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The repair of nerve gap injuries longer than 3 cm is limited by the need to sacrifice donor tissue and the morbidity associated with the autograft gold standard, while decellularized ...grafts and biodegradable conduits are effective only in short nerve defects. The advantage of isogenic nerve implants seems to be the release of various growth factors by the denervated Schwann cells. We evaluated the effect of vascular endothelial growth factor, neurotrophins, and pleiotrophin (PTN) supplementation of multi-luminal conduits, in the repair of 3 and 4 cm nerve gaps in the rabbit peroneal nerve. In vitro screening revealed a synergistic regenerative effect of PTN with glial-derived neurotrophic factor (GDNF) in promoting sensory axon density, and motor axonal growth from spinal cord explants. In vivo, pleiotrophins were able to support nerve regrowth across a 3 cm gap. In the 4 cm lesions, PTN-GDNF had a modest effect in the number of axons distal to the implant, while increasing the mean axon diameter (1 ± 0.4; p ≤ 0.001) over PTN or GDNF alone (0.80 ± 0.2, 0.84 ± 0.5; respectively). Some regenerated axons reinnervated muscle targets as indicated by neuromuscular junction staining. However, many were wrapped in Remak bundles, suggesting a delay in axonal sorting, explaining the limited electrophysiological function of the reinnervated muscle, and the modest recovery in toe spreading in the PTN-GDNF repaired animals. These results support the use of synergistic neurotrophic/pleiotrophic growth factors in long gap repair and underscore the need for re-myelination strategies distal to the injury site.
Nerve injuries due to trauma or tumor resection often result in long gaps that are challenging to repair. The best clinical option demands the use of autologous grafts that are associated with serious side effects. Bioengineered nerves are considered a good alternative, particularly if supplemented with growth factors, but current options do not match the regenerative capacity of autografts. This study revealed the synergistic effect of neurotrophins and pleiotrophins designed to achieve a broad cellular regenerative effect, and that GDNF-PTN are able to mediated axonal growth and partial functional recovery in a 4 cm nerve gap injury, albeit delays in remyelination. This report underscores the need for defining an optimal growth factor support for biosynthetic nerve implants.
Purpose
The aim of the study was to evaluate the anatomical details of the articular branch of the peroneal nerve to the proximal tibiofibular joint and to project the height of its descent in ...relation to the fibular length.
Methods
Twenty-five lower extremities were included in the study. Following identification of the common peroneal nerve, its course was traced to its division into the deep and superficial peroneal nerve. The articular branch was identified. The postero-lateral tip of the fibular head was marked and the interval from this landmark to the diversion of the articular branch was measured. The length of the fibula, as the interval between the postero-lateral tip of the fibular head and the tip of the lateral malleolus, was evaluated. The quotient of descending point of the articular branch in relation to the individual fibular length was calculated.
Results
The articular branch descended either from the common peroneal nerve or the deep peroneal nerve. The descending point was located at a mean height of 18.1 mm distal to the postero-lateral tip of the fibular head. Concerning the relation to the fibular length, this was at a mean of 5.1%, starting from the same reference point.
Conclusion
The articular branch of the common peroneal nerve was located at a mean height of 18.1 mm distal to the the postero-lateral tip of the fibular head, respectively, at a mean of 5.1% of the whole fibular length starting from the same reference point. These details represent a convenient orientation during surgical treatment of intraneural ganglia of the common peroneal nerve, which may result directly from knee trauma and indirectly from ankle sprain.
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 Chi
2
-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.
The recurrent peroneal nerve (RPN) branches from the common peroneal nerve or the deep peroneal nerve and it innervates to the lower patellar region. It has recently been reported that damage to the ...RPN causes pain in the lower patellar region; therefore, this study examined the recurrent position and the innervation pattern of the RPN.
Cases of knee deformity or atrophy were excluded, and 50 legs (25 males and 25 females) of 34 cadavers (15 males and 19 females) were examined to assess the recurrent position and the innervation pattern of the RPN.
