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Clinical Neurology and Neurosurgery May 2016The accessory deep peroneal nerve (ADPN) is a common anatomical variant arising from the superficial peroneal nerve (SPN) and, when present, is often responsible for... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
The accessory deep peroneal nerve (ADPN) is a common anatomical variant arising from the superficial peroneal nerve (SPN) and, when present, is often responsible for partial or complete innervation of the extensor digitorum brevis muscle (EDBM). The nerve lies posterior to the peroneus brevis muscle, traveling posterior to the lateral malleolus to terminate in the ankle by giving off sensory branches to the ankle and joints. Although the EDBM is usually supplied by the deep peroneal nerve (DPN), in the presence of an ADPN, electrodiagnostic procedures may be complicated. Due to the lack of detailed anatomical knowledge on the topography of the ADPN, its presence posterior to the lateral malleolus can be iatrogenically injured during surgical procedures on the ankle using a lateral approach. Therefore, this meta-analysis aimed to provide a comprehensive, evidence-based assessment of the anatomical characteristics of the ADPN, supplemented with data from our own cadaveric dissection.
PATIENTS AND METHODS
A comprehensive search of all major electronic databases, including Pubmed, Embase, Scopus, Web of Science, ScienceDirect, SciELO, and BIOSIS was performed. All articles with data on prevalence, symmetry and innervation of the EDBM by the ADPN were included. The anatomical data was then extracted and pooled into a meta-analysis using MetaXL 2.0. In addition, we dissected 21 cadavers (n=42 lower limbs) bilaterally to find the ADPN.
RESULTS
A total of 19 studies (n=6070 lower limbs) were included in the meta-analysis. The pooled prevalence of the ADPN was 18.8% (95%CI:14.2-24.0) with a 39.3% prevalence rate for cadaveric studies. The ADPN was present more commonly unilaterally (67.0%) and when it was present, provided branches to the EDBM in 79.5% of cases. In our cadaveric study, the ADPN was identified in 5 of the 42 lower limbs dissected (11.9%); on the right side in 3 lower limbs and on the left side in 2 lower limbs.
CONCLUSIONS
The ADPN is a clinically important nerve and has been inculpated in unexplained cases of chronic ankle pain and EDBM atrophy. The variability in detection of the ADPN using electrophysiological techniques can lead to misdiagnoses of peroneal nerve lesions and increase the risk for iatrogenic injury to the ADPN, especially in laterally approaching ankle procedures and sural nerve biopsies.
Topics: Cadaver; Humans; Peripheral Nervous System Diseases; Peroneal Nerve; Peroneal Neuropathies; Prevalence
PubMed: 27038872
DOI: 10.1016/j.clineuro.2016.03.026 -
Italian Journal of Anatomy and... 2010Superficial peroneal nerve and its branches are frequently at risk for iatrogenic damage. Although different studies on anatomical variations of superficial peroneal...
Superficial peroneal nerve and its branches are frequently at risk for iatrogenic damage. Although different studies on anatomical variations of superficial peroneal nerve are available in the medical literature, such reports are rare from India. Hence the present study was undertaken on Indian population. A total of 60 specimens of inferior extremities from 30 properly embalmed and formalin fixed cadavers were dissected and examined for the location and course of the superficial peroneal nerve including number, level, course and distributions of branches. The superficial peroneal nerve in 28.3% specimens was located in the anterior compartment of the leg. In 8.3% specimens the superficial peroneal nerve branched before piercing between the peroneus longus and extensor digitorum longus muscle whereas in 11.7% specimens it branched after piercing the aforementioned muscles and before piercing the deep fascia. In 41 out of 60 specimens the sensory division of superficial peroneal nerve branched into the medial dorsal cutaneous nerve and intermediate dorsal cutaneous nerve distal to its emergence from the deep fascia and proximal to its relation to the extensor retinaculum. In 20 out of 60 specimens the accessory deep peroneal nerve, an additional branch from the sensory division of superficial peroneal nerve, through its course in the anterior compartment of the leg passed deep to the extensor retinaculum and supplied the ankle and the dorsum of foot. Hopefully the present study will help in minimizing iatrogenic damage to the superficial peroneal nerve and its branches while performing arthroscopy, local anesthetic block, surgical approach to the fibula, open reduction and internal fixation of lateral malleolar fractures, application of external fixators, elevation of a fasciocutaneous or fibular flaps for grafting, surgical decompression of neurovascular structures, or miscellaneous surgery on leg, foot and ankle.
