Medial Dorsal Cutaneous Nerve Research Articles

ANATOMICAL VARIATIONS IN A FINITE ELEMENT NERVE MODEL OF THE HUMAN FOOT

The nerves in the foot offer a significant role in controlling the movement and correct loading of the foot by providing continuous feedback to the central nervous system. The health importance in the anatomical variations of nerves, such as the locations, the lengths, the communicating branches, and the distance between the adjacent nerve terminals between individuals have given prominence to anatomists as well as physiologists. A previously developed one-dimensional (1D) model of the nerve was extended to determine different anatomical variations in the nerves of the foot, as a realistic anatomical-based variant nerve model of the human foot is not available. The model was verified against experimental data from the literature for communicating branches and distances of various area of the human foot. For instance, the simulated distances of the communicating branches of the plantar nerves and medial dorsal cutaneous nerve (MDCN) division proximal to the first digital space were found to be 43.3 mm and 112.3 mm, respectively, which was in general agreement with the experimental distances of 8-56 mm and 96-116.74 mm, respectively. The developed nerve variant model provides a platform for future studies of the various geometrical and efficient concerns of neurovascular diseases such as diabetic neuropathies by determining the parameters of nerve conduction studies.

Medial dorsal cutaneous nerve entrapment following inversion ankle sprain

The medial dorsal cutaneous nerve is one of the terminal branches of the superficial peroneal nerve that provides sensory innervation to the dorsum of the foot. It may be prone to injury by direct blow, iatrogenic surgical lesion or in rare situations secondary to ankle sprains. The authors report a case of persistent ankle pain in a female patient caused by a post- traumatic compressive neuropathy of the medial dorsal cutaneous nerve secondary to an ankle sprain which was successfully surgically treated with complete resolution of the symptoms.

Minimally invasive subtalar joint and talonavicular joint preparation for hindfoot arthrodesis: A Cadaveric study evaluating structures at risk

Minimally invasive surgery (MIS) is growing in popularity due to smaller incisions, faster recovery times with less post-operative pain, and measurable decreases in morbidity. Our center performed an MIS hindfoot joint preparation about the talonavicular and subtalar joints and defined structures at risk in order to make this procedure more reproducible. Using ten fresh frozen cadaver limbs, we created a medial and lateral portal for talonavicular joint (TN) access, and an additional portal for subtalar joint (STJ) access to prepare the subtalar joint. After denuding the aforementioned joints of cartilage, the specimens were dissected to identify nearby anatomical structures. We documented the position of the peroneal sheath and sural nerve relative to the STJ portal, and the position of the dorsalis pedis artery (DP), medial dorsal cutaneous nerve (MDCN), extensor hallucis longus (EHL), extensor digitorum longus (EDL), tibialis anterior (TA), and tibialis posterior (TP) tendons relative to the TN portals. The average distance of the sural nerve and the peroneal sheath from the STJ portal was 34.21 mm and 14.12 mm respectively. The average distance of the DP, MDCN, and deep peroneal nerve from the medial and lateral TN portals were 13.31 mm, 11.54 mm, and 17.14 respectively. No neurovascular structures were transected throughout joint preparation. To our knowledge this is the first study looking into structures at risk for this specific procedure.