The recurrent position of the RPN was 27.9 ± 3.6 mm from the tip of the fibula. The RPN innervated to the patellar tendon in five of the 50 legs (10%), to the infrapatellar fat pad in 13 legs (26%), and to both the patellar tendon and the infrapatellar fat pad in 20 legs (40%), and to neither the patellar tendon nor the infrapatellar fat pad in 12 legs (24%). No significant sex differences were observed in the recurrent position and the innervation pattern of the RPN.
In all cases, the recurrent position of the RPN was almost fixed from the tip of the fibula. The RPN frequently innervated to the patellar tendon or the infrapatellar fat pad (76%) in both males and females. These findings would be useful in knee surgery to preserve the RPN or for the diagnosis of pain in the lower patellar region.
The lateral parabrachial nucleus (LPBN) is known to relay noxious information to the amygdala for processing affective responses. However, it is unclear whether the LPBN actively processes ...neuropathic pain characterized by persistent hyperalgesia with aversive emotional responses. Here we report that neuropathic pain-like hypersensitivity induced by common peroneal nerve (CPN) ligation increases nociceptive stimulation-induced responses in glutamatergic LPBN neurons. Optogenetic activation of GABAergic LPBN neurons does not affect basal nociception, but alleviates neuropathic pain-like behavior. Optogenetic activation of glutamatergic or inhibition of GABAergic LPBN neurons induces neuropathic pain-like behavior in naïve mice. Inhibition of glutamatergic LPBN neurons alleviates both basal nociception and neuropathic pain-like hypersensitivity. Repetitive pharmacogenetic activation of glutamatergic or GABAergic LPBN neurons respectively mimics or prevents the development of CPN ligation-induced neuropathic pain-like hypersensitivity. These findings indicate that a delicate balance between excitatory and inhibitory LPBN neuronal activity governs the development and maintenance of neuropathic pain.
Common peroneal nerve palsy leading to foot drop is difficult to manage and has historically been treated with extended bracing with expectant waiting for return of nerve function. Peroneal nerve ...exploration has traditionally been avoided except in cases of known traumatic or iatrogenic injury, with tendon transfers being performed in a delayed fashion after exhausting conservative treatment. We present a new strategy for management of foot drop with nerve exploration and concomitant tendon transfer.
We retrospectively reviewed a series of 12 patients with peroneal nerve palsies that were treated with tendon transfer from 2005 to 2011. Of these patients, seven were treated with simultaneous peroneal nerve exploration and repair at the time of tendon transfer.
Patients with both nerve repair and tendon transfer had superior functional results with active dorsiflexion in all patients, compared to dorsiflexion in 40% of patients treated with tendon transfers alone. Additionally, 57% of patients treated with nerve repair and tendon transfer were able to achieve enough function to return to running, compared to 20% in patients with tendon transfer alone. No patient had full return of native motor function resulting in excessive dorsiflexion strength.
The results of our limited case series for this rare condition indicate that simultaneous nerve repair and tendon transfer showed no detrimental results and may provide improved function over tendon transfer alone.
Traumatic neuromas are rare benign tumors, which are common in trauma or post-operation and accompanied with obvious symptoms of pain. This study will show the superficial peroneal nerve neuroma ...occurring after resection of hemangioma.
A 44-year-old male had an operation of the right leg cavernous hemangioma resection in 1995. Half a year after the operation, pain around the wound appeared and gradually aggravated. The patient had the lesion exploration resection in 2013, and the pathological result showed traumatic neuroma. Within half a year of the second operation, severe pain showed up again, so neuroma resection proceeded in May 2015. The postoperative pathological and immunohistochemical results showed traumatic neuroma. According to the postoperative follow-up, there were no symptoms of pain appearing again.
The pain is obvious, and B ultrasonography is the most efficient way to find neuromas. Both conservative and operative therapy have their advantages and disadvantages.
There remain many unanswered questions in relation to the treatment of traumatic neuromas, and further research is required, although we have already had adequate understanding of traumatic neuromas.
Objective
To determine if the thread release technique can be applied to common peroneal nerve entrapment at the fibular neck.
Methods
The thread common peroneal nerve release was performed on 15 ...fresh frozen cadaveric lower extremity specimens. All procedures were performed under ultrasound guidance and immediately underwent post-procedural gross anatomic inspection for completeness of decompression and presence or absence of iatrogenic neurovascular injury.
