Fibular Neck Research Articles

An Unusual Cause of Paralysis of the Peroneal Nerve

We present 3 cases of a 12-year-old boy, an 8-year-old girl, and a 9-year-old boy with progressive paresis of the peroneal nerve. Peroneal intraneural ganglia are a rare cause of paralysis of the lower limb in children; more often these symptoms occur because of exostosis. Ultrasound imaging in both patients showed a cystic mass near the fibular neck. Magnetic resonance imaging examination revealed that the ganglion is communicating with the proximal tibiofibular joint. Surgical exploration in these patients confirmed a cystic formation involving the common peroneal nerve. The ganglion originates from the articular nerve branch to the proximal tibiofibular joint. Total recovery of nerve function was seen 2 years later for the first patient, whereas the other 2 showed immediate postoperative improvement of peroneal nerve function and complete recovery within 6 to 8 weeks. On the other hand, patients with exostosis showed varying outcomes. In children with symptoms suspicious of nerve compression, fast diagnosis and immediate treatment are necessary to ensure the best possible recovery.

Deep Peroneal Nerve Injury following External Fixation of the Ankle: Case Report and Anatomic Study

We present a case of deep peroneal nerve injury after application of external fixator and conducted a cadaveric study of the relationship of the deep peroneal nerve to the lateral tibial cortex. A case of toe drop after application of the external fixator is reported. Twelve cadaveric lower legs were dissected to identify the course of the deep peroneal nerve. The tibia were divided into four Zones with equal length. The course of the nerve through each Zone of the tibia was studied Result: In Zone 1, the deep peroneal nerve went around the fibular neck and was found on the interosseous membrane at the distal portion of Zone 1. In Zone 2, the nerve still lay on the interosseous membrane in all specimens at the posterior edge of the lateral tibia. In Zone 3, the nerve moved away from the interosseous membrane and had direct contact with the tibia in nine specimens. In Zone 4, the nerve was on the anterior surface of the distal tibia. The deep peroneal nerve can be injured during the application of a unilateral frame ankle external fixator. The nerve is particularly at risk in Zone 2 and 3. The study provided an anatomic basis for the safe application of a unilateral external fixator of the tibia.

An anatomically based imaging sign to detect adventitial cyst derived from the superior tibiofibular joint

The origin for complex intraneural cysts remains controversial despite recent emerging evidence to support their articular origin. The coexistence of intraneural and adventitial cysts has been described due to the proximate neurovascular bundle, i.e., the articular (neural) branch and vessels at the joint capsule. To clarify the pathogenesis, anatomically based imaging patterns can be identified. This paper characterizes a common finding identified on MRI describing the adventitial component originating from the superior tibiofibular joint (STFJ). MRIs of patients with fibular (peroneal) (n = 24) and tibial (n = 7) intraneural ganglion cysts were reviewed. Eleven patients with fibular intraneural ganglion cysts were identified as having a coexisting adventitial component. In all cases, the adventitial cyst extended from the anterior portion of the STFJ, within the capsular vessels, and along the anterior tibial vessels. The reproducible anatomy permitted the identification of an imaging pattern: the "vascular U" sign, consisting of cystic anterior tibial vessels running through the interosseous membrane between the proximal tibia and fibula. This sign was seen on axial MR image(s) obtained at the level of the fibular neck in all cases. To generalize these findings, the rare tibial intraneural ganglion cysts (derived from the posterior aspect of the STFJ) were examined; two cases had coexisting adventitial cysts with visualization of the vascular U sign. This new imaging pattern can improve the identification of adventitial cysts at the level of the STFJ.

Common peroneal nerve decompression

Common peroneal neuropathy occurs as a result of compression of the common peroneal nerve (CPN) in the fibro-osseous tunnel between the fibular neck and the tendinous arch of peroneus longus. High rates of spontaneous recovery have been reported. However, there is a subset of patients who require decompression of the CPN at the fibular neck. We performed a retrospective analysis of patients that underwent decompressive surgery of the CPN. A total of 22 operations performed on 20 patients were analysed. Pre-operative workup included clinical examination, electrophysiological testing and magnetic resonance imaging (MRI) where indicated. Post-operatively, all patients were examined clinically for neurological recovery and where indicated, electrophysiology was repeated. 74% of patients (14 out of 19) with motor weakness improved, as did 68% with sensory dysfunction. 69% with foot drop improved to have no foot drop, most of these were those that underwent surgery within 12 months of symptom onset (OR 14.7, 95% CI 1.4–133.5). Patients with foot drop fared significantly better if their duration of symptoms prior to surgery was less than 12 months.

