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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 96-100

A safe corridor using palpable anatomical landmarks to avoid injury to common peroneal nerve – A South Indian cadaveric study


1 Director and Professor, Institute of Orthopaedics and Traumatology, Coimbatore Medical College Hospital, Coimbatore, The Tamil Nadu Dr. MGR Medical University, Tamil Nadu, India
2 Associate Professor, Department of Anatomy, Rajarajeshwari Medical College, Bengaluru, Karnataka, India
3 Senior Resident, Institute of Orthopaedics and Traumatology, Coimbatore Medical College Hospital, Coimbatore, The Tamil Nadu Dr. MGR Medical University, Tamilnadu, India
4 Junior Resident, Institute of Orthopaedics and Traumatology, Coimbatore Medical College Hospital, Coimbatore, The Tamil Nadu Dr. MGR Medical University, Tamil Nadu, India

Date of Submission22-Mar-2022
Date of Decision27-Apr-2022
Date of Acceptance28-Apr-2022
Date of Web Publication26-May-2022

Correspondence Address:
Vetrivel Chezian Sengodan
Institute of Orthopaedics and Traumatology, Coimbatore Medical College Hospital, Coimbatore, The Tamil Nadu Dr. MGR Medical University, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJCA.NJCA_68_22

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  Abstract 


Background: Surgeries involving the proximal third of the fibula are associated with the risk of common peroneal nerve (CPN) injury. Hence, a safe corridor using palpable anatomical landmarks is necessary to avoid injury to the CPN. Methodology: Sixty lower limbs (30 fresh cadavers) were in our study group. The distance between the Gerdy's tubercle (GT) and the CPN behind the fibular head (FH), distance from GT to the superficial branch of the CPN (superficial peroneal nerve [SPN]), and distance from GT to the anterior recurrent branch of the CPN (anterior tibial recurrent nerve [ATRN]) were measured, and a safe zone to avoid CPN injury was identified. Results: The distance between the GT and the CPN behind the FH was 45.52 ± 2.4 mm, distance from GT to the origin of the SPN was 46.44 ± 2.4 mm, and distance from GT to the ATRN was 45.59 ± 2.9 mm. Conclusion: The safe corridor to avoid CPN injury is identified by an arc trajectory with a radius of 45.85 mm with the GT as the center, which will be useful during surgical procedures to avoid injury to the CPN.

Keywords: Common peroneal nerve, Gerdy's safe zone, Gerdy's tubercle


How to cite this article:
Sengodan VC, Jyothilakshmi G L, Masilamani B, Rathinasamy S. A safe corridor using palpable anatomical landmarks to avoid injury to common peroneal nerve – A South Indian cadaveric study. Natl J Clin Anat 2022;11:96-100

How to cite this URL:
Sengodan VC, Jyothilakshmi G L, Masilamani B, Rathinasamy S. A safe corridor using palpable anatomical landmarks to avoid injury to common peroneal nerve – A South Indian cadaveric study. Natl J Clin Anat [serial online] 2022 [cited 2022 Jul 1];11:96-100. Available from: http://www.njca.info/text.asp?2022/11/2/96/346077




  Introduction Top


The sciatic nerve divides into two branches, one of which is the common peroneal nerve (CPN).[1] The CPN arises in the popliteal fossa and runs obliquely downward along the lateral part of the popliteal fossa.[2] It emerges beneath the long head of biceps femoris (LHBF), courses downward, and wraps around the fibular neck.[3] The nerve passes through the fibular tunnel and divides into the superficial peroneal nerve (SPN), deep peroneal nerve (DPN), and the anterior tibial recurrent nerve (ATRN) within or after the fibular tunnel. Surgeries involving the proximal third of the fibula are associated with the risk of injuring the CPN. In lower-limb surgeries, the CPN accounts for 30% of nerve injuries.[4] The CPN could be injured in various surgical procedures including closed pinning for Ilizarov ring fixation, proximal fibular osteotomy, a biopsy from the lesion of the fibular head (FH), and plating for tibial plateau fractures.[3],[5],[6],[7] Injury to the CPN leads to foot drop which affects the normal function of the leg and causes gait disturbances.[8] Hence, a clear understanding of the course of the CPN is required.[2] Preoperative planning, recognizing the path of the nerve using palpable anatomical landmarks, and cautious surgical technique through the safe zone can all help to avoid injury to the CPN.[9] The purpose of this study is to identify a safe corridor using palpable anatomical landmarks to avoid injury to the CPN.