Anatomical landmarks for ankle block

We aimed to describe anatomical landmarks to accurately locate the five nerves that are infiltrated to accomplish anaesthesia of the foot in an ankle block. Twenty-four formaldehyde-fixed cadaveric ankles were studied. Photographs of cross sections of the frozen legs, cut at a horizontal plane across the most prominent points of the medial and lateral malleoli, were analysed. The curvilinear distance from the most prominent point of the closest malleolus to each of the five cutaneous nerves and their depth from the skin surface were measured. Sural, tibial, deep peroneal, saphenous and medial dorsal cutaneous nerves were located 5.2 ± 1.3, 9.2 ± 2.4, 7.4 ± 1.9, 2.8 ± 1.1, 2.1 ± 0.6 mm deep to the skin surface. The curvilinear distances from the medial malleolus to the tibial, deep peroneal and saphenous nerves were 32.5 ± 8.9, 62.8 ± 11.1 and 24.4 ± 7.9 mm, respectively. The curvilinear distances from the lateral malleolus to the sural and medial dorsal cutaneous branches of superficial peroneal nerves were 27.9 ± 6.3 and 52.7 ± 7.3 mm, respectively. The deep peroneal nerve was found between the tendons of the extensor hallucis longus and the extensor digitorum longus in the majority of specimens, while the medial dorsal cutaneous nerve was almost exclusively found on the extensor digitorum longus tendon. The sural and tibial nerves were located around halfway between the most prominent point of the relevant malleolus and the posterior border of the Achilles tendon. In conclusion, this study describes easily identifiable, palpable bony and soft tissue landmarks that could be used to locate the nerves around the ankle.

Connection between medial dorsal cutaneous nerve and saphenous nerve: case report.

There are no data on the connection of the saphenous nerve (SN), located on the medial side of the foot, with the terminal branches of the superficial fibular nerve. The aim of this study is to reveal the variation that surgeons should pay attention to for anesthesia applied in foot surgeries. In this study, the left foot of a 70-year-old female cadaver fixed with formalin was dissected. The distance to the medial malleolus and the incision line was recorded using digital caliper to determine the reference points in the resulting variation. It was observed that a branch from the SN, which arose from the SN and proceeded anteriorly to the upper part of the medial malleolus and continued towards the dorsum of the foot, hooked with a branch from the medial dorsal cutaneous nerve (MDCN). The branches arising from this hook were distributed on the medial edge of the foot up to the proximal metatarsophalangeal joint I. The distance of this nerve connection to the medial malleolus is 91.14mm, and the distance to the incision line is 15.76mm. It is suggested that the case presented as an unusual SN variation, which may affect the success of local anesthesia in invasive procedures to the medial part of the foot and could be considered in the evaluation of sensory loss after anteromedial surgical approach to the ankle, should be included in the classification of the cutaneous innervation pattern of the foot.

Anatomical Variations in the Course and Level of Termination of Superficial Peroneal Nerve- A Cadaveric Study

Introduction: Several variations in the course and branching pattern of the Superficial Peroneal Nerve (SPN) have been reported. Knowledge of the different course of SPN is essential in reducing the risk of iatrogenic injury during the orthopaedic foot and ankle surgery and various other procedures. Aim: To observe any variations in the course, and level of termination of SPN. Materials and Methods: This descriptive analytical study was conducted on 50 lower limb specimens in the Department of Anatomy, Bangalore Medical College and Research Institute Bengaluru from January 2013 to January 2016. Dissection kit was used for dissection, digital camera was used for photography of specimens, measuring tape was used to measure the distance at which the SPN became cutaneous with respect to the tip of lateral malleolus and the distance at which SPN terminated into medial and Intermediate Dorsal Cutaneous Nerve (IDCN) with reference to the tip of lateral malleolus. Descriptive statistics was used and results were expressed as Mean±SD. Results: It was observed that the distance at which SPN became cutaneous with respect to tip of lateral malleolus was 10±2.82 cm. The level of termination of SPN into Medial Dorsal Cutaneous Nerve (MDCN) and IDCN with reference to tip of lateral malleolus was 4.7±2.08 cm. In 5 (10%) of 50 specimens the SPN terminated at a higher level before piercing the deep fascia. Out of these 5 specimens, it was observed that in one specimen the SPN terminated above the head of fibula before piercing Peroneus Longus (PL) muscle. In another specimen, the SPN terminated near the head of fibula before piercing PL muscle. In one of the specimens SPN terminated near head of fibula after piercing PL, in two specimens SPN terminated in upper third of the leg after piercing PL muscle and their terminal branches pierced the deep fascia and emerged out at different level with respect to tip of lateral malleolus. Conclusion: SPN became cutaneous and terminated in the distal third of the leg in most cases. This knowledge is very helpful to surgeons and orthopaedists in performing fasciotomy, and ankle arthroscopy to prevent iatrogenic injury to the nerve.

