Peroneal nerve damage by bicortical tibial screw in ACL reconstruction

Abstract

Arthroscopically assisted anterior cruciate ligament reconstruction is regarded as a minimally invasive surgery with low morbidity but complications still occur. Reports of neurovascular injuries related to graft harvesting, tunnel placement, or graft fixation are limited. A rare case of peroneal nerve injury related to hardware used for graft fixation in the tibial in a 28-year-old female patient who underwent an anterior cruciate ligament reconstruction surgery using a patellar tendon graft (bone-tendon-bone graft) is presented. Post-operatively, the patient presented with clinical signs of peroneal nerve damage and a reduced range of motion of the knee. Plain radiographs of the knee showed the bicortical screw which used for tibial fixation of the graft, penetrating the fibula and projecting beyond the lateral cortex of the fibular neck. The patient was treated with removal of the hardware and the graft. Intensive physiotherapy resulted in gradual improvement and at 6 months after the second operation the patient regained full range of motion of the knee and almost full muscle strength performing her daily activities without any difficulty and she is at the moment unwilling to undergo further procedure.

Uncommon Complications after Anterior Cruciate Ligament Reconstruction

“…The screw was removed and the patient recovered. 99 In the cases described by Vardi 97 and Balkey and Biant, the injury was probably related to the direction of the tendon stripper during hamstring harvesting. 97 98 Nerve revision was performed in three cases.…”

“…94 Injuries to the saphenous nerve, 95 96 the sciatic nerve, 97 and the common peroneal nerve are less common in ACL-R surgeries. 98 99 Five case reports are described in literature reporting about rare nerve injuries in ACL-R. 95 96 97 98 99 One case report was excluded from the analysis because full data were not available. 95 In one case, a BPTB graft was used, 99 while in the other patients hamstring autografts were chosen.…”

“…98 99 Five case reports are described in literature reporting about rare nerve injuries in ACL-R. 95 96 97 98 99 One case report was excluded from the analysis because full data were not available. 95 In one case, a BPTB graft was used, 99 while in the other patients hamstring autografts were chosen. 96 97 98 In all the cases, the symptoms begun immediately with sensory deficit in the medial side of the leg in case of saphenous nerve damage, 96 in the lateral side of calf muscles and dorsal foot in association to loss of function if the common peroneal nerve was involved 98 99 or complete sensory and motor deficit of the leg if the sciatic nerve was involved.…”

“…95 In one case, a BPTB graft was used, 99 while in the other patients hamstring autografts were chosen. 96 97 98 In all the cases, the symptoms begun immediately with sensory deficit in the medial side of the leg in case of saphenous nerve damage, 96 in the lateral side of calf muscles and dorsal foot in association to loss of function if the common peroneal nerve was involved 98 99 or complete sensory and motor deficit of the leg if the sciatic nerve was involved. 97 In case of saphenous nerve damage, the diagnosis was done with the clinical evaluation.…”

Neurological Complications Related to Elective Orthopedic Surgery

“…79 Finally, there are isolated case reports in the literature describing injury to the sciatic nerve by the tendon stripper 86 and CPN by the bicortical tibial screw. 87 …”