Deep Peroneal Nerve Injury Following Hardware Removal for Lisfranc Joint Injury

Abstract

Background: 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. Methods: 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. Results: 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. Conclusion: 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 of Evidence: Level IV, case series.

A Systematic Review of Outcomes Following Lisfranc Injury Fixation: Removal vs Retention of Metalwork

“…Another recent study of a single-surgeon case series reported on the rates of nerve injury complications, specifically of the primary fixation and of the subsequent planned surgery to remove metalwork 3-4 months later. This showed an overall nerve injury rate of 23% when routine metalwork removal was planned, 21 consistent with the results of this review.…”

“…In keeping with recent studies, 12,21 this review found that when planned, metalwork removal was scheduled most commonly at 3-4 months post fixation. The absence of justification found for the timing of metalwork removal, and variation in current practice, 31 further supports the notion of true equipoise regarding Lisfranc metalwork management.…”

“…36,42,47 The potential but unproven purported benefits of metalwork removal include optimization of midfoot biomechanics and function, reduced pain, lower risk of broken metalwork, and easier secondary surgery in the event of developing painful posttraumatic osteoarthritis. The disadvantages of routine metalwork removal include risks of surgery such as deep peroneal nerve injury, 21 a second anaesthesia, further time off work, rehabilitation delays, increased health care costs, and potentially no subjective benefit to the patient. 2,24,30,33,34 To date, no studies have compared the outcomes of patients following routine removal or retention of Lisfranc metalwork for nonarthrodesis surgery.…”

Clinical Study on Different Methods of Internal Fixation for Treatment of Lisfranc Joint Injury

“…e Lisfranc joints play an important role in connecting the forefoot and midfoot and maintaining the stability of the arch of the foot [1][2][3]. With the rapid development of transportation and construction industry in recent years, the incidence of Lisfranc injury has been increasing year by year, and if not treated in time, it will lead to poor walking, pain in the back of the foot, and even disability in severe cases [4][5][6].…”

Deep Peroneal Nerve: Orientation and Branching at the Ankle and Proximal Part of the Foot

“…DPN unveiled in this study can also correlate to clinical imaging information 32,33 and be used to predict clinical neurovascular consequences following a traumatic injury or treatment in the ankle and foot region. 34…”