Anterior Compartment Of Leg Research Articles

Anomalous origin of dorsalis pedis artery and its clinical significance

Arterial variations of the lower limb have been reported in the past. However, we report in here a very unusual variation. During routine dissections, an anomalous origin of the dorsalis pedis artery (DPA) was noted on the right foot of an adult male cadaver. In here, the arteries of the crural region arose from the popliteal artery, as usual. However, the anterior tibial artery (ATA) was very slender. The peroneal artery (PA) was larger than usual and reached the anterior compartment of the leg by piercing the interosseous membrane at its lower part. In the foot, the ATA joined with the PA to form the DPA. Knowledge of such type of variations in the anatomy of DPA is important for angiographers, vascular surgeons and reconstructive surgeons who operate upon these regions.

Using the Amplitude of Pulse-Synchronous Intramuscular Pressure Oscillations When Diagnosing Chronic Anterior Compartment Syndrome.

Background:To diagnose chronic anterior compartment syndrome (CACS) among patients with exercise-induced leg pain, intramuscular pressure (IMP) is regarded as the gold standard. Two recent studies have suggested that the evidence for commonly used IMP criteria are weak, and the validity has therefore come under question.Purpose:To evaluate whether the amplitude of pulse-synchronous IMP oscillations at rest after an exercise test is a reliable parameter that may aid in diagnosing CACS.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:A total of 89 consecutive patients with suspected CACS (mean age, 31 years) and 19 healthy subjects (mean age, 28 years) participated in this study. All participants performed an exercise test until they were unable to continue because of leg pain and/or muscle fatigue. The IMP was recorded continuously in the anterior compartment of the leg with a noninfusion pressure recording system, starting 15 to 30 seconds after discontinuation of exercise. To test the amplitude of pulse-synchronous IMP oscillations as an indicator of CACS, a peak-to-peak amplitude of >2 mm Hg was chosen as the cutoff value. The clinical diagnosis of CACS was considered reference standard.Results:The mean ± SD IMP 1 minute after exercise was 54 ± 16 mm Hg in 53 patients with CACS, 17 ± 6 mm Hg in 36 non-CACS patients, and 18 ± 5 mm Hg in control subjects. The mean amplitude of the oscillations was 7.1 ± 3 mm Hg in patients with CACS, 1.3 ± 0.9 mm Hg in non-CACS patients, and 1.5 ± 0.6 mm Hg in control subjects 1 minute after exercise. The sensitivity of the amplitude to validate CACS was 96%, while the specificity was 94%. The positive predictive value was 96%, and the negative predictive value was 94%.Conclusion:The amplitude of the pulse-synchronous IMP oscillations at rest after an exercise test that elicits a patient’s leg pain and muscle fatigue has high sensitivity to identify an abnormally elevated IMP.Clinical Relevance:Oscillations are easily recorded during clinical routine IMP measurements. They ascertain the diagnosis of CACS, corroborate the level of IMP, and ensure catheter patency.

Clinical Reasoning: A 52-year-old woman with progressive proximal weakness

A 52-year-old woman presented with a 12-year history of progressive limb weakness. She first had trouble climbing stairs and later difficulty getting up from a chair. She also experienced hip and shoulder pain. Over the previous 2 years, combing her hair became difficult. She denied any eyelid drooping, double vision, chewing or swallowing difficulty, slurred speech, shortness of breath, numbness, tingling, autonomic symptoms, or cognitive problems. She did not have any rashes or joint pain. She had no other medical problems and was not taking any medications. She was born full-term and had normal developmental milestones. She was able to keep up with her peers and was a good runner during her childhood. The patient was of German descent and her father and paternal uncle developed leg weakness in their early 40s and were diagnosed with limb-girdle muscular dystrophy (LGMD). They died in a plane crash in their late 40s. The patient's older brother and her uncle's son developed leg weakness in their early 40s and were also diagnosed with LGMD. Both died in their mid-to-late 50s due to respiratory failure. Her brother also had peripheral neuropathy. The diagnosis of LGMD in all family members is based on clinical presentations and muscle biopsies. Genetic studies were not performed. There was no family history of dementia, bone disorder, or motor neuron disease. Her neurologic examination revealed symmetrical weakness of shoulder and hip girdle muscles (Medical Research Council [MRC] grade 4), as well as anterior leg compartment muscles (MRC grade 4+). She also had scapular winging bilaterally. There was no myotonia, muscle rippling, fasciculation, muscle atrophy, or hypertrophy. Deep tendon reflexes were normal except for absent ankle reflexes on both sides. Cognition, cranial nerves, sensory examination, and coordination were normal. She had high-arched feet and hammertoes. There was neither joint contracture nor spinal rigidity.

