Search Results (115)

Background and Clinical Significance: Neurofibromatosis type 1 (NF1) predisposes individuals to various peripheral nerve sheath tumors (PNSTs), including benign neurofibromas, malignant peripheral nerve sheath tumors (MPNSTs), and intermediate lesions known as atypical neurofibromatous neoplasms of uncertain biologic potential (ANNUBP), previously often termed atypical neurofibroma. These atypical lesions are considered premalignant precursors to MPNST. Case Presentation: We present the case of a 33-year-old male with NF1 who developed a rapidly growing, painful mass in his right calf. Clinical examination revealed signs consistent with NF1. Magnetic resonance imaging showed a large, heterogeneous mass in the lateral compartment. Biopsy revealed a neurofibroma with hypercellularity, moderate atypia, scarce S100 positivity, focal CD34 positivity, and an elevated Ki-67 proliferation index of 10–12%, consistent with ANNUBP. The patient underwent wide surgical resection, including the fibula and peroneal muscles. At the 30-month follow-up, there was no local recurrence, though the patient had a mild residual limp. Discussion: This case highlights the clinical presentation, diagnostic features, and management considerations for ANNUBP in NF1, emphasizing the importance of recognizing warning signs and the role of pathology in guiding treatment for these high-risk precursor lesions. Full article

Background/Objectives: The co-existence of multiple compression sites on the same nerve can pose a clinical and diagnostic challenge, warranting a different treatment strategy. This so-called double crush syndrome (DCS) has mainly been investigated in the upper limb. Only a few studies have investigated DCS for the lower limb. In this article, a single-center illustrative clinical case series is presented, and current literature on L5 nerve root (NR) and concomitant common peroneal nerve (CPN) is reviewed. Methods: All patients presenting between 2019 and 2022 with L5 nerve root (NR) compression and, along their clinical courses, concomitant compression of the common peroneal nerve (CPN) at the fibular head were included. Information on clinical features, diagnostics and surgeries was obtained. The outcome was assessed at the last outpatient follow-up appointment. In addition, an extensive literature review has been conducted. Results: Fourteen patients were included with a mean follow-up of 6.8 months. The majority had pain (71%) or motor deficits (71%). Seven patients were referred for clinical and radiological L5 NR compression but were also found to have CPN compression; the other seven patients had persisting or recurrent symptoms after surgically or conservatively treated L5 NR compression, suggestive of additional peroneal neuropathy. All patients had CPN decompression at the fibular head, with successful results obtained in 93% of the patients. Pain of the lower leg improved in all patients, and dorsiflexion function improved in 78%. Conclusions: Concomitant L5 NR and CPN appear to occur more frequently than expected. Peroneal neuropathy can present simultaneously with L5 nerve radiculopathy or after surgically or conservatively treated L5 NR compression. Overlapping symptoms and variation in clinical presentations make it difficult to diagnose and, therefore, underrecognized. More awareness among treating physicians of this specific double crush syndrome is important to prevent any delay in treatment, in this case, a less invasive common peroneal nerve release at the fibular head, and to avoid unnecessary (additional) spinal surgery. Full article

