Deep Peroneal Research Articles

WS7.5. Neuromuscular ultrasound of the lower extremities

Neuromuscular ultrasound is rapidly evolving as an excellent diagnostic tool in the evaluation of peripheral neuropathies, especially so in focal neuropathies. It can be of use in understanding the underlying pathological mechanism of neuropathies. Focal neuropathies are more likely to be associated with structural abnormalities that can be easily recognized by imaging modalities. Certain subtypes of polyneuropathies are also associated with morphological changes. Point of care ultrasound helps with rapid examination of long segments of multiple nerves in the out-patient setting. This can result in early triaging of patients and rapid management decisions. Other advantages include easy patient tolerability when compared to nerve conduction studies and lower cost. The sonographic abnormalities that are commonly associated with neuropathies include focal or diffuse enlargement, hour-glass constriction, change in neural architecture, decreased mobility of the nerve and increased vascularity of the nerves. It can also be of use in detecting extra-neural abnormalities like tenosynovitis, soft tissue tumors, entrapment or compression from metallic implants. Peripheral nerves of the lower extremities that can be commonly assessed by sonographic studies include the sciatic, peroneal and tibial nerve. Other less common nerves that are assessed include the lateral femoral cutaneous nerve, the superficial and deep peroneal nerves and the sural nerves. It can also be of value in the evaluation of the digital nerves in the feet. Clinical conditions where sonographic studies can be of paramount importance include evaluation of the peroneal nerve at the fibular head in patients presenting with foot drop and assessment of the tibial nerve in the tarsal tunnel in those presenting with unilateral foot numbness. Its use as a diagnostic tool has extended beyond focal neuropathies to include polyneuropathies secondary to metabolic, inherited and inflammatory causes. Other uses of lower extremity ultrasound include its role as a tool in guiding with therapeutic interventions like steroid injections and detection of morphological changes within cutaneous nerves prior to consideration of nerve biopsy.

Mini open non vascularized fibula graft harvesting technique without any specialized instrumentation: A case report

Fibula graft harvesting is a common procedure in orthopedic practice. The common approach to the shaft of fibula is through long incision made over the fibula. This was fraught with complications including common peroneal nerve injuries, pain and significant graft site morbidity to patients. Techniques then came to describe harvesting fibula through minimal incisions. However these needed specialized circular harvesters and hence was difficult to perform in hospitals catering to poor socioeconomic strata. We have devised minimally invasive technique of fibula harvesting using a long 4.5 system narrow DCP (Dynamic compression plate) used as soft tissue stripper and have combined the procedure with mini open fasciotomy and compression dressing. Our patient did not have any postoperative common peroneal, superficial peroneal or deep peroneal nerve injury. Postoperative graft site pain was minimal.

An Update on Peroneal Nerve Entrapment and Neuropathy.

Peroneal neuropathy is the most common compressive neuropathy of the lower extremity. It should be included in the differential diagnosis for patients presenting with foot drop, the pain of the lower extremity, or numbness of the lower extremity. Symptoms of peroneal neuropathy may occur due to compression of the common peroneal nerve (CPN), superficial peroneal nerve (SPN), or deep peroneal nerve (DPN), each with different clinical presentations. The CPN is most commonly compressed by the bony prominence of the fibula, the SPN most commonly entrapped as it exits the lateral compartment of the leg, and the DPN as it crosses underneath the extensor retinaculum. Accurate and timely diagnosis of any peroneal neuropathy is important to avoid progression of nerve injury and permanent nerve damage. The diagnosis is often made with physical exam findings of decreased strength, altered sensation, and gait abnormalities. Motor nerve conduction studies, electromyography studies, and diagnostic nerve blocks can also assist in diagnosis and prognosis. First-line treatments include removing anything that may be causing external compression, providing stability to unstable joints, and reducing inflammation. Although many peroneal nerve entrapments will resolve with observation and activity modification, surgical treatment is often required when entrapment is refractory to these conservative management strategies. Recently, additional options including microsurgical decompression and percutaneous peripheral nerve stimulation have been reported; however, large studies reporting outcomes are lacking.

