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Peroneal Nerve Palsy in TKR


- See:  TKR Menu:  
               - Peroneal Nerve and Peroneal Nerve Palsy
               - Nerve Injury from THR 

- Discussion:
    - peroneal nerve palsy following TKR usually presents acutely but in some cases there will be a delayed presentation;
    - risk factors:
         - use of epidural anesthesia;
         - previous spinal surgery (double crush);
         - valgus knee deformity;
         - flexion contracture more than 20 deg;
         - it may also be more common following previous high tibial osteotomy, and patients who also have peripheral neuropathy;
    - prevention:
         - postoperative dressings include Xeroform (vasiline gauze) and gauze padding over the fibular head region;
         - keep knee flexed the first postoperative night inorder to reduce tension on the nerve;
         - w/ a valgus knee, intraoperative dissection & mobilization of nerve will not decrease incidence of peroneal palsy;


- Exam:
    - it is important to document the exact strength of each muscle innervated by the peroneal nerve;
         - peroneus longus, brevis, and tertius, EHL, TA, EDL, EDB;
    - the exam should be able to distinguish between a partial vs a complete palsy;
         - normal function of the peroneus brevis and longus indicates a partial palsy (deep branch only);


- EMG:
    - useful to objectively document the conduction block;
    - if possible should be performed w/ in one month of injury;


- Management:
    - initial post op management consists of removal of circumferential dressings and partial flexion of the knee;
    - w/ persistent palsy, use dropfoot brace and ROM exercises to prevent equinus deformity;
    - if complete neurological deficit is present for more than 3 months then operative exploration and decompression is indicated;
    - even following decompression, there may be persistent weakness of the EHL;
    - operative treatment:
            - if there is no neurologic improvement after 3-4 months, then operative decompression is consider;
            - operative treatment invovles external neurolysis of peroneal nerve at the level of the fibular head;
            - nerve and its branches need to be freed from its adherence to the proximal fibula, particularly at its most proximal 4 cm as well as a second
                    region of adherence which may lie between 7 and 15 cm from the fibular head 



 Peroneal-nerve palsy following total knee arthroplasty. A review of The Hospital for Special Surgery experience.  

 Peroneal nerve palsy after total knee arthroplasty.

 Surgical decompression for peroneal nerve palsy after total knee arthroplasty.

 Peroneal Nerve Palsy after Total Knee Arthroplasty. Assessment of Predisposing and Prognostic Factors. 

 Peroneal Nerve Dysfunction After Total Knee Arthroplasty



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, May 9, 2012 2:51 pm