An evaluation of the normal range of StO2 measurements at rest and following a mixed exercise protocol

BackgroundAssessment of local tissue oxygenation (StO2) using near infrared spectroscopy is an emerging technique in medical practice with applications in trauma/sepsis management, diagnosis of acute compartment syndrome and assessment of...

English

INTRODUCTION: Fibularis tertius (FT) was formerly called as the peroneus tertius 1 . FT muscle is a relatively small unipennate muscle found in the anterior compartment of the leg. It assists in dorsiflexion and eversion of foot 2 . The FT muscle originates from the distal third or more of the medial surface of fibula, the adjoining anterior surface of the interosseous membrane and the anterior crural intermuscular septum. Thereafter, tendon runs beneath the superior extensor retinaculum, inferior extensor retinaculum and gets inserted on the medial aspect of the dorsal surface of the base of the fifth metatarsal. FT muscle is supplied by the deep peroneal nerve (2, 3, and 4) . FT has been described as a part of the extensor digitorum longus (EDL) muscle in classical textbooks 2 . CASE REPORT: During routine dissection for the first MBBS students, we observed that the peroneus tertius was absent on the dorsum of the Right lower limb of a 50 years old, donated embalmed male cadaver in the Department of Anatomy, Lady Hardinge Medical College, New Delhi, India. Both the limbs were carefully observed and examined to differentiate the absence of FT muscle. There was no scar mark or sign of injury on the limb. The other muscles of the compartment were present normally with their normal anatomical features. The photographs of the dorsum of the foot were taken for proper documentation and for ready reference. The absence of the peroneus tertius is very rare and not found in literature. Usually, the peroneus tertius is involved in dorsiflexion and eversion of the foot.

Effect of Ambient Light on Near Infrared Spectroscopy

Background: Concerns have been raised about the ability of Near Infrared Spectroscopy (NIRS) to monitor skeletal tissue regional oxygen saturation (rSO2) in excessive light conditions, as are found under the overhead lights of the operating room. This study seeks to determine whether varying intensities of ambient light exert an influence on NIRS measurements of skeletal tissue rSO2. Methods: Thirty people were recruited from the staff of a local surgical center to participate in the study. Three separate NIRS devices (Covidien INVOS Cerebral Oximeter 510°C, Nonin EQUANOX Model 7600, and a CASMED MC-2030C Cerebral Oximeter) were used to obtain readings from the anterior compartment of the leg. Illuminance was recorded simultaneously with oximetry data in an operating room with (1) no lights on, (2) room lights, and (3) surgical lamps set to maximal intensity. Results: No differences were seen in rSO2 values under the different lighting conditions while using the Nonin device. There was a statistically significant difference between rSO2 for lights off versus room lights (-0.933, p=0.0045) as well as for lights off versus operating room (OR) lamps (level 5) (-0.50, p=0.0035) for the INVOS device, although the INVOS device was not always able to produce a reading in the presence of high-intensity OR light. While there was no difference found between lights off and room lights when using the CASMED device, it was unable to display a value in the presence of high-intensity OR lamp light. Conclusions: The results indicate that the presence of light has an effect on oximetry readings; however, the presence of such an effect is dependent upon the device being used. While other applications of the device, such as cerebral oximetry, may allow for drapes to cover the areas being monitored, monitoring for compartment syndrome of the leg would not be as forgiving. This application would be best served by a device capable of monitoring at all light levels.

The thickness of the anterior compartment does not indicate compartment syndrome in acutely traumatised legs?