Variable patterns of the cutaneous innervation of the dorsum of the foot and its clinical implication

BackgroundThe superficial sensory nerves are at great risk for injury from lacerations and operative incisions. Precise knowledge regarding the course and distribution of sensory nerves over the dorsum of foot is important to avoid iatrogenic damage by surgeons who are planning the surgical intervention around the distal leg, ankle and foot. The objective of the study is to report the variation in the branching pattern and distribution of the cutaneous nerves over the dorsum of foot. Materials and methodsThe study was carried out in 20 formalin fixed adult lower limbs in the Department of Anatomy, KMC Manipal, Manipal Academy of Higher Education, India. After the careful skin reflection, cutaneous nerves were traced. ResultsSix out of twenty (30%) adult limbs had different pattern of cutaneous nerve innervation on the dorsum of foot. Among these five limbs (83.34%) had variation in the sural nerve innervation. In two limbs (33.33%) communications were found between superficial peroneal nerve and deep peroneal nerve. In one adult limb (16.67%) deep peroneal nerve supplied the second interdigital cleft. We grouped these into five types of variation pattern in the cutaneous innervation over dorsum of foot. ConclusionWe observed five types of variation pattern, out of which variation II is not reported in the literature. The knowledge of these variations will help the surgeons to avoid iatrogenic damage of these nerves during surgeries involving distal leg, ankle and foot, open reduction and internal fixation of fracture, arthroscopy etc.

Clinical and neurophysiological findings in patients with hereditary neuropathy with liability to pressure palsy and chromosome 17p11.2 deletion

IntroductionHereditary neuropathy with liability to pressure palsy (HNPP) is an autosomal dominant disorder, typically presenting with recurrent episodes of mononeuropathy in nerves susceptible to compression, with similar neurophysiological characteristics. However, other clinical and neurophysiological presentations have been reported. MethodsWe retrospectively analysed the clinical and neurophysiological characteristics of 20 patients with genetically confirmed HNPP. Sixteen patients were studied in our department between 1996 and 2016. ResultsIn addition to the typical characteristics of HNPP, we found atypical forms including recurrent positional sensory symptoms in 3 patients, chronic sensorimotor polyneuropathy in one, and non-progressive mononeuropathy in one. Onset was early in 2 patients: one at the age of 7 years, with common peroneal nerve injury, and another at birth, with brachial plexus involvement. By frequency, the main pathological findings in the nerve conduction study were: decreased sensory nerve conduction velocity in the sural (84%) and the median and superficial peroneal nerves (94%); decreased motor nerve conduction velocity in the ulnar nerve through the elbow (97%), and increased motor distal latency of the median and deep peroneal nerves (74%). ConclusionOur results confirm the clinical variability of HNPP, with the most frequent nerve conduction study findings being the generalised decrease in sensory nerve conduction velocity, in addition to motor involvement, mainly in locations susceptible to nerve compression. The nerve conduction study can detect typical, atypical, and asymptomatic cases of HNPP.

Electrophysiological Study of the Tibial Nerve Across the Tarsal Tunnel in Distal Symmetric Diabetic Polyneuropathy.

The aim of the study was to demonstrate abnormalities of motor conduction of the tibial nerve across the tarsal tunnel in type 2 diabetes. One hundred twenty-four consecutive patients (mean age = 66.6 yrs, 62.1% male) with distal symmetric diabetic polyneuropathy clinically diagnosed were prospectively enrolled. Nerve conduction studies of deep peroneal, tibial, superficial peroneal, medial plantar, and sural nerves and standard needle electromyography in the lower limbs were performed. Demographic, anthropometric, and clinical findings were collected. Motor conduction velocity of the tibial nerve across tarsal tunnel was slowed in 60.5% of patients; another 4% showed conduction block across tarsal tunnel without reduction of motor conduction velocity. Overall percentage of abnormalities across tarsal tunnel (64.5%) exceeds that of the sensory conduction velocities of proximal sural and superficial peroneal nerves. Abnormal tibial motor conduction velocity across tarsal tunnel represents the most common abnormality among all motor nerve conduction study parameters and significantly correlates with hemoglobin level, diabetic neuropathic index score, and diabetic complications frequency. Tibial conduction abnormalities across tarsal tunnel are the most sensitive motor parameter in distal symmetric diabetic polyneuropathy, second only to conduction abnormalities of sensory/mixed distal nerves of the feet. The use of nerve conduction studies across tarsal tunnel of the tibial nerve may be useful in the electrophysiological protocol to confirm the diagnosis of distal symmetric diabetic polyneuropathy.

Foot Reanimation Using Double Nerve Transfer to Deep Peroneal Nerve: A Novel Technique for Treatment of Neurologic Foot Drop.