Identification of portals and evaluation of their safeness for MIS arthrodesis of the 1st tarsometatarsal joint

There has been a growing trend towards the use of minimally invasive surgical techniques in foot and ankle surgery. The aim of this study is to identify portal sites for minimally invasive arthrodesis of the 1st TMT joint and determine the safeness of each portal to the surrounding structures. 10 cadavers were utilized. 3 portal sites were utilized in preparing the 1st TMT joint which included dorsomedial, plantar medial and dorsolateral portals at the level of the 1st TMT joint. Fluoroscopic guided joint prep was performed. After joint prep, each specimen was dissected to evaluate structures at risk which included the deep peroneal nerve, dorsalis pedis artery, EHL Tendon, medial dorsal cutaneous nerve and medial marginal vein. In 1 specimen, there was noted to be disruption of the deep peroneal nerve, dorsalis pedis artery and partial tear of the EHL through the dorsolateral portal. No damage to any vital structures was noted at the dorsomedial or plantar medial portals. All but 1 specimen was determined to be underprepped with the dorsolateral aspect of the joint being the most common area. Additionally, upon open dissection to evaluate the joint prep, there was noted to be some small pieces of cartilage remaining despite thorough irrigation. The three-portal approach for the MIS 1st TMTJ arthrodesis is a relatively low risk procedure, with low risk of injury to the surround neurovasculature and tendon structures. However, care should be taken at each portal site with resecting cartilage to ensure no damage to surrounding vital structures occurs while also ensuring adequate joint preparation.

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.

Dual-incision minimally invasive fasciotomy of the anterior and peroneal compartments for chronic exertional compartment syndrome of the lower leg

To evaluate the risk of iatrogenic injury when using a dual-incision minimally invasive technique to decompress the anterior and peroneal compartments of the lower leg. Forty lower extremities from 20 adult cadavers, embalmed with Thiel’s method, were subject to fasciotomy of the anterior and peroneal compartment using a dual-incision minimally invasive fasciotomy. The first incision was made 12 cm proximal to the lateral malleolus to identify and protect the superficial peroneal nerve (SPN). The second incision was made at the mid-point of the Fibula (half-way between the fibular head and the lateral malleolus). Release of the anterior and peroneal compartments was successful in all specimens. Two nerve injuries of the superficial peroneal nerve were reported. More precisely, in these cases the medial dorsal cutaneous nerve got injured during the fascial opening of the extensor compartment. Two incision minimally invasive fasciotomy to decompress the anterior and peroneal compartments of the lower leg appears to be safe with regard to the results of this study.

Accuracy of Palpation to Identify the Medial Branch of the Medial Dorsal Cutaneous Nerve in Medial Column Surgery: Correlation of Preoperative Nerve Marking With Intraoperative Findings During Lapidus Fusion

The medial branch of the medial dorsal cutaneous nerve is frequently encountered in medial column surgery. Postoperative sensory nerve symptoms can lead to dissatisfaction and suboptimal outcome. The purpose of this case series is to correlate intraoperative nerve location on direct viewing with preoperative nerve localization to assess the accuracy of a specific nerve palpation technique. Hundred consecutive patients undergoing elective Lapidus fusion were prospectively evaluated. Preoperative nerve localization and intraoperative comparison was performed along with assessment of nerve position in relation to the cuneiform and first tarsometatarsal joint. Preoperative nerve identification correlated with intraoperative findings in 99 of 100 consecutive cases. In 1 of 100 cases, the palpated nerve was proximal to the zone of dissection and was not visualized. The medial branch of the medial dorsal cutaneous nerve crossed the dorsal Lapidus incision at the medial cuneiform or first metatarsal base level in 95 of 100 cases; at the mid metatarsal level in 2 of 100 cases; and proximal to the medial cuneiform in 3 of 100 cases.

