Dorsolateral Foot Research Articles

Repair of Small-Size Wound With Achilles Tendon Exposure With Proximal Pedicled Cutaneous Neurovascular Flap.

To investigate the clinical outcomes associated with repairing of small-sized wounds of Achilles tendon exposure with proximal pedicled cutaneous neurovascular flap in the dorsolateral foot. After thorough debridement, 16 cases with small-sized wounds of Achilles tendon exposure were repaired by proximal pedicled cutaneous neurovascular flap of the dorsolateral foot, and their clinical outcomes were observed. All the flaps in the 16 cases survived completely, excluding the marginal part necrosis in 1 case, and all the wounds were healed. The 2-point discrimination of the flaps was 14.53 ± 1.55 mm (range, 12-17 mm) in patients without sural nerve injury after 3 to 18 months follow-up. No discomfort was felt in wearing normal shoes by all the 16 patients. It is reasonable to repair the small-sized wounds of Achilles tendon exposure with proximal pedicled cutaneous neurovascular flap of dorsolateral foot due to its effective repair of the wound, relatively uncomplicated surgery, and had satisfactory healing recovery.

Analysis of the Sural Nerve Complex in North American Adult Cadavers: Distribution, Population Specific Morphology, and Anatomic Variants.

BACKGROUNDThe Sural nerve complex (SNC) consists of four components: the medial sural cutaneous nerve, lateral sural cutaneous nerve, sural communicating branch, and sural nerve proper. The sural nerve is a cutaneous nerve that innervates the distal posterolateral leg and dorsolateral foot. The SNC is highly variable and has six defined morphological types each representing different patterns in which the SNC can form the sural nerve proper. Because of variability amongst different populations the SNC may frequently become a site of iatrogenic injury.PURPOSEThe purpose of this study was to determine if the morphological type and spatial characteristics of the SNC we found in North Americans aligned with that described in the current literature.METHODSSix defined morphologic types of SNC have been described, each representing different patterns in which the SNC forms the sural nerve proper (Pirarvin, KR, Annals of Anatomy, 202, 36–44, 2015). Cadaveric data was obtained bilaterally in from 49 formalin‐ and three Thiel‐embalmed body donors (n=104 limbs) from KCUMB via superficial dissection methods revealing the SNC in the posterior leg. Measurements were obtained using forensic rules and calipers and documented using a digital camera. This study first approved by the KCUMB Institutional Biosafety Committee.RESULTSOur results showed a predominance of two major types of SNCs. In the first type (53%), the SNC originated from the lateral sural cutaneous nerve or common fibular cutaneous nerve. In the second type (34%), the SNC originated from the medial sural cutaneous nerve independent of the sural communicating branch, with or without the presence of lateral sural cutaneous nerve contribution. We also found a prevalence of bilateral asymmetry (67%) in the formation of the SNC. Lastly, were found higher frequencies of previously described SNC variants including connections of the SNC with the posterior femoral cutaneous nerve (30%) and terminal branches of the medial sural cutaneous nerve connecting with other cutaneous nerves adjacent the lateral malleolus (22%).CONCLUSIONOur data showed there are two prevalent forms of SNCs within the North American population and that bilateral asymmetry is more common than previously reported. A more complete understanding of the variation in the SNC is important for clinical electrophysiology evaluations, neurological disease testing, lower extremity tissue repair, and sural nerve use in autogenous nerve grafts.

Microsurgical Resection of a Common Peroneal Nerve Schwannoma: A 3-Dimensional Operative Video.

Peripheral nerve sheath tumors are benign entities that manifest with pain or neurological deficits from mass effect. Treatment is mostly surgical, however, the aggressiveness of treatment needs to be carefully considered with respect to preserving function. We present a case of a 62-year-old male with a 2-year history of left lower extremity pain radiating toward the dorsolateral foot. There was a tender and palpable mass in the lateral popliteal fossa with imaging consistent with Schwannoma of the common peroneal nerve. The patient was counseled for surgery and informed consent was obtained. Microsurgical resection was undertaken and gross total resection was achieved without compromise of function. We demonstrate the placement of neurophysiological monitoring electrodes in all 3 compartment of the calf as well as the use of stimulation to identify a nonfunctioning area for entering the nerve sheath. Anatomy of the popliteal fossa and microsurgical technique for resection of nerve sheath tumors are discussed. When dealing with these pathologies, it is important to use intraoperative neurophysiology as well as careful technique in order to achieve maximal resection without compromising neurological function.

Ultrasound of the Gruberi Bursa With Cadaveric and MRI Correlation.

