Fibular Tunnel Research Articles

Intraneural Topography and Branching Patterns of the Common Peroneal Nerve: Studying the Feasibility of Distal Nerve Transfers.

Common peroneal nerve (CPN) disruption is the most common lower extremity nerve injury and results in gait disturbances and sensory paresthesias. The goal of this study is to describe branching patterns and the intraneural topography of the CPN to facilitate operative planning in CPN reconstruction. The CPN and its distal motor and sensory branches were dissected in 6 lower leg cadavers. Branching patterns and distances were recorded with the fibular head as the landmark. Histological review of the nerve cross sections helped characterize the intraneural topography within the fibular tunnel. The CPN distal branching patterns were highly variable. The tibialis anterior motor branch was found on average 9.6 cm distal to the fibular head. Despite the variable branching patterns, the fascicular topography of the CPN within the fibular tunnel was consistent. Proximal to the tunnel, the nerve has 3 major fascicles, which include the superficial peroneal motor, common sensory, and deep peroneal motor (DPN) fascicles from lateral to medial. Within the tunnel, the topography consolidates into the superficial peroneal motor and DPN major divisions-motor axons anteriorly and sensory axons posteriorly. The data presented provide clinically relevant information for the peripheral nerve surgeon where fascicular reconstruction of the nerve and neurolysis should focus on the anterior half of the nerve to restore ankle dorsiflexion. The nerve proximally is divided into 3 major fascicles compared with 2 distally. Surgeons may consider distal nerve transfers from the tibial nerve motor branches to the DPN or tibialis anterior motor branch.

Valleix's Sign.

Some patients present with clinical symptoms of localized tenderness and pain associated with a specific peripheral nerve, such as the ulnar nerve at the elbow or the sciatic nerve, which has been called, although rarely, "Valleix point" or "Valleix phenomenon". The purpose of this article was to translate and research the 719-page book "Traité des névralgies ou affections douloureuses des nerfs" dated 1841, dedicated solely to nerve pain (neuralgia), written by the French physician François Louis Isidore Valleix (1807-1855). He may have been the first person to observe and describe this phenomenon of localized pain, but he was probably also the first to describe distal nerve radiation, which he called "élancement" or lancinating, or stabbing. He described the phenomenon of a nerve producing pain at points along its course that we now understand to be sites of compression, clearly describing cubital and fibular tunnel syndromes, which he called neuralgias. He also described some rarer sites of compression, such as supraorbital and occipital neuralgia, notalgia paresthetica, and ACNES, but he did not describe the most common site of compression today, the median nerve at the wrist. Valleix's descriptions are clear and precede the classic 1915 reports of Hoffmann's and Tinel's signs by 74 years.

Influence and Clinical Significance of Knee Flexion Angle on the Anatomic Course of the Common Peroneal Nerve in the Posterolateral Corner of the Knee Joint.

Detailed knowledge of the anatomic course of the common peroneal nerve (CPN) is crucial for the surgical treatment of the posterolateral corner (PLC) of the knee. To investigate the relationship of the CPN to the PLC of the knee at different flexion angles. Descriptive laboratory study. Ten healthy volunteers were recruited to undergo magnetic resonance imaging (MRI) of the knee joint at knee flexion angles of 0°, 30°, 60°, 90°, and 120°. MRI scans at 3 levels (joint line, tibial cut, and fibular tip) were evaluated to determine (1) the distance from the CPN to the PLC and (2) the distances between the CPN and the anterior-posterior and medial-lateral tibial axes. A 3-dimensional model of the knee joint created from MRI scans of a single participant was used to simulate the creation of a fibular tunnel for PLC reconstruction and investigate the relationship between the CPN, fibular tunnel, and guide pin. The CPN moved posteromedially with increased knee flexion angles. As the flexion angle increased, the distances from the CPN to the anterior-posterior axis and the PLC increased significantly, while the distance to the medial-lateral axis decreased significantly at all 3 measurement levels. The distances between the CPN and anterior-posterior and medial-lateral axes were significantly different among the different knee flexion angles at the different measurement levels. There were no significant differences in the mean distance from the CPN to the posterolateral border of the tibial plateau between 0° and 30° of flexion at the fibular tip level (P = .953). There were statistically significant differences in the distance from the CPN to the PLC of the tibial plateau at the different measurement levels. The 3-dimensional model demonstrated that the position of the CPN relative to the guide pin and the bone tunnel undergoes changes during knee flexion. Changes in the knee flexion angle produced corresponding changes in the course of the CPN on the posterolateral aspect of the knee joint. The CPN moved posteromedially with increased knee flexion angles. Increasing the knee flexion angle during PLC reconstruction can effectively avoid direct injury of the CPN.

