A Rare Case of Transepiphyseal Distal Femur Fracture Dislocation With Delayed Recovery of a Common Peroneal Nerve Injury.

The aim of this study is to bring attention to a unique case and our approach to treatment in this context. We describe a case of an 11-year-old male who presented to us with an injury to his left knee following trauma with pain, swelling, shortening and deformity for one day. An X-ray revealed a transepiphyseal fracture dislocation of the left distal femur (Salter-Harris type 1 injury) and neurovascular examination was conclusive of foot drop which pointed towards injury to common peroneal nerve (CPN). The patient was taken up for closed reduction with percutaneous pinning under mobile C-arm guidance. The fracture was reduced and fixed with two cross K-wires and immobilized with the above knee anterior-posterior slab for six weeks. The wires were removed after six weeks but there was no improvement in the dorsiflexion of the left ankle. An electromyography (EMG) and nerve conduction velocity (NCV) study test was performed after 12 weeks which showed decreased amplitude and prolonged latency in the left CPN with early denervation of the muscles supplied by the left CPN. Fifteen weeks of follow-up showed complete recovery in the dorsiflexion of the left ankle with a slight lag in the extension of the left great toe making this an unusually delayed recovery of CPN palsy following a distal femur transepiphyseal fracture.

Left common peroneal nerve palsy caused by cross-legged sitting during epidural labor analgesia: a case report.

BACKGROUND: Nerve injury in epidural labor analgesia can occur with various potential causes. We report a rare case of left common peroneal nerve palsy after delivery caused by a prolonged period of sitting cross-legged during epidural labor. CASE REPORT: Epidural labor analgesia in a 28-year-old primipara started at 39 weeks of gestation. She sat cross-legged to prompt delivery for approximately 4 h with a break of a few minutes every hour. She had numbness in her left lower limb and difficulty in dorsiflexion of the ankle joint that did not improve until 3 h after delivery. We made a diagnosis of left common peroneal nerve palsy. Most of the symptoms had improved at 2 months postpartum. CONCLUSION: Epidural labor analgesia prevented recognition of prolonged peroneal head compression caused by sitting cross-legged. When this position is used to facilitate delivery, it should be released frequently owing to the possibility of a neurologic deficit.

Peroneal Nerve Palsy After Total Knee Arthroplasty.

Background: Common peroneal nerve palsy (CPNP) is a rare complication of total knee arthroplasty (TKA). It may lead to impaired function and pain. The purpose of this study was to determine the frequency and outcome of CPNP in a single orthopedic unit and to identify potential risk factors. Methods: This is a single-center study using the hospital's prospectively collected quality registry. All TKAs from 2002 to 2022 were included and followed up from 3 to 24 months with a follow-up rate of 98.4%. The local joint register was reviewed to identify patients with CPNP and used to extract data regarding the operation and the patients with and without CPNP. The groups were compared to identify possible risk factors for nerve injury. The medical records of the patients with CPNP were reviewed to determine the CPNPs' severity and outcome, and their preoperative radiographs were analyzed and compared to a control group with no nerve injury. Results: A total of 7704 TKAs were included, and 25 CPNPs were identified (0.32%). Complete palsies occurred in 18 cases, and partial palsies in 7. Postoperative epidural anesthesia, preoperative excessive valgus, and female sex were significant risk factors. Body mass index and age were not associated with CPNP. Two-thirds of the complete palsies had complete recovery, and four-fifths of the partial palsies recovered. Conclusions: The incidence of CPNP was 0.32%, and risk factors were epidural anesthesia, excessive valgus, and female sex. Most patients with CPNP recovered completely. Partial palsies had better outcomes than complete palsies in our cohort.

Deep Learning-Based Knee MRI Classification for Common Peroneal Nerve Palsy with Foot Drop.

