Common Peroneal Nerve Injury and Recovery after Total Knee Arthroplasty: A Systematic Review

Risk Factors for Peripheral Nerve Injury Following Revision Total Knee Arthroplasty in 132,960 Patients

BACKGROUND

Peripheral nerve injury (PNI) following revision total knee arthroplasty (rTKA) is a potentially devastating injury for patients. This study assessed the frequency of and risk factors for postoperative PNI following rTKA.

METHODS

Patients who underwent rTKA from 2003 to 2015 were identified using the National Inpatient Sample. Demographics, medical histories, surgical details, and complications were compared between patients who sustained a PNI and those who did not to identify risk factors for the development of PNI after rTKA.

RESULTS

Overall, 132,960 patients who underwent rTKA were identified, and 737 (0.56%) sustained a postoperative PNI. After adjusting for confounders, patients with a history of a spine condition (adjusted odds ratio [aOR]: 1.7, 95%-confidence interval 1.2 to 2.4, P = .003) and postoperative anemia (aOR: 1.3, 95%-CI: 1.1 to 1.5, P = .004) had higher risk of PNI following rTKA. Intraoperative periprosthetic fracture (aOR: 1.3, 0.78 to 2.2, P = .308), rheumatoid arthritis (aOR: 1.0, 95%-CI: 0.68 to 1.6, P = .865), and history of knee dislocation (aOR: 1.1, 95%-CI: 0.85 to 1.5, P = .412), were not significantly associated with higher risk for PNI.

CONCLUSIONS

This study found a 0.56% incidence of PNI following rTKA, and patients who had preexisting spine conditions or postoperative anemia were at an increased risk for this complication. Orthopedic surgeons may use the results of this study to appropriately counsel patients on the potential for a PNI following rTKA.

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.

Preoperative Femoral Nerve Block and Postoperative Sciatic Nerve Block at the Subgluteal Space After Total Knee Arthroplasty: A Retrospective Cohort Study

Background A preoperative sciatic nerve block (SNB) before total knee arthroplasty (TKA) frequently causes postoperative drop foot; however, this can also occur as an unintended result of surgical invasion. This study assessed the benefits of a postoperative SNB at the subgluteal space for patients who underwent TKA. Methodology This was a single-center, retrospective cohort study. Patients who underwent TKA under general anesthesia between May 2018 and June 2019 at the Teikyo University School of Medicine were screened for inclusion. They received either a preoperative femoral nerve block alone (control group; n = 87) or a preoperative femoral nerve block and postoperative SNB at the subgluteal space (post-SNB group; n = 40). The primary outcome was the pain-related Numerical Rating Scale (NRS) scores. The secondary outcomes were postoperative nausea and vomiting (PONV), intravenous patient-controlled analgesia (iv-PCA) suspension, and postoperative complications. Results No significant differences were observed in the characteristics, NRS scores, time to first drug use for pain, and iv-PCA suspension between groups. However, the incidence of PONV was significantly lower in the post-SNB group (p = 0.03). Logistic regression analysis revealed that droperidol doses of iv-PCA and the presence of postoperative SNB were independently associated with PONV occurrence [A1] {(p = 0.008, 95% confidence intervals (CI) [0.46, 0.89] and (p = 0.02, 95% CI [0.25, 0.88])}. Conclusions A postoperative SNB at the subgluteal space following TKA does not improve postoperative pain control; however, it may have contributed to reduced PONV.

The effect of HIV prevalence, CD4 counts and disease severity on the outcome of total knee arthroplasty for haemophilic arthropathy: a systematic review and meta-analysis

PURPOSE

End-stage knee arthropathy is a recognised complication of haemophilia. It is often treated by total knee arthroplasty (TKA), which is more technically challenging in patients with haemophilia (PwH). It remains unclear what factors may predict implant survivorship and deep infection rate. Therefore, we systematically review the evidence regarding TKA survivorship and infection in PwH, compared to the general population, and determine the important factors influencing survivorship, particularly HIV and CD4 + count.

