Lateral Dorsal Cutaneous Nerve Research Articles

Anatomical Structures at Risk in Percutaneous Distal Bunionette Correction

Introduction/Purpose: Bunionette deformity affects 23% of the population and has numerous surgical options, including a minimally invasive approach (MIA) to decrease complications. Percutaneous surgery is favored by patients as it decreases pain, inflammation, and noticeable incision sites. Three possible osteotomy sites have been identified: proximal, diaphyseal, and distal. The study investigates the anatomic structures at risk during distal osteotomy of bunionette deformity using a Shannon burr. The distal osteotomy site was on average greater than 8mm from the extensor digitorum longus and adductor digiti minimi while it was 1.64mm from the lateral dorsal cutaneous nerve. The study highlighted the challenges posed by minimally invasive approaches to treating bunionette deformity and the need for cautious consideration when utilizing percutaneous methods. Methods: Eleven fresh frozen below-knee amputated foot and ankle cadavers were used for this study. Cadavers were allowed to thaw for 12 hours at room temperature before performing any tissue handling. All cadavers were visually inspected for evidence of gross pathology. Fluoroscopic radiographs were used to inspect for evidence of preexisting pathology of the fifth metatarsal. All cadavers with gross pathology or radiographic fifth metatarsal pathology were excluded from the study. All procedures were performed by a fellowship trained orthopaedic foot and ankle surgeon. Results: All eleven cadavers met the inclusion criteria for this study. The average age of the patients was 66.6 +/- 20.1 years. There were five female feet and six male feet. There were seven right feet and four left feet. Distance from the percutaneous access site was measured to structures at potential risk. The closest structure at risk was the lateral dorsal cutaneous nerve (LDCN) (1.64 mm), which was contacted 2/11 times and transected both times. The extensor digitorum longus (EDL) and abductor digiti minimi (ADM) had no instances of contact during the procedure. Dissection allowed for the identification of structures at risk and the assessment of osteotomy. All procedures resulted in a complete osteotomy. Conclusion: Overall, distal percutaneous bunionette osteotomy is largely safe. Structures pertinent to the surgery were identified with ease and were intact after osteotomy with a Shannon burr. Anatomic variations of LDCN can present challenges to the procedure. Meticulous dissection and judicious use of fluoroscopy can help prevent further damage. Surgeons should be aware of anatomic variations in order to proceed safely.

Variations in Innervation Pattern to Dorsum of Foot by Medial Dorsal Cutaneous Nerve, Intermediate Dorsal Cutaneous Nerve, Lateral Dorsal Cutaneous Nerve with Surgical and Clinical Correlations: A Cadaveric Dissection Based Study

The complete reconstruction of any soft tissue defect includes even the sensory recovery which is very significant aspect pertaining to prognosis. Superficial nerves in the vicinity of the vascular axis can be considered as vascular relays and neuroskin grafts can be constructed on them. Variations in innervation to various part of the dorsum of the foot by this nerve should be kept in mind while making these grafts. Authors dissected 50 formalinized cadaveric feet and studied normal anatomy and variations in origin, course, branching pattern, communications, and any other variations in medial, intermediate and lateral dorsal cutaneous nerve. The intermediate dorsal cutaneous nerve was innervating larger area of the skin around 3rd and 4th web spaces in 60% of cadaveric feet. The 2nd web space was innervated by medial dorsal cutaneous nerve in 92% of cadaveric feet. In 52% of cadaveric feet communicating branches were found between intermediate dorsal cutaneous nerve and lateral dorsal cutaneous nerve. In 63% cadaveric feet communicating branches were found between medial dorsal cutaneous nerve and branch of deep peroneal nerve to 2nd web space. The mean distance between lateral malleolus and intermediate dorsal cutaneous nerve was 4.05cm. These all observations can provide anatomical basis at the time of preparing medial dorsal cutaneous nerve flaps and intermediate dorsal cutaneous nerve flaps and also can minimize morbidity at donor site. KEY WORDS: Medial Dorsal Cutaneous Nerve, Intermediate Dorsal Cutaneous Nerve, Lateral Dorsal Cutaneous Nerve, Medial Dorsal Cutaneous Nerve Flap, Intermediate Dorsal Cutaneous Nerve Flap, Soft Tissue Defects, Open Reduction And Internal Fixation Of Fibula, Arthroscopy, Local Anesthetic Block, First Dorsal Metatarsal Artery Flap, Defects In Distal Dorsalis Pedis, Compression And Entrapment Neuropathies.