Foot drop can have a variety of causes, including the common peroneal nerve (CPN) injuries, and is often difficult to diagnose. We aimed to develop a deep learning-based algorithm that can classify foot drop with CPN injury in patients with knee MRI axial images only. In this retrospective study, we included 945 MR image data from foot drop patients confirmed with CPN injury in electrophysiologic tests (n = 42), and 1341 MR image data with non-traumatic knee pain (n = 107). Data were split into training, validation, and test datasets using a 8:1:1 ratio. We used a convolution neural network-based algorithm (EfficientNet-B5, ResNet152, VGG19) for the classification between the CPN injury group and the others. Performance of each classification algorithm used the area under the receiver operating characteristic curve (AUC). In classifying CPN MR images and non-CPN MR images, EfficientNet-B5 had the highest performance (AUC = 0.946), followed by the ResNet152 and the VGG19 algorithms. On comparison of other performance metrics including precision, recall, accuracy, and F1 score, EfficientNet-B5 had the best performance of the three algorithms. In a saliency map, the EfficientNet-B5 algorithm focused on the nerve area to detect CPN injury. In conclusion, deep learning-based analysis of knee MR images can successfully differentiate CPN injury from other etiologies in patients with foot drop.

Delayed Recovery of Idiopathic Common Peroneal Nerve Palsy After Total Knee Arthroplasty: A Rare Case Report.

Introduction: Common peroneal nerve palsy (CPNP) is a rare complication post total knee arthroplasty (TKA). Even though it is diagnosed acutely, the recovery potential is just over 50%. The average period for complete recovery in such cases is 5 months; however, the management remains controversial. Through this report, we present one such case of left sided complete CPNP after bilateral TKA who was conserved with various modalities. Even though the recovery was delayed, the patient made full recovery. Case Report: A 70-year-old female patient was diagnosed to have bilateral tricompartmental knee osteoarthritis with varus deformity, both clinically and radiologically (Kellgren-Lawrence grade 4). She underwent bilateral TKA in a single sitting as per the standard protocols practiced by the primary author. On post-operative day 1, she had left-sided foot drop with a complete sensory deficit. The patient underwent routine rehabilitation with an ankle foot orthosis splint in the immediate post-operative period, with simultaneous faradic current stimulation for the left lower limb. Periodic electromyography and nerve conduction study was done at the end of 4-week and 3-month post-TKA. At 6.5-month post-surgery, she made a full clinical recovery. Conclusion: The surgical maneuvers and full neurovascular examination before and after every TKA surgery should be carefully performed. Despite this, if a patient presents with CPNP, the surgeon need not take an aggressive approach, unlike fracture fixation cases. These patients can be managed conservatively using appropriate orthosis, physical therapy, and faradic current stimulation. Through this case, we attempt to report that CPNP patient can recover even after 6 months of surgery when there is no tangible cause for the palsy.

Common peroneal nerve injury after tibial plateau fractures: A case series.

Introduction: Common peroneal nerve (CPN) injury is a rare but significant complication of knee trauma. Given its low incidence, there is limited published evidence, but reports have shown dislocations and fractures associated with varus deformity are more likely to injure the nerve, causing foot drop. This study aims to document the incidence and outcome of CPN palsy in tibial plateau fractures (TPF). Methods: We reviewed 746 cases of tibial plateau fractures treated between 2011 and 2020. We analysed patients' demographics, injury mechanisms, clinical course, and complications, and identified those with CPN palsies. Fractures were classified using the Schatzker, Luo and AO/OTA systems. The details of the CPN injury, including nerve conduction studies, duration of symptoms and outcome were recorded. Results: We identified 11 patients who had concurrent TPFs and CPN palsies, an overall incidence of 1.47 %. Most fractures involved the medial column (n = 9), with the C3 fragmentary TPF pattern being the most common (n = 4). The incidence of CPN injury was higher in medial fractures (5 %) and bicondylar fractures (3 %). We also found that most patients (n = 9) recovered full neurological function within 2 years. Discussion: This is the first study looking at a patient cohort sustaining concurrent TPFs and CPN injuries. It is a rare complication but should be looked for in high-risk medial and bicondylar fractures. We found that prognosis is better in TPF-associated CPN palsy than in other knee trauma, and that the majority of patients can expect a full recovery of nerve function.

Motor Nerve Palsy After Direct Anterior Versus Posterior Total Hip Arthroplasty: Incidence, Risk Factors, and Recovery.