Differential Diagnosis of "Foot Drop": Implications for Peripheral Nerve Surgery.

At least 128,000 patients in the United States each year suffer from foot drop. This is a debilitating condition, marked by the inability to dorsiflex and/or evert the affected ankle. Such patients are rendered to a lifetime of relying on an ankle-foot orthosis (AFO) for walking and nighttime to prevent an equinovarus contracture. This narrative review explores the differential diagnosis of foot drop, with a particular focus on clinical presentation and recovery, whether spontaneously or through surgery. Contrary to popular belief, foot drop can be caused by more than just insult to the common peroneal nerve at the fibular head (fibular tunnel). It is a common endpoint for a diverse spectrum of nerve injuries, which may explain its relatively high prevalence. From proximal to distal, these conditions include lumbar spine nerve root damage, sciatic nerve palsy at the sciatic notch, and common peroneal nerve injury at the fibular head. Each nerve condition is marked by a unique clinical presentation, frequency, likelihood for spontaneous recovery, and cadre of peripheral nerve techniques. The ideal surgical technique for treating foot drop, other than neurolysis for compression, remains elusive as traditional peripheral nerve procedures have been marred by a wide spectrum of functional results. Based on a careful understanding of why past techniques have achieved limited success, we can formulate a working set of principles to help guide surgical innovation moving forward, such as fascicular nerve transfer.

The Triple Varus Knee: A Case Presentation

Background: Knee instability due to posterior cruciate ligament (PCL) and posterolateral corner (PLC) deficiency is a devastating condition that negatively affects patient quality of life. This video presents the surgical management of a triple varus knee, including combined high tibial osteotomy (HTO), revision PCL and PLC reconstruction, and meniscus root repair. Indications: Combined HTO and revision PCL and PLC reconstruction is indicated for patients with previously failed PCL and PLC reconstruction in the setting of varus malalignment. Technique Description: The procedure begins with a medial opening-wedge biplanar HTO, which is fixed with a patient-specific locking plate. The PCL femoral tunnel is drilled via a low anterolateral portal, and the tibial insertion is debrided via a posteromedial portal. The medial meniscus is carefully freed from the posterior capsule, and 2 luggage tag sutures are placed through the posterior root. The PCL tibial tunnel and meniscus root tunnels are drilled via their respective guides. The meniscal sutures are passed through the tunnel but not fixed. An Achilles bone-block allograft is passed through the PCL tibial tunnel and fixed with suspensory fixation and an interference screw on the femoral side, while the tibial side is left free. A peroneal nerve neurolysis is performed. A fibular tunnel is drilled, and a semitendinosus allograft is whip-stitched on both sides and passed through the tunnel. A Beath pin is inserted into the femur, and the tunnel is over drilled. Both limbs of the graft are passed deep to the iliotibial band and into the tunnel. The tibial side of the PCL is fixed with an interference screw at 90° of knee flexion. The PLC grafts are fixed with an interference screw at 30° of knee flexion with slight valgus. The medial meniscus root sutures are tied over a button, with 60° of knee flexion. Screws from osteotomy fixation are replaced as needed. Results: Although outcomes following the combined procedure are lacking, good to excellent clinical outcomes have been reported in isolation following each procedure. Conclusion: A combination of HTO and revision PCL and PLC reconstruction should be considered for patients with persistent instability and/or pain in the setting of triple varus knee. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Fibular canal syndrome: modern principles of diagnosis and treatment

Fibular tunnel syndrome is the most common tunnel syndrome of the lower extremity. Compression of the fibular nerve most often occurs at the level of the fibular head. The article describes in detail the etiology and pathogenesis of this tunnel neuropathy. Clinical manifestations of fibular tunnel syndrome are considered, methods of diagnosis and treatment are described. The prognosis of peroneal nerve neuropathy is favorable, and in most patients there is a complete or almost complete restoration of nerve function. If conservative treatment is ineffective, surgical techniques are recommended.