Our primary objective was to assess the efficacy of a new technique for foot reanimation in patients with neurologic foot drop using double nerve transfer from the tibial to the deep peroneal nerve. Our secondary objective was to document the technical nuances of our technique. Thirty-one patients with common peroneal nerve injury between October 2015 and March 2019 were prospectively enrolled in the study. Patients underwent a transfer of the tibial nerve branches to flexor digitorum longus and lateral head of gastrocnemius to the deep peroneal nerve. Motor recovery, range of ankle dorsiflexion, pain, leg girth, and complications were examined as outcome measures. The modified Medical Research Council (MRC) scale was adopted to assess the motor power recovery. All patients were followed up for a minimum of 1 year. Motor recovery of M3 or M4 grade of tibialis anterior, extensor hallucis longus, and extensor digitorum longus was achieved in 15 of 31, 13 of 31, and 12 of 31 patients, respectively. Those patients could discontinue use of orthosis. Most patients with high-energy traumas or knee-level injuries failed to recover antigravity function. Only 2 patients reported weak postoperative toe plantarflexion. Our patients achieved significant improvement of the pain perception and range of active ankle motion at the final follow-up. The double nerve transfer technique represented a feasible and safe surgical option. It has been shown to improve function in some patients with neurologic foot drop resulting from a less than 12-month injury of the deep peroneal nerve. Level IV, therapeutic.

Monocortical fixation for locking plate distal screws does not impair mechanical properties in open-wedge high tibial osteotomy

BackgroundThe neurovascular bundle containing the deep peroneal nerve has a potential risk of injury during open-wedge high tibial osteotomy (OWHTO), particularly due to drilling for bicortical fixation at distal screw holes. Therefore, monocortical fixation is recommended for distal fixation of a long locking plate as long as good stability is ensured. The purpose of this study was to analyse the biomechanical properties of monocortical fixation of distal locking screws for OWHTO.MethodsThree-dimensional models of bone and fixation materials simulating OWHTO were created using computed tomographic data of patients and material data of a T-shaped long locking plate and screws. Three of the four distal screws of the locking plate were chosen for a bicortical fixation or monocortical fixation procedure. In addition, loss of correction was assessed by measuring the medial proximal tibial angle (MPTA) in patients who underwent OWHTO with two bicortical and two monocortical distal fixation screws at 1 month and 1 year after surgery.ResultsNo significant differences in stress were observed in either the normal or osteoporotic bone model between the monocortical and bicortical fixation models, including in the area of the lateral hinge at the osteotomy site.Furthermore, there were no significant differences in MPTA between the early post-operative period and 1-year follow-up.ConclusionsThe monocortical fixation method for three distal screws of the locking plate did not worsen the mechanical properties of fixation for OWHTO using a long locking plate with four proximal and four distal screws. In actual surgery, the number of distal bicortical screws should be reduced based on the patient’s condition, taking into account the risk of lateral hinge fracture and unexpected surgical complications. Using at least two bicortical screws would be practical considering the various factors related to reduced fixing ability.

Intraneural Ganglion cyst of The Deep Peroneal Nerve Causing Rapidly Progressive Foot Drop

Intraneural ganglion cysts are a relatively uncommon cause of peroneal nerve palsy. Patient’s typically present with weakness or absent ankle dorsiflexion, knee or leg pain, and paresethesia. Surgical decompression is widely accepted as the first line treatment for intraneural ganglion cysts of the peroneal nerve, with earlier intervention associated with better functional outcomes. Here, we describe the case of a 57-year-old male found to have a intraneural ganglion cyst of the peroneal nerve, three months after the onset of symptoms, including eventual complete foot drop. He underwent surgical decompression of the cyst. The intraneural ganglion cyst was found to be intricately involved with the nerve fibers, and the patient still does not have the ability to dorsiflex the affected ankle one month post-operation.

Chronic Leg Pain in Athlete Caused by Deep Peroneal Schwannoma, a Case Report

Schwannomas are benign, well-encapsulated and slow growing tumor arising from Schwann cells of the peripheral nerve sheath. They commonly saw in the head and neck, rarely from deep peroneal nerve in the lower limb. We present a case of 42-year-old active national hockey coach, who presented with mild pain and numbness over lateral aspect of left leg for 2 years. The pain was provoked by sporting activities, and was initially relieved by analgesics, until recently, hence his presentation. MRI was done and showed well-defined oval lesion within the deep intermuscular fascia between tibialis anterior and extensor halluces longus muscles. He had an open dissection, and the histology showed a diagnosis of schwannoma. Post-operative healing was uneventful, the pain and numbness improving after 12 months.