BACKGROUND: There is limited literature on motor nerve palsy in modern total hip arthroplasty (THA). The purpose of this study was to establish the incidence of nerve palsy following THA using the direct anterior (DA) and postero-lateral (PL) approaches, identify risk factors, and describe the extent of recovery. METHODS: Using our institutional database, we examined 10,047 primary THAs performed between 2009 and 2021 using the DA (6,592; 65.6%) or PL (3,455; 34.4%) approach. Postoperative femoral (FNP) and sciatic/peroneal nerve palsies (PNP) were identified. Incidence and time to recovery was calculated, and association between surgical and patient risk factors and nerve palsy were evaluated using Chi-square tests. RESULTS: The overall rate of nerve palsy was 0.34% (34/10,047) and was lower with the DA approach (0.24%) than the PL approach (0.52%), P = .02. The rate of FNPs in the DA group (0.20%) was 4.3 times more than the rate of PNPs (0.05%), while in the PL group the rate of PNPs (0.46%) was 8 times more than that of FNPs (0.06%). Higher rates of nerve palsy were observed with women, shorter patients, and nonosteoarthritis preoperative diagnoses. Full recovery of motor strength occurred in 60% of cases with FNP and 58% of cases with PNP. CONCLUSION: Nerve palsy is rare after contemporary THA through the PL and DA approaches. The PL approach was associated with a higher rate of PNP, whereas the DA approach was associated with a higher rate of FNP. Femoral and sciatic/peroneal palsies had similar rates of complete recovery.

ICU-Acquired Weakness Complicated With Bilateral Foot Drop After Severe COVID-19: Successful Rehabilitation Approach and Long-Term Follow-Up.

Coronavirus disease 2019 (COVID-19) is associated with muscle and nerve injuries as a consequence of prolonged critical illness. We report here a case of intensive care unit-acquired weakness (ICU-AW) with bilateral peroneal nerve palsy after COVID-19. A 54-year-old male with COVID-19 was transferred to our hospital. He was treated by mechanical ventilation and veno-venous extracorporeal membrane oxygenation (VV-ECMO), from which he was successfully weaned. However, by day 32 of ICU admission, he had developed generalized muscle weakness with bilateral foot drop and was diagnosed with intensive care unit-acquired weakness complicated with bilateral peroneal nerve palsy. Electrophysiological examination showed a denervation pattern in the tibialis anterior muscles, indicating that the foot drop was unlikely to recover immediately. Gait training with customized ankle-foot orthoses (AFO) and muscle-strengthening exercises were started as part of a regimen that included a stay in a convalescent rehabilitation facility and outpatient rehabilitation. Seven months after onset, he returned to work, and 18 months after onset, he had improved to the same level of activities of daily living (ADLs) as before onset. Outcome prediction by electrophysiological examination, appropriate prescription of orthoses, and continuous rehabilitative treatment that focused on locomotion contributed to the successful outcome in this case.

Proximal Tibiofibular Joint Arthrodesis Due to Recurrent Giant Ganglion Cyst Causing Peroneal Nerve Palsy.

Ganglion cysts are masses that we encounter frequently in our daily practice, usually in the upper extremity, less frequently in the lower extremities, and rarely cause compression symptoms. We present a case of a massive ganglion cyst of the lower limb causing peroneal nerve compression, managed with excision and proximal tibiofibular joint arthrodesis to prevent recurrence. Examination and radiological imaging of a 45-year-old female patient who was admitted to our clinic showed new-onset weakness in right foot movements and numbness on the dorsum of the foot and lateral cruris, a mass consistent with a ganglion cyst expanding the muscle was detected in the peroneus longus muscle. In the first surgery, the cyst was carefully resected. After three months, the patient came with a repeated mass on the lateral side of the knee. After confirmation of the ganglion cyst with clinical examination and MRI, a second surgery was planned for the patient. In this stage, we performed a proximal tibiofibular arthrodesis for the patient. Her symptoms recovered during the early follow-up period and no recurrence occurred during the two years of the follow-up period. Although the treatment of ganglion cysts seems easy, it can sometimes be challenging. We think that arthrodesis may be a good treatment option in recurrent cases.

Bilateral peroneal nerve palsy due to prolonged squatting in farmers: clinical and electrophysiological outcome.