An Anatomic Study of the Lateral Dorsal Cutaneous Nerve Using 3-Tesla MRI: A Comparison to Cadaveric Data With Surgical Applications.

The lateral dorsal cutaneous nerve (LDCN) and the anastomotic branch of the sural nerve (AB) are cutaneous sensory nerves at risk of iatrogenic injury during lateral foot surgery. This study is the first to use a large cohort of high-resolution magnetic resonance images (MRIs) of the ankle to better describe the course of these nerves in vivo in order to aid surgeons intraoperatively. Our study intends to build on the "high and inside" approach to the proximal 5MT by accounting for variations in course of the LDCN and AB. One hundred twenty-five 3-tesla (T) MRI studies of the ankle were analyzed. Three reviewers measured the distance from the LDCN and AB to landmarks including the most proximal aspect of the fifth metatarsal tuberosity (5MT) and the peroneus brevis tendon (PBT). Mean vertical distance from the LDCN to the 5MT was 0.8 ± 0.2 cm. Presence of an AB was visualized in 59 of 125 studies (47.2%) and was found 2.2 ± 0.5 cm dorsal to the 5MT. The AB was found to become superior to PBT at a horizontal distance 1.9 ± 0.5 cm proximal to the 5MT. The LDCN was found superior to the PBT at its insertion onto the 5MT in approximately 10% (n = 12) of our studies. During these instances, the LDCN was located an average of 0.3 cm dorsal to the PBT. Our proposed "safe zone" for the approach to the proximal 5MT remains superior to the LDCN and inferior to the AB and avoids crossing directly over either nerve in >95% of analyzed MRI studies. This incision begins 1.5 cm dorsal to the most proximal aspect of the 5MT and extends no more than 1 cm posteriorly. Careful dissection and identification of the LDCN and possible AB is necessary prior to further extension of incision. Level IV, case series.

Lateral Dorsal Cutaneous Nerve and Anastomotic Branch to the Intermediate Dorsal Cutaneous Nerve: A Review of Cadaveric Data and Comparison with 3 Tesla MRI

Category:Other; HindfootIntroduction/Purpose:The lateral dorsal cutaneous nerve (LDCN) and anastomotic branch to the intermediate dorsal cutaneous nerve (AICN) can be injured during foot and ankle surgery. Cadaveric specimen studies are limited by small sample size.1-11 We sought to use high-field 3-tesla (3T) magnetic resonance imaging (MRI) to examine a significantly larger cohort and obtain a more representative sample of the course of the LDCN and AICN. A more generalizable understanding of the course and position of these structures will aid surgeons intraoperatively in avoiding iatrogenic injury when performing the sinus tarsi approach, as well as during percutaneous intramedullary fixation of the 5th metatarsal.Methods:High-field 3T MRI studies performed between January 2015 to January 2020 were reviewed. Three blinded reviewers at a single academic center measured the coronal distances of LDCN and AICN from the fifth metatarsal styloid (5MS). Intraclass correlation coefficients (ICC) were calculated to assess reviewer reliability. Foot and ankle MRIs with major structural abnormalities, such as tumor or the presence of hardware, were excluded.Results:A total of 125 foot and ankle 3T MRIs were identified. Intraclass correlation coefficient was excellent at 0.87 for LDCN to 5MS and 0.88 for AICN to 5MS. The mean distance of the LDCN to the 5MS was 0.8 cm (range 0.3-1.4 cm, CI 0.8-0.8 cm) and that from the AICN to the 5MS was 2.1 cm (range 1.6-3.2 cm, CI 2.0-2.2 cm. Height had no significant correlation with the nerves' distance from bony landmarks with r values of 0.14 and 0.29 for the LDCN and AICN, respectively. Similarly, we did not find BMI to significantly correlate, with r values of 0.10 and 0.30 for the LDCN and AICN, respectively.Conclusion:Our study demonstrated the LDCN and AICN can be found on average 0.8 cm and 2.1 cm, respectively, above the 5MS with no clear association to patient height or BMI. Literature studying the range of distances the LDCN is found from the 5MS is scarce, but one study noted the range to be 0.7-1.2 cm, which is significantly smaller than our range of 0.3-1.4 cm.3 To our knowledge, our study is first to note the range of distances the AICN can be found from the 5MS, which is 1.6-3.2 cm.