BackgroundThe study was conducted to achieve early detection of increased compartment pressure by comparing the changes between the thickness and pressure within the musculofascial compartments after lower leg injury. MethodsWe included cases of a lower-leg fracture between January and December 2007. Bilateral lower leg compartment pressure and thickness were measured before the surgery and post-anaesthesia, and the surgery was performed within 12h after the initial trauma. The intracompartment pressure (ICP) was measured with a Wick catheter pressure monitor. The thickness (width) of the anterior compartment of lower leg was measured using ultrasound. ResultsAll data were measured within 4–6h of the injury. The average thickness in injured legs versus uninjured was 30mm (15–46mm) versus 20.4mm (13–30mm), P<0.001. The average intracompartment pressure (ICP) in injured leg versus uninjured was 45.3mmHg (26–80mmHg) versus 17.5mmHg (15–20mmHg), P<0.001. The thickness and ICP were significantly increased for injured lower legs compared to the uninjured legs, but the increase in ICP did not show a significant relationship with the change in thickness of the injured lower leg. ConclusionIn this study, the results of ICP and thickness changes of injury lower leg compared with uninjured leg revealed no statistically significant correlation. Some injuries showed a high ICP with only mild changes in thickness, while some showed a high ICP with significant changes. Although ultrasound has many advantages for the evaluation of soft tissue changes after trauma, this study revealed that thickness changes are not a predicable parameter for determining pressure on the acute fracture of lower leg.

P.14.4 Diagnostic role of quantitative NMR imaging exemplified by 3 cases of juvenile dermatomyositis

Skeletal muscle diagnostic imaging is classically based on visual inspection of T1-weighted NMR images and interpretation of patterns of fatty infiltration. The existence of oedematous/inflammatory/necrotic lesions is subjectively appreciated on T2-weighted images, typically acquired with the STIR sequence to minimize fat confounding effects. Because it relies on identification of hyperintensities between and within muscles, the interpretation risk with T2-weighted images is to miss global, homogenous increases in T2. In this report, we demonstrate this concern to be more than theoretical. Three patients aged 6, 7 and 12 were referred for further investigation of progressive muscle wasting (P1) or clinical suspicion of dermatomyositis (P2, P3). All of them had normal CK values. Whole-body T1w showed no fatty infiltration in muscles. Standard T2w imaging was normal in P1, showed discrete differences in signal intensity, particularly between anterior and posterior leg compartments in P2 and was moderately positive with hyperintense streaks in P3. Quantitative T2 maps were obtained from multi TE spin echo data after extraction of the water component by tri-exponential fitting. In the 3 patients, muscle water T2s were abnormally elevated in the scapular and pelvic girdles, the thighs and the legs: 45/51 muscles of P1, 46/60 of P2 and 47/51 of P3 had T2s higher than 39 ms, the upper normal value. Mean T2s were 42.3, 42.3 and 45.9 ms, with highest T2s measured at 50.0, 51.9 and 53.3 ms in P1, P2 and P3 respectively. Juvenile dermatomyositis was histologically confirmed in all patients. After 3 months on steroid, P1 was rescanned. In the previously inflamed muscles, T2 had on average decreased by 3.4 ms (p < 0.001) and 17 muscles had resumed normal T2 values. Quantitative T2 mapping can be required to detect unambiguously muscle lesions as shown here in juvenile dermatomyositis. It is also essential to monitor response to treatment in the absence of biological biomarkers. Skeletal muscle diagnostic imaging is classically based on visual inspection of T1-weighted NMR images and interpretation of patterns of fatty infiltration. The existence of oedematous/inflammatory/necrotic lesions is subjectively appreciated on T2-weighted images, typically acquired with the STIR sequence to minimize fat confounding effects. Because it relies on identification of hyperintensities between and within muscles, the interpretation risk with T2-weighted images is to miss global, homogenous increases in T2. In this report, we demonstrate this concern to be more than theoretical. Three patients aged 6, 7 and 12 were referred for further investigation of progressive muscle wasting (P1) or clinical suspicion of dermatomyositis (P2, P3). All of them had normal CK values. Whole-body T1w showed no fatty infiltration in muscles. Standard T2w imaging was normal in P1, showed discrete differences in signal intensity, particularly between anterior and posterior leg compartments in P2 and was moderately positive with hyperintense streaks in P3. Quantitative T2 maps were obtained from multi TE spin echo data after extraction of the water component by tri-exponential fitting. In the 3 patients, muscle water T2s were abnormally elevated in the scapular and pelvic girdles, the thighs and the legs: 45/51 muscles of P1, 46/60 of P2 and 47/51 of P3 had T2s higher than 39 ms, the upper normal value. Mean T2s were 42.3, 42.3 and 45.9 ms, with highest T2s measured at 50.0, 51.9 and 53.3 ms in P1, P2 and P3 respectively. Juvenile dermatomyositis was histologically confirmed in all patients. After 3 months on steroid, P1 was rescanned. In the previously inflamed muscles, T2 had on average decreased by 3.4 ms (p < 0.001) and 17 muscles had resumed normal T2 values. Quantitative T2 mapping can be required to detect unambiguously muscle lesions as shown here in juvenile dermatomyositis. It is also essential to monitor response to treatment in the absence of biological biomarkers.