Prevalence of Accessory Deep Peroneal Nerve in Sample of Bosnia and Herzegovina Subjects: an Electrophysiological Study.

Background:The accessory deep peroneal nerve (ADPN) is as an anomalous nerve derived from the superficial peroneal nerve or its branch and supplies motor innervations for extensor digitorum brevis (EDB) and sensory innervations for the lateral part of the ankle and foot regions. It is the most common anomalous innervation present in the lower limb.Objective:The aim of this study was to determine the prevalence of ADPN electrophysiologically in a sample of Bosnia and Herzegovina subjects who referred to an electromyography lab.Methods:This cross-sectional descriptive study included 316 lower limbs from 171 subjects referred for electrodiagnostic studies to Electromyography Lab, Department of Neurology, University Clinical Center Tuzla (Bosnia and Herzegovina) (102 females/60% and 69/40%) males). Motor nerve conduction studies for the peroneal nerve and ADPN were done. Compound muscle action potential (CMAP) and nerve conduction velocity (NCV) of deep peroneal nerve (DPN) were measured by using EMG machine by stimulating DPN at knee, ankle and lateral malleolus areas accordingly, with recording from extensor digitorum brevis (EDB) muscle.Results:ADPN was found in 46 (14.5%) of 316 legs. ADPN was found in 18 (39.1%) right lower limbs and 28 (60.9%) left lower limbs. Ten subjects (5.8%) had bilateral ADPN. There was no statistically significant difference between the occurrence of ADPN in women versus men (p=0.757), as well as in right versus left legs (p=0.237).Conclusion:This study demonstrated that ADPN prevalence, in a sample of Bosnia and Herzegovina subjects who referred to an electromyography lab is 14.5%. Recognition of ADPN is very important for proper interpretation of lower limbs electrophysiological data.

Prevalence of Accessory Deep Peroneal Nerve in Sample of Bosnia and Herzegovina Subjects: an Electrophysiological Study

Prevalence of Accessory Deep Peroneal Nerve in Sample of Bosnia and Herzegovina Subjects: an Electrophysiological Study

Dorsal Medial Cuneiform Bony Outgrowth—Apophysis or Exostosis

Case: Three female children (11-15 years) presented with painful dorsomedial medial cuneiform masses that did not improve after conservative treatment. Findings were consistent with a diagnosis of medial cuneiform apophysis. After surgical resection, no patients had recurrence, although one continued to have pain from a deep peroneal nerve sensory branch that was resected. One patient had an intramass physis identified. Conclusion: When surgically removing dorsomedial cuneiform masses, surgeons should decompress overlying sensory nerve branches, detach and subsequently repair muscular attachments, and remove the entire stump to prevent regrowth because some of these masses may be apophyses and not exostoses.

Recurrent position and innervation pattern of recurrent peroneal nerve: A cadaveric study

BackgroundThe recurrent peroneal nerve (RPN) branches from the common peroneal nerve or the deep peroneal nerve and it innervates to the lower patellar region. It has recently been reported that damage to the RPN causes pain in the lower patellar region; therefore, this study examined the recurrent position and the innervation pattern of the RPN. MethodsCases of knee deformity or atrophy were excluded, and 50 legs (25 males and 25 females) of 34 cadavers (15 males and 19 females) were examined to assess the recurrent position and the innervation pattern of the RPN. ResultsThe recurrent position of the RPN was 27.9 ± 3.6 mm from the tip of the fibula. The RPN innervated to the patellar tendon in five of the 50 legs (10%), to the infrapatellar fat pad in 13 legs (26%), and to both the patellar tendon and the infrapatellar fat pad in 20 legs (40%), and to neither the patellar tendon nor the infrapatellar fat pad in 12 legs (24%). No significant sex differences were observed in the recurrent position and the innervation pattern of the RPN. ConclusionsIn all cases, the recurrent position of the RPN was almost fixed from the tip of the fibula. The RPN frequently innervated to the patellar tendon or the infrapatellar fat pad (76%) in both males and females. These findings would be useful in knee surgery to preserve the RPN or for the diagnosis of pain in the lower patellar region.

AAOS Clinical Practice Guideline: Management of Acute Compartment Syndrome.

