Deep Peroneal Research Articles

Ultrasound Imaging of the Deep Peroneal Nerve.

Ultrasound is considered an excellent imaging modality to evaluate the nerves of the limbs. The deep peroneal nerve (DPN) is one of the terminal branches of the common peroneal nerve. The DPN may be affected by various disorders, which may be clinically challenging to show. This Pictorial Essay reviews the normal ultrasound anatomy of the DPN and presents disorders that may involve the nerve and its main branches along its course, from proximal to distal.

Deep Peroneal Neurectomy for Midfoot Arthritis

Osteoarthrosis of the tarsometatarsal joint (TMTJ) and naviculocuneiform joint (NCJ) is a common pathology treated by foot and ankle specialists. Arthrodesis is the most widely accepted surgical treatment. Patients that are not candidates for arthrodesis are often left without surgical treatment options. Neurectomy has been described for treatment of upper extremity joint arthrosis but has not been well described in the foot. The deep peroneal nerve innervates the first, second, third TMTJs and NCJ. We present a retrospective case series on the outcomes of patients treated with deep peroneal neurectomy for TMTJ and NCJ arthrosis (N = 34 feet in 26 patients). The median postoperative American Orthopedic Foot and Ankle Society midfoot score was 53 (range 16-75) points. Twenty two (85%) of 26 patients stated that their expectations were met as a result of the deep peroneal neurectomy procedure, and 20 (77%) of 26 patients stated that they would have deep peroneal neurectomy for their symptoms again. There were recurrent symptoms prompting patients to seek additional treatment in 7 (21%) of 34 feet. Recurrent pain is also documented in hand denervation studies and the physiologic explanation remains unclear. Our results suggest that deep peroneal neurectomy is an effective treatment option for TMTJ and NCJ arthritis and may be particularly helpful in patients that are poor candidates for arthrodesis.

Effectiveness of lower extremity Dellon triple nerve decompression in treatment of early-stage diabetic Charcot foot

To study the effectivenss of lower extremity Dellon triple nerve decompression in the treatment of early-stage diabetic Charcot foot. The clinical data of 24 patients with Eichenholtz stage 0-1 diabetic Charcot foot who were admitted between September 2017 and February 2019 were retrospectively analyzed. Among them, 14 cases were treated with lower extremity Dellon triple nerve decompression (treatment group), and 10 cases were treated with conservative treatment such as immobilization the affected limbs and nutritional nerve drugs (control group). There was no significant difference between the two groups ( P>0.05) in gender, age, diabetes duration, diabetic foot duration, Eichenholtz stage, and the blood glucose level, bone mineral density (T value), nerve conduction velocity, and two-point discrimination before treatment. Before treatment and at 6 months after treatment, bone mineral density (T value) was measured by dual energy X-ray absorptiometry to evaluate the improvement of osteoporosis. The electromyogram of the lower limbs was used to detect the conduction velocity of the common peroneal nerve, deep peroneal nerve, and tibial nerve, and to evaluate the recovery of nerve function. The two-point discrimination in plantar region was used to evaluate the recovery of skin sensation. Both groups were followed up 6-12 months, with an average of 6.5 months. In the treatment group, 3 patients showed numbness around the incisions, all recovered after 12 months, without affecting the prognosis; all the incisions healed by first intention, and there was no complication such as incision infection, nonunion, or vascular and nerve injury. At 6 months after treatment, there was no significant difference in nerve conduction velocity, bone mineral density (T value), and two-point discrimination when compared with the values before treatment ( P>0.05) in the control group; but the above indicators in the treatment group were significantly improved when compared with preoperative ones, and were all significantly better than those in control group ( P<0.05). Lower extremity Dellon triple nerve decompression can improve the symptoms of Eichenholtz stage 0-1 diabetes Charcot foot, and has the advantages of less trauma, faster recovery, and fewer complications.

The articular branch of the peroneal nerve to the proximal tibiofibular joint descends at a mean height of approximately 18mm distal to the postero-lateral tip of the fibular head.