The purpose of this study was to describe the appearance and ultrasound characteristics of the Gruberi bursa using a cadaveric model and retrospective ultrasound imaging review. For the cadaveric study, ultrasound of the dorsolateral ankle of a foot-ankle specimen was performed and was followed by injection of latex between the extensor digitorum longus (EDL) tendons and the talus and dissection. For the ultrasound imaging review, the radiology database was searched for ultrasound studies performed from September 15, 2000, through April 1, 2015, to identify subjects with a dorsolateral foot or ankle fluid collection detected on ultrasound. Images were retrospectively reviewed to characterize the location and size of the fluid collection, assess for the number of locules, and evaluate the compressibility of the fluid collection. It was determined whether the ultrasound findings were significantly different from chance: CI and p values were obtained from performing a test for one proportion. Dissection of a cadaveric specimen revealed latex within a well-defined region between the EDL tendons and the dorsolateral talus; this location is consistent with a Gruberi bursa. For the image review, the imaging examinations of 162 subjects (age range, 16-88 years; 31 male subjects and 131 female subjects) were reviewed. On the ultrasound images, a fluid collection with its epicenter between the dorsolateral talus and EDL was found in 93% of ankles. Of the fluid collections identified on ultrasound, 98% were unilocular and 94% were anechoic. Of these fluid collections, 133 were assessed for compressibility, and 89% were compressible. The positive findings for a Gruberi bursa that were different from chance (p < 0.0001) were a fluid collection being located between the EDL tendons and the dorsolateral talus and being unilocular, anechoic, and compressible. The Gruberi bursa characteristically is located between the EDL and the talus; on ultrasound, the Gruberi bursa is most commonly unilocular, anechoic, and compressible.

Intratendinous ganglion cyst of the extensor digitorum longus tendon: A case report

IntroductionGanglion cysts are benign lesions, common in the hand and wrist. Intratendinous ganglion, however, are rare. We present the first reported case of an intratendinous ganglion cyst in an extensor digitorum longus (EDL) tendon of the foot. Case reportA 35-year old presented with a left-sided painful dorsolateral foot swelling. Ultrasound suggested a ganglion cyst in proximity to the EDL tendon of the 5th toe. Two distinct swellings were identified on surgical exploration, including a 6×1cm ganglion lying within the EDL tendon substance that had resulted in tendon splitting. The lesions were excised and EDL tendon repaired. Histological analysis confirmed that both lesions were ganglion cysts. Post-operative recovery was uneventful. DiscussionIntratendinous ganglion cysts are rare lesions that pose a unique set of diagnostic and treatment challenges. Unlike conventional ganglion, their diagnosis may not be possible until surgical exploration. They have been reported to increase the risk of spontaneous tendon rupture. As such, a lower operative threshold should be applied to prevent their progression. A high index of suspicion should be applied to any ganglion reported radiologically to be in close contact with tendons. If diagnosed upon surgical exploration, it is essential that the operating surgeon is prepared to appropriately modify the procedure to involve primary tendon repair, tendon transfer or tenodesis.

A Novel Approach To A Runner’S Foot Pain

HISTORY: 32-year old female recreational runner experienced the insidious onset of bilateral heel pain, followed by arch pain in the AM and after running. She was treated for plantar fasciitis by a podiatrist with custom orthotics, night splints and rest. She discontinued the orthotics due to discomfort and persistence of pain. She began cycling due to being unable to run. Three months later, her pain finally resolved and she returned to running. At this time, she decided to try transitioning to a forefoot strike pattern in minimal shoes. She increased her distance from 400m to 2000m before she experienced the onset of BIL dorsolateral foot pain, which she continued to run through. She increased to running 10km before a reaggravation of her heel and arch pain caused her to stop. She then sought treatment at the running clinic. PHYSICAL EXAMINATION: The patient reported pain with walking and running. Palpation of the 4th and 5th metatarsals elicited tenderness, reproducing her complaint of dorsolateral foot pain. Palpation of her medial arch elicited tenderness and reproduced her complaint of plantar fascia pain. A manual muscle test revealed normal muscle performance of her lower leg muscles. During running, she exhibited increased foot inversion at foot-strike, followed by rapid pronation. She also demonstrated increased femoral internal rotation and adduction. She reported a VAS of 6/10 for the dorsolateral foot pain, and 3/10 heel pain. DIFFERENTIAL DIAGNOSIS: -Plantar fasciitis -Metatarsal stress reaction/fracture FINAL/WORKING DIAGNOSIS: -Plantar fasciitis -Possible metatarsal stress reaction TREATMENT AND OUTCOMES: 1. 8 weeks of rest to unload possible stress reaction. During this time, her dorsolateral foot pain resolved. Her heel and arch pain did not. 2. Progressive intrinsic and extrinsic foot strengthening. 3. Movement reeducation, using bilateral dynamic movements and unilateral dynamic movements to improve her lower extremity control. 4. Gait training to reduce her excessive inversion, rapid pronation, femoral adduction/internal rotation during running. 5. Run time was slowly increased to 35 min over 4 weeks. Patient was pain free at discharge. 6. Patient then independently progressed to prior level of running. She has had no reaggravation of her plantar fasciitis as of a 2-year follow-up.

