Disclosures: Matthew R. Kelly, MD: Nothing to disclose

Case Description: A 43-year-old male with a history of steroid-induced bilateral osteonecrosis of the femoral heads (ONFH), status-post free vascularized fibular grafting (FVFG), presented for electrodiagnostic work-up of bilateral lower extremity pain and weakness. 4 years prior to presentation, the patient was treated with bilateral FVFG to prevent femoral head collapse. Surgery was well tolerated, however he developed progressive dysesthesias of his lower legs and subjective weakness.

Setting: Outpatient Electrodiagnostics Clinic.

Patient: 43-year-old male.

Assessment/Results: Examination was significant for bilateral lateral compartment surgical scars and decreased sensation to light touch over the distal anterolateral legs. Foot eversion weakness was also noted bilaterally. Electrodiagnostics revealed absent bilateral superficial peroneal sensory nerve action potentials (SNAPs) with normal motor studies. Needle electromyography demonstrated increased insertional activity in the bilateral peroneus brevis muscles with fibrillation potentials and positive sharp waves consistent with active denervation. Ultrasound examination demonstrated focal enlargement of the superficial peroneal nerves with disrupted fascicular architecture proximal to the lateral malleoli bilaterally.

Discussion: ONFH treatment with FVFG has shown favorable outcomes compared with other surgical approaches. Successful surgery can help prevent progression to femoral head collapse which prevents or delays the need for total hip arthroplasty. This can also allow for participation in higher levels of physical activity. There are, however, risks associated with both the fibular graft harvesting and subsequent hip reconstruction. While relatively uncommon, nerve injury is an important surgical complication and the superficial peroneal nerve is particularly vulnerable during the fibular harvesting procedure.

Conclusion: FVFG is an effective surgical option for the treatment of ONFH, however it is not without risks. In patients who have undergone fibular harvesting and exhibit distal lower extremity dysesthesias with subtle weakness, there should be a high clinical suspicion for superficial peroneal nerve injury. Electrodiagnostics and ultrasound can serve as useful tools to help localize such a lesion and guide further treatment.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/bilateral-peroneal-neuropathy-as-a-complication-of-free-vascularized-fibular-grafting-for-steroid-induced-avascular-necrosis-of-the-femoral-heads-a-case-report/