The distance between the fibular collateral ligament tunnel and the common peroneal nerve allows a posterolateral corner reconstruction without neurolysis.

The most popular knee posterolateral corner (PLC) reconstruction techniques describe that a common peroneal nerve (CPN) neurolysis must be done to safely address the posterolateral aspect of the knee. The purpose of this study was to measure the distance between the CPN and the fibular insertion of the FCL in different degrees of knee flexion in cadaveric specimens, to identify if tunnel drilling could be done anatomically and safely without a CPN neurolysis. Ex vivo experimental analytical study. Ten fresh frozen human knees were dissected leaving FCL and CPN in situ. Shortest distance from the centreof the FCL distal tunnel and CPN was measured (antero-posterior and proximal-distal wire-nerve distances) at 90°, 60°, 30°, and 0° of knee flexion. Measurements between different flexion angles were compared and correlation between knee flexion angle and distance was identified. The mean distance between the FCL tunnel and the CPN at 90° were 21.15 ± 6.74 mm posteriorly (95% CI: 16.33-25.97) and 13.01 ± 3.55 mm distally (95% CI: 10.47-15.55). The minimum values were 9.8 mm posteriorly and 8.9 mm, respectively. These distances were smaller at 0° (p ≤ 0.017). At 90° of knee flexion, the mean distance from the fibular tip to the CPN distally was 23.46 ± 4.13 mm (20.51-26.41). Anatomic localization and orientation of fibular tunnels can be done safely while avoiding nerve neurolysis. Further studies should aim to in vivo measurements and results.

Optimal fibular tunnel direction for anterior talofibular ligament reconstruction: 45 degrees outperforms 30 and 60 degrees.

There is currently no consensus on the optimal drilling direction of the fibular bone tunnel for anterior talofibular ligament (ATFL) reconstruction, and few studies have investigated the potential injury to the peroneus longus and brevis tendons and the possibility of fibular fractures during the drilling process. The aim of this study was to assess the potential risk of drilling the tunnel from different directions and determine the most appropriate tunnel direction. The hypothesis was that drilling the tunnel in the 45-degree direction would be the safest and most suitable for the fibular tunnel. Forty-eight fibular tunnels were drilled on fresh ankle specimens using a K-wire guide and a 5.0mm hollow drill. Three tunnel orientations were created, parallel to the sagittal plane of the long axis of the fibula and angled 30°, 45°, and 60° to the coronal plane. The length of the fibular tunnel and the distances from the outlet of the K-wire to the peroneus longus and brevis tendons were measured. The occurrence of a fibula fracture was also observed. The lengths of the bone tunnels in the three groups were 32.9 ± 6.1mm (30°), 27.2 ± 4.4mm (45°) and 23.6 ± 4.0mm (60°). The length of the tunnel drilled at 30° was the longest when compared with that of the tunnels drilled at 45° and 60° (all p values < 0.05). The distances from the outlet of the K-wire to the peroneus longus tendon were 3.0 ± 3.8mm (30°), 3.8 ± 3.2mm (45°) and 5.3 ± 1.8mm (60°), and the distances to the peroneus brevis tendon were 4.2 ± 4.0mm (30°), 6.1 ± 3.8mm (45°), 7.9 ± 3.5mm (60°). In terms of protecting the peroneus longus and brevis tendons, drilling in the 60° direction was better than drilling in the 30° and 45° directions (all p values < 0.05). The risk of injury to the peroneal longus and brevis tendons was 62.5% (30°), 31.3% (45°), and 0% (60°). Although no fibular fractures were observed in any of the three directions, drilling the bone tunnel in the 60° direction disrupted the lateral cortex of the fibula. This study shows that drilling the tunnel in the 45° direction is less likely to cause injury to the peroneus longus and brevis tendons, while ensuring that the tunnel has a sufficient length and avoiding fracturing the distal fibula. Drilling a fibular bone tunnel in a 45° direction is safer and recommended for ATFL reconstruction.