The aim of the study was to evaluate the anatomical details of the articular branch of the peroneal nerve to the proximal tibiofibular joint and to project the height of its descent in relation to the fibular length. Twenty-five lower extremities were included in the study. Following identification of the common peroneal nerve, its course was traced to its division into the deep and superficial peroneal nerve. The articular branch was identified. The postero-lateral tip of the fibular head was marked and the interval from this landmark to the diversion of the articular branch was measured. The length of the fibula, as the interval between the postero-lateral tip of the fibular head and the tip of the lateral malleolus, was evaluated. The quotient of descending point of the articular branch in relation to the individual fibular length was calculated. The articular branch descended either from the common peroneal nerve or the deep peroneal nerve. The descending point was located at a mean height of 18.1mm distal to the postero-lateral tip of the fibular head. Concerning the relation to the fibular length, this was at a mean of 5.1%, starting from the same reference point. The articular branch of the common peroneal nerve was located at a mean height of 18.1mm distal to the the postero-lateral tip of the fibular head, respectively, at a mean of 5.1% of the whole fibular length starting from the same reference point. These details represent a convenient orientation during surgical treatment of intraneural ganglia of the common peroneal nerve, which may result directly from knee trauma and indirectly from ankle sprain.

Safety of neurovascular structures in ankle arthroscopy: cadaveric study

Introduction: Anterior and posterior portals used for ankle arthroscopy but anterior portals are safer, provide good access and visualisation of joint. Aims: The anatomical structures nearby portals are vulnerable to injury during surgery. To study the anatomy of ankle joint using dissection method. Methods and material: 20 cadaveric limbs were dissected and the distance of different portals to the nearby neurovascular structures was measured. Results: The mean distance from anteromedial portal to the great saphenous vein and saphenous nerve was 5.28 mm, 9.12mm and that between the medial midline portal to the dorsalis pedis artery and deep peroneal nerve was 10.08 mm and 16.20mm. The mean distance from anterocentral portal to the dorsalis pedis artery was 2.38mm, to superficial peroneal nerve was 7.09mm and deep peroneal nerve was 4.12mm. The mean distance from anterolateral portal to lateral branch of superficial peroneal nerve was 3.18mm. There was injury in one specimen. Conclusions: This present study concluded that medial midline portal is comparatively safe for ankle arthroscopy. Anterocentral portal has potential risk of injury to dorsalis pedis artery.

The distribution pattern of the dorsal cutaneous nerves of the foot and its clinical implications.

Iatrogenic injury to subcutaneous nerves on the dorsum of the foot is an established risk factor during the surgical procedures resulting in postoperative pain, sensation loss and painful neuroma. Previous studies have reported on the distribution pattern of the superficial peroneal, deep peroneal and sural nerves (SNs) and their branches with various classifications about specific populations. The purpose of the present study was to evaluate the distribution pattern and classification of the nerves on the dorsum of the foot and analyze the location of these nerves into five zones with clinical implications. Fifty-four lower limbs of fresh frozen cadavers were used in the present study. The anatomical patterns of the superficial peroneal, deep peroneal, SN and their branches were classified into eight, two and five patterns respectively. Type VI pattern, a classic distribution pattern of the superficial peroneal nerve was the most frequent type with a prevalence of 13 limbs (25.00%). In Zone 5, where the arthroscopic portal placements for the first metatarsophalangeal joint arthrodesis, 29 limbs (55.77%) showed three nerve branches located in this zone. The results of the present study provide anatomical knowledge that may help the surgeon to choose the appropriate treatment for their patients and reducing the rate of complications in surgery.

Anterocentral Portal in Ankle Arthroscopy.