INTRODUCTION: Peroneal neuropathy is the most common mononeuropathy of the lower extremities. However, bilateral peroneal nerve palsy (BPNP) is extremely rare due to prolonged squatting. We aimed to evaluate the clinical-electrophysiological findings in patients with BPNP caused by long-term squatting for cotton harvesting in our region. METHODS: Eight patients (16 limbs), admitted to our center between February 2018 and March 2021 with bilateral foot drop after prolonged squatting, were included in our study. The clinical and electrophysiological findings were re-evaluated six months later. RESULTS: We observed that 18.75% of the limbs had pure conduction block, 31.25% had mixed involvement, and half had predominantly axonal damage. Good recovery was observed in ankle dorsiflexion in seven patients during follow-ups. None of the patients were referred for surgery. Electrophysiological examinations showed that the conduction block was resolved, and reinnervation was observed in all patients with axonal degeneration. CONCLUSION: Since the etiology is nontraumatic compression, good recovery can be seen with conservative treatment in BPNP. Electrophysiological studies may determine reinnervation along with clinical examination. The patient should be followed-up for six months with conservative treatment before surgical intervention.

Predictors Using Machine Learning of Complete Peroneal Nerve Palsy Recovery After Multiligamentous Knee Injury: A Multicenter Retrospective Cohort Study.

Background: Peroneal nerve (PN) palsy is one of the most debilitating sequelae of multiligamentous knee injuries (MLKIs). There is limited research on recovery from complete PN palsy. Purpose/Hypothesis: The purpose of this study was to characterize PN injuries and develop a predictive model of complete PN recovery after MLKI using machine learning. It was hypothesized that elevated body mass index (BMI) would be predictive of lower likelihood of recovery. Study Design: Case-control study; Level of evidence, 3. Methods: The authors conducted a retrospective review of patients seen at 2 urban hospital systems for treatment of MLKI with associated complete PN palsy, defined as the presence of complete foot drop with or without sensory deficits on physical examination. Recovery was defined as the complete resolution of foot drop. A random forest (RF) classifier algorithm was used to identify demographic, injury, treatment, and postoperative variables that were significant predictors of recovery from complete PN palsy. Validity of the RF model was assessed using overall accuracy, F1 score, and area under the receiver operating characteristic curve (AUC). Results: Overall, 16 patients with MLKI with associated complete PN palsy were included in the cohort. Among them, 75% (12/16) had documented knee dislocation requiring reduction. Complete recovery occurred in 4 patients (25%). Nerve contusions on magnetic resonance imaging were more common among patients without PN recovery, but there were no other significant differences between recovery and nonrecovery groups. The RF model found that older age, increasing BMI, and male sex were predictive of worse likelihood of PN recovery. The model was found to have good validity, with a classification accuracy of 75%, F1 score of 0.86, and AUC of 0.64. Conclusion: The RF model in this study found that increasing age, BMI, and male sex were predictive of decreased likelihood of nerve recovery. While further study of machine learning models with larger patient data sets is required to identify the most superior model, these findings present an opportunity for orthopaedic surgeons to better identify, counsel, and treat patients with MLKIs and concomitant complete PN palsy.

Common peroneal nerve palsy after primary total hip arthroplasty.

PURPOSE: The study wants to evaluate the incidence, the clinical evolution, and treatment of common peroneal nerve (CPN) palsy after primary total hip arthroplasty. METHODS: Our clinical prospective study was made between January 2016 and December 2020. The study group comprised 1240 total hip replacements over a period of five years. Six cases were diagnosed with CPN palsy (0.48%). Five were women and one man, aged from 52 to 71 years old. The common peroneal nerve lesion was diagnosed clinically and by electromyography. RESULTS: The follow-up period was at least 24 months post-operatively. In all six cases, there was a complete common peroneal nerve palsy, documented by electromyography. The poorest results were obtained in the older patients and those who had the highest body mass index, which at two years post-operatively achieved only a partial sensory rehabilitation, with complete motor deficit. All patients can walk unassisted, without support, with one case having complete rehabilitation achieved 18 months postoperatively and three with partial rehabilitation. CONCLUSION: CPN palsy after primary THA is a very serious complication with poor functional outcome. There is no consensus regarding the treatment. The age and the intensity of the rehabilitation program are the only significant factors for the medical rehabilitation after this debilitating post-operative complication.

