Outcomes with microsurgery of common peroneal nerve lesions

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Summary

Objectives

The purpose of this retrospective study is to present our results with peroneal nerve lesions, to examine the relative significance of various factors, to assess their effect on outcome, and to establish guidelines of treatment for the microsurgical management of these difficult lesions.

Methods

Over a 33-year period, a total of 62 patients were treated at McGill University and the Microsurgical Research Center, Eastern Virginia Medical School. The clinical records of all patients treated for peroneal nerve lesions were reviewed for retrospective analysis.

Results

Of 62 patients, 35 had microneurolysis and nerve decompression of the common peroneal nerve (CPn) as the only surgical procedure while 27 required reconstruction with nerve grafting. Postoperatively muscle power was graded from M + 4 to M − 5 in 27 patients, from M − 4 to M4 in 26 patients, from M − 3 to M + 3 in 8 patients, and from M − 2 to M + 2 in 1 patient. The behavioral video data showed a mean preoperative ankle dorsiflexion of 6.79° ± 5.6 and postoperative ankle dorsiflexion of 37.9° ± 9.3. Overall, excellent functional results were achieved in 27 of 62 patients (43%) with peroneal palsy who underwent microsurgical reconstruction, and good results were observed in 25 patients (40%).

Conclusions

Despite previous widespread pessimism, the surgical repair of CPn lesion is worthwhile, yielding good to excellent results in the majority of patients, after a careful preoperative consultation, establishment of a sound strategy of reconstruction and using aggressive and atraumatic microsurgery.

Introduction

Peroneal nerve palsy is the most frequent nerve injury of the lower extremity and accounts for about 15–20% of all peripheral nerve lesions.1 Vulnerability of the common peroneal nerve (CPn) has been attributed to various factors, including its internal organization, blood supply, superficial topography over the fibular head, and its course among others.2

Because of its location, the peroneal nerve seems particularly prone to injury from iatrogenic accidents,3, 4, 5 motor vehicle accidents,6, 7, 8 sport injuries,9, 10, 11 and gunshot wounds.12 Compression and entrapment lesions are probably the most frequent causes of peroneal neuropathy.13, 14, 15 The CPn may be compressed by a ganglion cyst, cysts of lateral meniscus, or a tumor of the head of the fibula.16, 17, 18, 19, 20

While previously published papers showed pessimistic results with CPn lesions,21,22 more recent studies have shown more encouraging results.23, 24, 25, 26 Better understanding of fascicular topography, the use of improved microsurgical techniques such as vascularized nerve grafts (VNG) along with the knowledge that tension plays a detrimental role at the repair site, have allowed for optimal alignment at the fascicular level.27, 28, 29, 30, 31

The aims of this study are as follows:

  • 1) To present our 33-year experience with CPn lesions.

  • 2) To examine the relative significance of various factors including the type of injury, denervation time, and the length of nerve graft to assess their effect on the outcome.

  • 3) To establish principles of treatment of these difficult lesions.

Section snippets

Materials/patients and methods

The patient population for this study consists of 62 consecutive patients (43 male and 19 female) treated for peroneal nerve lesions at McGill University and at the Microsurgical Research Center of Eastern Virginia Medical School between 1978 and 2011. The inclusion criteria were 12 months or longer follow up for patients who underwent microneurolysis, and 24 months or longer for patients who had repair with nonvascularized nerve grafts (NNG) or VNG.

Video and photographic documentation were

Results

Of the 62 operated patients 43 were male and 19 female, with ages ranging from 4 to 64 years (mean age, 30.2 years) at the time of surgery. In 40 patients, the lesion was in the right side, in 20 patients the left peroneal nerve was involved while two patients had bilateral lesions.

The average time from initial injury to microreconstruction was 15.8 months (range, 1–71 months). Mean follow-up for patients who had undergone surgery was 32 months, range 9–117 months.

A motor vehicle accident was

Discussion

A complex array of tightly interrelated prognostic factors including those associated with the patient, such as associated fractures and/or vascular injury, the mechanism and type of injury, denervation time, nerve gap length, and nerve graft length, as well as the surgical strategy, all have a profound impact on the functional outcomes.

In this series, surgical exploration was carried out in all patients who failed to show any clinical or electrophysiological recovery within 3 months from

Conclusions

  • 1. In CPn lesions, early surgical exploration and repair are recommended.

  • 2. The goal of treatment is to achieve useful motor function, and at least protective sensibility.

  • 3. Implementation of principles that optimize nerve regeneration.

  • 4. In cases with highly unfavorable scarred beds and large nerve gaps, the use of VNG in combination with the transfer of VPCF is strongly advocated.

Declaration of Conflict of Interest

Dr. Julia K Terzis and Dr. Ioannis Kostas report no biomedical financial interests or potential conflicts of interest.

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