Risk of Injury to the LDCN and IACN During Surgical Approaches to the Foot and Ankle: an Anatomical Study using 3-Tesla Magnetic Resonance Imaging

Category:Ankle; OtherIntroduction/Purpose:The dorsomedial branch of the lateral dorsal cutaneous nerve (dmLDCN) and anastomotic branch to the intermediate dorsal cutaneous nerve (AICN) are at risk during foot and ankle surgery. Prior studies of the distal sural nerve on cadaveric specimens are limited by small sample size.1-7 We sought to use high-field 3-tesla (3T) magnetic resonance imaging (MRI) to examine a significantly larger cohort and obtain a more representative sample of the course of the dmLDCN and AICN. A more generalizable understanding of the course and position of these structures will aid surgeons intraoperatively in avoiding iatrogenic injury when performing the dorsomedial approach to the fifth metatarsal, as well as the sinus tarsi and extended sinus tarsi approaches for calcaneal fractures and subtalar/calcaneocuboid fusions.Methods:High-field 3T MRI studies performed between January 2015 to January 2020 were reviewed. Three blinded reviewers at a single academic center measured the coronal distances of dmLDCN and AICN from the fifth metatarsal styloid (5MS). Intraclass correlation coefficients (ICC) were calculated to assess reviewer reliability. We analyzed the upper and lower quartile ranges to evaluate the risk of iatrogenic nerve injury with standard surgical approaches.Results:A total of 125 foot and ankle 3T MRIs were measured. Intraclass correlation coefficient was excellent at 0.87 for dmLDCN to 5MS and 0.88 for AICN to 5MS. 1st and 4th quartile range for the dmLDCN to the 5MS was 0.5-0.7 cm and 0.9-1.4 cm, respectively. 1st and 4th quartile range for the AICN to the 5MS was 1.6-1.9 cm and 2.3-3.2 cm respectively. The AICN was identified in 47.2% of the images.Conclusion:The dmLDCN, AICN, and SN are vulnerable to iatrogenic injury during surgical approaches to the fifth metatarsal and calcaneus. Our 1st quartile range for the dmLDCN to the 5MS of 0.5-0.7 cm suggests that nearly 25% of our values measured by 3T MRI were lower than the reported range of 0.7-1.2 cm by Fansa, suggesting iatrogenic injury to the dmLDCN with the 'high and inside approach' to the fifth metatarsal may be higher than previously thought. The 4th quartile range of the AICN's distance from the 5MS of 2.3-3.2cm places it at risk with the sinus tarsi approach.

Anatomical considerations for minimally invasive osteotomy of the fifth metatarsal for bunionette correction — A pilot study

IntroductionOperative correction of symptomatic bunionette by means of minimally invasive (MI) osteotomies of the 5th metatarsal (M5) has gained popularity. This study aims to investigate the safe zones of commonly used techniques and the risk of injury to neurological structures. Materials and methodsTen human fresh frozen cadaveric feet were dissected and branches of the sural nerve were identified. A frontal section of the feet was performed at the site of the skin incision described for M5 MI osteotomies (corresponding to distal and mid diaphyseal osteotomies). The location of the lateral dorsal cutaneous nerve (LDCN) of the sural nerve or its branches was documented using a goniometer and o’clock references placed on the frontal section of the M5. ResultsThe LDCN showed variations in the distribution of its branches, forming the dorsolateral branch – a single terminal branch for the 5th toe – in 6/10 cases or two terminal branches – the dorsolateral and dorsomedial – in 4/10. At the point of osteotomies, the dorsolateral branch was identified at a mean of 22.7° from the extensor tendon around the M5 circumference and in all cases between 12 and 2 o’clock in a right foot or 10 o’clock to 12 o’clock in a left. ConclusionThe studied M5 osteotomies can place the dorsolateral branch of the fifth toe at risk and safe zones lie between 10 o’clock to 2 o’clock in any foot laterality. If these landmarks are considered, the risk of nerve damage is minimized when performing MI osteotomies of the M5.