METHODS

A systematic literature review was conducted using MEDLINE, EMBASE, and PubMed for studies reporting Kaplan-Meier survivorship for TKA in PwH (PROSPERO CRD42021284644). Meta-analysis was performed for survivorship, and the results compared to < 55-year-olds from the National Joint Registry (NJR). Meta-regression was performed to determine the impact of relevant variables on 10-year survivorship, with a sub-analysis focusing on HIV.

RESULTS

Twenty-one studies were reviewed, totalling 1338 TKAs (average age 39 years). Implant survivorship for PwH at 5, 10, and 15 years was 94%, 86%, and 76% respectively. NJR-reported survivorship for males < 55 years was 94%, 90%, and 86%. Survivorship improved over time (1973-2018), and correlated inversely with HIV prevalence. Infection rate was 5%, compared to 0.5-1% in the NJR. Infection was not significantly increased with higher HIV prevalence, and CD4 + count had no effect. Complications were inconsistently reported.

CONCLUSION

Survivorship was similar at 5 years but declined thereafter, and infection rate was six-fold higher. HIV was related to worse survivorship, but not increased infection. Meta-analysis was limited by inconsistent reporting, and standardised reporting is required in future studies.

Diagnostic Approach to Lower Limb Entrapment Neuropathies: A Narrative Literature Review

Entrapment neuropathies of the lower limb are a misunderstood and underdiagnosed group of disorders, characterized by pain and dysesthesia, muscular weakness, and specific provoking movements on physical examination. The most frequent of these syndromes encountered in clinical practice are fibular nerve entrapment, proximal tibial neuropathy, sural nerve neuropathy, deep gluteal syndrome or sciatic nerve entrapment, and lateral femoral cutaneous nerve entrapment, also known as meralgia paresthetica. These are commonly mistaken for lumbar plexopathies, radiculopathies, and musculotendinous diseases, which appear even more frequently and have overlapping clinical presentations. A comprehensive anamnesis, physical examination, and electrodiagnostic studies should help clarify the diagnosis. If the diagnosis is still unclear or a secondary cause of entrapment is suspected, magnetic resonance neurography, MRI, or ultrasonography should be conducted to clarify the etiology, rule out other diseases, and confirm the diagnosis. The aim of this narrative review was to help clinicians gain familiarity with this disease, with an increase in diagnostic confidence, leading to early diagnosis of nerve damage and prevention of muscle atrophy. We reviewed the epidemiology, anatomy, pathophysiology, etiology, clinical presentation, and EDX technique and interpretation of the entrapment neuropathies of the lower limb, using articles published from 1970 to 2022 included in the Pubmed, MEDLINE, Cochrane Library, Google Scholar, EMBASE, Web of Science, and Scopus databases.

Prophylactic Common Peroneal Nerve Release for Total Arthroplasty of the Valgus Knee: Surgical Technique and Early Outcomes

Background

Common peroneal nerve (CPN) palsy after primary total knee arthroplasty represents a relatively rare but serious complication. Recently, there has been a growing interest in prophylactic CPN decompression in high-risk patients with significant combined valgus and flexion deformity. This study aimed to examine outcomes at our institution in those undergoing prophylactic CPN decompression at the time of total knee arthroplasty.

Methods

A retrospective evaluation of a single-institution experience with selected patients at high risk for CPN palsy who underwent prophylactic nerve decompression through a separate incision at the time total knee arthroplasty was performed between July 1, 2018 and December 31, 2022. Patient demographics as well as perioperative and intraoperative clinical and radiographic measurements were collected and analyzed.

Results

A total of 14 patients (15 knees) met our inclusion criteria. The mean preoperative femorotibial angle was 18.6° of valgus (range 13°-22°). The mean preoperative flexion contracture was 4.3° (range 0°-25°). The patients with flexion contractures preoperatively had a mean combined valgus/flexion contracture deformity of 28.8° (range 23°-38°) . There was preservation of nerve function in all knees. No knees required subsequent operative intervention within 90 days of surgery.