Background: Previous studies have indicated that transcutaneous electrical nerve stimulation (TENS) is highly effective in improving the treatment of neuropathy and achieving maximum recovery in the shortest time. However, its effectiveness in the early stages of the disease has not been studied, and no comparative analysis has been conducted between different modalities of TENS. Materials and Methods: This study included 82 patients with acute and subacute fibular tunnel (FT) syndrome lasting no more than 15 days. Patients were randomized into the following four groups depending on the modality of TENS used: sham TENS (20 patients), HF TENS (20 patients), LF TENS (21 patients), and a combined HF/LF TENS group (21 patients). Before treatment, immediately after treatment, and 3 months after the end of treatment patients were examined to determine the severity of hypoesthesia, motor deficit, and gait disturbance. Results: The reduction in hypoesthesia averaged after HF TENS, LF TENS, and sham TENS was 50.7% (p ≤ 0.01), 37.8 (p ≤ 0.01), and 11.4% (p > 0.05), respectively. The regression of motor deficit and gate disorders reached 61% after LF TENS (p ≤ 0.01), 6% after HF TENS (p > 0.05), and 6% (p > 0.05) after sham TENS. The combination of HF and LF TENS resulted in a 54.8% (p ≤ 0.01) reduction in hypoesthesia and 61.3% (p ≤ 0.01) regression of motor deficit, with a superior 30% (p ≤ 0.05) improvement in quality of life compared to separate use of HF and LF TENS. Conclusions: Early use of TENS in the treatment of FT syndrome turned out to be highly effective compared to sham TENS in reducing hypoesthesia, motor deficit, and gait disturbance. The analgesic effect and sensory recovery were higher after HF TENS. Motor and gait disturbances were reduced only after LF TENS, with evidence of prolonged regenerative and protective effect for at least 3 months after the end of treatment. The combination of HF TENS and LF TENS increases the therapeutic range of TENS with the achievement of the maximum positive effect of HF TENS and LF TENS after treatment and during the long-term period, which leads to a more pronounced improvement in the quality of life of patients with this pathology. Full article

Common peroneal nerve neuropathy at the fibular head secondary to weight loss is known as slimmer’s paralysis. Although this pathology has long been documented in medical literature, it has gained more clinical significance in recent years due to the global rise in obesity and the increasing pursuit of rapid weight loss methods. While case reports exist in the current literature, there are limited data regarding its optimal management. This study summarizes all reported cases of common peroneal nerve paralysis after weight loss and reports one additional case, exploring disease mechanisms as well as diagnostic and therapeutic strategies. A literature review was conducted on the platforms PubMed, Google Scholar, and EMBASE. A total of 380 patients were included. Laterality of neuropathy was specified in 297 (78.16%) patients: 285 (95.96%) with unilateral neuropathy and 12 (4.04%) with bilateral neuropathy. A total of 19 (5.00%) patients had sudden onset, and in 145 (38.16%) of cases, the Tinel’s sign was positive. Additionally, 373 (98.16%) patients underwent nerve conduction studies, demonstrating the fibular head as the site of injury. MRI or ultrasound imaging of the knee is indicated to exclude compressive etiology. A total of 302 (79.47%) cases were treated surgically and 42 (11.58%) conservatively, predominantly with favorable outcomes, regardless of the therapeutic approach chosen. Although the predominance of surgically treated cases in the literature limits definitive treatment recommendations, conservative management appears appropriate when an extended recovery time is acceptable, while surgical decompression is indicated in cases showing no improvement after 3 months. Full article

Background: Lateral ankle sprains can result in adverse outcomes, including reinjuries or chronic ankle instability. The peroneal musculature plays a key role in stabilizing the ankle and preventing sudden ankle inversions that may lead to sprains. Objective: The purpose of the study is to investigate (1) inter-limb differences in peroneal myoelectrical activity in athletes with a history of ankle sprain during the past six months and (2) to investigate peroneal myoelectrical activity differences between athletes with and without a history of ankle sprain. Methods: Sixty-seven athletes (53% females, 46.3% males) were included in this observational cross-sectional study. Self-reported data regarding history of ankle sprain were collected. The peroneal myoelectrical activity was obtained during (1) isometric ankle eversion, (2) dynamic ankle eversions, (3) single leg squat, (4) unilateral and (5) bilateral drop jump test, (6) sprint, and (7) change of direction. Results: No significant differences in peroneal myoelectrical activity were observed between individuals with (n = 46) and without (n = 21) a history of ankle sprain in the past six months (p > 0.05). Additionally, no significant inter-limb differences were found within the previous ankle sprain group (p > 0.05). Conclusions: This study found no significant inter-limb differences in peroneal muscle activity among athletes with a history of ankle sprain during the past six months. Moreover, no differences were observed between athletes with and without a history of ankle sprain. This study has certain limitations, including the lack of data regarding the timing and severity of the ankle sprain, as well as the duration and specific characteristics of the rehabilitation process. Full article