An anomalous variation in the division pattern of the common peroneal nerve

The muscles of the leg are partitioned into three compartments (anterior, lateral, and posterior) by two intermuscular septa that have separate innervations. Anterior compartment is innervated by the deep peroneal nerve and lateral compartment is innervated by the superficial peroneal nerve. Common peroneal nerve divides into superficial and deep peroneal nerve at the neck of fibula. An unusual finding in the dividing pattern of the common peroneal nerve in the male cadaver on the left side was observed. This finding is of academic interest and clinical significance to the orthopedician operating on the proximal fibula for nerve decompression, high tibial osteotomy, and nerve transfer operations.

Magnetic resonance imaging features of antibioma of the common peroneal nerve

DOI: 10.4103/0028-3886.86583 A 54-year-old male, who was operated for an osteochondroma of the right fibular neck a year ago, presented with severe neuralgic pain radiating along the course of the right common peroneal nerve. The pain started 2 months after the surgery and progressed in severity and frequency over the year, leading to disturbance in sleep and daily activities. With the diagnosis of perineural fibrosis and entrapment neuropathy, the patient was subjected to exploration and neurolysis. The nerve was released microsurgically from the thick fibrous bands encasing it and the thickened epineurium was incised along the length of the nerve till all the fascicles became lax. There was immediate and dramatic relief from pain. After a symptom-free interval of 2 weeks, he had recurrence of symptoms in the form of neuralgic pain, with fever and tender swelling at the site of surgery. As the patient had no relief with multiple antibiotics given by a local physician, he once again visited our department. Magnetic resonance imaging (MRI) showed a well-defined T2 hyperintense lesion in close relation to the common peroneal nerve [Figure 1], with thick post-contrast rim enhancement [Figure 2] suggestive of an abscess. During operation, a thickwalled abscess, the inner wall of which was intimately adherent to the common peroneal nerve, was found. It was deroofed and pus was evacuated. The inner wall of the abscess was gently washed with dilute hydrogen peroxide and saline. The pus flakes and inflammatory tissue were separated from the nerve fascicles under a microscope. Pus culture did not grow any organism, suggesting diagnosis of an antibioma of the common peroneal nerve. The patient had an excellent recovery after the surgery. Figure 1: T2-weighted sagittal (a) and axial (b) images show a welldefined T2 hyperintense thick-walled lesion (arrows) in close relation to the common peroneal nerve suggestive of an abscess a

Minimally invasive peripheral nerve surgery: A short scar technique

As peripheral nerve specialists can have a wide variety of training backgrounds, few standards of care exist with respect to necessary incision length, amount of dissection, and operative technique for common nerve decompressions. Approaches for the following 12 common peripheral nerve surgeries were minimized using shorter incisions and a simple lighted retractor: zygomatico-temporal and auriculotemporal, greater occipital, brachial plexus, ulnar, radial, median, lateral femoral cutaneous nerve of the thigh, peroneal at the groin, fibular neck and lateral calf, and tibial and inner ankle. The new "minimal" incision length was recorded as was that of the "classical" approach as taught to the senior author and frequently represented in atlases. A Mann-Whiney analysis was independently performed to evaluate for significance between the lengths of incisions for each procedure. The average length of the "minimal" incisions was 3.9 ± 0.6 cm (range, 3.1-6.1 cm), with an average reduction in length of 51% as compared with the "classical" incisions (range, 30-75%; P < 0.001). There were no perioperative morbidities. Minimally invasive peripheral nerve surgery applied to the above procedures yields successful surgical outcomes while shortening incision lengths and maximizing patient satisfaction without sacrificing patient safety.

Peroneal and Tibial Intraneural Ganglion Cysts in the Knee Region

Recent research has resulted in an improved understanding of the pathogenesis and treatment of intraneural ganglia, particularly with respect to the most common form, the peroneal nerve at the fibular neck region. To outline the mechanism for the development and propagation of intraneural ganglia located in the knee region, along with their treatment, as well as highlight how shared principles can be exploited for successful treatment of the more commonly occurring peroneal intraneural ganglia. A surgical approach has been developed for peroneal intraneural cysts based on the pathogenesis. The treatment of the less common tibial intraneural cysts is designed along the same principles. A strategy consisting of (1) disarticulation (resection) of the superior tibiofibular joint (ie, the source), (2) disconnection of the articular branch connection (ie, the conduit), and (3) decompression (rather than resection) of the cyst has improved outcomes and eliminated intraneural recurrences in peroneal intraneural cysts. These same principles and techniques can be applied to the rarer tibial intraneural ganglia derived from the same joint. The mechanism of development and propagation for intraneural cysts in the knee region as well as a surgical technique and its rational are described and illustrated. Understanding the joint-related basis of intraneural cysts leads to simple targeted surgery that addresses the joint, its articular branch, and the cyst. The success of the shared surgical strategy for both peroneal and tibial intraneural ganglia confirms the principles of the unifying articular theory.