Sural Intraneural Ganglion Cysts Are Joint-related

The recent article by Kim and Kim [1] provides a valuable case of a rare sural intraneural ganglion cyst to the literature. We offer yet another example to highlight recent developments in our understanding of this entity. A 42-year-old woman presented with a 6 month history of the spontaneous onset of moderately severe pain developing in the right lateral rearfoot in the retrolateral malleolar region with radiating dysesthesias into the dorsolateral foot. Symptoms were worse with standing or with activity. Exam revealed a 3×2 cm soft tissue tubular mass along the course of the sural nerve which had features consistent with a ganglion cyst. It was tender to palpation. Percussion produced radiating paresthesias in the sural nerve distribution. Sensation was intact on the dorsal foot to light touch. Magnetic reconance imaging (MRI) demonstrated a sural intraneural ganglion cyst with a joint connection to the subtalar joint (Figs. 1, ​,2).2). At operation, this articular branch connection was identified, ligated and resected. The patient had full recovery immediately postoperatively; there was no clinical evidence of persistent pain or cyst at last follow-up examination. Fig. 1 Conventional MRI of a patient with sural intraneural ganglion originating from subtalar joint. Serial coronal T2-weighted fast spin echo (FSE) images with fat suppression from posterior to anterior demonstrates an intraneural cyst arising from the lateral ... Fig. 2 Three-dimensional rendering of conventional magnetic resonance images obtained in this patient with a sural intraneural ganglion cyst. Maximum intensity projection image created from the same series as Fig. 1 shows the entire course of the cyst (asterisk) ... As Kim and Kim [1] point out, the pathogenesis of these cysts has been controversial and poorly understood. Recent reports have clarified this. Layers of robust evidence have substantiated an articular origin for all types of intraneural cysts first at the prototypic site (the common fibular nerve) and then at other joints throughout the appendicular skeleton and axial spine [2,3]. The unifying articular (synovial) theory has been shown to be generalizable and universal. Joint connections must be assumed to be present. We have emphasized the difficulties in identifying the joint connection with imaging and at operation. Experience with both can reliably and reproducibly identify the joint connection. High resolution imaging (MRI or computed tomography imaging with or without arthrography; or ultrasound) with conventional or 3-dimensional renderings may show convincingly a seemingly occult joint connection [3,4], even when reported by others not to be present. The consistent articular connection has fostered an understanding of the principles of these cysts. A capsular defect allows the passage of joint fluid to pass from the joint (often degenerative) along an articular branch and into the parent nerve. Propagation follows the pass of least resistance within the epineurium of nerve. Intra-articular pressure and pressure fluxes influence cyst dimensions. We have identified 9 cases of sural intraneural ganglia (Appendix). Of these, joint connections were only found in 3 instances: twice to the subtalar joint and once to the calcaneocuboid joint. Nevertheless, we are confident that joint connections were present in all of the remaining cases in the literature, including the one by Kim and Kim [1]. These joint connections can be predicted and must be anticipated. The articular branch anatomy of the sural nerve [5] would explain all of the locations of these cysts (Fig. 3). The unifying articular theory could explain all of their patterns of propagation [2,3]. Fig. 3 The anatomy and pathoanatomy of known and potential sites of sural intraneural ganglion cysts. The drawing of the normal anatomy was based on descriptions by anatomists [5]. The confirmed joint-related sites of origin (subtalar and calcaneocuboid joints) ... Understanding the pathogenesis can help target surgery so as to simplify it. Surgery should include ligating or resecting the articular branch near the joint. The cyst itself need not be resected as it will be resorbed as long as the connection is disrupted. This approach minimizes intraneural dissection and eliminates intraneural recurrence, which is known to occur with high rates and was documented in several of these sural examples (Appendix). We believe that such recurrence would likely have been present in other patients (even those who were asymptomatic) if postoperative imaging had been performed. Resecting the nerve, while possible in the case of a distal cutaneous nerve (such as the sural nerve) and has been performed in several cases, could still result in intraneural (distal) recurrence. Furthermore, nerve sacrifice can not be extrapolated to other cases of intraneural ganglia involving major mixed peripheral nerves. Knowledge of current pathogenesis and experience with the imaging and operative findings with these rare cysts will improve outcomes and eliminate intraneural recurrences.