Background: Inside-out meniscal repair is a widely adopted treatment for lateral meniscal injuries. A significant complication associated with this procedure is iatrogenic peroneal nerve (PN) injury, reported in approximately 9% of cases. The risk varies depending on the choice of surgical portals, curvature of repair devices, and anatomical landmarks. This study aimed to assess the risk of PN injury and define safe zones for inside-out lateral meniscal repair using different device curvatures and portal combinations. Methods: Axial MRI scans of knees positioned in the figure-of-four posture, with joint fluid distension and varus force applied, were analyzed in 29 adult patients. Transparent overlays representing the operative routes of the anterior-, middle-, and posterior-curved needles were superimposed on the MRI scans. Simulations of repair procedures were performed using the anteromedial, accessory anteromedial, anterolateral, and accessory anterolateral portals, targeting the medial and lateral borders of the popliteus tendon (PT). Instances where the needle path intersected or contacted the PN were recorded to delineate risk zones. Results: Repairs targeting the medial PT border with anterior-curved devices via the anteromedial or accessory anteromedial portals were identified as safe. At the lateral PT border, all device curvatures and portals were considered safe, except for middle- and posterior-curved devices used through the accessory anteromedial portal, which posed a risk of PN injury. Conclusions: The risk of iatrogenic PN injury in inside-out lateral meniscal repair depends on the curvature of the repair device and portal used. Adhering to the identified safe zones can substantially reduce this risk. Full article

Peripheral arterial disease (PAD) is a major complication in individuals with diabetes and is increasingly prevalent in those with diabetic foot ulcers (DFUs). Despite this, the characterisation of PAD in diabetic patients remains insufficiently refined, leading to suboptimal management and outcomes. This review underscores the necessity for a more nuanced understanding of PAD’s anatomical and biological aspects in diabetic patients. The distribution of atherosclerotic plaques varies significantly among individuals, influencing prognosis and treatment efficacy. We describe three key patterns of PAD in diabetes: pattern 1 PAD—below-the-knee (BTK) disease (with infrageniculate disease where present); pattern 2—below-the-ankle (BTA) disease; and pattern 3—small artery disease (SAD), each presenting unique challenges and require tailored therapeutic approaches. BTK PAD, characterised by occlusions in the anterior tibial, posterior tibial, and peroneal arteries, necessitates targeted revascularisation to improve foot perfusion. BTA PAD, involving the pedal and plantar arteries, is associated with higher risks of amputation and requires advanced revascularisation techniques. SAD, affecting the small arteries of the foot, remains an enigma and is challenging to treat with the current mechanical methods, highlighting the potential of autologous cell therapy as a promising alternative. A refined characterisation of PAD in diabetes is crucial for developing effective, individualised treatment strategies, ultimately improving patient outcomes, and reducing the burden of diabetic foot complications. In light of these complexities, it is incredulous that we often use a single term, “peripheral arterial disease”, to describe such a diverse array of disease patterns. This oversimplification can be perilous, as it may lead to inadequate therapeutic approaches and suboptimal patient care. Full article

Axonotmesis, a common peripheral nerve injury in humans and animals, leads to significant biomechanical and physiological consequences. The lack of a standardized crushing protocol for complex animal models limits research and therapeutic translations for humans and clinically relevant animal species. This study aimed to assess the impact of different crushing forces on the biomechanical behavior of the sheep common peroneal nerve and to establish a force for standardized in vivo protocols. Fourteen nerves of equal length were harvested and preserved and their initial diameter measured. They were subjected to crushing forces of 0 N, 80 N, and 180 N for one minute. Post crushing, the diameter, ultimate tensile strength, displacement at rupture, stress, strain, and stiffness were evaluated. Results showed that increasing crushing forces significantly affected nerve biomechanical parameters. Nerves crushed with 180N displayed lower tensile strength, displacement, and stiffness but higher stress and strain, indicating greater physical damage and structural degradation. These findings suggest that 180N induces substantial nerve fiber rupture and disruption of nerve trunk support elements, making it a candidate force for an axonotmesis protocol in the ovine model. Future in vivo studies should validate its effectiveness in creating complete crush injuries with functional and histological consequences, facilitating protocol standardization and translational research. Full article