Background:The anterocentral portal is not a standard portal in anterior ankle arthroscopy due to its proximity to the anterior neurovascular bundle. However, it provides certain advantages, including a wide field of vision, and portal changes become redundant. The purpose of this study was to evaluate the neurovascular complications after anterior ankle arthroscopy using the anterocentral portal.Methods:We retrospectively identified patients who had undergone anterior ankle arthroscopy with an anterocentral portal at our institution from 2013 to 2018. Medical record data were reviewed and patients were invited for clinical follow-up, where a clinical examination, quantitative sensory testing for the deep peroneal nerve, and ultrasonography of the structures at risk were performed. A total of 101 patients (105 arthroscopies) were identified and evaluated at a mean follow-up of 31.5 ± 17.7 months.Results:Leading indications to surgery were heterogeneous and included anterior impingement (48.6%), osteochondral lesions of the talus (24.8%), chronic ankle instability (14.3%), and fractures (8.6%). The overall complication rate was 7.6%, and no major complications were observed. In 1.9% (2/105) of the cases, the complications were associated with the anterocentral portal and included injury to the medial branch of the superficial nerve (1/105) and to the deep peroneal nerve (1/105). Injury to the deep peroneal nerve was associated with a loss of detection and nociception. There were no injuries to the anterior tibial artery. In 41.9% (44/105) of the cases, only 1 working portal was used in addition to the anterocentral portal, and in 19% (20/105) the anterolateral portal could be avoided. Ultrasonography confirmed the integrity of the deep peroneal nerve, the medial branch of the superficial peroneal nerve, and the anterior tibial artery in all patients. Patients with nerve injuries associated with the anterocentral portal showed no signs of neuroma or pseudoaneurysm.Conclusion:Using a standardized technique, the anterocentral portal in ankle arthroscopy is safe with a low number of neurovascular injuries and can be recommended as a standard portal. The anterolateral portal remains associated with a high number of injuries to the superficial peroneal nerve.Level of Evidence:Level III, retrospective cohort study.

Novel Branching Pattern of the Common Fibular Nerve: Emergence of the Superficial Fibular Nerve Within the Anterior Crural Compartment.

Distal to its origination from the sciatic nerve, the common fibular (peroneal) nerve divides into the superficial and deep fibular (peroneal) nerves. Whereas the deep fibular nerve continues its course into the anterior compartment, the superficial fibular nerve (SFN) usually arises near the fibular neck and projects distally within the lateral crural compartment before entering the superficial fascia proximal to the ankle. In this report, we describe a unilateral case where the SFN arises within the anterior crural compartment and remains there for the remainder of its course deep to the deep fascia of the leg. Surgeons should be aware of anomalies such as this, for example, when performing fasciotomies to avoid inadvertently damaging an anomalously placed SFN.

Anatomic structures at risk in anteroposterior screw fixation of posterior malleolar fractures: A cadaver study

IntroductionPercutaneous anterior-posterior (AP) screw is an option for posterior malleolus fracture fixation when the fracture fragment can be reduced indirectly by the mean of ligamentotaxis. However, anterior anatomic structures could be injured during screw placement. Materials and methodsEleven below-knee cadavers were employed for the placement of AP screws in an attempt of fixing assumed Haraguchi Type-I posterior malleolar fractures. Three entry points were selected as medial to the anterior tibial tendon (ATT), lateral to the ATT, and lateral to the extensor digitorum longus (EDL). Three AP screws were placed under guidance of fluoroscopy. After dissection, measurements were made (mm) from each screw to nearby structures. Distances were calculated and damage to structures was documented. ResultsMean, minimum, and maximum distances from the medial screw to the greater saphenous vein, TA, EHL, anterior tibial artery (ATA), and deep peroneal nerve (DPN), were 18.1 (12–25) mm, 2.0 (0–5) mm, 13.6 (9–20) mm, 16.6 (9–25) mm, and 20.1 (12–27) mm. From the middle screw to the ATA, DPN, TA, EHL, and EDL, were 1.2 (0–3) mm, 4.9 (3–9) mm, 3.8 (1–7) mm, 0.4 (0–2) mm, and 13.6 (10–18) mm. From the lateral screw to the superficial peroneal nerve (SPN), EDL, DPN, and ATA, were 10.8 (0–16) mm, 1.2 (0–4) mm, 15.9 (11–25) mm, 19 (15–27) mm. The SPN was found partially cut by the lateral screw on 1 specimen. ConclusionsLateral and middle percutaneous AP screw placement put certain anatomic structures at-risk of injury. Medial screw placement did not result in appreciable damage to adjacent structures. Entry point of AP screws should be selected with respect to posterior malleolar fracture and anatomic structures. Level of evidenceIV.