  Materials and Methods Top


The study was performed in the Department of Anatomy and Institute of Orthopedics and Traumatology, Coimbatore Medical College Hospital, Coimbatore, India, from June 2019 to August 2021 after obtaining approval from the Institutional Ethical Committee (No. 0312/2019). Sixty lower limbs (30 fresh adult cadavers) were in our study. Twenty-two were male, and eight were female. Cadavers without any external injury to the lower limbs were included in our study. Cadavers in the pediatric age group and adult cadavers with external injuries to the lower limb were excluded from our study. The cadaver was dissected in supine position. A sandbag was placed under the hip on the side of dissection to expose the lateral part of the leg. The CPN was identified at its exit beneath the LHBF and its course was traced distally, up to the fibular tunnel, which was incised [Figure 1]. Peroneus longus was retracted and in some cases removed partially to visualize the branches of the CPN.
Figure 1: CPN dissected from its exit beneath the LHBF up to fibular tunnel. CPN: Common peroneal nerve, LHBF: Long head of biceps femoris

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The CPN and its branches were identified and marked with marker pins [Figure 2]. The marker pins were placed at the following sites: one at the exit of CPN beneath the LHBF, one at the CPN behind the FH, one at the origin SPN, and one at the anterior recurrent branch of the CPN (ATRN). A 2-mm K-wire was inserted in the Gerdy's tubercle (GT) for measurement.
Figure 2: Illustration showing the important landmarks used for measurement - Common peroneal nerve behind the long head of biceps femoris (1) and behind the fibular head (2), branches of common peroneal nerve – the origin of superficial peroneal nerve (3), deep peroneal nerve (4), anterior recurrent branch of common peroneal nerve (5), bony landmarks – Gerdy's tubercle (6), fibular head (7)

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After fixing the marker pins and K-wire, using a Vernier caliper and an inch tape, the following parameters were measured: (1) fibular length (AB) measured from the lateral aspect of the tip of FH (A) to the tip of lateral malleolus (B), (2) distance between the tip of the FH (A) and the exit of the CPN beneath the LHBF (C)-(AC) [Figure 3]a, (3) distance between the tip of FH (A) and the origin of DPN (D)-(AD) [Figure 3]b, (4) distance between the GT and the CPN behind the FH [Figure 3]c, (5) distance between the GT and the origin of SPN [Figure 3]d, and (6) distance between the GT and the ATRN[2] [Figure 3]e.
Figure 3: (a) Distance from the tip of fibular head (A) to exit of the common peroneal nerve beneath the long head of biceps femoris (C)-(AC). (b) Distance from the tip of the fibular head (A) to the point of origin of the deep peroneal nerve (D)-(AD). (c) Distance from GT to the CPN behind the FH. (d) Distance from GT to the origin of the superficial branch of common peroneal nerve (SPN). (e) Distance from GT to anterior recurrent branch of the common peroneal nerve (ATRN). GT: Gerdy's tubercle, CPN: Common peroneal nerve, FH: Fibular head, SPN: Superficial peroneal nerve, ATRN: Anterior tibial recurrent nerve

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Using these measurements, a safe zone to approach the proximal fibula without injuring the CPN was identified [Figure 4].
Figure 4: Schematic diagram showing the safe corridor with Gerdy's tubercle as the center to approach the lateral aspect of the proximal third of the leg. GT: Gerdy's tubercle, CPN: Common peroneal nerve, SPN: Superficial peroneal nerve, ATRN: Anterior tibial recurrent nerve

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  Results Top


In our study, the mean fibular length (AB) was 37.6 ± 1.8 cm. Regarding the mean fibular length, among the males, it was 38.18 ± 1.5 cm, and among the females, it was 35.71 ± 1.1 cm. This correlation was analyzed using the t-test and was found to be statistically significant (P < 0.05). The mean fibular length on the right side was 37.31 ± 1.9 cm, whereas on the left side, it was 37.88 ± 1.6 cm, which was statistically insignificant (P > 0.05) as per the t-test.