Anatomic Posterolateral Corner Reconstruction With Single Graft Tibial Socket Fixation

Introduction: The posterolateral corner (PLC) is comprised of the fibular collateral ligament, popliteus tendon, and popliteofibular ligament. Injuries to the PLC are associated with significant morbidity and functional limitation, most frequently manifested through a varus thrust gait. In the previous 2 decades, advances have been made in understanding the importance of the PLC and as a result, many techniques have been developed to address its reconstruction. Material and Methods: The Laprade technique is a previously described anatomic reconstruction of the PLC. We propose some modifications to this technique, which involve dissection of the posterolateral tibia to allow direct protection of the popliteal neurovascular bundle while establishing tibial fixation. A single hamstring graft is utilized for the reconstruction, is routed through the fibular tunnel and subsequently secured with the use of a dual-expanding tenodesis anchor, placed in a tibial socket removing the need for a tibial tunnel. Conclusion: The present study describes a novel anatomic technique that allows for improved protection of neurovascular structures, better control of graft tensioning and tunnel management, and the judicious use of a single tendon autograft while maintaining the described benefits of the anatomic Laprade technique.

Fibular tunnel syndrome (modern principles of diagnosis and treatment)

Fibular tunnel syndrome is the most common tunnel syndrome of the lower extremity. The compression of the peroneal nerve leads to motor and sensory disorders, which is manifested by weakness of the muscles that normally provide dorsiflexion of the foot and toes, abnormal gait, and loss of sensitivity. The paper presents the etiology, pathogenesis, and clinical picture of this disease. Particular attention is paid to modern methods of treating this pathology. Decompression of the common peroneal nerve is an effective and safe treatment for fibular tunnel syndrome. At the moment, the majority of clinicians do not associate the clinical manifestations with damage to the peroneal nerve, which leads to diagnostic errors and, as a result, to incorrect treatment tactics and a decrease in the patients’ quality of life for a long time.

Modified anatomical posterolateral corner reconstruction of the knee using combined fibula-and tibia-based anatomic reconstruction with tibial posterior cortical fixation using a titanium staple

AbstractPurposeThe purpose of this study is to evaluate the results of the anatomical reconstruction of a posterolateral corner (PLC) using a technique of combined fibula-and tibia-based anatomic reconstruction using a single semitendinosus autograft with posterior tibial cortical surface fixation using a titanium staple.Patients and methodsBetween August 2016 and July 2018, 13 male patients with chronic PLC injury underwent a PLC reconstruction of the knee by a modified anatomical PLC reconstruction using a technique of combined fibula-and tibia-based anatomic reconstruction using a single semitendinosus autograft with posterior tibial cortical fixation using a titanium staple. Instability was the main complaint, the mean age was 27.54 ± 4.63 with motorcycle accident being the most common cause of injury in five (38.5%) patients, contact sport was the second common cause of injury in four (30.8%) patients, twisting injury represented 15.4%, and motor vehicle injury in 15.4%. The mean time from injury to surgery was 3.54 ± 1.51 months, all cases had associated injuries; seven cases presented as combined PLC and anterior cruciate ligament injuries with one case having chondral lesion and another case having medial meniscal injury; the other five cases had combined PLC and posterior cruciate ligament injury with one case having a medial meniscal injury. The mean follow-up period was 11.31 ± 2.78 months. Before surgery as well as at the final follow-up, all study patients completed the subjective Lysholm and International Knee Documentation Committee (IKDC) questionnaires. The side-to-side difference (SSD) of the lateral joint opening in stress varus radiographs and external rotation angle (dial test) were measured.ResultsThe final results at the end of the follow-up period showed marked improvement in IKDC and Lysholm score presented as a significant improvement of IKDC score from the preoperative mean score 25.92 ± 7.02–71.08 ± 4.39 (P&lt;0.001) and Lysholm score improvement from 33.4 ± 5.7 to 87.7 ± 8.5 (P&lt;0.001). Improvement of SSD of lateral joint opening in stress radiographs from 6.1 ± 0.6 to 3.4 ± 0.3 mm (P&lt;0.001) and SSD of the external rotation angle (dial test) improved from 26.5 ± 3.8° preoperatively to 7.7 ± 3.3° postoperatively (P&lt;0.001).ConclusionAnatomical PLC reconstruction using the fibular tunnel technique using a single semitendinosus graft with posterior cortical fixation at the tibial side using a titanium staple is a simple technique that gives excellent short-term follow-up results that need long-term follow-up to determine the graft function, especially in cases of multiple-ligament injured knee.

