Clinical and Functional Outcomes after Multiligament Knee Injury with Associated Peroneal Nerve Palsy: Comparison with a Matched Control Group at 2-18 Years

Aaron J. Krych, MD Steven A. Giuseffi, MD

Scott A. Kuzma, MD Joshua L. Hudgens, MD

Michael J. Stuart, MD Bruce A. Levy, MD

Department of Orthopedic Surgery and Sports Medicine Mayo Clinic

Rochester, MN

•!Peroneal nerve (PN) injury in multiligament knee injuries (MLKI)

•!Reported incidence = 25%6,7,9 •!Mechanism:

•!Hyperextension and varus stress1 •!Often high-energy4,5,9

Background

•!Significant functional impairment •!Loss of ankle dorsiflexion/eversion •!Loss of dorsal foot sensation •!Only about 1/3 get full recovery3,6,7

•!Paucity of data on clinical and functional outcomes

Background

1) Report clinical and functional outcomes after MLKI with concomitant PN injury

2) Compare recovery and outcomes with

partial versus complete PN injury 3) Compare outcomes to a matched cohort

of MLKI without concomitant PN injury

Purpose

•!Level III Retrospective comparative study (1993-2010)

•!Patients with MLKI (n= 114) •!Patients with Peroneal nerve Injury (PI)

•!Complete PN palsy (CNP) •!Partial PN palsy (PNP)

•!Matched cohort: No peroneal nerve Injury (NI) •!Matched for age, gender, and Schenck

Classification8

Methods

•!Motor strength at last clinical follow-up •!Manual muscle testing (1-5/5) •!Tibialis Anterior (TA) •!Extensor Hallucis Longus (EHL)

•!Outcomes scores at 2-18 yr follow-up (mean 6.0 years)

•! IKDC •!Lysholm

Methods

•! 27 patients •! 9 Complete peroneal nerve palsy (CNP) •! 18 Partial peroneal nerve palsy (PNP)

•! Prevalence = 23.7%

•! Treatment

Tibial nerve

Common peroneal nerve

Results Peroneal Nerve Injury (PI) Group

Treatment CNP=9 PNP=18

AFO All patients 12

Non-operative 1 12

Neurolysis 2 4

Tendon transfer 3 0

Nerve transfer 1 1

Combined nerve & tendon transfer

1 1

Additional Surgery 1 (below knee amputation*)

2 (1 TKA, 1 arthrodesis)

*excluded from peroneal nerve comparison Partial tibial nerve transfer to tibialis anterior motor branch of peroneal nerve 2

Results Peroneal Nerve Injury Outcomes

37.5%

83.3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

TA motor strength antigravity (!3/5)

CNP PNP

15/18 3/8

p=0.06

12.5%

72.2%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

EHL motor strength antigravity (!3/5)

CNP PNP

13/18 1/8

p=0.0093

•!IKDC and Lysholm Scores

•!No significant difference between complete peroneal nerve palsy and partial peroneal nerve palsy

Results Peroneal Nerve Injury Outcomes

•!20 patients per group with ! 2 year fu •!Peroneal Nerve Injury (PI)

•! 6 CNP, 14 PNP •!No Peroneal Nerve Injury (NI)

PI NI Gender - Male - Female

18 2

18 2

Age 30.8 29.5

KD Classification - KD-I - KD-IIIL - KD-IV - KD-V

2 10 5 3

2 7 8 3

Results Matched Cohort

• PI group had significantly worseoutcomes than NI group

64.5 67.1 77.3

83

0 10 20 30 40 50 60 70 80 90

100

IKDC Lysholm

PI NI

p=0.036 p=0.023

Results Matched Cohort Injury Outcomes

•!Our series of multiligament knee injuries:

• No significant difference in IKDC or Lysholm scores between patients with complete versus partial peroneal nerve palsy

• Patients with partial peroneal nerve palsy more often regained antigravity EHL strength but not TA strength

Conclusions

•!Our series of multiligament knee injuries:

•!Patients with peroneal nerve injury have significantly worse IKDC and Lysholm scores than matched patients without peroneal nerve injury

Conclusions

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