F-Wave Abnormalities in a Patient with Possible Chronic Exertional Compartment Syndrome

The F-waves demonstrated here were obtained from a 20-yr-old woman referred for several months of bilateral exertional calf pain (Fig. 1). In addition, she reported that 5 days before testing, she developed severe bilateral calf pain after walking 1 mile, and by the next day, she had developed left lateral foot numbness and weakness at the left ankle. On physical examination, sensation was impaired to light touch and pinprick over the left lateral malleolus and the lateral aspect of the foot. Reflexes were intact and symmetric at the bilateral patella and achilles. Strength was impaired with all movements of her left ankle and toes only.FIGURE 1: F-wave responses in the left lower limb. Runs 1 and 2 were measured at the extensor digitorum brevis, run 3 was measured at the tibialis anterior, and the final run was measured at the abductor hallucis.Sural sensory, fibular motor, and tibial motor nerve conduction studies were unremarkable. Interestingly, no F-waves could be obtained when measured from the fibular nerve at the extensor digitorum brevis bilaterally. However, when measured from the fibular nerve at the tibialis anterior and the tibial nerve at abductor hallucis, F-wave responses were obtained with normal latency and penetrance. Needle examination was not performed because weakness had been present only for several days. Chronic exertional compartment syndromes (CECSs) can affect any lower limb compartment, and it seems to affect the lower leg anterior compartment most frequently.1 Although early research on acute compartment syndromes documented resultant neuropathy,2,3 electrodiagnostic findings in CECS have not been definitively characterized, and previous studies of electrodiagnostic evaluations in patients with a presumptive diagnosis of CECS have been unremarkable.4 Therefore, it is likely that elevated compartment pressures may cause neuropathy if pressures of sufficient severity and duration are produced, although this threshold remains uncertain. In our patient, we observed the absence of F-wave responses from the bilateral extensor digitorum brevis only. These findings are suggestive of a subtle neuropathy of the deep fibular nerve in a clinical scenario strongly suggestive of CECS of the anterior compartment of the lower leg, and we propose that these findings may represent the mildest findings of CECS that may be appreciated on electrodiagnostic studies. To summarize, CECS of the lower leg is a well-recognized diagnosis, and although not the diagnostic test of choice for this diagnosis, these patients are referred not infrequently for electrodiagnostic testing, as symptoms may include pain, weakness, and numbness. As such, the electromyographer should be aware of this entity and potential electrodiagnostic abnormalities.