Posterolateral Transfibular Approach to Tibial Plateau Fractures: Technique, Results, and Rationale

We describe a posterolateral transfibular neck approach to the proximal tibia. This approach was developed as an alternative to the anterolateral approach to the tibial plateau for the treatment of two fracture subtypes: depressed and split depressed fractures in which the comminution and depression are located in the posterior half of the lateral tibial condyle. These fractures have proved particularly difficult to reduce and adequately internally fix through an anterior or anterolateral approach. The approach described in this article exposes the posterolateral aspect of the tibial plateau between the posterior margin of the iliotibial band and the posterior cruciate ligament. The approach allows lateral buttressing of the lateral tibial plateau and may be combined with a simultaneous posteromedial and/or anteromedial approach to the tibial plateau. Critically, the proximal tibial soft tissue envelope and its blood supply are preserved. To date, we have used this approach either alone or in combination with a posteromedial approach for the successful reduction of tibial plateau fractures in eight patients. No complications related to this approach were documented, including no symptoms related to the common peroneal nerve, and all fractures and fibular neck osteotomies healed uneventfully.

Sequential Compression Device May Cause Peroneal Nerve Palsy

This article presents 2 cases of foot drop after joint replacement surgery that presented after sequential compression device application. In both cases, intact peroneal nerve function was documented by the surgeon in the recovery room prior to sequential compression device application. We believe that excessive pressure over the superficial aspect of the peroneal nerve in conjunction with decreased pain stimulus from analgesia may have contributed to these complications. We maintain sequential compression devices are the current mechanical thromboprophylaxis of choice; however, 4 recommendations are made to minimize the chances of this potential complication. First, precise attention should be given to patients who are short statured, as these patients can be more susceptible to having a sequential compression device improperly placed over the peroneal nerve at the fibular neck. Second, we recommend different size options become more widely available to accommodate varying patient sizes such that placement of the device is ensured to be distal to the fibular neck. Third, when using sequential compression device brands that have hook and look fastener straps, the straps should not be tight on application and frequent skin checks should be made to look for signs of over-compression. Lastly, we recommend considering delaying postoperative application of the sequential compression device until resolution of sensation following spinal or epidural anesthetic.

Intraneural Ganglion of the Superficial Peroneal Nerve: A Case Report

Ganglia affecting the peripheral nerves of the foot and ankle are rare. The most frequent location of occurrence is the common peroneal nerve at the level of the fibular neck. We report the case of an intraneural ganglion of the superficial peroneal nerve and its branches. Although there have been many previous reports of intraneural ganglion involvement with the common peroneal nerve, deep peroneal nerve, sural nerve, and the posterior tibial nerve, to our knowledge, this is the first reported occurrence of an intraneural ganglion distinctly localized to the superficial peroneal nerve and its branches. The presumptive diagnosis was made preoperatively using magnetic resonance imaging, and then confirmed postoperatively by pathologic examination. Despite the use of operative magnification, it was impossible to remove all of the cyst elements within the nerve trunk, because the nerve fascicles were intimately intertwined. Therefore, complete resection of the common trunk of the superficial peroneal nerve and its terminal branches was performed, and the proximal stump was buried in a hole in the distal fibula. Two years after the surgery, the patient was pain free and asymptomatic except for cutaneous anesthesia in the distribution of the superficial peroneal nerve.

POSITION OF NUTRIENT FORAMEN ON FIBULA, ITS VARIATIONS AND DISTANCE FROM THE STYLOID PROCESS AND ITS CLINICAL APPLICATION IN FIBULAR FLAP IN A MANDIBULAR RECONSTRUCTION

The main aim of the present work is to study the position and variation in nutrient foramen in relation to styloid process and its distance from the the styloid process which is most important in a fibular flap during mandibular reconstruction. Fibula is one of the long bones present on the lateral side of leg. It receives its own neuro‐vascular bundle apart from the muscles attached to it. The upper end of the fibula with its nutrient artery and nerve entering its nutrient foramen along with muscles attached to it is preferred in most of the mandibular reconstruction and is called as fibular flap. While doing the fibular flap, care is being taken to avoid damage to neuro‐vascular bundle to fibula. The aim of the present work is study the position of nutrient foramen and its distance from the styloid process. The nutrient artery to fibula arises from the peroneal artery which winds around the neck of fibula and descends down along the fibula deep Flexor Hallucis Longus. Near the middle of fibula, it gives off nutrient artery which enters the nutrient foramen, and ramify within the fibula. The study has been carried out in 50 dry specimen (fibula) and radiological study has been carried out in 30 normal individuals. Various parameters like position and direction of nutrient foramen, distance from the styloid process were studied in the dry fibula and the same study was carried out in the radiology of fibula of normal individuals. The results have been tabulated and compared between the dry specimen and the normal individuals. These results were later correlated with the clinical application while tracing the nutrient foramen with the artery during mandibular reconstruction.