Soleus nerve transfer to deep peroneal nerve for treatment of foot drop

Different mechanisms including knee dislocation, replacement surgery, nerve tumor, lumbar disc herniation, sharp injury, and gunshot wound lead to foot drop. Several surgical techniques have been used for treatment of foot drop, however, they have had sub-optimal outcomes. Soleus branch of tibial nerve is a good donor for nerve transfer for treatment of foot drop. In this is retrospective study, we reviewed medical records of 6 consecutive patients with sustained foot drop following injury to lumbar root or peroneal nerve, who underwent transfer of the soleus branch of tibial nerve to deep peroneal nerve during 2014–2016. The mean age of the patients was 44.8 years and duration of injury to surgery and follow-up was 8.3 and 14.6 months, respectively. At the end of the follow-up, ankle dorsiflexion force was M4 in two patients (with traumatic peroneal nerve injury with M3 toe extension) and was M2 in one patient. There were three patients with lumbar degenerative disease. Of these patients, two showed M0 and one patient experienced M1 ankle dorsiflexion. We recommend that transfer of soleus nerve to deep peroneal nerve is used as an alternative technique for treatment of foot drop.

Ultrasound-guided diagnostic deep peroneal nerve blocks prior to potential neurectomy: a retrospective review.

To describe our technical and preliminary clinical experience with ultrasound-guided diagnostic deep peroneal nerve (DPN) blocks for patients considering deep peroneal neurectomy. Retrospective analysis of ultrasound-guided diagnostic DPN blocks performed in the anterior lower leg in patients pursuing deep peroneal neurectomy for foot pain not directly attributable to the DPN. Patient age, sex, foot laterality, diagnosis, nerve block complications, location of the DPN with respect to vascular landmarks in the lower leg, pain relief from nerve block, and pain relief from neurectomy (if performed) were recorded. Twenty-six DPN blocks were performed for 25 feet, of which a majority had pain attributable to midfoot osteoarthritis (22/25). Variable DPN locations with respect to vascular landmarks in the lower leg were observed, including lateral to the anterior tibial artery (12/25), anterior to the artery (5/25), medial to the artery (3/25), lateral to the lateral paired vein (4/25), and 1-cm lateral to the artery (1/25). After DPN blocks, patients reported pain relief in 22/25 feet. Of the eleven patients who proceeded to have a deep peroneal neurectomy, ten reported improved foot pain. Diagnostic deep peroneal nerve blocks for patients considering deep peroneal neurectomy for denervation therapy should be performed in the anterior lower leg where the anterior tibial vessels serve as anatomic landmarks. Those who perform DPN blocks with ultrasound guidance should be aware of variable DPN position with respect to the vascular landmarks.

Interrogating interneurone function using threshold tracking of the H reflex in healthy subjects and patients with motor neurone disease

ObjectiveThe excitability of the lower motoneurone pool is traditionally tested using the H reflex and a constant-stimulus paradigm, which measures changes in the amplitude of the reflex response. This technique has limitations because reflex responses of different size must involve the recruitment or inhibition of different motoneurones. The threshold-tracking technique ensures that the changes in excitability occur for an identical population of motoneurones. We aimed to assess this technique and then apply it in patients with motor neurone disease (MND). MethodsThe threshold-tracking approach was assessed in 17 healthy subjects and 11 patients with MND. The soleus H reflex was conditioned by deep peroneal nerve stimulation producing reciprocal Ia and so-called D1 and D2 inhibitions, which are believed to reflect presynaptic inhibition of soleus Ia afferents. ResultsThreshold tracking was quicker than the constant-stimulus technique and reliable, properties that may be advantageous for clinical studies. D1 inhibition was significantly reduced in patients with MND. ConclusionsThreshold tracking is useful and may be preferable under some conditions for studying the excitability of the motoneurone pool. The decreased D1 inhibition in the patients suggests that presynaptic inhibition may be reduced in MND. SignificanceReduced presynaptic inhibition could be evidence of an interneuronopathy in MND. It is possible that the hyperreflexia is a spinal pre-motoneuronal disorder, and not definitive evidence of corticospinal involvement in MND.

Communications between the superficial and deep fibular nerves in the foot: An anatomical and electrophysiological study.