Mechanical Evaluation of Salvage Fixation Techniques for a Lateralized Fibular Tunnel in Posterolateral Corner Reconstruction of the Knee.

Posterolateral corner (PLC) reconstruction of the knee involves precise drilling of a single tunnel from anterolateral to posteromedial in the fibular head (FH) to ensure adequate graft fixation. Misplacement of the tunnel in a too lateral or too superior trajectory can lead to cortical breach and inadequate graft fixation. To (1) determine the mechanical consequence of a lateralized FH tunnel in PLC reconstruction and (2) compare the mechanical strength of 3 salvage fixation techniques for a lateralized FH tunnel. Controlled laboratory study. Sawbones models of a uniform density were utilized. FH tunnels (7-mm diameter) were drilled from anterolateral to posteromedial in positive controls (lateral cortex thickness, 7.6 ± 0.7 mm) to represent an improperly placed FH tunnel at risk of lateral cortical breach. For negative controls and salvage experimental groups, FH tunnels were drilled from anterolateral to posterolateral (lateral cortex thickness, 2.7 ± 0.9 mm). Three salvage fixation techniques were compared: suture anchor fixation, tunnel redrilling, and nitinol staple fixation. Samples (n = 5 per group) underwent uniaxial tension testing, and the ultimate tensile strength (UTS) and mode of failure were recorded. Data were analyzed using the 1-sample t test and nonparametric 1-sample Wilcoxon signed-rank test. The negative control group had a 4-fold lower mean UTS relative to the positive control group (1.49 ± 0.17 vs 6.25 ± 1.98 MPa; P < .01) and exhibited failure through the lateral cortex and tunnel. Nitinol staple fixation improved the mean UTS by >16 times compared with the negative control group (24.06 ± 6.49 vs 1.49 ± 0.17 MPa; P < .01). Suture anchors and tunnel redrilling exhibited similar UTS and mode of failure to those of negative controls. Reinforcement of a thinned lateral FH cortex with a single nitinol staple improved graft fixation strength in a sawbones model. A lateralized FH tunnel can be a common intraoperative pitfall during PLC reconstruction. Salvage of a thinned lateral FH cortex with a single nitinol staple may reduce the risk of cortical breach and graft failure.

Posterolateral Corner Reconstruction Using Double Femoral Fixation With Adjustable Loop Cortical Suspension and Interference Screw

Background: The posterolateral corner (PLC) of the knee is a complex anatomic region of the knee comprising the popliteus tendon, the popliteofibular ligament (PFL), and the fibular collateral ligament (FCL). Treatment of PLC injuries is based on the degree of varus and rotational instability on preoperative examination and is recommended in grade 3 injuries.1,6 Technique Description: The key concept of this new surgical technique is to use adjustable loop cortical suspensory fixation implants for initial femoral fixation of the popliteus and the FCL grafts. This allows for individual tensioning of the grafts prior to definitive fixation with an interference screw. An anatomic fibular tunnel is initially created, followed by popliteus and FCL anatomic femoral socket drilling. A TightRope RT implant is attached to the popliteus end of the graft and secured through a bone tunnel on the medial femoral cortex initially. The popliteus end of the graft is then pulled into the femoral socket before tunneling the graft through the fibular tunnel. A second TightRope RT implant is secured to the FCL end of the graft before securing it to the medial femoral cortex through a bone tunnel and pulling the graft into the drilled femoral socket. An interference screw is first used to secure the graft at the fibular tunnel. The knee is then taken to 60° where the TightRope device is used to remove residual creep and optimize final tensioning prior to final fixation with interference screw in femoral socket. With the knee at 30° of flexion, neutral rotation, and slight valgus, the same steps are repeated for FCL graft. A posterolateral capsular shift is completed for additional stability. Results: Residual posterolateral corner instability or failure after reconstruction surgery has been reported in 6% to 9.4% of surgical reconstruction case.2,3,5 The use of cortical suspensory devices in PLC reconstructions allows independent dialing of optimal graft tension for both the popliteus and FCL reconstruction before final interference screw fixation, therefore presumably limiting any residual creep and allowing for a double femoral fixation of the graft. Discussion: We describe a novel technique for posterolateral corner reconstruction which allows for optimal and individual tensioning of the structures of the posterolateral corner. Given the technique still uses well-described and validated graft choices and anatomic landmarks for reconstruction, we expect this new technique to allow for similar if not improved outcomes when compared with current gold standard.4