Every Treatment Plan Has Its Consequences

HISTORY: A 24 yo male tri-athlete presents 5 days after an injury while playing ping-pong. The athlete jumped to celebrate a point and landed on the lateral portion of his left foot inverting and twisting it at which point he heard and felt a "pop." Thirty minutes later he still had excruciating pain at the base of his 5th metatarsal and presented to the immediate care center where he was diagnosed with a fracture, and was placed in a posterior splint, given crutches, and told to follow up. At clinic, he had been non-weight-bearing for 4 days and kept his left leg immobilized in a posterior splint. In the past two days he noticed dorsolateral foot numbness following several bouts of intermittent left calf cramping lasting several minutes which was not relieved by massage. Today he notes left foot and ankle joint swelling, stiffness, and weakness. He denied using tobacco, drugs or alternative medicines. PHYSICAL EXAMINATION: General: Muscular, healthy appearing, well tempered male in no acute distress. Left foot: Tender, 5th metatarsal, yellow-brown discoloration, unable to weight-bear due to pain. Left ankle: Erythema, 1+ swelling, slight discoloration, full ROM. Left Calf: Tender to palpation medially, increased calf pain with dorsiflexion. Negative Thompson test. Left knee: normal. Right Foot/Ankle/Calf/Knee: normal findings. Neurological: Numbness/tingling in his left foot post calf cramps, but otherwise no abnormalities. Skin: No petechiae, swelling, erythema, and discoloration only in locations noted earlier DIFFERENTIAL DIAGNOSIS: 5th metatarsal Jones-Type fracture 5th metatarsal stress fracture, lateral ankle sprain Calf pain due to inactivity/immobilization with posterior splint, Deep venous thrombosis, as complication of immobilization Calf strain due to injury TEST AND RESULTS: X-RAY: Foot films consistent with Jones-type fracture. No evidence of stress fracture. Doppler Ultrasound Left lower extremity (LLE): an acute venous thrombus in the LLE Peroneal Vein. FINAL WORKING DIAGNOSIS: 1. Fifth Metatarsal Jones Type Fracture on Left Foot- metaphyseal area 2. Acute DVT LLE in the Peroneal Vein TREATMENT AND OUTCOMES: Placed in a hard shoe with crutches Aspirin 325mg 2x/day Scheduled for a f/u US with Vascular Radiology in 5days.

Using Three-Dimensional Gait Data for Foot/Ankle Orthopaedic Surgery

We present the case of a forty year old male who sustained a torn carotid during strenuous physical activity. This was followed by a right hemispheric stroke due to a clot associated with the carotid. Upon recovery, the patient’s gait was characterized as hemiparetic with a stiff-knee pattern, a fixed flexion deformity of the toe flexors, and a hindfoot varus. Based on clinical exams and radiographs, the surgical treatment plan was established and consisted of correction of the forefoot deformities, possible hamstrings lengthening, and tendon transfer of the posterior tibial tendon to the dorsolateral foot. To aid in surgical planning, a three-dimensional gait analysis was conducted using a state-of-the-art motion capture system. Data from this analysis provided insight into the pathomechanics of the patient’s gait pattern. A forefoot driven hindfoot varus was evident from the presurgical data and the tendon transfer procedure was deemed unnecessary. A computer was used in the OR to provide surgeons with animations of the patient’s gait and graphical results as needed. A second gait analysis was conducted 6 weeks post surgery, shortly after cast removal. Post-surgical gait data showed improved foot segment orientation and position. Motion capture data provides clinicians with detailed information on the multisegment kinematics of foot motion during gait, before and during surgery. Further, treatment effectiveness can be evaluated by repeating gait analyses after recovery.

