Traumatic Peroneal Nerve Injuries

Abstract

Background: The common peroneal nerve (CPN) is the most commonly injured peripheral nerve of the lower extremity in patients with trauma. Traumatic CPN injuries have historically been associated with relatively poor outcomes and patient satisfaction, although improved surgical technique and novel procedures appear to improve outcomes. Given the variety of underlying injury modalities, treatment options, and prognostic variables, we sought to evaluate and summarize the current literature on traumatic CPN injuries and to provide recommendations from an analysis of the included studies for treatment and future research.Methods: A systematic review was performed using PubMed, Embase, and Cochrane databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Search terms consisted of variations of "peroneal nerve" or "fibular nerve" combined with "injury," "laceration," "entrapment," "repair," or "neurolysis." Information with regard to treatment modality, outcomes, and patient demographic characteristics was recorded and analyzed. Results:The initial search yielded 2,301 articles; 42 met eligibility criteria. Factors associated with better outcomes included a shorter preoperative interval, shorter graft length when an interposed graft was used, nerve continuity, and younger patient age. Gender or sex was not mentioned as a factor affecting outcomes in any study. Motor grades of $M3 on the British Medical Research Council (MRC) scale are typically considered successful outcomes. This was achieved in 81.4% of patients who underwent neurolysis, 78.8% of patients who underwent end-to-end suturing, 49.0% of patients who underwent nerve grafting, 62.9% of patients who underwent nerve transfer, 81.5% of patients who underwent isolated posterior tibial tendon transfer (PTTT), and 84.2% of patients who underwent a surgical procedure with concurrent PTTT.Conclusions: Studies included in this review were heterogenous, complicating our ability to perform further analysis. It is not possible to uniformly advocate for the best treatment option, given diverse injury modalities and patient presentations and a variety of prognostic factors. Many studies do not show outcomes with respect to injury modality. Future studies should show preoperative muscle strengths and should clearly define outcomes based on the injury modality and surgical treatment option. This would allow for greater analysis of the most appropriate treatment option for a given mechanism of injury. Newer surgical techniques are promising and should be further explored.

Useful functional recovery and quality of life after surgical treatment of peroneal nerve injuries

“…Neurolysis is employed in the least extensive nerve injuries when nerve continuity is preserved and yields good results with a motor recovery ratio nearing 80% ( 30 , 31 ). These results correspond to ours, with 88% of patients achieving M3+, and 72.2% recovering to the M4+.…”

“…TT have very good results when only motor strength recovery is observed with recovery rates over 80% (almost 85% when concurrent posterior tibial TT was employed in a systematic review, and up to 100% in single studies ( 16 , 31 ). However, this procedure is indicated as salvage, for isolated PN palsy with good ankle mobility, good strength of the posterior tibial muscle and poor prognosis of spontaneous recovery in order to decrease dependence on brace for walking, and to improve hip and knee function with improved gait kinematics ( 16 , 34 ).…”

Differential Diagnosis of “Foot Drop”: Implications for Peripheral Nerve Surgery

“…In a systematic review of 4 studies comprising 35 patients who underwent nerve transfer reconstruction, 62.9% of patients recovered dorsiflexion to MRC ≥ 3. 37 The percent recovery was quite diverse, spanning 36% to 100%. On meta-analysis, there were no significant correlations between postoperative dorsiflexion strength and patient age or time to surgery.…”

“…In a systematic review of 15 studies comprising 441 patients who underwent common peroneal nerve decompression, 81.4% of patients recovered dorsiflexion to MRC ≥3. 37 With that being said, the frequency of recovery was diverse and ranged from 25 to 100%. This reflected the heterogenous nature of these studies, comprising a diverse set of injury modalities, patient presentations, and comorbidities such as presence of diabetes.…”

Foot Drop: The Importance of Imaging as Part of the Peripheral Nerve Evaluation

“…Trauma to the common peroneal or sciatic nerve can occur from a multitude of reasons including sharp injuries from knives, gunshot wounds, stretch injuries from knee trauma, and iatrogenic injuries during orthopedic or vascular procedures. 10 The peroneal nerve/division is especially sensitive or vulnerable to traumatic injury such as seen with knee-related trauma or total hip arthroplasty. Patient history will help to define whether any trauma has been sustained; however, one must be alerted to the potential for recall bias.…”