and hyperextension of tarsal joint
FIG 2: The appearance of the tarsal joint. The calf with peroneal 
paralysis, with excessive extension between 180° and 220° 
decrease in the tarsal joint, and a hyperflexion in the fetlock joint
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The main clinical symptom of peroneal paralysis is the animal 
pushing on the ground with the dorsal surface of the fetlock joint due 
to extension in the tarsal joint and flexion in the phalanges (Brown 
and Francisco 1972, Akin and Besalti 2000, Yilmaz and others 2004, 
Durmus and Unsaldi 2005, Bekler and others 2007, Kilic and others 
2009). Decubitus develops in this area in untreated animals (Keown 
1956, White and White 1995, Durmus and Unsaldi 2005, Kilic and 
others 2009). In all our subjects, stiffness was observed in the phalan-
ges when the extremity in question was held in the flexed position, 
while a pronounced increase in the angle of the tarsal joint was also 
noted. In addition, needle pricks and electrical stimulation applied to 
the extremity elicited no response in a region extending from the front 
surface of the tarsal joint to the edge of the coronary corium, and it 
was determined that the phalanges could not be held in the normal 
position even with passive motion.
For a definitive diagnosis, the subject must be first clinically evalu-
ated, and an electromyography or electroencephalography (EEG) 
is helpful to determine the existence and degree of neuromuscular 
transmission. MR and ultrasonographic examination can identify 
the lesion in the nerve tissue, and they can also reveal the presence 
of perilesional scar tissue and neuroma (Esquerra and others 1989, 
Steuart 1993, Akarirmak 2000, Akin and Besalti 2000, Slawinska and 
Kasicki 2002, Ruegsegger and others 2012). In our subjects, the diag-
nosis was made based on the clinical history of calves, the findings of 
the clinical examination and the application of pin prick and electrical 
stimulation as well as the presence of thrust and withdrawal reflexes.
Our study also showed that no positive response was achieved 
from the medical treatment of the five calves which were included 
in the study and were monitored for two months. Consequently, 
the results of the aforementioned study on sheep (Kilic and others 
2009) and the study presented here indicate that it could save time and 
money to initiate surgical treatment right away.
In severe cases, nerve regeneration is prevented because the 
sheath of Schwann cells and the axons inside the myelin sheath of 
Schwann become degenerate, and because the area becomes filled 
with fibrous tissue (Akin and Besalti 2000). Although surgical repair 
of the nerve can be attempted, the long recovery period makes animal 
TABLE 1: The clinical and neurologic procedures, and results
The clinical and neurologic procedures Results
Determination of the affected leg 15 L, 8 R of cases
Inflammation presence In all cases, the signs present in the 
caudo-lateral site of the stifle joint
Sensitivity test
 Cranial All cases (−)
 Caudal/plantar All cases (+)
Excessive tarsal extension 10 cases (+)
13 cases (−)
Hyperflexion of fetlock joint All cases (+)
Medical or conservative cure Applied initially in all cases, but no 
improvement occurred
Operation and its results 18 cases were operated upon, and 
were successful in all of them
FIG 3: Intraoperative views of the surgical technique. (a) 10–12 cm-long lateral parapatellar skin incision. (b) Opening up the area. 
(c) Dissection of musculus vastus lateralis at the insertion, and musculus extensor digitalis longus with musculus fibularis tertius at the 
origin. (d) Locking loop suture technique for the anastomosis of musculus vastus lateralis and musculus extensor digitalis longus/musculus 
fibularis tertius tendons. P: proximal; D: distal; M: medial; L: lateral; 1: musculus vastus lateralis; 2: musculus extensor digitalis longus 
with musculus fibularis tertius
FIG 4: General appearance of a calf three weeks after the surgery. 
The calf seems, immediately after removal of the bandage, to 
favour the limb and put it in front of the right hind limb. Also, a 
muscular atrophy on the left limb is present
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owners unsatisfied (Forterre and others 2007, Leighton 2008, Kilic 
and others 2009). The technique of tendon transposition requires 
a strong muscle with healthy nerve structures that is anatomically 
suited for transposition and that is biomechanically able to perform 
the functions of the affected muscle or muscle group (Esquerra and 
others 1989, Casaus and others 1991, Aslanbey and Unsaldi 1992, 
Akin and Besalti 2000, Bekler and others 2007, Kilic and others 
2009). It was believed that these criteria were met by the m vastus 
lateralis, and the satisfyingresults achieved from this procedure have 
confirmed our prediction.
The results of the present study suggest that muscle transposition 
technique can be recommended to veterinarians as a successful surgi-
cal option for treatment of peroneal paralysis in calves that cannot be 
treated conservatively.
Acknowledgements
The authors wish to thank Prof. Dr Yavuz OZTURKLER for translat-
ing and writing this manuscript.
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