Variations in sural nerve formation pattern and distribution on the dorsum of the foot.

The sural nerve, a cutaneous nerve, is clinically important because it is frequently for nerve conduction testing, biopsy, and harvesting for nerve grafts. This nerve exhibits a wide variety of variation in formation, distribution on the dorsum of the foot, and so on, depending on the population observed. In this study, we examined the variation in the sural nerve in 110 Korean cadavers. Of these cadavers, 86.1% of the sural nerves corresponded to type A, where tibial and peroneal components were united to form the sural nerve. These two components most frequently united (65.9%) in the third quarter of the calf, and when the union position was expressed as a ratio to calf length, it corresponded to 0.408 in men and 0.346 in women, with a statistically significant difference. Due to this sexual dimorphism in addition to shorter calf length in females, the length of the sural nerve was shorter in females (male average length: 14.5 ± 4.8 cm; female average length: 11.4 ± 2.9 cm). In terms of distribution of the lateral dorsal cutaneous nerve, the distal continuation of the sural nerve on the dorsum of the foot, it showed variation in association with the superficial peroneal nerve. The innervation of the sural nerve extended most frequently up to the lateral two and a half toes, solely or in conjunction with the superficial peroneal nerve. Obtaining further information regarding sural nerve variation will be useful for various clinical procedures and interpretation of sural nerve conduction results. Clin. Anat. 30:525-532, 2017. © 2017 Wiley Periodicals, Inc.

Anatomical basis and design of the distally based lateral dorsal cutaneous neuro-lateral plantar venofasciocutaneous flap pedicled with the lateral plantar artery perforator of the fifth metatarsal bone: a cadaveric dissection.

Detailed investigation of the vasculature of the lateral aspect of the foot has rarely been presented. However, harvesting the flap in this area to cover defects of the foot and hand is highly important. Repair of soft-tissue defects at the forefoot remains a challenge in reconstructive surgery. This study explores the characteristics of the distal-based lateral dorsal cutaneous neuro-lateral plantar venofasciocutaneous flap pedicled with the lateral plantar artery perforator of the fifth metatarsal bone to establish a repair procedure for ulcers or defects in the forefoot region. This study is divided into two parts: anatomical study and simulated operation. Thirty cadavers were utilized in the anatomical study after arterial injection. The tuberosity of the fifth metatarsal bone was used as the anatomical landmark. The lateral plantar artery perforator of the fifth metatarsal bone was identified through dissection. The perforators were dissected under a microscope. The details of the lateral plantar artery perforators, the distribution of the lateral dorsal cutaneous nerve and lateral plantar vein, the anastomosis in the lateral plantar artery perforator of the fifth metatarsal bone, the nutrient vessels of the lateral dorsal cutaneous nerve and lateral plantar vein, and other arteries of the lateral foot were recorded. The flap-raising procedure was performed on three fresh cadavers. The lateral dorsal cutaneous nerve originated from sural nerve, traveled obliquely downward along the anterior lateral margin of the foot, and accompanied by the lateral plantar vein after bifurcation, and was eventually distributed on the lateral aspect of the foot. The nutrifying arteries to the lateral dorsal cutaneous nerve and lateral plantar vein were present segmentally and mainly originated from the lateral plantar artery perforator of the fifth metatarsal bone. These nitrifying arteries constantly originated from the lateral plantar artery in the area of tuberosity of the fifth metatarsal, ran along the medial side of the fifth metatarsal, traveled between the fifth metatarsal bone and the lateral muscle group (the flexor digitorum brevis and the abductor digiti minimi muscles), pierced the aponeurosis, vascularized the skin of the anterior lateral plantar region, and resulted in many minute branches, which anastomosed with the lateral tarsal artery and fourth dorsal metatarsal artery. The anatomical study showed that (1) the vasculature pattern can roughly be classified into three types and (2) constant anastomoses occurred between the above-mentioned arteries in the lateral-dorsum region of the foot. A reliable large- or medium-sized neuro-venocutaneous flap with lateral dorsal cutaneous nerve, lateral plantar vein, and nutrient vessels can be raised using only the perforator of the lateral plantar artery of the fifth metatarsal bone, which is thin, is in the immediate vicinity of the forefoot, and has a reliable retrograde blood supply. This flap can be considered an alternative means to reconstruct soft-tissue defects of the forefoot.