AAOS Clinical Practice Guideline: Management of Acute Compartment Syndrome.

Surgical Treatment of Complete Foot Drop: Partial Tibial Nerve Transfer to the Motor Branch of the Tibialis Anterior: 2-Dimensional Operative Video.

This video will be demonstrating the surgical treatment of complete foot drop with partial tibial nerve transfer to the motor branch of the tibialis anterior. Foot drop occurs when there is injury to the deep peroneal nerve that results in the paralysis of the tibialis anterior muscle and subsequent loss of ankle dorsiflexion.1-5 The patient who is the subject of this video is a 27-yr-old female with a 6-mo history of foot drop. She presented with complete loss of ankle dorsiflexion and great toe extension due to traumatic fall on her left knee while running. Upon physical examination, she had all the features of complete foot drop with loss of ankle dorsiflexion and ankle eversion. She also had decreased sensation to light touch over left dorsal foot, left great toe, and left lateral lower leg. The patient has consented to this procedure. The partial tibial nerve transfer to the motor branch of tibialis anterior muscle is the preferred treatment option for foot drop as it restores ankle dorsiflexion with minimal donor site complications. At 12 mo postsurgery, she has regained 4/5 for ankle dorsiflexion on motor testing compared to the 0/5 she had preoperatively.

Minimally Invasive Surgery for Correction of Adult Acquired Flat Foot Deformity: An Anatomic Study

Category:Midfoot/Forefoot; HindfootIntroduction/Purpose:Adult acquired flatfoot deformity (AAFD) is a complex and chronic debilitating condition characterized by a decrease in the medial arch height and, in advanced stages, a decrease in the talonavicular coverage angle as the forefoot drifts into pronation and abduction. Operative treatment of stage II deformity has changed significantly over the past few decades. Joint sparing procedures which aim to realign the hindfoot and augment the diseased tibialis posterior tendon with the flexor digitorum longus transfer are commonly performed. The introduction of minimally invasive surgery (MIS) has been associated with smaller incisions, less blood loss, and quicker recovery times. The purpose of this study was to qualitatively and quantitatively observe the tendinous and neurovascular structures at risk with MIS AAFD osteotomy procedures in cadaveric feet.Methods:MIS technique was used to perform medial displacement calcaneal, Evans, and Cotton osteotomies on nine cadaveric feet under fluoroscopic guidance. The sural nerve, superficial peroneal nerve and its branches, deep peroneal nerve, dorsalis pedis artery, saphenous vein, and peroneal and extensor hallucis longus tendons were carefully dissected from each cadaveric foot and evaluated for injuries following the MIS osteotomy cuts. The distance from the osteotomy cuts and these anatomic structures were measured and recorded.Results:On average, the sural nerve was 8.4 mm and 9 mm from the calcaneal and Evans osteotomy sites, respectively. The intermediate dorsal cutaneous nerve was on average 68.3 mm and 41.1 mm from the calcaneal and Evans osteotomy sites, respectively. The peroneal tendons were on average 16.7 mm and 0 mm from the calcaneal and Evans osteotomy sites, respectively. The extensor hallucis was an average of 1 mm from the Cotton osteotomy site. There was a partial tear injury to the peroneus brevis in four of the cadaveric specimens at the Evans osteotomy site without complete laceration. There was no injury to the sural nerve, superficial peroneal nerve and its branches, saphenous vein, deep peroneal nerve, dorsalis pedis artery, or extensor hallucis longus tendon.Conclusion:Tendinous and neurovascular structures are at risk with MIS AAFD osteotomy procedures. Care should be taken with soft tissue handling and blunt dissection to decrease iatrogenic injuries to these structures. Specifically, extra care and recognition of the peroneal tendons during the Evans osteotomy may prevent damage, as this structure was at greatest risk among the three osteotomy cuts. Future research studies evaluating this technique and the functional outcomes in patients in a clinical setting is warranted. Surgical technique studies are underway to implement smaller, yet appropriate bone grafts through mini incisions.

A Porcine Model of Peripheral Nerve Injury Enabling Ultra-Long Regenerative Distances: Surgical Approach, Recovery Kinetics, and Clinical Relevance.