Effect of free medial plantar perforator flap in repairing deep burn wound on palm with the assistance of three dimensional computed tomography angiography

Objective: To explore the effect of free medial plantar perforator flap in repairing deep burn wound on palm with assistance of three dimensional computed tomography angiography (CTA). Methods: From March 2015 to January 2018, 11 patients with deep burn wounds of palm were admitted to the Department of Burns and Plastic Surgery of Yidu Central Hospital of Weifang City, including 6 males and 5 females, aged 19-53 years. The wound area after debridement was 3.0 cm×2.5 cm-8.0 cm×6.0 cm. Before the operation, CTA of the foot was performed, and the three dimensional digital model was reconstructed by computer software to observe the initial position, course, and distribution of the arteries and veins in the donor site. The medial plantar perforator flap was designed according to the area and shape of the wound, with area of 3.5 cm×3.0 cm-8.5 cm×6.5 cm. After the wound was covered by the flap, the perforating branch of the medial plantar artery was anastomosed end to end with the carpal epithelial branch of the ulnar artery, the accompanying vein or the branch of the great saphenous vein was anastomosed end to end with the accompanying vein of the carpal epithelial branch of the ulnar artery, and the terminal branch of the saphenous nerve or the medial dorsal cutaneous nerve was anastomosed end to end with the superficial palmar branch of the ulnar nerve. The wound of donor site was covered with full-thickness skin graft from the outer thigh of the same side. The perforators of the medial plantar artery observed during the operation were compared with the reconstructed three dimensional CTA images. The survival of flap was observed, and the appearance and function of the flap were followed up and evaluated with trial standard for the evaluation of the functions of the upper limbs of the Hand Surgery Society of the Chinese Medical Association. Results: The initial position, course, and distribution of the perforator of the medial plantar artery during the operation were basically the same as those of the reconstructed three dimensional CTA images before the operation. All the flaps of patients survived after the operation. During the 6 months to 1 year follow-up, the appearance of flap was good, with no obvious swelling or pigmentation, but with good elasticity. The discrimination distance between the two points was 5.0-8.0 mm, and the flaps were evaluated as excellent in 4 cases, good in 6 cases, and fair in 1 case. Conclusions: The free medial plantar perforator flap is an ideal choice for repair of the deep burn wound on palm. Three dimensional CTA before the operation can detect condition of vascular variation, with high accuracy of vascular anastomosis during operation.

Surgical Anatomy of the Medial Cuneiform (Cotton) Osteotomy.

Background:The Cotton osteotomy, or dorsal-opening wedge osteotomy of the medial cuneiform (MC), is used to address medial column alignment to restore the static-triangle of support. There are many described techniques regarding the incision and osteotomy. Successful completion of the osteotomy requires knowledge of the anatomy, particularly the location of the medial dorsal cutaneous nerve (MDCN). This study describes the relationship between MDCN, tibialis anterior, extensor-hallucis-longus tendon, and ligamentous attachments to the MC. A technique to determine a safe location for the osteotomy is also described.Methods:Twelve fresh-frozen adult foot specimens were used for this study (7 male and 5 female). The MDCN and its branches were dissected and its relationship with the MC was documented. Osteotomy tilt angle and relationship to structures around the MC were measured.Results:MDCN traveled medially and distally over the dorsum of the MC, and a small branch to the MC was observed. The tilt angle was 80.1 ±1.4 degrees. There was no significant difference between the distance from the distal-articular surface to the midline of the cuneiform and to the interosseous ligament (P = .69), or between the distance from the distal-articular surface to the second tarsometatarsal joint and to the origin of the Lisfranc ligament (P = .12).Conclusions:The dorsal-medial-oblique incision effectively protected MDCN and the MC. We believe the osteotomy should be performed in the safe zone to maintain the stability of the opening wedge.Clinical relevance:The dorsal-medial-oblique incision could reduce the risk of injury to the MDCN and the tibialis-anterior tendon.

