Prophylactic Common Peroneal Nerve Release in Complex Total Knee Replacement: A Narrative Review of Rationale, Surgical Techniques, Outcomes, and Future Directions

Common peroneal nerve (CPN) palsy is a rare but serious complication following total knee arthroplasty (TKA), particularly in patients with severe valgus deformities and multiple comorbidities. Traditional soft tissue balancing techniques and postoperative precautions do not reliably prevent nerve injury in high-risk cases. Prophylactic common peroneal nerve release (PPNR) has emerged as a promising strategy to mitigate this risk by decompressing the nerve prior to deformity correction. This narrative review explores the anatomical and biomechanical basis for CPN vulnerability, the clinical rationale for PPNR, and its surgical technique. It also summarizes early clinical outcomes demonstrating preserved nerve function, faster rehabilitation, and minimal complications across multiple small series. Despite encouraging results, the current evidence is limited by small sample sizes. Future research should focus on establishing standardized indications, refining surgical protocols, and validating long-term outcomes through prospective trials. PPNR may represent a safe and effective adjunct in the management of complex valgus knees undergoing TKA, warranting broader consideration in high-risk patients.