The deep fibular sensory nerve can be recorded to evaluate for peripheral nerve injury; however, it can be challenging in some individuals. Anatomic variation could account for some of this difficulty. Cadaver dissection and electrophysiological testing were used to characterize deep and superficial fibular sensory nerve supply to the foot. Nineteen feet from 15 (8 males and 7 females) cadavers were dissected to identify the deep fibular nerves (DFNs) and superficial fibular nerves (SFNs). Sensation to the first dorsal web space was tested electrophysiologically in 101 participants (31 males and 70 females) with an age range of 18-47 years with stimulation over both DFNs and SFNs. Eleven of the 19 (58%) cadaver limbs had a communication between SFNs and DFNs in the dorsum of the foot. A reliable sensory response was recorded in the first dorsal web space in 88% of the limbs tested. Deep fibular stimulation alone produced a response in 34% of the limbs, while superficial fibular stimulation alone produced a response in 10% of the limbs. A separate response with stimulation of both the DFNs and SFNs was recorded in 44% of the limbs. A functional superficial to deep fibular sensory communication is present in a significant portion of the population. Those with the communication may not have the isolated sensory loss that would be expected in the first dorsal web space in conditions impacting the DFNs.

Effect of Monochromatic Infrared Energy Light Versus Laser Therapy in Diabetic Peripheral Neuropathy

Abstract Diabetic peripheral neuropathy (DPN) is known to be a severe longterm sequelae of diabetes mellitus (DM) and correlated with high morbidity and mortality. There's no widely agreed optimal method for its treatment. Monochro-matic Infrared Photo Energy (MIRE) and Low Level Laser Therapy) LLLT) are relatively new modalities of light used to boost the velocity of nerve conduction (NCV), minimize pain and increase peripheral circulation. Purpose: The objective of this study was to compare the effect MIRE versus LLLT in DPN on NCV, pain, and daily living function (ADL) activity. Material and Methods: Thirty patients with DPN, type 2 diabetes (T2DM) with neuropathic pain, particularly in the lower limbs, were recruited at (56.29±2.98) years of age. Any of the patients had 10 to 15 years of DM. They were split into two groups: Group A (15 patients) had MIRE applied to each limb for 40 minutes. Group B (15 patients) had LLLT applied to each limb for 20 minutes. All patients were subjected to various physical assessment tests, including a questionnaire on NCV, pain and quality of life (QOL), both assessed before and after treatment. Results: Significant changes in NCV, pain and functional ADL (p 0.05). Conclusion: MIRE and LLLT are both effective in im-proving deep peroneal nerve neuronal activity, decreasing pain and improving activity of daily living (ADL) in DPN.

Surgical Outcome of Peripheral Nerve Injury

: Our article focuses on various surgical treatments and outcomes in patients who had upper and or lower extremity musculoskeletal disorders due to peripheral nerve injuries. Here, we mainly discuss the benefits of the Nath method of surgical management in infants, children (preteen and teen), and adult patients in the following four categories of peripheral nerve damage. Brachial Plexus Injury and Upper Extremity Musculoskeletal Dysfunctions: Improvements in detail are discussed in obstetric brachial plexus palsy patients, who had the soft tissue surgical procedure, modified Quad, and the novel osseous operative technique, triangle tilt at our clinic. Upper Trunk of Brachial Plexus and Long Thoracic Nerve Damage and Winging Scapula: There are at least 18 categories of causation/etiology of upper plexus and long thoracic nerve lesions in 575 patients who visited our clinic with winging scapula, limited shoulder movements, and or pain. Further, we discuss the results of the excellent recovery of hundreds of these patients, who had decompression and neurolysis of the upper trunk of brachial plexus and long thoracic nerve. Peroneal Nerve Lesion and Foot Drop:: Our management of foot drop by nerve transfers to the deep peroneal nerve is discussed. Sural Nerve Grafting to Cavernous Nerve Impairment after Prostatectomy or Genital Surgery: We also discuss briefly our experience and results of the sural nerve grafting, which restores the function of cavernous nerves resected during radical prostatectomy. Conclusion: The lead author (RKN) has developed and implemented several innovative new surgical approaches as a reconstructive microsurgeon. These surgical techniques have proven clinical and functional improvements in patients with upper and lower extremity musculoskeletal disorders due to peripheral nerve injuries.

Critical Limit of Lower-Extremity Lengthening in Total Hip Arthroplasty: An Intraoperative Neuromonitorization Study.