Applied anatomy of the first metatarsal proximal perforator-based neurocutaneous vascular flap

Objective To explore the anatomical characteristics of mediate dorsal pedal cutaneous nerve and its nutritional vessels to provide anatomical basis of the perforator pedicle flap based on the medial dorsal pedal neurocutaneous vessels for repairing the forefoot soft-tissue defects. Methods From December, 2016 to April, 2017, the following contents were investigated in 30 adult feet specimens perfused with red latex: ①The course, branches and distribution of the medial dorsal pedal cutaneous nerve. ②The origin, course, branches and distribution of the nutrient vessels of the medial dorsal pedal neurocutaneous vessels. Mimic operation was performed on 1 fresh specimen. Results ①The mediate dorsal pedal cutaneous nerve mainly arose from the medial branch of the superficial peroneal nerve and processed forward for a distance of (2.5±0.4) cm under the surface of the inferior extensor retinaculum, and then divided into the mediate dorsal branch, the 1st and 2nd dorsal metatarsal branch over part of the dorsal pedal and digital skin. ②The medial dorsal pedal neurocutaneous vessels were multiple segmental and polyphyletic, mainly include dorsalis pedis artery proximal perforator, the first metatarsal proximal perforator, the tibial proper plantar digital artery of the great toe and the perforater of the second toe web artery, of which the first metatarsal proximal perforator was most associated with operating methods. The first metatarsal proximal perforator perforate through the deep fascia to the subcutaneous area within the range of 1.0-2.0 cm near the proximal first plantar gap, the piercing point of which on deep fascia was constant,and the anatomical plane of the first metatarsal proximal perforator was higher than that of both the perforator of the toe web artery and the tibial proper plantar digital artery of the great toe. The first metatarsal proximal perforator divide into a large number of branches, which closely anastomose with adjacent perforators and other medial dorsal pedal neurocutaneous vessels. ③Simulated surgery showed that the first metatarsal proximal perforation pedicle flap to meet the forefoot soft tissue defect repair. Conclusion The first metatarsal proximal perforator is constant in piercing point and reliable in blood supply, and it have a higher anatomical plane than that of both the perforator of the toe web artery and the tibial proper plantar digital artery of the great toe. The first metatarsal proximal perforator-based medial dorsal pedal neurocutaneous vascular flap can be transferred to repair the soft-tissue defects of forefoot. Key words: First metatarsal proximal perforator; Medical dorsal pedal cutaneous nerve; Surgical flaps; Applied anatomy

A Technique for the Reduction of Complications Associated With Anterior Portal Placement During Ankle Arthroscopy Using a Peripheral Vein Illumination Device

Ankle arthroscopy is a minimally invasive technique for ankle joint treatment. However, injury to the intermediate dorsal cutaneous nerve (IDCN) and the medial dorsal cutaneous nerve (MDCN) is a common complication during anterior portal placement. To prevent injuries, methods such as palpating the nerves topographically and marking the nerves by transilluminating the skin with an arthroscope have been proposed. Easier and more definitive methods of identifying the IDCN and MDCN should result in a reduction of complications. Recently, a vein imaging system was developed that projects images of subcutaneous vasculature directly onto the skin with the use of near-infrared (NIR) light. Because anatomic studies have shown that superficial veins accompany the IDCN and MDCN, protecting the subcutaneous veins could lower the risk of nerve injury. We introduce our technique for the creation of an ankle arthroscopic portal using an NIR imaging system, which displays the vein image on the skin, to prevent injury to the superficial veins and, consequently, reduce IDCN and MDCN injuries. This is the first technical report on the prevention of vein and nerve injuries using an NIR imaging system. Our technique for avoiding vein injury using a peripheral vein illumination device during anterior portal placement in ankle arthroscopy could lower the risk of complications.

Sonography-guided recording for superficial peroneal sensory nerve conduction study.