The mean distance between the tip of the FH and the CPN exit beneath the LHBF (AC) was 62.4 ± 5.2 mm. The mean distance from the tip of the FH to the origin of the DPN (AD) was 33 ± 4.6 mm. When the distance AD was expressed as a percentage of fibular length (AB), the distance from the tip of the FH to the origin of the DPN was about 8.9% of the total fibular length, which was insignificant (P > 0.05) between male and female as per t-test [Table 1].
Table 1: Comparison of distance fibular length-tip of the fibular head (A) to tip of the lateral malleolus (B) for right versus left legs, male versus female legs, and ratio the distance between the tip of the fibular head (A) and the origin of the deep peroneal nerve (D) for male versus female legs

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The distance between the GT and the CPN behind the FH was 45.52 ± 2.4 mm (42.1–49.8 mm). The distance between the GT and the SPN origin was 46.44 ± 2.4 mm (42.0–51.2 mm). The distance between the GT and the ATRN was 45.59 ± 2.9 mm (40.0–51 mm) [Table 2].
Table 2: Distance from the Gerdy's tubercle to branches of the common peroneal nerve

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The average of these distances was found to be 45.85 mm. Using this distance, an arc trajectory is drawn with the GT as the center of this circumferential trajectory. The CPN and all its branches are out of this trajectory [Figure 5].
Figure 5: Gerdy's safe zone: Cadaveric dissection showing the circled zone which is the safe area to avoid injury to the common peroneal nerve. GT: Gerdy's tubercle, CPN: Common peroneal nerve

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  Discussion Top


The course of the CPN is traced and measured from its exit beneath the LHBF up to the proximal third of the leg with respect to palpable bony landmarks, namely GT and FH.

GT is a large, readily palpable landmark 3 cm lateral to the tibial tuberosity.[10] The GT provides insertion for the iliotibial tract. The FH and GT are easily palpable bony landmarks. These bony landmarks will be very useful during surgery to avoid injury to the CPN.

Rubel et al. reported that the course of the CPN, the proximal portion of the SPN, DPN, and the ATRN followed an arc with a radius of 45.32 ± 2.6 mm (41–49 mm) centered at the GT.[11]

Thi et al. reported that the course of the CPN and its ATRN branch defined an arc with a radius of 45 mm, with the GT as the center of this circumferential trajectory.[2]

Takeda et al. reported that biopsies of the FH should be approached in the safe area between the FH and the DPN in the anterior compartment.[6]

Stitgen et al. reported that the area bordered superiorly by a line connecting the FH and the tibial tubercle and extending distally for 2 cm is the “safe zone” which minimized the risk of nerve injuries while passing wires.[5]

In our study, the safe corridor to avoid injury to the CPN in the proximal part of the leg is identified by using an arc of 45.85 mm radius with the GT as the center of the circumferential trajectory (Gerdy's safe zone), whereas in the study done by Rubel et al.[11] in the USA and Thi et al.[2] in Vietnam, it was 45.32 mm and 45 mm, respectively [Table 3].
Table 3: Comparison of the radius of Gerdy's safe zone with similar studies done in other countries

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The average distance between the GT and the CPN behind the FH (45.52 mm), the GT and the SPN origin (46.44 mm), and the GT and the ATRN (45.59 mm) is not equal to each other in our study, whereas in the study done by Rubel et al.[11] in the USA and Thi et al.[2] in Vietnam, these values were almost equal to each other. This variation in distance may be due to the ethnic differences in our study population.

Based on Gerdy's safe zone, so far, no study has been done in India to avoid injury to the CPN.

The distance between FH and the origin of DPN when expressed as a percentage of fibular length is 8.9% in our study, whereas it was 9.7% in the study done by Ryan et al.[12] in Ireland, 8% in the study done by Chompoopong et al.[13] in Thailand, and 9% in the study done by Baruah et al.[14] in Assam, India [Figure 6].
Figure 6: Comparison of fibular length (AB), distance from the head of the fibula to the deep peroneal nerve (AD), and ratio (AD/AB) in various studies

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The distance from the FH to the origin of the DPN is 3.3 cm in the South Indian population in our study, whereas in the study done in Assam, India, by Baruah et al.,[14] it was 3.2 cm. In the same study done in Ireland by Ryan et al.,[12] it was 3.46 cm, whereas in the study done in Thailand by Chompoopong et al.,[13] it was 2.84 cm, and in the study done in Japan by Takeda et al.,[6] it was 2.6 cm [Table 4]. This variation in distance may be due to the ethnic differences in our study population.
Table 4: Comparison of the distance of the common peroneal nerve and its branches from the Gerdy's tubercle and fibular head with various studies

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  Conclusion Top


Knowledge about the anatomy of CPN is essential for orthopedic surgeons to prevent iatrogenic injury to the CPN.

