Is left deep peroneal neurectomy medically indicated for a patient with primary osteoarthritis of the right ankle and foot, who has undergone midfoot fusion and conservative management, including orthotics and medications like CELEBREX (celecoxib)?

Left Deep Peroneal Neurectomy for Contralateral Midfoot Osteoarthritis

Direct Answer

Left deep peroneal neurectomy is NOT medically indicated at this time for a patient with primary osteoarthritis of the RIGHT ankle and foot who has already undergone right midfoot fusion. The patient's pathology and previous surgical interventions are on the right side, while the proposed neurectomy targets the left side—this represents a fundamental mismatch between the disease location and the proposed intervention 1, 2.

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Critical Analysis of the Clinical Scenario

Anatomic and Laterality Concerns

• The patient has right-sided pathology (primary osteoarthritis of right ankle and foot, previous right midfoot fusion, right tarsometatarsal joint injections), but the proposed intervention is a left deep peroneal neurectomy 1.
• Deep peroneal neurectomy is specifically indicated for denervation of the ipsilateral (same-side) midfoot joints, including the first, second, and third tarsometatarsal joints and naviculocuneiform joint 1, 2.
• There is no clinical rationale for performing a neurectomy on the contralateral (opposite) limb when the symptomatic pathology exists on the right side 1.

When Deep Peroneal Neurectomy IS Indicated

Deep peroneal neurectomy would only be appropriate if the following conditions are met on the same side as the procedure:

• Failed conservative management including orthotics, NSAIDs (such as CELEBREX/celecoxib), physical therapy, and injections 3, 1.
• Persistent dorsal midfoot pain attributable to tarsometatarsal or naviculocuneiform joint arthritis 1, 2.
• Patient is a poor candidate for arthrodesis due to medical comorbidities, previous failed fusion, or patient preference to avoid fusion 1, 2.
• Positive response to diagnostic deep peroneal nerve block performed under ultrasound guidance in the anterior lower leg, which predicts surgical success 4.

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Evidence-Based Treatment Algorithm for Right-Sided Midfoot Osteoarthritis

First-Line Conservative Management (Already Completed)

The patient has appropriately received:

• Core non-pharmacological treatments: Exercise programs, weight management if indicated, and patient education are foundational 3, 5.
• Orthotics: Custom orthotic devices to redistribute pressure and accommodate deformity 3, 5.
• Oral NSAIDs: CELEBREX (celecoxib) at the lowest effective dose for the shortest duration, with consideration of gastroprotection given cardiovascular and gastrointestinal risks 3, 6.
• Intra-articular corticosteroid injections: Fluoroscopic-guided tarsometatarsal joint injections with lidocaine, ropivacaine, and triamcinolone for moderate to severe pain 3.

Second-Line Surgical Options for Right-Sided Disease

If conservative management fails and symptoms substantially affect quality of life:

1. Revision or extension of right midfoot arthrodesis remains the gold standard surgical treatment for midfoot osteoarthritis, with 93.3% union rates and 90% good-to-excellent patient-reported outcomes 7.

2. Right deep peroneal neurectomy (NOT left) should be considered if:

   • The patient is a poor surgical candidate for arthrodesis 1, 2.
   • Diagnostic ultrasound-guided deep peroneal nerve block in the right anterior lower leg provides significant pain relief (positive in 88% of cases) 4.
   • The patient understands this is a denervation procedure that preserves joint motion but does not address the underlying arthritis 1, 2.
   • Expected outcomes include 85% patient satisfaction, 77% willingness to repeat the procedure, and 91.7% pain relief in the first 6 months, though 21% may require additional treatment 1, 2.

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Critical Pitfalls to Avoid

Laterality Errors

• Always verify the side of pathology matches the side of proposed intervention before proceeding with any surgical procedure 1, 2.
• Review all imaging studies (CT scans, X-rays) to confirm the symptomatic side 1.
• Perform a focused physical examination to identify the location of maximal tenderness and deformity 3.

Premature Surgical Intervention

• Do not proceed with neurectomy without first performing a diagnostic nerve block on the symptomatic side, as this predicts surgical success 4.
• The American College of Rheumatology emphasizes that joint replacement or other surgical referrals should only occur after comprehensive conservative management has been exhausted 3.

Misunderstanding Neurectomy Indications

• Deep peroneal neurectomy is not a first-line surgical treatment for midfoot osteoarthritis—arthrodesis remains the gold standard 1, 7.
• Neurectomy is specifically reserved for patients who are poor candidates for fusion or who wish to avoid fusion 1, 2.
• Recurrent symptoms requiring additional treatment occur in 21% of cases, and patients must understand this limitation 1.

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Recommended Next Steps

For the Right-Sided Pathology

1. Reassess the adequacy of current conservative management: Ensure optimal dosing of celecoxib, appropriate orthotic fitting, and consideration of adjunctive treatments such as topical NSAIDs or duloxetine if there is inadequate response 3, 5, 6.

2. If symptoms remain refractory and substantially affect quality of life, consider:

   • Ultrasound-guided diagnostic right deep peroneal nerve block in the anterior lower leg to assess candidacy for right neurectomy 4.
   • Referral to foot and ankle surgeon for evaluation of revision right midfoot arthrodesis versus right deep peroneal neurectomy 1, 7.

3. Surgical decision-making should prioritize:

   • Patient-specific factors including age, comorbidities, functional demands, and previous surgical history 3, 7.
   • Shared decision-making regarding the trade-offs between arthrodesis (definitive treatment with longer recovery) versus neurectomy (motion-preserving with potential for recurrent symptoms) 1, 2.

For the Left Side

• No intervention is indicated on the left side unless there is documented symptomatic left-sided midfoot pathology that has failed conservative management 3.