Common Peroneal Nerve Compression and Heterotopic Ossification Resulting from Severe Burn Injury

Heterotopic ossification is defined as the abnormal location of lamellar bone within soft tissue, where bone normally does not exist1. Despite various theories, the exact mechanism (etiology and pathogenesis) of heterotopic ossification remains uncertain2. Johnson first described heterotopic ossification in patients with burn injuries in 19573, but thermal injury has been reported to be one of the least common causes of heterotopic ossification, with an estimated prevalence of 1% to 3% of all patients with burn injuries1,4-6. The most common location of heterotopic ossification in patients who have sustained a burn injury appears to be the elbow, leading to stiffness and contracture; far lower rates have been reported in other regions5,7-13. Lesions of peripheral nerves as a complication of heterotopic ossification are a relatively rare phenomenon and mainly consist of compression of the ulnar nerve in the elbow region4,5,14,15. The common peroneal nerve follows a curved course, lateral to the fibular neck, and then runs deep to the peroneus longus muscle, where it divides into the superficial and deep peroneal nerves16,17. The entrance into the fibular tunnel is a musculo-aponeurotic arch, derived from the soleus and peroneus longus muscles, called the fibrous arch 18. It is believed that peroneal nerve entrapment or fibular tunnel syndrome, which has been described on occasion in the literature, is caused by this fibrous arch16,17. To the best of our knowledge, there is only one well-documented report of heterotopic ossification in combination with a lesion of the common peroneal nerve19, but an associated entrapment of the nerve by this fibrous arch or other altered connective tissue was not …

Ein modifizierter posterolateraler Zugang für die operative Versorgung von Tibiakopffrakturen

Open reduction and internal fixation of posterolateral tibial plateau fractures. Tibial plateau fractures involving the posterolateral quadrant. Critical soft-tissue conditions. Tibial plateau fractures which do not involve the posterolateral quadrant. 90 degrees side positioning on the contralateral side, skin incision along the fibular head, exposure of the peroneal nerve, lateral arthrotomy and exposure of the joint, dissection of the popliteal cavity between the lateral head of the gastrocnemius muscle and soleus muscle. Blunt preparation between popliteus muscle and soleus muscle under preservation of the popliteal artery and vein. Sharp dissection of the soleus muscle from the dorsal parts of fibula and tibia until the peroneal nerve at the fibular neck enters into the muscle. Exposure of the posterolateral tibial head. The dorsal joint capsule and the popliteal corner are prevented from any soft-tissue damage. Visual control of fracture reduction by viewing in the joint gap through lateral arthrotomy. Reduction of the fracture from dorsal with pointed reduction forceps. A conventional or locking radius T-plate can be pinched off with lateral cutters and anatomically bent for fracture fixation and is dorsally fixed at the tibial plateau. 10 kg partial weight bearing for 6-8 weeks. Limited range of motion 0-0-90 degrees for 6 weeks. In a period of 2 years, seven patients with posterolateral tibial plateau fractures received open reduction and internal fixation by using the modified posterolateral approach. The patients were examined at follow-up between 12 and 24 months after surgery. Six patients were free of pain with full range of motion and stable knee joints. Radiologically, a good fracture reduction was achieved in six cases. In one patient with a posterolateral comminuted dislocation fracture, a small fracture step and a gap could be observed. No approach-related complications were found.

An unusual cause of paralysis of the peroneal nerve—a case report

A 12-year-old boy was referred to our clinic because of progressive paresis of left peroneal nerve. Ultrasound showed a cystic mass close to the proximity of the fibula neck. Puncture revealed jelly-like fluid, but that could not relieve symptoms. Six weeks after onset of symptoms, the boy had complete paresis. Peroneal intraneural ganglia are a rare entity of paralysis of the lower limb in children; more often these symptoms occur because of exostosis. Surgical exploration showed a cystic formation involving the common peroneal nerve. Total recovery of nerve function was seen two years later. Patients with exostosis showed varying outcomes. In children with symptoms suspicious of nerve compression, fast diagnosis and immediate treatment are mandatory to regain best possible recovery.