Topics: Adolescent; Adult; Aged; Cadaver; Female; Humans; Intraoperative Complications; Leg; Male; Middle Aged; Muscle, Skeletal; Peroneal Nerve; Peroneal Neuropathies; Skin; Young Adult
PubMed: 21287977
DOI: No ID Found -
Acta Orthopaedica Belgica Sep 1996An anatomical cadaver study was carried out on 13 human cadavers to disclose the close anatomical relationship between the peroneal nerve and the surgical area of the...
An anatomical cadaver study was carried out on 13 human cadavers to disclose the close anatomical relationship between the peroneal nerve and the surgical area of the high tibial osteotomy techniques. The common peroneal nerve passes within 3 to 6 mm. of the posterior aspect of the fibular head and neck and divides into its superficial and deep branches, 22 to 28 mm. distal to the fibular apex. Generally the extensor hallucis longus (EHL) muscle is innervated by one of the motor branches of the deep peroneal nerve which is anatomically located 74 to 82 mm. distal to the fibular apex. To avoid neurological complications with a high tibial osteotomy, fibular osteotomy should be carried out at the junction of the middle and distal thirds of the fibula without excessive medial and anterior displacement of fragments; a small fibular segment should be resected in knees which have a severe deformity and need a significant angle correction.
Topics: Fibula; Humans; Osteotomy; Peroneal Nerve; Tibia
PubMed: 8890541
DOI: No ID Found -
Acta Neurochirurgica Nov 2023
Topics: Humans; Peroneal Nerve; Peripheral Nerve Injuries; Leg; Peroneal Neuropathies; Iatrogenic Disease
PubMed: 37718334
DOI: 10.1007/s00701-023-05807-z -
Acta Neurochirurgica Nov 2023
The usefulness of ultrasound in iatrogenic nerve injuries. Letter in response to the paper by Carlson Strother et al. "Surgical management of peroneal nerve injuries." - Reply.
Topics: Humans; Peroneal Nerve; Peripheral Nerve Injuries; Leg; Peroneal Neuropathies; Iatrogenic Disease
PubMed: 37698729
DOI: 10.1007/s00701-023-05795-0 -
The Journal of Foot and Ankle Surgery :... 2021Although nerve transfer and repair are well-established for treatment of nerve injury in the upper extremity, there are no established parameters for when or which... (Meta-Analysis)
Meta-Analysis Review
Although nerve transfer and repair are well-established for treatment of nerve injury in the upper extremity, there are no established parameters for when or which treatment modalities to utilize for tibial nerve injuries. The objective of our study is to conduct a systematic review of the effectiveness of end-to-end repair, neurolysis, nerve grafting, and nerve transfer in improving motor function after tibial nerve injury. PubMed, Cochrane, Medline, and Embase libraries were queried according to the PRISMA guidelines for articles that present functional outcomes after tibial nerve injury in humans treated with nerve transfer or repair. The final selection included Nineteen studies with 677 patients treated with neurolysis (373), grafting (178), end-to-end repair (90), and nerve transfer (30), from 1985 to 2018. The mean age of all patients was 27.0 ± 10.8 years, with a mean preoperative interval of 7.4 ± 10.5 months, and follow-up period of 82.9 ± 25.4 months. The mean graft repair length for nerve transfer and grafting patients was 10.0 ± 5.8 cm, and the most common donor nerve was the sural nerve. The most common mechanism of injury was gunshot wound, and the mean MRC of all patients was 3.7 ± 0.6. Good outcomes were defined as MRC ≥ 3. End-to-end repair treatment had the greatest number of good outcomes, followed by neurolysis. Patients with preoperative intervals less than 7 months were more likely to have good outcomes than those greater than 7 months. Patients with sport injuries had the highest percentage of good outcomes in contrast to patients with transections and who were in MVAs. We found no statistically significant difference in good outcomes between the use of sural and peroneal donor nerve grafts, nor between age, graft length, and MRC score.