Conclusions

Early experience with prophylactic CPN release in our high-risk population demonstrates preservation of nerve function in all patients and is reasonable to consider in patients with a large preoperative combined valgus/flexion deformity. Further studies with larger sample sizes would be beneficial in verification of the results with this technique, as well as determining an angular deformity threshold for which CPN release should be considered.

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.

Nerve Injuries in Total Knee Arthroplasty

Nerve injury is one of the potential complications of total knee arthroplasty. The extent of the injury includes motor and sensory dysfunction, either temporary or permanent. Although the consequences of nerve injury may be dramatic, the probability of occurrence during the course of primary knee arthroplasty is low, around 0.12% to 0.4%. Local dressing removal and knee flexion are imperative, and the initial investigations include ultrasound or MRI and nerve conduction studies. The extent of recovery depends on the type and severity of the initial nerve palsy; however, most patients are expected to have at least a partial recovery.

Surgical Treatment of Foot Drop: Pathophysiology and Tendon Transfers for Restoration of Motor Function

Foot drop is a common condition that may impact physical function and health-related quality of life. A detailed clinical history and physical examination are critical components of the initial evaluation of patients presenting with foot drop. Patients with refractory foot drop without spontaneous recovery of motor deficits, delayed presentation greater than 12 months from injury, or neural lesions that are not amenable to or have failed nerve reconstruction may be candidates for tendon transfers to restore active ankle dorsiflexion. The modified Bridle procedure is a dynamic tendon transfer that has demonstrated excellent functional outcomes in patients with refractory foot drop.

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.

An Update on Peroneal Nerve Entrapment and Neuropathy

Peroneal neuropathy is the most common compressive neuropathy of the lower extremity. It should be included in the differential diagnosis for patients presenting with foot drop, the pain of the lower extremity, or numbness of the lower extremity. Symptoms of peroneal neuropathy may occur due to compression of the common peroneal nerve (CPN), superficial peroneal nerve (SPN), or deep peroneal nerve (DPN), each with different clinical presentations. The CPN is most commonly compressed by the bony prominence of the fibula, the SPN most commonly entrapped as it exits the lateral compartment of the leg, and the DPN as it crosses underneath the extensor retinaculum. Accurate and timely diagnosis of any peroneal neuropathy is important to avoid progression of nerve injury and permanent nerve damage. The diagnosis is often made with physical exam findings of decreased strength, altered sensation, and gait abnormalities. Motor nerve conduction studies, electromyography studies, and diagnostic nerve blocks can also assist in diagnosis and prognosis. First-line treatments include removing anything that may be causing external compression, providing stability to unstable joints, and reducing inflammation. Although many peroneal nerve entrapments will resolve with observation and activity modification, surgical treatment is often required when entrapment is refractory to these conservative management strategies. Recently, additional options including microsurgical decompression and percutaneous peripheral nerve stimulation have been reported; however, large studies reporting outcomes are lacking.

Incidence, Injury Mechanisms, and Recovery of Iatrogenic Nerve Injuries During Hip and Knee Arthroplasty

Iatrogenic nerve injury is a rare but potentially devastating complication in total joint arthroplasty of the hip and the knee. Multiple previous studies have evaluated the incidence, mechanisms of injury, recovery, and potential treatments for this complication. Injury in total hip arthroplasty generally involves direct injury of sensory nerves from the incision, direct or traction injury of during exposure, or limb lengthening. Injury in total knee arthroplasty generally involves direct injury of sensory nerves from incision, injury due to errant placement of retractors, during balancing, or from traction because of deformity correction. Treatment of iatrogenic nerve injuries has ranged from observation, intraoperative prevention by nerve monitoring, limb shortening postoperatively, medications, and decompression. The orthopaedic surgeon should be versed in these etiologies to advise their patients on the incidence of injury, to prevent occurrence by understanding risky intraoperative maneuvers, and to select appropriate interventions when nerve injuries occur.