Plastics

Preop Dx: Right common peroneal neuropathy
Procedure: Right common peroneal nerve release at the fibular head
Findings: Compression of right common peroneal at fibular head
Drains: None

Operative Procedure:
  The patient was brought back to the operating room and placed supine on the operating room table. After successful induction of anesthesia, a surgical timeout confirming patient and procedure was performed.
  A non-sterile tourniquet was applied to the right thigh. The right lower extremity was prepped and draped in the usual sterile fashion using chloraprep. The anticipated incision was marked with a surgical marker. The leg was exsanguinated with an esmarch and the tourniquet was inflated to 275 mmHg. 10cc of 0.5% marcaine with epinephrine was injected into the site.
  Incision was made through skin using a scalpel. Subcutaneous dissection was performed with the use of tenotomies, to the level of the superficial fascia covering the common peroneal nerve and the musculature of the lower leg. Through this layer, the common peroneal nerve and the leading edge of the peroneus longus, defined by the posterior crural intermuscular septum were identified. The overlying fascia was incised over these structures to better define them and determine the anticipated course of the common peroneal nerve moving anteriorly.
  The superficial fascia was then incised sharply with a scalpel moving from the region of the posterior crural intermuscular septum towards the anterior and innominate crural intermuscular septa.
  The posterior, anterior, and innominate crural intermuscular septa were then sequentially dissected free from surrounding musculature and released, taking care to avoid injury to underlying vasculature and nerve branches.
  On release of the posterior crural intermuscular septum, it was found to be quite tight and compressive on the peroneal nerve beneath. The septum was followed deep to the peroneus longus to ensure that no septal strands or tight fascia remained overlying the nerve.
  Attention was then turned to the common peroneal nerve proximal to its course beneath the peroneus longus. Neurolysis was performed to free it from fascia overlying it in this proximal course. In this dissection, the lateral sural nerve was examined for, but not encountered. Deep to the common peroneal nerve, the fascia overlying the surface of the soleus was also released to relieve chance of compression against this deeper structure.
  The course of the peroneal nerve was checked once more in the operative field to ensure that no further points of compression existed. None were appreciated and the tourniquet was deflated.
  Hemostasis was obtained and the site was irrigated.
Closure commenced with 3-0 monocryl deep dermal stitches followed by a running 4-0 subcuticular stitch and dermabond.
  The site was dressed with 4x4s, an abdominal pad, and an ace wrap from the toes to the knee.
  The patient awoke from anesthesia without difficulty and was transported in stable condition to the PACU

Drains: none

The patient was taken to the operating room and secured on the operating room table. Following patient and procedure confirmation, anesthesia was begun. The site was prepped and draped in standard sterile fashion. A preoperative time-out was performed confirming site, laterality, patient and procedure to be performed.

The scapular spine and border was marked. A curvilinear incision was made over the posterior arm at shoulder, posterior to the deltoid. The deltoid and teres minor interval was identified, and there was a significant amount of scarring and adhesion along the axillary nerve. The sensory branch was identified and traced to the main superior and inferior branches, and these were circumferentially dissected free of the scar and neurolysed.

Nerve stimulation demonstrated no firing of the superior or inferior branch, and we therefore proceeded with the nerve transfer.

The interval between the triceps was identified, and the radial nerve found. The medial most branch was excluded and protected with a vessel loop. Nerve stimulation demonstrated isolated triceps stimulation without hand or forearm extensor function. The branch was traced into the muscle to gather sufficient length. It was distally transected and brought superiorly.

Using the microscope, the axillary nerve was tripped of the surrounding soft tissue scarring and adhesions, and cut back to healthy appearing fascicles. An end to end coaptation between the radial branch and recipient axillary branch was performed with 9-0 nylon and the microscope. Fibrin glue was placed over the coaptation.

The deep muscular layers were then re approximated with 2-0 and 3-0 pds. The skin flaps were then closed with 3-0 and 4-0 monocryl and dermabond. A bulky dressing was applied.

He was then transferred to the stretcher and returned to supine position. The patient was awoken from anesthesia and transported to recovery in stable condition.

Tourniquet: No
Drain: No
Sutures: 9-0 nylon, 3-0 and 4.0 monocryl and dermabond
Dressing: bulky dressing