Intraneural Ganglion of the Peroneal Nerve-A Rare Cause of Pediatric Peroneal Nerve Palsy: A Case Report.

Intraneural ganglia are benign mucinous cysts located within the epineurium of a peripheral nerve. The pathogenesis and formation of intraneural ganglia are controversial. The main theories described in the literature are of degenerative, synovial or de novo occurrence. We present the case of a 14-year-old boy who presented in our outpatient clinic with a complaint of interdigital neuralgia between hallux and second toe, as well as left foot drop. MRI examination showed a hyperintense cystic distension of the common peroneal nerve measuring 130 mm × 5 mm extending from the poplitea to the anterior compartment of the leg. We performed microscopic decompression and neurolysis surgery. The cyst showed a sac-like distension at its distal end with connection to the tibiofibular joint and was resected. After 8 weeks, postoperatively, the boy claimed to be pain-free and slight recovery of the superficial peroneal nerve was noticed. At 6 months postoperative, the patient showed a continuous improvement of motor function, demonstrating foot eversion with 3/5 muscle strength and foot extension with 2/5 muscle strength. Intraneural ganglia reported for pediatric patients represent a very rare entity. To the best of our knowledge, less than 15 cases have been described within the English-speaking literature.

No common peroneal nerve palsies found after a peroneal nerve release prior to TKA in fixed valgus deformities (a retrospective cohort study).

PURPOSE: The main purpose of this study was to analyse the incidence of Common Peroneal Nerve Palsy (CPNP) after Total Knee Arthroplasty (TKA) for all alignments. Secondarily, the efficiency and safety of a Peroneal Nerve Release (PNR) prior to TKA in preoperative severe fixed valgus deformities were evaluated to prevent a CPNP. METHODS: Overall, 7612 TKAs were performed in the institution from 2009 to 2021. 1913 TKAs were performed by three surgeons, who consistently performed a PNR in case of a fixed valgus deformity of (1) more than 15°, or (2) more than 10° but in combination with a flexion contracture of more than 15°. Patients with fixed valgus deformities of more than 10° were identified (81 knees) and a comparison was made between the patients who received a PNR (26 knees) and those who did not receive a PNR (55 knees). Data for the analysis were collected from patient medical files and were compared with the Chi2-test or Fisher Exact test. RESULTS: A CPNP incidence of 0.2% (16/7612) was found after TKA for all alignments together. No CPNP cases (0%) were developed in the PNR-group, compared to five (9%) in the non-PNR group (p = NS). A larger preoperative valgus angle (17° vs 13°, p < 0.001) and flexion contracture (10° vs 3°, p < 0.001) was present in the PNR group compared with the non-PNR group. No PNR-related complications were reported. CONCLUSION: The CPNP incidence in this study is consistent with the previous literature. Furthermore, although not significant, the group that received a PNR procedure developed fewer CPNPs compared to the group without PNR. LEVEL OF EVIDENCE: Retrospective cohort study, III.

Common peroneal nerve palsy after TKA in valgus deformities; a systematic review.

PURPOSE: The aim of this systematic review is to investigate the prevalence of Common Peroneal Nerve Palsy after total knee arthroplasty in valgus deformities. Furthermore, the effectiveness of a peroneal nerve release prior to arthroplasty to prevent the palsy will be investigated. METHODS: PubMed and Google Scholar were searched. Search terms regarding valgus deformity and total knee arthroplasty were used. Data analysis and extraction were performed using the web application 'Rayyan QCRI' according to PRISMA guidelines and screened according to the inclusion and exclusion criteria. RESULTS: Twenty-seven studies were included, representing 1397 valgus knees. Knee balancing was performed in 19 studies with lateral soft tissue releases (1164 knees) and 8 studies (233 knees) with an additional osteotomy. Two studies (41 knees) in the lateral soft tissue release group conducted a peroneal nerve release simultaneous to arthroplasty. Common peroneal nerve palsies occurred in 26 cases (1.9%). Overall, no significant difference in palsy ratio between studies was found by using a peroneal nerve release (p = 0.90), between lateral soft tissue releases and osteotomies (p = 0.11) or between releases of specific ligaments. CONCLUSION: Common peroneal nerve palsies occur in 1.9% of the cases after total knee arthroplasty in valgus deformities. No difference in the number of palsies was seen when using a peroneal nerve release or using different balancing techniques. However, literature about peroneal nerve releases was very limited, therefore, the effectiveness of a peroneal nerve release remains unclear. LEVEL OF EVIDENCE: LEVEL III: Systematic review.