Topics: Adolescent; Adult; Humans; Nerve Transfer; Neurosurgical Procedures; Peroneal Nerve; Sural Nerve; Tibial Nerve; Treatment Outcome; Wounds, Gunshot; Young Adult
PubMed: 34366221
DOI: 10.1053/j.jfas.2021.07.001 -
AJR. American Journal of Roentgenology Nov 2005Traumatic knee dislocation needs immediate surgical repair to restore joint function. A concomitant traction injury of the peroneal nerve is reported to exist in up to...
OBJECTIVE
Traumatic knee dislocation needs immediate surgical repair to restore joint function. A concomitant traction injury of the peroneal nerve is reported to exist in up to 25% of cases and is often overlooked initially. In patients with major nerve lesions, immediate surgical nerve repair might be necessary to avoid irreversible loss of neural function. In the present study, we tried to evaluate whether sonography is a valuable tool for identification of nerve pathology that warrants surgical intervention.
SUBJECTS AND METHODS
In this prospective study, both peroneal nerves in nine patients with one-sided peroneal nerve palsy after closed knee luxation and the peroneal nerves of 11 healthy volunteers were investigated with sonography. Using statistical analysis, we tried to define the comparability and significance of the findings.
RESULTS
The mean cross-sectional area of healthy peroneal nerves in the genicular region was 0.18 cm2 (SD, 0.07 cm2). Impaired nerves were significantly discerned because of their increased cross-sectional area at the level of the injury (mean cross-sectional area, 0.7 cm2; SD, 0.46 cm2; p < 0.05). Identification of caliber changes and depiction of at least one nerve stump were found to be the most specific criteria for the definition of a major neural lesion. The ability of sonography to provide additional information about surrounding soft-tissue impairment (scar tissue and hematoma formation) proved helpful.
CONCLUSION
Sonography allows radiologists to visualize neural and extraneural pathology and to define the exact level and extent of lesions. Thus, it may be a valuable adjunct in the decision of whether surgical intervention is necessary.
Topics: Adolescent; Adult; Aged; Female; Humans; Knee Dislocation; Male; Middle Aged; Peroneal Nerve; Peroneal Neuropathies; Prospective Studies; Ultrasonography
PubMed: 16247119
DOI: 10.2214/AJR.04.1050 -
Journal of Neurosurgery Jan 2017OBJECTIVE The authors of this study sought to determine the outcomes of patients undergoing superficial peroneal nerve (SPN) release to treat lower-extremity pain and...
OBJECTIVE The authors of this study sought to determine the outcomes of patients undergoing superficial peroneal nerve (SPN) release to treat lower-extremity pain and describe consistent anatomical landmarks to direct surgical planning. METHODS This retrospective cohort study examined 54 patients with pain in the SPN distribution who were treated with decompression between 2011 and 2014. Patients rated pain and the effect of pain on quality of life (QOL) on the visual analog scale (VAS) from 0 to 10. Scores were then converted to percentages. Linear regression analysis was performed to assess the impact of the preoperative effect of pain on QOL, age, body mass index (BMI), and preoperative duration of pain on the postoperative effect of pain on QOL. Measurements were made intraoperatively in 13 patients to determine the landmarks for identifying the SPN. RESULTS A higher BMI was a negative predictor for improvement in the effect of pain on QOL. A decrease in pain compared with the initial level of pain suggested a nonlinear relationship between these variables. A minority of patients (7 of 16) with a preoperative pain VAS score ≤ 60 reported less pain after surgery. A large majority (30 of 36 patients) of those with a preoperative pain VAS score > 60 reported improvement. Intraoperative measurements demonstrated that the SPN was consistently found to be 5 ± 1.1, 5 ± 1.1, and 6 ± 1.2 cm lateral to the tibia at 10, 15, and 20 cm proximal to the lateral malleolus, respectively. CONCLUSIONS A majority of patients with a preoperative pain VAS score > 60 showed a decrease in postoperative pain. A higher BMI was associated with less improvement in the effect of pain on QOL. This information can be useful when counseling patients on treatment options. Based on the intraoperative data, the authors found that the SPN can be located at reliable points in reference to the tibia and lateral malleolus.