Millions of Americans experience residual deficits from traumatic peripheral nerve injury (PNI). Despite advancements in surgical technique, repair typically results in poor functional outcomes due to prolonged periods of denervation resulting from long regenerative distances coupled with slow rates of axonal regeneration. Novel surgical solutions require valid preclinical models that adequately replicate the key challenges of clinical PNI. To develop a preclinical model of PNI in swine that addresses 2 challenging, clinically relevant PNI scenarios: long segmental defects (≥5cm) and ultra-long regenerative distances (20-27cm). Thus, we aim to demonstrate that a porcine model of major PNI is suitable as a potential framework to evaluate novel regenerative strategies prior to clinical deployment. A 5-cm-long common peroneal nerve or deep peroneal nerve injury was repaired using a saphenous nerve or sural nerve autograft, respectively. Histological and electrophysiological assessments were performed at 9 to 12 mo post repair to evaluate nerve regeneration and functional recovery. Relevant anatomy, surgical approach, and functional/histological outcomes were characterized for both repair techniques. Axons regenerated across the repair zone and were identified in the distal stump. Electrophysiological recordings confirmed these findings and suggested regenerating axons reinnervated target muscles. The models presented herein provide opportunities to investigate peripheral nerve regeneration using different nerves tailored for specific mechanisms of interest, such as nerve modality (motor, sensory, and mixed fiber composition), injury length (short/long gap), and total regenerative distance (proximal/distal injury).

Accuracy of Percutaneous Lateral Release for Hallux Valgus: An Anatomic Study

Category:Bunion; OtherIntroduction/Purpose:Minimally Invasive Chevron and Akin (MICA) surgery is growing in popularity. There are now multiple studies comparing minimally invasive bunion correction to traditional open techniques. Many of these studies include percutaneous lateral soft tissue release using a specific blade, while others use an open technique. To our knowledge, there is no prior study confirming the accuracy of soft tissue release via percutaneous technique. Our objective was to evaluate the precision of the percutaneous release, both the structures released and percent release. Additionally, we identified adjacent nerves potentially at risk with a lateral soft tissue release, measuring their proximity to the incision and if they were damaged.Methods:Sixteen fresh frozen cadaveric foot specimens (8 paired limbs) underwent percutaneous lateral release utilizing a beaver blade under fluoroscopic guidance by two Foot and Ankle Fellowship Faculty who regularly perform the procedure. As described in early MICA technique papers by Redfern and Vernois, the blade was inserted into the plantar plate between the lateral sesamoid and the proximal phalanx. Then the blade was rotated laterally while the hallux was directed into varus. The goal was to release the lateral head of the Flexor Hallucis Brevis (FHB) without violating the Lateral Collateral Ligament (LCL). During our experiment the sesamoids were able to be successfully reduced after each release. The specimens were then dissected to reveal the extent of release of the FHB and LCL. Distance was measured between the blade path and the dorsal digital branch of the deep peroneal nerve, as well as the plantar digital nerve.Results:The FHB was at least partially released in 15/16 specimens. It was completely released in two specimens. 5/16 specimens had greater than 50% but less than 100% release and 8/16 specimens had <50% release. The LCL was completely intact in 8/16 specimens. It was partially released in 8/16 specimens (5 less than 50% released and 3 greater than 50% released). There was no correlation between percent of FHB release and the likelihood of LCL release. The dorsal cutaneous nerve was consistently near the path of the beaver blade, with a median distance of 2mm (range 1-8mm). However, the nerve was never found to be incised or transected. Likewise, the plantar nerve was never injured.Conclusion:This study sought to verify the effectiveness of percutaneous lateral release. We found the FHB to be at least partially released in all but one case, resulting in adequate clinical correction of sesamoid position. Full FHB release may not be necessary to achieve the clinical objective of sesamoid reduction. There was no correlation between percent of FHB release and concomitant release of the LCL, which demonstrates the challenge of an isolated FHB release. The dorsal cutaneous nerve was consistently near the blade path but was never injured, suggesting patients should be counseled regarding the risk.

Bilateral injury of deep peroneal nerve in the patient after heart transplant

In March 2015, a 62-year-old patient with advanced heart failure underwent a failed radiofrequency ablation, followed by paresis of muscles in the anterior compartment of the leg. After rehabilitation, partial recovery of the paresis was achieved. Orthotopic heart transplantation was performed 9 months after ablation at the at the Institute of Cardiology, followed by a bilateral paresis of muscles in the anterior leg compartment. Rehabilitation was implemented. The possible cause of paresis is most likely to be due to food shortages, mainly related to a folic acid deficiency.