We sought to establish the optimal recording position for antidromic conduction of the superficial peroneal nerve (SPN) by using ultrasonography (USG). The sensory nerve action potentials (SNAPs) of the intermediate dorsal cutaneous nerve (IDCN) and medial dorsal cutaneous nerve (MDCN) in 64 limbs of 32 healthy participants were recorded (nerve conduction study [NCS]-1). Both nerves were identified by using USG, and the SNAPs were obtained from the USG-guided repositioned electrodes (NCS-2). The IDCN and MDCN were located at 29.3% ± 5.1% and 43.9% ± 4.9% of the intermalleolar distance from the lateral malleolus, respectively. Significantly greater amplitude was shown for SNAPs of both nerves in NCS-2 versus NCS-1. The optimal recording position is likely to be lateral, one-third from the lateral malleolus for the IDCN, and just lateral to the midpoint of the intermalleolar line for the MDCN. When the SPN response is unexpectedly attenuated, USG-guided repositioning of the electrodes should be considered. Muscle Nerve 57: 628-633, 2018.

Variations in the distal branches of the superficial fibular sensory nerve.

We evaluated anatomic variations of distal branches of the superficial fibular sensory nerve electrophysiologically. Orthodromic nerve conduction studies (NCS) of the first and third branches (M-I, M-III) of the medial dorsal cutaneous nerve and the fourth and fifth branches (I-IV, I-V) of the intermediate dorsal cutaneous nerve (IDCN) were performed. To find anomalous innervations from the dorsal sural nerve (DSN) in the IDCN territory, NCS of the fourth and fifth branches (S-IV, S-V) of the DSN were also performed. All sensory nerve action potentials (SNAPs) of M-I and M-III could be obtained bilaterally from 31 healthy Japanese volunteers. SNAPs of I-IV and I-V were recordable in 85.5% and 43.5% of feet, respectively. Anomalous innervations from the DSN were confirmed in 71.0% of S-IV and 93.5% of S-V. These results suggest that anatomical variations in the IDCN territory are very frequent in Japanese subjects. Muscle Nerve 55: 74-76, 2017.

Superficial fibular nerve variations of fascial piercing: A meta-analysis and clinical consideration.

The superficial fibular (peroneal) nerve (SFN) is one of the successive branches of the common fibular (peroneal) nerve and goes on to bifurcate into the medial dorsal cutaneous (MDN) and intermediate dorsal cutaneous (IDN) nerves. The SFN is a main contributor to sensory innervation of the foot and lower leg. It varies widely in its penetrance of the deep (crural) fascia, and differences in its subsequent course can result in iatrogenic injuries. Articles on the prevalence of this anatomical variation were identified by a comprehensive database search. The data collected were extracted and pooled into a meta-analysis. A total of 14 articles (n = 665 lower limbs) were included on the meta-analysis of SFN variations in fascial piercing. The normal Type 1 variation, where the SFN pierces the deep fascia as a single entity and later bifurcates into the MDN and IDN, had a pooled prevalence of 82.7% (95%CI: 74.0-89.4). The Type 2 variant, where the SFN bifurcates early and then pierces the fascial layer separately as the MDN and IDN, had a pooled prevalence of 15.6% (95%CI: 8.9-23.6). Type 3, when the SFN penetrates the deep fascia and courses similar to the MDN with absent IDN was noted in 1.8% (95%CI: 0.0-4.9) of cases. A substantial portion of the population has a pattern of SFN piercing that deviates from the normal Type 1 anatomy. It is recommended that possible SFN variants in patients should be addressed thoroughly to help prevent iatrogenic injuries and postoperative complications. Clin. Anat. 30:120-125, 2017. © 2016 Wiley Periodicals, Inc.