The safe corridor to avoid injury to the CPN is identified by an arc trajectory with a radius of 45.85 mm with the GT as the center (Gerdy's safe zone). This safe corridor will be useful during surgical procedures such as closed pinning for Ilizarov ring fixation, proximal fibular osteotomy, a biopsy from the lesion of the FH, and plating for lateral tibial plateau fractures to avoid injury to the CPN.

After reviewing the available literature, the current study is the first in Indian subcontinent regarding the safe corridor using Gerdy's safe zone to prevent injury to the CPN.

The authors sincerely thank those who donated their bodies to science so that anatomical research could be performed. Results from such research can potentially increase humankind's overall knowledge that can then improve patient care. Therefore, these donors and their families deserve our highest gratitude.[15]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Watt T, Hariharan AR, Brzezinski DW, Caird MS, Zeller JL. Branching patterns and localization of the common fibular (peroneal) nerve: An anatomical basis for planning safe surgical approaches. Surg Radiol Anat 2014;36:821-8.  Back to cited text no. 1
    
2.
Thi C, Van Huy N, Nguyen NC, Thanh TH. Applied anatomy of common peroneal nerve: A cadaveric study. Int J Med Pharm 2018;6:6-10.  Back to cited text no. 2
    
3.
Rupp RE, Podeszwa D, Ebraheim NA. Danger zones associated with fibular osteotomy. J Orthop Trauma 1994;8:54-8.  Back to cited text no. 3
    
4.
Khan R, Birch R. Latropathic injuries of peripheral nerves. J Bone Joint Surg Br 2001;83:1145-8.  Back to cited text no. 4
    
5.
Stitgen SH, Cairns ER, Ebraheim NA, Niemann JM, Jackson WT. Anatomic considerations of pin placement in the proximal tibia and its relationship to the peroneal nerve. Clin Orthop Relat Res. 1992;278:134-7.  Back to cited text no. 5
    
6.
Takeda A, Tsuchiya H, Mori Y, Tanaka S, Kikuchi S, Tomita K. Anatomical aspects of biopsy of the proximal fibula. Int Orthop 2001;24:335-7.  Back to cited text no. 6
    
7.
Deangelis JP, Deangelis NA, Anderson R. Anatomy of the superficial peroneal nerve in relation to fixation of tibia fractures with the less invasive stabilization system. J Orthop Trauma 2004;18:536-9.  Back to cited text no. 7
    
8.
Hildebrand G, Tompkins M, Macalena J. Fibular head as a landmark for identification of the common peroneal nerve: A cadaveric study. Arthroscopy 2015;31:99-103.  Back to cited text no. 8
    
9.
Reebye O. Anatomical and clinical study of the common fibular nerve. Part 1: Anatomical study. Surg Radiol Anat 2004;26:365-70.  Back to cited text no. 9
    
10.
Donegan DJ, Seigerman DA, Yoon RS, Liporace FA. Gerdy's tubercle: The lighthouse to the knee. J Orthop Trauma 2015;29:e51-3.  Back to cited text no. 10
    
11.
Rubel IF, Schwarzbard I, Leonard A, Cece D. Anatomic location of the peroneal nerve at the level of the proximal aspect of the tibia: Gerdy's safe zone. J Bone Joint Surg Am 2004;86:1625-8.  Back to cited text no. 11
    
12.
Ryan W, Mahony N, Delaney M, O'Brien M, Murray P. Relationship of the common peroneal nerve and its branches to the head and neck of the fibula. Clin Anat 2003;16:501-5.  Back to cited text no. 12
    
13.
Chompoopong S, Apinhasmit W, Sangiampong A, Amornmettajit N, Charoenwat B, Rattanathamsakul N, et al. Anatomical considerations of the deep peroneal nerve for biopsy of the proximal fibula in Thais. Clin Anat 2009;22:256-60.  Back to cited text no. 13
    
14.
Baruah RK, Harikrishnan SV, Baruah JP. Safe corridor for fibular transfixation wire in relation to common peroneal nerve: A cadaveric analysis. J Clin Orthop Trauma 2019;10:432-8.  Back to cited text no. 14
    
15.
Iwanaga J, Singh V, Ohtsuka A, Hwang Y, Kim HJ, Moryś J, et al. Acknowledging the use of human cadaveric tissues in research papers: Recommendations from anatomical journal editors. Clin Anat 2021;34:2-4.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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