Postoperative outcomes and reliability of “sensation‐sparing” sural nerve biopsy

Sural nerve biopsy is a valuable tool for the diagnosis of neuropathic disorders. However, concerns of persisting pain and numbness resulting from traditional whole sural nerve biopsy have led to interfascicular dissection techniques with inconsistent benefits over whole nerve biopsy. In this study we describe a novel technique of atraumatic anterior fascicular sural nerve biopsy designed to preserve calcaneal sensation while maintaining diagnostic benefit, without requiring significant interfascicular dissection. A 10-year chart review was conducted to identify patients who underwent anterior fascicular sural nerve biopsy. Pathology reports were reviewed to confirm specimen adequacy, and clinical notes were reviewed to determine if a diagnosis was rendered. Retrospective questionnaires were conducted to evaluate perioperative and long-term sequelae and patient satisfaction. The proportion of patients with symptoms involving the heel versus the dorsolateral foot was evaluated with Fisher's exact test. Specimens from all 53 patients were acceptable and permitted a diagnosis. Twenty-two patients completed the retrospective survey with an average follow-up of 5 years (1.2-11.4 years). Eight patients (34%) experienced numbness of the dorsolateral foot, and 1 patient (4.5%) reported numbness of the lateral heel that lasted >6 months (P = 0.001). Persistent dorsolateral foot pain and cold sensitivity were reported by 5 patients (22.7%), but no patients reported lateral heel symptoms (P = 0.04). Symptoms were noted by patients most commonly while standing or walking, but they did not result in functional impairment in any case. Atraumatic anterior fascicular sural nerve biopsy predictably preserved essential lateral heel sensation in patients with neuropathic disorders while providing diagnostic utility.

Clinical Importance of the Lateral Branch of the Deep Peroneal Nerve

Persistent recalcitrant dorsolateral foot pain after ankle sprain cannot always be explained by known anatomic nerve pathways. To determine whether an impingement of a lateral branch of the deep peroneal nerve might be responsible for atypical pain, we conducted a cadaveric anatomic study to identify the anatomy and course of the nerve. Furthermore, using this information, we conducted a clinical study to determine if targeted treatment to a lateral branch of the deep peroneal nerve would resolve these symptoms. We dissected 22 cadaveric feet to identify a large lateral branch of the deep peroneal nerve. This nerve arborized into five main branches. We identified two areas of compression in the lateral branch of the deep peroneal nerve. We also performed a prospective clinical study including 11 consecutive patients with a 1-year minimum followup. Pain and clinical findings corresponded to the anatomic compression sites in all 11 patients. All patients responded to a local anesthetic injection or surgical release of the lateral branch of the deep peroneal nerve. We identified a previously unreported complex course of the lateral branch of the deep peroneal nerve that correlated with clinical impingement syndrome and responded to specifically targeted treatment.

The gene for mesomelic dysplasia Kantaputra type is mapped to chromosome 2q24-q32.

Mesomelic dysplasia Kantaputra type (MDK) (MIM *156232) is a new autosomal dominant skeletal dysplasia characterized by dwarfism, shortening of the forearms/lower-legs, carpal/tarsal synostosis, and dorsolateral foot deviation. We studied a Thai family in which 15 members in 3 generations were affected with MDK. With reference to the breakpoints of a balanced translocation [t(2;8)(q31;p21)] in patients from a previously reported Italian family with a skeletal dysplasia that appears similar to MDK, a linkage analysis was performed in the Thai family using 50 CA-repeat markers mapped to nearby regions (2q22-q34 and 8p24-p21) of the translocation breakpoints. The results clearly ruled out a linkage of MDK to marker loci at the 8p24-p21 region, whereas all nine affected members available for the study shared a haplotype at four loci (D2S2284, D2S326, D2S2188, and D2S2314) spanning about 22.7 cM in the 2q24-q32 region. The computer-assisted two-point linkage analysis revealed maximum logarithm of odds (lod) scores of 4.82, 4.21, 4.82, and 4.21 (theta = 0) at these loci, respectively. These data indicated that the MDK locus is in the vicinity of D2S2284 and D2S2188 loci that are most likely mapped to 2q24-q32.

The distal course of the sural nerve and its significance for incisions around the lateral hindfoot.

Twenty preserved cadaver limbs were dissected to show the distal course of the sural nerve and the number and site of origin of its branches. The mean position of the main nerve trunk was calculated at various points related to bony landmarks of the fibula and the fifth metatarsal base. Ninety-five percent confidence limits for the course of the main nerve trunk could be described. A fibula incision may damage the nerve if it extends more than 7 mm inferior to the lateral malleolar tip with the foot in equinus. Dorsolateral foot incisions may damage both the main trunk and the major anterior branch.

Metabolism of phenol in the terrestrial snail Cepaea nemoralis L.

1. The metabolism of phenol in the terrestrial snail Cepaea nemoralis was studied after injection into the haemocoel of the dorsolateral foot region. 2. Excreted metabolites, and metabolites extracted from the body, were analysed by h.p.l.c. In addition to phenyl beta-D-glucoside, arbutine (quinol beta-D-glucoside), a new conjugate of phenol, was detected.