The Utility of Ultrasound in Detecting Anterior Compartment Thickness Changes in Chronic Exertional Compartment Syndrome

To test the hypothesis that patients with chronic exertional compartment syndrome (CECS) of the anterior leg compartment have an increased anterior compartment thickness (ACT) compared with control subjects after exertion using ultrasound. Prospective comparison study. Diagnostic imaging department of a tertiary care hospital. Four patients with CECS and 9 control subjects. Patients with CECS and control subjects ran on a treadmill for up to 10 minutes. Anterior compartment thickness (both groups) and anterior compartment pressure (CECS patients) were measured before exertion and at scheduled intervals after exertion. Anterior compartment thickness, percentage change in ACT from rest, and compartment pressure. Anterior compartment pressures were diagnostic of CECS using the modified Pedowitz criteria in patients with CECS. Mean percentage change in ACT from rest in patients with CECS versus control subjects at 0.5 minutes was 21.3% versus 6.32% [95% confidence interval (CI), 6.92-35.6 and 0.094-12.5, respectively; P = 0.011]; at 2.5 minutes, it was 24.6% versus 4.22% (95% CI, 10.7-38.5 and -1.85-10.3, respectively; P = 0.003); and at 4.5 minutes, it was 24.9% versus 5.08% (95% CI, 14.3-35.5 and -0.813-11.0, respectively; P = 0.003). Mean ACT in patients with CECS versus control subjects significantly increased after exertion (P = 0.003) at 0.5 minutes, 2.5 minutes, and 4.5 minutes. Ultrasonography reveals a significant increase in ACT in patients with CECS of the anterior leg compartment. Further studies are warranted to validate these findings with the goal of developing anterior leg compartment CECS ultrasound diagnostic criteria and exploring the role of using ultrasound to diagnose CECS in other compartments.

Endovascular Exclusion Coupled With Operative Anterior Leg Compartment Decompression in a Case of Postthromboembolectomy Tibialis Anterior False Aneurysm

The aim of this study was to present a case of iatrogenic thromboembolectomy-related tibialis anterior false aneurysm (FA) treated with endovascular FA exclusion and anterior leg compartment (ALC) operative decompression and to assess the current management options in posttraumatic leg vessel FAs. A 68-year-old man had a painful pulsating mass in the superior ALC 2 months after a thromboembolectomy was performed during popliteal aneurysm repair. He had been discharged under oral anticoagulation and had ALC manual massages for mild post-revascularization leg edema. Angio-CT showed tibialis anterior injury successfully treated with a covered stent graft, while a residual ALC hematoma was surgically evacuated. Endovascular treatment of tibialis anterior FAs using a covered stent graft is an excellent therapeutic option. After an endovascular procedure, caution must be taken to identify the need for early operative ALC decompression. Current leg vessel FA management should consider both the specific anatomic characteristics of the FA and the possibility of development of delayed compartment syndrome.

Calcific Myonecrosis of the Leg Treated by Debridement and Limited Access Dressing

Calcific myonecrosis is a rare late complication of limb trauma characterized by liquefaction and dystrophic calcification of muscles in the single compartment, usually in the leg. This occurs many years after the trauma and is probably due to chronic compartment syndrome. We report 2 cases of calcific myonecrosis involving the anterior compartment of the leg that presented to us in an advanced stage of multiple sinuses discharging calcific material. Incision and drainage had been attempted at a local hospital prior to presentation at our hospital resulting in a non healing wound. Both patients had a history of antecedent trauma to the leg a few years ago. Patients were treated by thorough debridement of the involved muscles in the anterior compartment. Limited access dressing (LAD) was used to manage the dead space left after debridement. After application of the LAD, the wound was covered with split skin grafting. In both patients, healing of the cavity following debridement was facilitated by application of limited access dressing. While the wound completely healed, the disability due to extensive debridement of anterior compartment of the leg persisted. At the latest follow-up, the patients were asymptomatic without any recurrence. Thorough debridement of the compartment involved and application of LAD may be another option of treating calcific myonecrosis of the leg, which was initially considered a "do not touch" lesion. Morbidity due to surgery and need of repeated surgeries for recurrences should be kept in mind and regular follow-up should be considered.