The effect of limb lengthening on neural structures was assessed with use of intraoperative neuromonitoring (IONM) during primary total hip arthroplasty (THA). The relationship between the critical limit of lengthening and anthropometric measurements was evaluated. Motor evoked potentials (MEPs) from the deep peroneal nerve (tibialis anterior muscle), tibial nerve (gastrocnemius muscle), and femoral nerve (quadriceps muscle), as well as somatosensory evoked potentials (SEPs) from the posterior tibial nerve, were recorded in 16 patients undergoing THA. Height, weight, the distance between the anterior superior iliac spine and the medial malleolus (ASIS-MM distance), and the total femoral length were measured preoperatively. Lower-extremity traction was performed after resection of the femoral head, and the amount of extremity lengthening was measured with use of an image intensifier. A maximum of 50% reduction in any one of the SEP or MEP amplitudes or a 10% increase in the SEP latency were considered to be indicative of the critical limit of lengthening. Initial IONM changes (indicating the safe limit of lengthening) and maximum allowed IONM changes (indicating the critical limit of lengthening) were reached in the deep peroneal nerve in all cases. The mean safe limit of lengthening (and standard deviation) was 14.9 ± 6.2 mm (3% relative to femoral length and 1.7% relative to ASIS-MM distance), whereas the critical limit of lengthening was exceeded at a mean of 22.4 ± 5.6 mm (5% relative to femoral length and 2.6% relative to ASIS-MM distance). When the critical limit was reached in the deep peroneal nerve, the mean decrease in MEP amplitudes was 27% (95% confidence interval [CI], 22.1% to 32.7%) for the tibial nerve and 12% (95% CI, 6.9% to 18.1%) for the femoral nerve. There was a positive correlation between critical lengthening and femoral length (r = 0.782; p < 0.001), ASIS-MM distance (r = 0.811; p < 0.001), and height (r = 0.835; p = 0.001). No correlation existed between the critical lengthening amount and the decrease in amplitude in the tibial and femoral nerves. The critical limit of nerve lengthening was directly correlated with anthropometric measurements. Nerve lengthening of 5% relative to femoral length and of 2.6% relative to ASIS-MM distance was found to be critical; however, these limits depended on the predetermined threshold values for IONM. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Ankle block

The so-called ankle block represents alocal anesthesia form which enables easy performance of all surgical procedures of the foot and ankle. Interventions distal to the medial and lateral malleoli. Acute and chronic infections in the area of injection; allergy to the local anesthesia. All five sensory foot nerves are blocked. The two deep lying nerves, the tibial nerve and the deep fibular nerve, can be directly anesthetized perineurally using anatomical landmarks. The other three nerves are subcutaneously infiltrated near their branches. The success rate ranges from 88 to 94%; smaller areas may also be further blocked intraoperatively. The ankle block is acost-effective procedure which can also be performed without problems in multimorbid patients due to its minor side effects.

A Rare Case of Atraumatic Unilateral Isolated Compartment Syndrome of the Peroneal Compartment Leading to Common Peroneal Nerve Palsy

Acute Compartment syndrome (ACS) is an orthopaedic surgical emergency with very poor prognosis when left untreated. The majority of cases are preceded by trauma, but importantly there is a small percentage of patients presenting with non-traumatic causes. Although rare with only two other case reports describing non-traumatic, spontaneous compartment syndrome of the peroneal compartment, the complications are equally devastating. We report a 67-year-old female with a history of Factor V Leiden, pulmonary embolism (PE) and deep vein thrombosis (DVT). She was seen by orthopaedic surgery six weeks after acute onset right leg pain with associated foot-drop. Her symptoms were initially managed by a medical team as she had no history of trauma and no fractures were evident on plain radiographs. This was on a background of severe bilateral knee osteoarthritis, chronic bilateral lower leg pain and neurogenic claudication for the preceding six months. Given her atypical presentation with confounding comorbidities, she was admitted under the medical team for further investigations instead of urgent fasciotomy. As orthopaedics was not involved in the acute phase of her symptoms, a non-surgical approach was taken. MRI right knee and calf six weeks after onset of symptoms were suggestive of sequela of compartment syndrome isolated to the peroneal compartment. This scan showed myonecrosis in this compartment as well as denervation myopathy of the anterior compartment. Over the next twelve months, there was resolution of leg pain and gradual progression of a positive tinel’s sign from the fibular head to anterior shin with associated return of some ankle range of movement and power. Given the atraumatic presentation and patient risk factors, we believe she suffered a venous thrombotic event at the popliteal trifurcation leading to a subacute compartment syndrome of the peroneal compartment. Swelling of the compartment led to compression of the deep peroneal nerve, causing denervation of the anterior compartment. This is of interest given the rarity of such presentations, and will serve as a timely reminder for non-traumatic causes of ACS. Keywords: Compartment syndrome, non-traumatic, Factor V Leiden, common peroneal nerve palsy.