Results
All 15 specimens demonstrated complete transection of the deep fascia of the peroneus longus overlying the common peroneal nerve. The transections extended to the bifurcation of the superficial peroneal and deep peroneal nerves. There was no evidence of any iatrogenic damage to the neurovascular bundle or adjacent tendons. The average operating time was less than 30 min.
Conclusion
This cadaveric validation study demonstrates the accuracy of the thread common peroneal nerve release. Future pilot studies are warranted to ensure the safety of this procedure in the clinical setting.
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Promoting axon growth after peripheral nerve injury may support recovery. Soluble laminin polymers formed at pH 4 (aLam) accelerate axon growth from adult dorsal root ganglion neurons ...in vitro. We used an adult rat model of a peripheral (peroneal) nerve crush to investigate whether an injection of aLam enhances axon growth and functional recovery in vivo. Rats that received an injection of aLam into the crush at 2 days post-injury show significant improvements in hind limb motor function at 2 and 5 weeks after injury compared with control rats that received phosphate-buffered saline. Functional improvement was not associated with changes in sensitivity to thermal or mechanical stimuli. Treatment with aLam decreased the occurrence of autophagia and abolished non-compliance with treadmill walking. Rats treated with aLam showed increased axon presence in the crush site at 2 weeks post-injury and larger axon diameter at 10 weeks post-injury compared with controls. Treatment with aLam did not affect Schwann cell presence or axon myelination. Our results demonstrated that aLam accelerates axon growth and maturity in a crushed peroneal nerve associated with expedited hind limb motor function recovery. Our data support the therapeutic potential of injectable aLam polymers for treatment of peripheral nerve crush injuries.
Incidence of peripheral nerve injury has been estimated to be as high as 5% of all cases entering a Level 1 trauma center and the majority of cases are young males. Peripheral nerves have some endogenous repair capabilities, but overall recovery of function remains limited, which typically has devastating effects on the individual, family, and society, as wages are lost and rehabilitation is extended until the nerves can repair. We report here that laminin polymers injected into a crush accelerated repair and recovery, had no adverse effects on sensory function, obliterated non-compliance for walking tests, and decreased the occurrence of autophagia. These data support the use of laminin polymers for safe and effective recovery after peripheral nerve injury.
This study aims to assess the recovery patterns and factors influencing outcomes in patients with common peroneal nerve (CPN) injury.
This retrospective study included 45 patients with CPN injuries ...treated between 2009 and 2019 in Jing'an District Central Hospital. The surgical interventions were categorized into three groups: neurolysis (group A; n = 34 patients), nerve repair (group B; n = 5 patients) and tendon transfer (group C; n = 6 patients). Preoperative and postoperative sensorimotor functions were evaluated using the British Medical Research Council grading system. The outcome of measures included the numeric rating scale, walking ability, numbness and satisfaction. Receiver operating characteristic (ROC) curve analysis was utilized to determine the optimal time interval between injury and surgery for predicting postoperative foot dorsiflexion function, toe dorsiflexion function, and sensory function.
Surgical interventions led to improvements in foot dorsiflexion strength in all patient groups, enabling most to regain independent walking ability. Group A (underwent neurolysis) had significant sensory function restoration (P < 0.001), and three patients in Group B (underwent nerve repair) had sensory improvements. ROC analysis revealed that the optimal time interval for achieving M3 foot dorsiflexion recovery was 9.5 months, with an area under the curve (AUC) of 0.871 (95% CI = 0.661-1.000, P = 0.040). For M4 foot dorsiflexion recovery, the optimal cut-off was 5.5 months, with an AUC of 0.785 (95% CI = 0.575-0.995, P = 0.020). When using M3 toe dorsiflexion recovery or S4 sensory function recovery as the gold standard, the optimal cut-off remained at 5.5 months, with AUCs of 0.768 (95% CI = 0.582-0.953, P = 0.025) and 0.853 (95% CI = 0.693-1.000, P = 0.001), respectively.
Our study highlights the importance of early surgical intervention in CPN injury recovery, with optimal outcomes achieved when surgery is performed within 5.5 to 9.5 months post-injury. These findings provide guidance for clinicians in tailoring treatment plans to the specific characteristics and requirements of CPN injury patients.
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