Comparison of tissue oxygenation and compartment pressure following tibia fracture

ObjectiveWe investigated the ability of direct continuous measurement of intramuscular tissue oxygenation (PmO2) to detect acute ischaemia in the leg in patients at risk for acute extremity compartment syndrome. Following tibia fracture treated by intramedullary nailing, we compared the proportions of PmO2 and compartment pressure (CP) measurements that met the warning criteria for compartment syndrome. MethodsParticipants included 10 patients sustaining acute isolated closed tibia shaft fractures treated by intramedullary nailing. A tissue oxygenation probe and a CP probe were percutaneously placed into the anterior compartment of the leg. PmO2 and CP in the anterior compartment were measured in the injured leg for 48h postoperatively. Measurements meeting the warning criteria were defined as PmO2<10mmHg, CP>30mmHg and perfusion pressure ΔP<30mmHg. ResultsNone of the patients developed compartment syndrome. Comparison of CP and PmO2 showed a CP>30mmHg in 50.39% of CP measurements in all patients and a PmO2<10mmHg in 0.75% of PmO2 measurements in two patients (P=0.005). Comparison of ΔP and PmO2 showed a ΔP<30mmHg in 31.01% of ΔP measurements in nine patients and a PmO2<10mmHg in 0.76% of PmO2 measurements in one patient (P=0.01). ConclusionIn the absence of compartment syndrome, pressure measurements following tibia fracture treated with intramedullary nailing often met the warning criteria, whereas PmO2 did not, suggesting that measurement of intramuscular tissue oxygenation may represent a potential method for the identification of acute compartment syndrome that deserves continued investigation.

D.P.17 Whole body muscle MRI in three patients suffering from XMEA: A peculiar involvement pattern

X-linked myopathy with excessive autophagy (XMEA) is a rare childhood-onset disease characterized by progressive vacuolation and atrophy of skeletal muscle. It is caused by mutations in the VMA21 gene. The VMA21 protein is an essential assembly chaperone of the V-ATPase, the principal mammalian proton pump complex. Decreased VMA21 is thought to raise lysosomal pH, which reduces lysosomal degradative ability and blocks autophagy. In patients with inherited muscular disorders, extensive evaluation of muscle alterations by magnetic resonance imaging (MRI) can significantly contribute to a specific diagnosis. The aim of this work was to describe muscle involvement on whole-body MRI scans in three patients from two separate families, presenting with XMEA confirmed by genetic testing. Patients 1, 2 and 3 were aged of 13, 41 and 30 respectively. Patients 1 and 2 were related. Patients 1 and 3 were ambulatory, presenting with lower limb girdle myopathy and mainly proximal amyotrophy. Patient 2 was in electrical wheel chair with movements basically restricted to the hands. In the three patients, whole-body imaging was performed on a 1.5-tesla MRI system. Selected imaging sequences were T1-weighted turbo spin echo and STIR (short T1 inversion recovery) with axial slices and coronal reconstruction. No paramagnetic contrast agent was injected. Muscles changes consisted essentially of fat replacement with faded signal. In patients 1 and 3, most affected muscles were vastus lateralis, vastus medialis, soleus, adductor magnus, gluteus maximus. Rectus femoris was relatively spared. In patient 1 (youngest one), upper limb and girdle muscles were normal. In patient 2, shoulder muscles and biceps brachialis were affected. In patient 3, all muscle territories but the anterior compartment of the leg and the forearms were involved. Description of MRI patterns of muscle involvement can therefore help providing diagnosis clues when XMEA is suspected.

Diagnosis of Acute Compartment Syndrome

We present a technique and feasibility study of continuous measurement of intramuscular tissue oxygenation as a potential novel approach to the diagnosis of acute extremity compartment syndrome. Polarographic probes were inserted percutaneously into the anterior compartment of the leg to measure the partial pressure of oxygen (PmO2). Five patients underwent open reduction internal fixation of ankle fracture under a thigh tourniquet. With application of the tourniquet, the mean PmO2 decreased rapidly from 26.62 to 0.52 mm Hg (range, 0.1 to 1.4 mm Hg). Eleven patients underwent monitoring of tissue oxygenation after intramedullary nailing for an isolated closed tibia fracture. No compartment syndrome occurred. In the absence of compartment syndrome, 1.35% of PmO2 measurements spanning 424 hours fulfilled the predefined warning criterion of PmO2<10 mm Hg. Our data establish the feasibility of measuring tissue oxygenation and its responsiveness to ischemia. In contrast to compartment pressure, PmO2 measurements after tibia fracture rarely fulfilled the warning criterion in the absence of compartment syndrome. A floor PmO2 value of nearly zero was established in live ischemic muscle. Tissue oxygenation may represent a minimally invasive, physiologic, and specific method for diagnosing compartment syndrome.