A Part of the Medial Branch of the Deep Peroneal Nerve Distributes the Dorsal Pedis Artery and Its Distribution Area is Close to the Acupuncture Point LR3 (Taichong).

Cutaneous nerves have vascular branches (VBs) that reach the arteries and are thought to be involved in arterial constriction. We aimed to examine the anatomical and histological relationship between the VBs of a cutaneous nerve in the foot and the acupuncture point LR3 (Taichong), which is a depression between the base of the first and second metatarsal bones on the dorsum of the foot and is a source point of the foot. We examined 40 cadaver feet to assess the distribution areas of the VBs of the medial branch of the deep peroneal nerve (MBDPN). MBDPNs were distally followed to identify the point where the VBs reached the arteries. The distance between the point and LR3 was measured. Sympathetic fibers in the VBs were histologically observed using tyrosine hydroxylase (TH) immunostaining. The VBs of the MBDPNs reaching the dorsal pedis arteries were observed in all specimens (100%). The mean distance between LR3 and the point where the VBs of the MBDPN reached the arteries was 3.2 ± 2.6 mm. Among the VBs, 70% were distributed proximal to LR3. Moreover, TH-positive fibers were present in the VBs. These findings revealed that a part of the MBDPN distributed the dorsal pedis artery and contained sympathetic fibers. We also found that the distribution area of the VBs was close to LR3. Our study provides anatomical evidence that LR3 is a specific area and its stimulation would be useful for treating peripheral circulatory failure.

Deep Peroneal Nerve Injury Following Hardware Removal for Lisfranc Joint Injury.

Surgical exposure of the Lisfranc joint complex is within close proximity to the deep peroneal nerve, which can be injured in this approach. Common clinical practice is to remove Lisfranc hardware at 3 to 4 months postoperatively. However, it is unknown if this provides a clinical benefit or risks injury to the deep peroneal nerve. The rate of nerve injury is currently unknown from the published literature. This study clarifies rates of neurological injury to the deep peroneal nerve during primary surgery and hardware removal. This retrospective study was performed on all patients of a single surgeon from 2012 to 2018. Fixation was performed with locking plates or screws depending on the injury pattern. All patients who required open reduction and internal fixation routinely underwent hardware removal during this time. Neurological injury was assessed in a binary fashion (normal or abnormal) at 2, 6, and 12 weeks after the primary surgery and 2 and 12 weeks after hardware removal. McNemar's test was performed to compare the rates of injury. Patients were contacted at a minimum follow-up of 15 months (range, 15-87 months) to assess persistent nerve injury and satisfaction. Fifty-seven patients with an average age of 29.8 years were included in the final analysis; all had documentation at 3 months postsurgery. All patients had normal neurology before surgery. The rate of nerve injury for the primary surgery (11%) was significantly lower than the rate for patients with nerve injury following hardware removal (23%). However, the rate of spontaneous neurological recovery was low, with symptoms persisting in 5 of 6 patients between the primary operation and subsequent hardware removal. When these patients were excluded from the analysis, the rate of new nerve injury following hardware removal (15%) was not significantly different from the primary surgery rate. Seventy-one percent of nerve injuries persisted at the minimum 15-month final follow-up, with all patients with nerve injury being very or partially satisfied. The rate of deep peroneal nerve injury from primary Lisfranc fixation was 11%, and when routine hardware removal was planned the overall rate of nerve injury rose to 23%. This may be useful information during the patient consent process. Level IV, case series.