Painful Os Peroneum Syndrome (POPS) is a rare cause of lateral midfoot pain due to pathologies involving the os peroneum, an accessory ossicle within the peroneus longus tendon. POPS may result from fractures, tendon tears, tenosynovitis, or degenerative changes. This review evaluates outcomes of conservative and surgical management of POPS based on the current literature. A comprehensive review of published case reports, series, and relevant studies on POPS management was conducted. Clinical outcomes, radiographic findings, and complications following conservative and surgical interventions were analysed. Conservative management, including immobilisation, physiotherapy, cryotherapy, and corticosteroid injections, showed variable success, particularly in nondisplaced fractures or inflammatory causes. Surgical management demonstrated better outcomes in severe cases, including displaced fractures or tendon ruptures. Techniques such as os peroneum excision, tendon repair, tenodesis to the peroneus brevis, and tendon grafting yielded high patient satisfaction, reduced pain scores, and improved functional outcomes. Reported complications included delayed wound healing, sural neuritis, and chronic pain. Despite promising surgical results, a lack of standardised treatment protocols remains a challenge. Both conservative and surgical management of POPS can be effective, depending on injury severity and pathology. Surgical intervention appears superior for advanced cases, especially with tendon rupture or os peroneum fracture. Further research with standardised scoring systems and larger cohorts is needed to establish optimal treatment algorithms and improve clinical outcomes. Full article

Background: The operative indication for posterior malleolar fracture (PMF) remains controversial. This study aimed to assess the midterm outcomes of PMF treatment for developing a treatment strategy for each morphological type. Methods: In this retrospective analysis, patients undergoing operative treatment for an unstable ankle fracture involving PMF were included after at least 3 years of follow-up. PMFs were classified by fracture morphology according to the Haraguchi classification. This study divided the entire cohort into three independent populations based on the types of PMF. For each population, patients were further categorized into two groups depending on whether PMF was surgically fixed or not, and comparisons were made between these two groups. Demographic data, functional and radiographical outcomes were compared between two groups in each of the three populations. Results: With a total of 472 patients, the mean patient age was 45.8 years, and the mean follow-up was 51 months. For type 1 fracture, a total of 237 cases were found. Quality of reduction by CT (QRC) was mostly good in both groups (83.6% vs. 83.3% in the non-fixation vs. fixation group, respectively, p = 0.269). Functional and radiological outcomes between both groups showed no significant difference. For type 2 PMFs, a total of 199 cases were found, and QRC was significantly different between the two groups (good grade, 5.4% vs. 60.7% in the non-fixation vs. fixation group, respectively, p < 0.001). The radiological and clinical outcomes of the PMF fixation group were statistically superior to those of the non-fixation group (both p < 0.001). For type 3 fractures, a total of 36 cases were found. In all the cases in this group, surgical fixation of PMF was not performed. Only the syndesmosis instability was analyzed as a viable factor to be considered for achieving favorable surgical outcomes. PMF fixation group showed significantly more postoperative complications (24.4% vs. 40.4%, non-fixation vs. fixation, respectively, p < 0.001). Major complications in the fixation group were deep wound infection (6.8%), superficial peroneal nerve injury (6.8%), and hallux flexion deficit (5.0%). Conclusions: Different treatment strategies seem to be required for each PMF morphological subtype. Further studies with more detailed designs for each PMFs are warranted for more clinically related results that are helpful for making practical surgical decisions. Full article