Peroneal nerve palsy due to synovial cyst: An unusual cause of foot drop in a nine-year-old child.

Foot drop is the inability to dorsiflex the foot, and peroneal nerve palsy, a common cause of foot drop, is a rare condition in pediatric patients. Herein, we present a nine-year-old patient with foot drop due to peroneal nerve palsy verified by electrophysiologic examination. A cystic mass was observed in ultrasonography and magnetic resonance imaging, and hyaluronic acid was detected in the cystic material by histopathological examination. The patient was referred to surgery, and one month after surgery, an increase in muscle strength was observed. It should be kept in mind that peroneal nerve palsy due to synovial cysts may cause foot drop in pediatric patients.

Resolution of Deep Peroneal Nerve Palsy after Seroma Evacuation in a Primary Total Hip Arthroplasty: A Case Report.

Introduction: In this manuscript, we present a late presentation of deep peroneal nerve symptoms after total hip arthroplasty (THA) which subsequently completely resolved after seroma evacuation and sciatic nerve decompression. While hematoma formation causing deep peroneal nerve symptoms after THA has been reported in the literature, we are unaware of any reports of seroma formation causing similar symptoms. Case Presentation: A 38-year-old female underwent an uncomplicated primary THA and developed paresthesia's over the lateral leg and foot drop on post-operative day 7. Ultrasound diagnosed a fluid collection compressing the sciatic nerve. The patient underwent seroma evacuation and sciatic nerve decompression. Patient regained active dorsiflexion and minimal paresthesia's over the dorsal lateral foot at the 12-month post-operative clinic visit. Conclusion: Early operative intervention in patients with diagnosed fluid collection and worsening neurological deficits can result in good outcomes. This is a unique case as there are no other case reports of seroma formation causing deep peroneal nerve palsy.

Palliative surgery for foot drop.

Dysfunction of the common peroneal nerve is the most common mononeuropathy in the lower limb and a source of significant disability for patients. The nerve can be damaged at various levels for various reasons (direct or indirect trauma, extrinsic compression, anatomical variant, endocrine, rheumatological, or neurological disease). Clinical evidence of foot drop with steppage gait is very typical. Conservative treatment should be considered as a first step (avoidance of the contributing factors, functional rehabilitation, foot drop brace ± injection). If properly conducted conservative treatment is not successful, palliative surgery is indicated: either tendon transfer using the posterior tibial tendon or ankle arthrodesis.

Bilateral peroneal nerve palsy secondary to prolonged sitting in an adolescent patient.

Peroneal nerve palsy most commonly occurs due to focal compression of the peroneal nerve at the level of the fibular head and causes foot drop and variable sensory loss. Mononeuropathies infrequently occur in childhood, bilateral peroneal palsy is very rare. In this article, we report the case of a 14-year-old boy with bilateral peroneal nerve entrapment which developed secondary to a prolonged sitting posture. We discuss the clinical assessment, diagnosis, and treatment of this rare case of bilateral peroneal palsy following prolonged immobility in light of the current literature.

Foot drop in patients treated with bortezomib - a case series and review of the literature.

Bortezomib-induced peripheral neuropathy (BIPN) has a profound impact on quality of life, which is an important issue considering the growing number of survivors of multiple myeloma and amyloidosis. BIPN is typically symmetric, distal, "stocking and glove" distribution and predominantly consists of sensory rather than motor symptoms. In this case series, we report an acute neurotoxicity syndrome induced by bortezomib, which is clinically distinct from BIPN by not being peripheral and distal. We describe six patients that developed unilateral or bilateral foot drop attributed to bortezomib. With bortezomib discontinuation symptoms improved gradually over months to years.