Sudden Peroneal Nerve Palsy in a Varus Arthritic Knee

Peroneal nerve palsy has been reported in association with traumatic and nontraumatic causes. We encountered a 75-year-old man whose peroneal nerve palsy developed suddenly following varus deformity of the arthritic knee. A review of the literature found 1 other report describing a progressive peroneal nerve palsy associated with a varus deformity of the knee due to arthritis. Our patient had progressive intractable knee pain; 3-compartment, severe degenerative changes in the knees; varus knee malalignment and laxity; right peroneal nerve palsy; and decreased sensation to light touch and pinprick on the dorsum of the right foot. The preoperative WOMAC score was 36. Nerve conduction studies confirmed acute peroneal neuropathy with conduction block at the fibular neck and secondary axonal degeneration. Magnetic resonance imaging of the knee showed osteophytes and cysts surrounding the fibular neck. Although their compression could be responsible for the nerve palsy, the sudden process made this less possible. Thus, the patient underwent total knee arthroplasty of both knees without exploration of the nerve. At 5-month follow-up, the WOMAC score was 78. The patient walked with a cane with no varus thrust, and his right knee had no varus laxity in full extension. The peroneal nerve did not retain its function. Sensory examination and postoperative nerve conduction studies showed no improvement.

Peroneal nerve damage by bicortical tibial screw in ACL reconstruction

Arthroscopically assisted anterior cruciate ligament reconstruction is regarded as a minimally invasive surgery with low morbidity but complications still occur. Reports of neurovascular injuries related to graft harvesting, tunnel placement, or graft fixation are limited. A rare case of peroneal nerve injury related to hardware used for graft fixation in the tibial in a 28-year-old female patient who underwent an anterior cruciate ligament reconstruction surgery using a patellar tendon graft (bone-tendon-bone graft) is presented. Post-operatively, the patient presented with clinical signs of peroneal nerve damage and a reduced range of motion of the knee. Plain radiographs of the knee showed the bicortical screw which used for tibial fixation of the graft, penetrating the fibula and projecting beyond the lateral cortex of the fibular neck. The patient was treated with removal of the hardware and the graft. Intensive physiotherapy resulted in gradual improvement and at 6 months after the second operation the patient regained full range of motion of the knee and almost full muscle strength performing her daily activities without any difficulty and she is at the moment unwilling to undergo further procedure.

A case of extension loss of great toe due to peroneal nerve compression by an osteochondroma of the proximal fibula

The authors present a case of extension loss of great toe caused by entrapment neuropathy of a peroneal nerve due to an osteochondroma of the proximal fibula. Plain radiographs revealed no bony abnormality around the foot or ankle, but a sessile exophytic bony growth at the proximal fibula. A positive Tinel sign in this area led us to a suspicion of compressive neuropathy of the peroneal nerve, and a subsequent electrophysiologic study confirmed the entrapment neuropathy. The peroneal nerve was decompressed by excisional biopsy. At 3 months postoperatively, normal full extension of the great toe was completely restored. The current case deserves attention in that the only clinical manifestation of peroneal nerve entrapment neuropathy by the osteochondroma at the fibular neck was extension loss of great toe.

0009: Ultrasound of Entrapment Neuropathies of the Lower Extremity

Ultrasound (US) can give direct demonstration of a wide range of neuropathies of the lower extremity. In the hip, the entrapment of the sciatic, femoral and lateral femorocutaneous nerves can be depicted with US. Main signs of nerve compression include echotextural abnormalities, displacement of the affected nerve from its normal course by space-occupying masses and selective changes in the innervated muscles related to denervation edema and fatty infiltration. At the lateral knee, the entrapment of the common peroneal nerve typically occurs between the bone and the fascia as the nerve winds around the fibular neck.

Combined peroneal and proximal tibial nerve palsies

Combined compression of both the common peroneal nerve and the proximal tibial nerve at the level of the popliteal fossa is rare. Recently, an anatomic site of compression of the proximal tibial nerve at the soleal sling (originating arch for the soleus muscle) has been described in cadavers. The present report includes three patients who had a combined compression of the common peroneal nerve at the fibular neck (fibular tunnel syndrome) and compression of the proximal tibial nerve at the soleal sling (soleal sling syndrome). In each case, blunt trauma was the precipitating event. Neurolysis of both nerves resulted in restoration of motor and sensory function in each of these three patients. This is the first clinical report illustrating combined neurolysis of the common peroneal at the knee and the proximal tibial nerve in the soleal sling.