Poster 148 Delayed Presentation of Chronic Exertional Compartment Syndrome in the Bilateral Anterior and Lateral Leg Compartments in a Soldier Exposed to Multiple Blasts From Improvised Explosive Devices: A Case Report

Poster 148 Delayed Presentation of Chronic Exertional Compartment Syndrome in the Bilateral Anterior and Lateral Leg Compartments in a Soldier Exposed to Multiple Blasts From Improvised Explosive Devices: A Case Report

Orthopaedic Case of the Month: Painful Lower-leg Mass in a 76-year-old Man

Orthopaedic Case of the Month: Painful Lower-leg Mass in a 76-year-old Man

Dynamic measurements of musculus tibialis anterior ligaments with different angles

The tibialis anterior muscle is the most medial muscle of the anterior compartment of the leg and responsible for dorsiflexing and inverting the foot. It functions to stabilise the ankle as the foot hits the ground during the contact phase of walking (eccentric contraction) and acts later to pull the foot clear off the ground during the swing phase (concentric contraction). It also functions to ‘lock’ the ankle, as in toe-kicking a ball, when held in an isometric contraction. Essentially, the movements of tibialis anterior are dorsiflexion and inversion of the ankle. When the foot is on the ground the muscle helps to balance the leg and talus on the other tarsal bones so that the leg is kept vertical even when walking on uneven ground. Drop foot is an inability or difficulty in moving the ankle and toes upward (dorsiflexion). In walking, while stepping forward, the front of the foot must be lifted upward to prevent the foot from dragging along the ground. Drop foot is usually caused by nerve damage, but may also be caused by muscle damage, abnormal anatomy, or a combination. Drop foot (a weakness in ankle dorsiflexion) is however not a disease but more like a symptom of an underlying problem (could be neurological, muscular or anatomical problem). It may be temporary or permanent, depending on the causes of it. The most common cause for drop foot syndrome is an injury to the peroneal nerve at the top of the calf behind the knee. Other major causes of drop foot also include multiple sclerosis, amyotrophic lateral sclerosis (ALS), Parkinson's disease, Lou Gehrig's disease, and muscular dystrophy. The aim of the study is to get some numerical data on tibialis anterior muscle during dorsiflexion, plantar flexion, inversion and eversion of the foot. 9 cases were compared with left and right foot including 4 neurological disability and 5 healthy people. In four neurological disabled patients, the muscle force differences between healthy and normal legs are obtained as 9 N/81 N, 49 N/78 N, 182 N/58 N and 89 N/0 N. In conclusion, we obtain some in vivo data showing that there are important differences in forces of muscles between the healthy and drop foot patients. These numerical data will help us to develop new orthosis and drop foot shoes for treatment of drop foot syndrome.

Discovery of the anterior fibulocalcaneus muscle: an anomalous leg muscle

A novel muscle, the anterior fibulocalcaneus, has been discovered bilaterally in the anterior compartment of the leg in three separate cadaveric dissections. This muscle originates from the fibula, anterior crural septum, and the investing fascia of the fibularis tertius. Its tendon passes anterior to the lateral malleolus to insert onto the calcaneus, anterosuperior to the fibular trochlea. Anomalous fibulocalcaneal muscles associated with the lateral malleolus have been noted to cause a variety of ankle pathologies, and supernumerary muscles within the talocrural joint have been utilized for surgical reconstructive procedures. Radiologists and clinicians should be aware of this muscle when embarking in diagnosis and imaging interpretation, especially when chronic ankle pain is localized anterior to the lateral malleolus (Lambert and Atsas, 2010).

Closure of Deep Fascia in Ankle Fracture Surgery

Closure of the deep fracture after open reduction and internal fixation of the ankle is often difficult due to the damage from the injury or from the intraoperative exposure. The technique described herein provides a consistent method for coverage of the hardware. The specific maneuver capitalizes on the unique arrangement of the fascial overlying the anterior compartment of the leg.