"Combination of Fibular Tunnel Syndrome with Distal Polyneuropathy in Patients with Type 2 Diabetes Mellitus"

"Combination of Fibular Tunnel Syndrome with Distal Polyneuropathy in Patients with Type 2 Diabetes Mellitus"

Comparison of Arthroscopic versus Open Placement of the Fibular Tunnel in Posterolateral Corner Reconstruction.

Precise fibular tunnel placement in posterolateral corner (PLC) reconstruction is crucial in restoring rotational and lateral stability. Despite the recent progress of arthroscopic PLC reconstruction techniques, landmarks for arthroscopic fibular tunnel placement and a comparison to open tunnel placement have not yet been described. This study aimed to (1) identify reasonable soft-tissue and bony landmarks, which can be identified by either arthroscopy, fluoroscopy, or open surgery in anatomic fibular tunnel placement and (2) to compare accuracy and reliability of arthroscopic fibular tunnel placement with open surgery. In a retrospective study, 41 magnetic resonance images (MRIs) of the knee were analyzed with emphasis on distances of an ideal anatomic fibular tunnel to 11 soft-tissue and bony landmarks. Subsequently, in eight cadaver knees, the ideal fibular tunnel was created arthroscopically and with a standard open technique from antero-latero-inferior to postero-medio-superior with a 2-mm K-wire. Positions of both tunnels were compared on postinterventional computed tomography scans. Based on MRI measurements, the anatomic tunnel entry should be 14.50 (±2.18) mm distal to the tip of the fibular styloid and 10.76 (±1.37) mm posterior to the anterior edge of the fibula. The anatomic fibular tunnel exit was located 12.89 (±2.35) mm below the tip of the fibular head. Arthroscopic fibular tunnel placement was reliable in all cases. Instead, in five out of the eight cases with open surgery, the fibular tunnel crossed the defined safety distance to the closest cortical edge/tibiofibular joint (distance < 8 mm). Reliable soft-tissue and bony landmarks of the fibular head allow arthroscopic anatomic fibular tunnel placement in PLC surgery, which shows a lower risk of tunnel malposition compared with open surgical techniques. Future studies will have to show whether clinical results of arthroscopic PLC reconstruction are in line with this study's technical results. Level III.

The Common Peroneal Nerve Injuries

The dorsiflexion function of the peroneal nerve is important for human walking. Peroneal nerve damage has various etiologies, and the classification of the mechanism depends on the energy of the force responsible for injury. Peroneal nerve damage caused by low-energy mechanisms (entrapment, compression, and compartment) is not uncommon in neurosurgery, and accurate diagnosis and treatment of these conditions necessitate an understanding of the anatomical characteristics of the peroneal nerve, clinical symptoms, and prognosis. In addition to recent conventional diagnostic methods, diagnosis using magnetic resonance imaging and the surgical method of external neurolysis and decompression of the fibular tunnel in PICPNe patients will be described.

