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The anatomical relationship of the common peroneal nerve to the proximal fibula and its clinical significance when performing fibular-based posterolateral reconstructions

Archives of Orthopaedic and Trauma Surgery volume 141, pages 437–445 (2021)Cite this article

Abstract

Purpose

The common peroneal nerve (CPN) can be injured during fibular-based posterolateral reconstructions due to its close relationship to the neck of the fibula. Therefore, the purpose of this study was to observe the course of the CPN and its branches around the fibular head and neck and quantify the position in relation to relevant bony landmarks and observe the relation between tunnel drilling for posterolateral corner reconstruction and both the tunnel entry and exit at the proximal fibula and the CPN and its branches was observed.

Methods

In 101 (mean age = 70.6 ± 16 years) embalmed cadaver knees, the relationship between bony landmarks (tibial tuberosity, styloid process of fibula (APR)) and the CPN and its branches were established and 8 (M1–M8) distances from these landmarks measured; mean, SD and 95% CI were recorded. In 21 of these knees, a fibula tunnel was drilled as in PLC reconstruction and the association of the CPN and its branches to the tunnel entry and exit were judged by two independent observers. Fisher’s exact test of independence was used to determine significant differences between genders. Tunnel intersection was analysed in a binary yes/no fashion and was described in frequencies and percentages.

Results

The mean distance from the APR to where the CPN reaches the fibula neck (M1) was 31.4 ± 8.9 mm (CI:29.8–33.0); from the apex of the styloid process (APR) to where the CPN passes posterior to the broadest point of the fibular head (M3) was 21.7 ± 12.6 mm (CI:19.4–24.0); from the apex of the APR to the most proximal point of the CPN/CPN first branch in the midline of the fibular head (M2) was 37.0 ± 6.7 mm (CI: 35.4–37.7). Out of the 21 randomly selected knees for drilling, the first branch of the CPN was damaged at the tunnel entry point in 7 (33%), and in 5 knees (24%), the CPN was damaged at the tunnel exit. In one knee, at both the tunnel entry and exit, the first branch of the CPN and the CPN were intersected, respectively.

Conclusion

The results of this study strongly suggest that the CPN is at risk when drilling the fibula tunnel performing fibula-based posterolateral corner reconstructions. The total injury rate was 57% with a 33% incidence of injury to the first branch of the nerve at the tunnel entry and 24% to the CPN at the tunnel exit.

Clinical Relevance

Due to the high incidence of injury, percutaneous placement of guide pins and tunnel drilling is not recommended. The nerve should be visualized and protected by either a traditional open approach or minimally invasive techniques. With a minimally invasive approach, the nerve should be identified at the fibula neck and then followed ante- and retrograde.

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Author information

Affiliations

  1. Valiant Clinic/Houston Methodist Group, Dubai, United Arab Emirates

    Erik Hohmann

  2. Faculty of Health Sciences, School of Medicine, University of Pretoria, Cnr Bophelo and Dr Savage Road, Gezina, Pretoria, 0001, South Africa

    Erik Hohmann

  3. Department of Anatomy, Faculty of Health Sciences, School of Medicine, University of Pretoria, Pretoria, South Africa

    Reinette Van Zyl & Natalie Keough

  4. Department of Orthopaedic Surgery, University of Texas Health Science Center, San Antonio, TX, USA

    Vaida Glatt

  5. Orthopaedic Research Centre of Australia, Brisbane, Australia

    Vaida Glatt & Kevin Tetsworth

  6. Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia

    Kevin Tetsworth

  7. Department of Surgery, School of Medicine, University of Queensland, Brisbane, Australia

    Kevin Tetsworth

  8. Limb Reconstruction Centre, Macquarie University Hospital, Sydney, NSW, Australia

    Kevin Tetsworth

  9. Department of Anatomy and Cellular Biology, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates

    Natalie Keough

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  1. Erik Hohmann
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  2. Reinette Van Zyl
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Correspondence to Erik Hohmann.

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This project was approved by the University of Pretoria Institutional Review Board and Human Research Ethics Committee.

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Hohmann, E., Van Zyl, R., Glatt, V. et al. The anatomical relationship of the common peroneal nerve to the proximal fibula and its clinical significance when performing fibular-based posterolateral reconstructions. Arch Orthop Trauma Surg 141, 437–445 (2021). https://doi.org/10.1007/s00402-020-03708-9

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  • DOI: https://doi.org/10.1007/s00402-020-03708-9

Keywords

  • Iatrogenic nerve injuries
  • Common peroneal nerve
  • Posterolateral corner reconstructions
  • Minimally invasive surgery
  • Proximal fibula