Association between the Levels of IL-6, sE-Selectin and Distal Sensory Nerve Conduction Studies in Patients with Prediabetes

Aim: To determine the association between interleukin-6 (IL-6) and soluble E-selectin (sE-selectin) levels with the electrodiagnostic abnormalities in patients with impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). Methods: Serum HbA1c, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, IL-6 and sE-selectin levels were analyzed in 25 IFG patients, 22 IGT patients and 41 controls. Nerve conduction studies (NCS) of sural, dorsal sural (DS), medial dorsal cutaneous and medial plantar sensory nerves were conducted. Results: HbA1c and IL-6 levels were significantly higher in IFG and IGT patients than the controls. IGT patients had higher sE-selectin levels compared to controls and IFG patients. IL-6 levels were significantly correlated with levels of CRP, fibrinogen, ESR and sE-selectin in patients with prediabetes. Both IFG and IGT patients had substantial impairments in very distal sensory NCS. IL-6 levels were positively correlated with HbA1c and negatively correlated with DS NCS in prediabetic patients. Conclusions: Inflammation and endothelial dysfunction might be important in patients with IFG or IGT. Furthermore, our findings strengthen the idea that inflammation (increased levels of IL-6) might be associated with early electrophysiological impairments in patients with prediabetes. NCS of the most distal sensory nerves significantly enhanced the diagnosis of subclinical neuropathy in patients with prediabetes. Subclinical peripheral sensory neuropathy should be investigated in prediabetes to lower the number of future outcomes they are associated with.

Anterior Approach Total Ankle Arthroplasty: Superficial Peroneal Nerve Branches at Risk

In ankle arthroplasty, little attention has been given to intraoperative nerve injury and its postoperative sequelae. The aim of the present anatomic study was to determine the relationship of the superficial peroneal nerve to the standard anterior approach for total ankle arthroplasty. The superficial peroneal nerve was dissected in 10 below-the-knee cadaver specimens. The medial and intermediate dorsal cutaneous branches were identified. A needle was placed at the ankle joint. The following measurements were recorded: bifurcation into the medial and intermediate dorsal cutaneous branches, reference needle to the branches of the medial and intermediate superficial peroneal nerve, and the crossing branches of the medial dorsal cutaneous nerve. Two specimens (20%) had a medial dorsal cutaneous branch cross from medially to laterally. Eight specimens (80%) had a crossing branch of the medial dorsal cutaneous branch within 5 cm of the incision. No intermediate dorsal cutaneous branches were within the incision. The results from the present cadaver study suggest that during an anterior ankle approach, aberrant branches of the superficial peroneal nerve could require transection in 20% of patients at the joint level and ≤80% of patients with distal extension >35 mm from the ankle joint. The risk of injury to branches of the superficial peroneal nerve is substantial. The risk of nerve injury can be decreased with meticulous operative technique, smaller incisions, and the avoidance of aggressive retraction.

Determination and classification of cutaneous innervation of the dorsum of the foot in foetal cadavers.

The aim of this study is to determine cutaneous innervation of the dorsum of the foot on foetal cadavers. In this study. 200 limbs from 100 embalmed foetuses (54 males and 46 females) were studied in Anatomy Laboratory. Contributions of medial, lateral and intermediate dorsal cutaneous nerves (MDCN, LDCN and IDCN) of the foot were identified. Cutaneous innervation of the dorsum of the foot was classified into five types. Type I (75%) where MDCN innervated medial border of the foot and second interdigital cleft; IDCN innervated third, fourth and fifth interdigital clefts; and LDCN innervated the lateral border of the foot. Type II (21%) where MDCN innervated medial border of the foot, second and third interdigital clefts; IDCN innervated fourth and fifth interdigital clefts; and LDCN innervated the lateral border of the foot. Type III (1.5%) where saphenous nerve innervated medial border of the foot; MDCN innervated second and third interdigital clefts; IDCN innervated fourth and fifth interdigital clefts; and LDCN innervated the lateral border of the foot. Type IV (1.5%) was similar to type I, with an extra connection between the MDCN and IDCN on the dorsum of the foot. Type V (1%) where superficial fibular nerve innervated medial border of the foot, and second, third and fourth interdigital clefts; and sural nerve innervated fifth interdigital cleft and lateral border of the foot. The present study provides a new classification for the cutaneous innervation of the dorsum of the foot.