Background/Objectives: Docetaxel is a cytotoxic agent for the treatment of breast cancer, and its toxicities include peripheral neuropathy (PN). This study evaluated the ability of frozen sock (FS) treatment to prevent docetaxel-induced PN by performing nerve conduction study (NCS). Methods: From October 2017 to October 2018, 48 patients who had invasive carcinoma and were planned for docetaxel treatment every three weeks were evaluated. Patients wore a FS on the right foot, and the left foot was not protected by the FS during docetaxel infusion. Motor and sensory NCS as well as nail and skin toxicities were assessed. Results: The amplitude and velocity of the motor and sensory nerves significantly decreased after three months in both feet. Before and after three months of chemotherapy, the compound motor action potentials (CMAPs) for the right peroneal nerve were 7.64 ± 2.42 and 6.81 ± 2.21 mV, respectively (p < 0.001), and 7.13 ± 2.41 and 5.90 ± 2.24 mV, respectively (p < 0.001), for the left peroneal nerve. Reductions in the CMAP amplitude of the peroneal nerve were significantly lower in the right foot compared to the left foot (−9.58 vs. −16.8, p = 0.043). Application of the FS did not significantly decrease the overall incidence of skin and nail toxicity compared with the left foot during the study period (all p > 0.05). Conclusions: Docetaxel induced motor and sensory PN, but the use of a FS resulted in a smaller reduction in peroneal nerve amplification three months after the end of chemotherapy. Full article

Background and Objectives: Proximal tibiofibular joint detachment (PTFJD) is a fibular untethering procedure during lateral closing-wedge high tibial osteotomy (LCWHTO) for varus knee osteoarthritis. However, the PTFJD procedure is technically demanding, and confirmation of clear joint separation is not straightforward. The aim of this study was to compare the degree of completion and safety of PTFJD versus tibial-sided osteotomy (TSO); this latter procedure is our novel technique for fibular untethering during LCWHTO. Materials and Methods: Sixteen fresh frozen cadaver knees from eight cadavers were included in the study. Among the eight pairs of knees, one knee was randomly assigned to undergo PTFJD and the other knee to undergo TSO, which separates the fibula by osteotomizing the lateral cortex of the proximal tibia at the medial side of the proximal tibiofibular joint for fibular untethering during LCWHTO. After each procedure with LCWHTO, the posterior compartment of each knee was dissected to compare the degree of procedural completion and the distance from the posterior detachment or osteotomy site to posterior neurovascular structures between PTFJD and TSO groups. The pass-through test crossing the separation site from anterior to posterior using an osteotome was also performed to evaluate the protective effect of the muscular structures of the posterior compartment. Results: In the PTFJD group, four of eight cases (50%) showed fibular head fractures rather than division of the proximal tibiofibular joint. In contrast, in all TSO cases, the lateral cortex of the proximal tibia was clearly osteotomized from the medial side of the posterior proximal tibiofibular joint. Distances from the posterior detachment or osteotomy site to the common peroneal nerve, popliteal artery, and anterior tibial artery in the PTFJD and TSO groups were 20.8 ± 3.3 mm and 22.9 ± 3.6 mm (p = 0.382), 11.0 ± 2.4 mm and 9.8 ± 2.8 mm (p = 0.382), and 14.8 ± 1.9 mm and 14.9 ± 2.5 mm (p = 0.721), respectively. In the pass-through test, an osteotome was able to pass anteriorly to posteriorly in all eight PTFJD group cases. However, the osteotome was blocked posteriorly by the popliteus muscle in the TSO group cases, indicating protection of posterior neurovascular structures during the TSO procedure. Conclusions: TSO, a novel fibular untethering procedure for LCWHTO, resulted in clear separation of the fibula from the lateral tibial cortex, and protection of posterior neurovascular structures by the popliteus muscle during the procedure. We anticipate that our novel surgical technique will provide more clear-cut and safer fibular untethering for LCWHTO. Full article