Salvage Fixation With a Single Nitinol Compression Staple for a Lateralized Fibular Tunnel in Posterolateral Corner Reconstruction of the Knee

Recognition and treatment of injuries to the posterolateral (PLC) corner of the knee have increased in recent decades. Despite advancements in surgical technique, complications can occur in up to 20% of PLC reconstructions. Lateralization of the fibular tunnel during drilling is a common intraoperative pitfall and can lead to cortical breach or fibular head fracture after graft tensioning. Compression staples have been increasingly used for fracture fixation in the hand, foot, and ankle. Because of its pseudo-elastic properties, insertion of a low-profile, compressive Nitinol staple could serve as an intraoperative salvage technique to reinforce and prevent failure through a thin lateral cortex of the fibular head. The purpose of this Technical Note is to describe a reproducible technique for the implementation of a Nitinol staple for reinforcement of a lateralized fibular tunnel in posterolateral corner reconstruction.

Microsurgical decompression of the peroneal nerve in treatment of fibular tunnel syndrome

Fibular tunnel syndrome (FTS) is the most common neuropathy of the lower extremity. Compression of the peroneal nerve leads to movement and sensory disorders, which is manifested by weakness of the muscles that normally provide dorsiflexion of the foot and toes, gait disturbance and loss of sensitivity. Our study involved 30 patients with symptoms of FTS. All underwent microsurgical two-level decompression of the peroneal nerve. In the postoperative period, the results of the operation were assessed by changes in sensory and motor neurological deficits according to the British Medical Research Council Scale (BMRCS). It has been proven that the peroneal nerve decompression technique is an effective way to treat primary and secondary FTS. In this case, the restoration of sensitive fibers occurs earlier than motor ones. Taking into account the similarity of clinical manifestations with proximal lesions and the structural features of the canal, it is necessary to develop a clinic-diagnostic algorithm to determine the therapeutic tactics and the volume of surgical intervention.

A CADAVERIC STUDY OF COMMON PERONEAL NERVE IN RELATION TO FIBULAR TUNNEL

INTRODUCTION: The common peroneal nerve is major lateral division of the sciatic nerve supplies lateral and anterior compartment of leg, when injured may leads to debilitating conditions such as foot drop and sensory loss or numbness in its supplied area. Common peroneal nerve's position subjects it to nerve injuries at two places one behind the knee joint where the nerve is superficial and other being the course of nerve through the fibular tunnel where its being tugged between musculo-aponeurotic fibers of peroneus longus muscle. Nerve injuries to common peroneal nerve has been attributed to several factors depending upon its anatomical position such as this may be due to sudden weight loss, prolonged sitting in squatting position, meniscus injuries in athletes or whether it is any surgical procedures involving the upper part of tibia and fibula. MATERIAL &amp; METHODS: In present study we examine 70 lower limbs equally of right and left sides, the course, branching pattern and other reference point distances were measured with the help of metallic scale and dissections were photograph. RESULT: In 60% cases nerve separate from sciatic at the apex of popliteal fossa and in 80% cases it passes through the groove and then in about 70% specimen it passes through fibular tunnel, where it remains on an average 1.33 cm below the fibular head. The average distance of the nerve division was found 2.73 cm and just below that at a distance of 4.29 cm the nerve is in close contact with the bone. CONCLUSION: In present study we have observed average 7 muscular branches with variable origin from the common peroneal nerve in fibular tunnel which are likely to be damaged during surgical incision at this site.

The Location of the Fibular Tunnel for Anatomically Accurate Reconstruction of the Lateral Ankle Ligament: A Cadaveric Study.

We aimed to describe the location of fibular footprint of each anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL), as well as their common origin in relation to bony landmarks of the fibula in order to determine the location of the fibular tunnel. In 105 ankle specimens, the center of the footprints of the ATFL and CFL (cATFL and cCFL, respectively) and the intersection point of their origin (intATFL-CFL) were investigated, and the distances from selected bony landmarks (the articular tip (AT) and the inferior tip (IT) of the fibula) were measured. Forty-two (40%) specimens had single-bundle ATFL, and 63 (60%) had double-bundle patterns. The distance between intATFL-CFL and IT was 12.0 ± 2.5 mm, and a significant difference was observed between the two groups (p = 0.001). Moreover, the ratio of the intATFL-CFL location based on the anterior fibular border for all cadavers was 0.386. The present study suggests a reference ratio that can help surgeons locate the fibular tunnel for a more anatomically accurate reconstruction of the lateral ankle ligament. Also, it may be necessary to make a difference in the location of the fibular tunnel according to the number of ATFL bundles during surgery.