We thank Dr Randelli for his interest in our paper(1) and offer the following thoughts. Although using a blunt ended tendon harvesting device may reduce the risk of iatrogenic injury to soft tissues, it does not abolish it. Although blunt, the stripper must be able to free the tendon and it is not impossible for this same injury to occur to a nerve.

Nerves are at risk during ‘blind’ procedures. The risks provoked by displacement of the common peroneal nerve have been well described (2,3). A lateral compartment procedure may have explained the injury had the nerve transection been at level of the knee, and not at the mid thigh as with this case. The nerve was, of course, exposed at the knee during elevation of the sural nerve at the time of proximal repair. It was intact, excluding the possibility of a two level injury.

It is fortunate in this case, that at the level of the nerve injury, the two components of the sciatic nerve were distinct and separate entities, avoiding concurrent injury to the tibial nerve.

Damage to the common peroneal nerve by the femoral tunnel guide wire is certainly a possibility. However, as seen with Kirschner wire insertion around the elbow, the nerve would more likely be transfixed by the wire and encased in scar tissue rather than completely transected (4).

The most important message, however, is that the mechanism of injury is secondary to the importance of considering that if after operating in the vicinity of a nerve, there is paralysis of that nerve and it has not been displayed intact, it is cut until proven otherwise.

References:

1. Blakey CM, Biant LC. Transection of the Common Peroneal Nerve during Harvesting of Tendons for Anterior Cruciate Ligament Reconstruction. A Case Report. J Bone Joint Surg Am. 2008; 90: 1567-1569

2. Montgomery AS, Birch R, Malone A. Entrapment of a displaced common peroneal nerve following knee ligament reconstruction. J Bone Joint Surg. 2005; 87-B: 861-862

3. Bottomley N, Williams A, Birch R, Noorani A, Lewis A, Lavelle J. Displacement of the common peroneal nerve in posterolateral corner injuries of the knee. J Bone Joint Surg. 2005; 87-B: 1225-1226

4. Ramachandran M, Birch R, Eastwood DM. Clinical outcome of nerve injuries associated with supracondylar fractures of the humerus in children. The experience of a specialist referral centre. J Bone Joint Surg. 2006; 88-B: 90-94

Dear Editor:

I read with interest the case report by Blakey and Biant(1) but question whether they have considered alternative explanations for this complication. It seems unlikely that the lesion was caused by the tendon stripper for the following reasons: first, the device is blunt, making it difficult to cause a nerve transection; secondly, the nerve lies lateral to the tibial nerve so if the stripper was progressing from medial to lateral, why was there no concomitant tibial nerve injury?

The common peroneal nerve is at risk because of a patient’s positioning for lateral compartment procedures.(1-3). Possible alternative explanations of this nerve lesion can be: 1) A concurrent unreported procedure in the lateral compartment (i.e. lateral meniscus suture/meniscectomy); 2) An intra-operative complication during the preparation of the femoral tunnel(eg., a guide wire cutting through posteriorly can transect the peroneal nerve).

The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

References:

1. Caroline M. Blakey and Leela C. Biant Transection of the Common Peroneal Nerve During Harvesting of Tendons for Anterior Cruciate Ligament Reconstruction. A Case Report J Bone Joint Surg Am 2008; 90: 1567-1569

2. Peicha G, Pascher A, Schwarzl F, Pierer G, Fellinger M, Passler JM. Transsection of the peroneal nerve complicating knee arthroscopy: Case report and cadaver study. Arthroscopy 1998;14: 221–223.

3. Rodeo SA, Sobel M, Weiland AJ. Deep peroneal-nerve injury as a result of arthroscopic meniscectomy. A case report and review of the literature. J Bone Joint Surg 1993;75A: 1221–1224.

4. Kim TK, Savino RM, McFarland EG, MD, Cosgarea AJ. Neurovascular Complications of Knee Arthroscopy. AJSM 2002; 30(4): 619-629.