Background: This study aims to analyze potential risk factors that may influence the clinical outcomes following surgical treatment of traumatic peroneal nerve lesions. Methods: We conducted a retrospective analysis of patients with traumatic peroneal nerve injuries treated with decompression, split repair, or nerve grafting between 2010 and 2020. Motor function and potential risk factors were evaluated. Results: Out of 93 patients, 42 (45%) underwent decompression, 15 (16%) received split repair, and 36 (39%) required autologous nerve grafting. Up to one year after surgery, weakness of the anterior tibial muscle improved from a median of M0 to M3. After one year following nerve decompression, functional recovery was observed in 28 (65%) cases, in 9 (21%) cases after split repair, and in 7 (16%) cases following autologous nerve grafting. A defect greater than 8 cm was associated with significantly poorer improvement of extensor hallucis longus (p = 0.037, HR 0.109). We found no significant associations between age, diabetes mellitus, arterial hypertension, obesity, and postoperative outcomes. Conclusions: According to the present data, a significant number of patients achieved functional improvement following surgical treatment, indicating that this procedure should be considered an important treatment option in selected cases. Full article

Background and Objectives: Despite its advantages, lateral close-wedge high tibial osteotomy (LCWHTO) requires proximal tibiofibular joint detachment (PTFJD) or fibular shaft osteotomy for gap closing. These fibula untethering procedures are technically demanding and not free from the risk of neurovascular injuries. Our novel fibula untethering technique, tibial-sided osteotomy (TSO) near the proximal tibiofibular joint (PTFJ), aims to reduce technical demands and the risk of injury to the peroneal nerve and popliteal neurovascular structures. The purposes of this study were to introduce the TSO technique and compare the complexity and safety of TSO with those of radiographic virtual PTFJD, which is defined based on radiographic landmarks representing the traditional PTFJD technique. Materials and Methods: Between March and December 2023, 13 patients who underwent LCWHTO with TSO for fibula untethering were enrolled. All patients underwent MRI preoperatively and CT scanning postoperatively. The location of the TSO site on the postoperative CT scans was matched to preoperative MRI to measure the shortest distance to the peroneal nerve and popliteal artery. These values were compared with estimates of the distance between the PTFJ and neurovascular structures in the radiographic virtual PTFJD group. The protective effect of the popliteus muscle was evaluated by extending the osteotomy direction toward the posterior compartment of the knee. Results: The TSO procedure was straightforward and reproducible without producing incomplete gap closure during LCWHTO. On axial images, the distances between the surgical plane and the peroneal nerve or popliteal artery were significantly longer in the TSO group than in the radiographic virtual PTFJD group (both p = 0.001). On coronal and axial MRI, the popliteus muscle covered the posterior osteotomy plane in all patients undergoing TSO but did not cover the PTFJD plane in the radiographic virtual PTFJD group. Conclusions: Our novel TSO technique for fibula untethering during LCWHTO is reproducible and reduces the risk of neurovascular injury by placing the separation site more medially than in the PTFJD procedure. Full article

The use of dietary supplements is widespread in sports and fitness, with many products containing multiple ingredients. Among supplements often consumed to support musculotendinous health, collagen hydrolysate (CH) has gained popularity for its potential in improving joint comfort and function. This single-blind quasi-experimental study investigated the effects of a three-month oral supplementation with a specific CH-based product, Chondrovita FIT^® (Bone Srl, Rome, Italy), on tendon structure in elite Italian skaters. Eighteen male and female elite skaters (mean age: 21 ± 3 years) participated, receiving daily pre-workout (4500 mg CH) and post-workout (2500 mg CH) doses. Tendon structure in the patellar and peroneal tendons was assessed using ultrasound imaging at baseline and post-supplementation. Results showed a significant increase in tendon thickness in both the patellar and peroneal tendons after supplementation, although no changes were observed in the tendon cross-sectional area. These findings suggest that Chondrovita FIT^® supplementation may induce beneficial structural changes in tendons, potentially supporting tendon health and performance in high-load sports. However, further research is needed to confirm long-term effects and functional outcomes. Full article