The Lateral Dorsal Cutaneous Branch of the Sural Nerve

Background: Fractures of the proximal fifth metatarsal are one of the most common forefoot injuries encountered by orthopaedic surgeons in sports medicine. The percutaneous surgical approach to Jones fracture fixation and corresponding anatomy has received little attention in the literature to date. Purpose: To describe in detail the location of the lateral dorsal cutaneous nerve (LDCN) and its branches relative to the base of the fifth metatarsal and to the standard lateral approach. Study Design: Descriptive laboratory study. Methods: Ten fresh-frozen cadaveric foot specimens were used for this study. Specimens were dissected at the lateral aspect of the foot over the proximal fifth metatarsal, and the LDCN and its branches were identified. The distance of the LDCN to the superior border of the peroneus brevis tendon (PBT) was measured relative to standard reference points in all specimens, and the presence of an anastomotic branch was noted. A set of vertical and horizontal reference lines were also constructed to determine whether the LDCN or its branches would be compromised by a standard lateral approach. Results: The LDCN was superficial (ie, lateral) and inferior to the superior border of the PBT in all specimens and at all reference points. A bifurcation of the LDCN was present in 8 specimens, located an average of 18 mm posterior and 11 mm dorsal to the base of the fifth metatarsal. The dorsolateral branch and dorsomedial branch of the LDCN each intersected with the base of the fifth metatarsal horizontal line and vertical line, respectively, indicating potential compromise of the nerve with a standard lateral surgical approach. Conclusion: The standard lateral approach to the base of the fifth metatarsal carries a higher risk for surgical injury to the LDCN. A “high and inside” approach that remains superior to the superior border of the PBT is anatomically safe and may decrease the chance of intraoperative nerve injury and irritation postoperatively.

Variable patterns of cutaneous innervation on the dorsum of foot in fetuses

The aim of this study was to classify the different patterns of cutaneous nerves found on the dorsum of foot in Indian fetuses and compare them with patterns found in other population groups. A total of 60 lower limbs from 30 fetuses (19 male, 11 female) were dissected and the branching patterns of nerves were sketched and specimens photographed. Six main types and few subtypes of innervation patterns were found. Type 1 (53.3%): deep peroneal nerve supplied the 1st cleft, lateral dorsal cutaneous nerve supplied the lateral border of little toe and the remaining part of the dorsum of the foot is supplied by superficial peroneal nerve. Type 2 (28.3%): deep peroneal nerve supplied the 1st cleft, superficial peroneal nerve supplied the medial border of big toe, 2nd cleft and lateral 2(1/2) digits supplied by the lateral dorsal cutaneous nerve. Type 3 (8.3%): deep peroneal nerve supplied the 1st cleft, lateral 1(1/2) digits supplied by the lateral dorsal cutaneous nerve and the remaining dorsum by superficial peroneal nerve. Type 4 (3.3%): deep peroneal nerve supplied the 1st and 2nd clefts, superficial peroneal nerve supplied the medial border of great toe, lateral 2(1/2) digits were supplied by lateral dorsal cutaneous nerve. Type 5 (5%): deep peroneal nerve supplied 1st and 2nd clefts, lateral border of the little toe by lateral dorsal cutaneous nerve and remaining part of the dorsum of foot by superficial peroneal nerve. Type 6 (1.7%): deep peroneal nerve supplied 2nd cleft, lateral border of little toe supplied by the lateral dorsal cutaneous nerve and the remaining area by superficial peroneal nerve. A comparison with cutaneous innervation patterns found in other population groups revealed three new variants which have not been reported in the other populations.