Topics: Age Factors; Body Mass Index; Chronic Pain; Decompression, Surgical; Female; Follow-Up Studies; Humans; Intraoperative Neurophysiological Monitoring; Male; Middle Aged; Pain Measurement; Peroneal Nerve; Quality of Life; Retrospective Studies; Treatment Outcome
PubMed: 27104849
DOI: 10.3171/2016.1.JNS152454 -
Neurosurgery Jun 1992Vascular compression syndromes of the peroneal nerve are rare. The case history of a patient with a peroneal nerve compression caused by a true anterior tibial artery...
Vascular compression syndromes of the peroneal nerve are rare. The case history of a patient with a peroneal nerve compression caused by a true anterior tibial artery aneurysm is reported. The surgical excision of the aneurysm resulted in marked improvement.
Topics: Aneurysm; Humans; Male; Middle Aged; Nerve Compression Syndromes; Peroneal Nerve; Thrombosis; Tibial Arteries; Tomography, X-Ray Computed
PubMed: 1614598
DOI: 10.1227/00006123-199206000-00021 -
Neurosurgery Dec 2005There are few large-volume studies of the repair of complete missile-caused peroneal nerve and peroneal division lesions. In this prospective study, the outcomes of such...
OBJECTIVE
There are few large-volume studies of the repair of complete missile-caused peroneal nerve and peroneal division lesions. In this prospective study, the outcomes of such repairs are studied and the factors influencing the outcomes are analyzed.
METHODS
During a 3-year period, 157 patients with complete missile-caused lesions of the peroneal nerve or peroneal division were treated surgically in the Belgrade Military Medical Academy: 37 patients with high-level (above the middle of the thigh), 90 patients with intermediate-level (above the popliteal crease), and 30 patients with low-level repairs. After at least 4 years of follow-up, outcome was defined on the basis of motor recovery, neurophysiological recovery, and patient judgment of the quality of outcome (poor, insufficient, good, or excellent). Good and excellent outcomes were considered successful. The factors of repair level, defect length, manner of repair, preoperative interval, severity of tissue damage in the repair region, and patient age were studied for their effect on outcome.
RESULTS
A successful outcome was obtained in 10.8% of high-level repairs, 31.1% of intermediate-level repairs, and 56.7% of low-level repairs (P < 0.001). Nerve defect and preoperative interval were significantly shorter for patients with a successful outcome compared with those with an unsuccessful outcome (P< 0.001). Worsening of the outcome began with the nerve defect larger than 4 cm and preoperative interval greater than 3 months (P< 0.001). Severity of local tissue damage significantly influenced the outcome (P= 0.008). Repair level (P< 0.001), preoperative interval (P= 0.001), severity of local tissue damage (P= 0.011), and length of nerve defect (P= 0.011) were independent predictors for a successful outcome.
CONCLUSION
After peroneal nerve or peroneal division repairs, a successful outcome is most probable with low-level lesions repaired in the first 3 months after injury using grafts smaller than 4 cm. Conversely, high-level repairs delayed for more than 7 months after injury and using grafts larger than 8 cm are probably not worthwhile.
Topics: Adolescent; Adult; Child; Hospitals, Military; Humans; Middle Aged; Nerve Tissue; Neurosurgical Procedures; Peroneal Nerve; Prospective Studies; Recovery of Function; Sciatic Nerve; Transplantation, Autologous; Trauma Severity Indices; Treatment Outcome; Warfare; Wounds, Gunshot
PubMed: 16331168
DOI: 10.1227/01.neu.0000186034.58798.bf