A Posttraumatic, Joint-connected Sural Intraneural Ganglion Cyst—With a New Mechanism of Intraneural Recurrence: A Case Report

Intraneural ganglion cysts are rare in occurrence and most commonly involve the peroneal nerve at the fibular neck. We present a case of a traumatically induced intraneural ganglion cyst of the sural nerve that developed after a nondisplaced posterior malleolus ankle fracture. The intraneural ganglion cyst was connected to the subtalar joint by its articular branch and ascended several centimeters into the distal fourth of the leg. It was resected from the sural nerve proper and the posterior branch of the lateral calcaneal nerve, and the articular trunk was ligated. The patient developed subclinical intraneural recurrence, which was detected on a postoperative magnetic resonance imaging (MRI). Retrospective reinterpretation of the preoperative and postoperative MRIs revealed that ligation of the articular trunk proximal to a major branch (ie, the anterior branch of the lateral calcaneal nerve) led to increased intraneural cyst propagation distally: within the blind stump of the articular trunk and within several anterior branches of the lateral calcaneal nerve but not within the parent sural nerve or its continuation, the lateral dorsal cutaneous nerve. This mode of intraneural, but extraparental nerve recurrence can be easily understood by considering the altered fluid dynamics, particularly the increased resistance. This case report provides further evidence not only supporting the articular theory of intraneural ganglion formation but also highlighting the importance of searching for, identifying, and treating the pathologic articular branch connection near its joint connection in all cases. 4.

Continuous lateral dorsal cutaneous nerve block by a portable disposable pump

Continuous lateral dorsal cutaneous nerve block by a portable disposable pump

Continuous lateral dorsal cutaneous nerve block by a portable disposable pump

Continuous lateral dorsal cutaneous nerve block by a portable disposable pump

A neuroma of an intact lateral dorsal cutaneous nerve. A case report.

A neuroma of an intact lateral dorsal cutaneous nerve. A case report.

Recalcitrant pain syndromes of the food and ankle: evaluation of the lateral dorsal cutaneous nerve.

Recalcitrant pain syndromes of the food and ankle: evaluation of the lateral dorsal cutaneous nerve.

The innervation of the joints of the foot.

AbstractThe nerve supply of the ankle joint and of the joints of the foot was studied in dissections of fetal and adult feet and in serial sections of fetal feet stained with silver.The ankle joint was supplied by the tibial, sural, deep peroneal, and saphenous nerves, and by the accessory deep peroneal nerve when present.The tarsal joints were supplied on their plantar aspects by the medial or lateral plantar nerves, and on their dorsal aspects chiefly by the deep peroneal nerve. The joint between the lateral and intermediate cuneiform received branches from the intermediate dorsal cutaneous nerve also. The lateral dorsal cutaneous nerve and the accessory deep peroneal nerve when present provided additional branches to the subtalar and calcaneocuboid joints.The tarsometatarsal joints were supplied on their plantar aspects by the medial or lateral plantar nerves. Most of them were supplied on their dorsal aspects by the deep peroneal nerve, but the cuboid‐metatarsal joints received their supply from the intermediate dorsal cutaneous nerve. The intermetatarsal joints had a similar but sparser supply. The joint between the fourth and fifth metatarsal received branches from the intermediate dorsal cutaneous nerve.The plantar digital nerves provided the main supply to the metatarsophalangeal joints. The dorsal aspect of the first metatarsophalangeal joint was supplied by the deep peroneal and the medial dorsal cutaneous nerves, of the second metatarsophalangeal joint by the deep peroneal nerve, and of the fourth and fifth metatarsophalangeal joints by the lateral dorsal cutaneous nerve. The interphalangeal joints did not receive articular branches from the dorsal digital nerves, except in the case of the interphalangeal joint of the big toe, which was supplied by the deep peroneal and the medial dorsal cutaneous nerves.