Medial Plantar Research Articles

Innervation of the Pelvic Limb of the Adult Ostrich (Struthio camelus)

The pelvic limb of the ostrich is innervated by the lumbar and sacral plexuses. The lumbar plexus gave rise to several nerves (N.s) including, N. coxalis cranialis, lateral and cranial femoral cutaneous N.s, N. femoralis, cranial, caudal and medial crural cutaneous N.s, and N. obturatorius. The remaining nerves emanated from the sacral plexus. The N. iliotibial, N. ischiofemoralis, N. iliofibularis, and N. coxae caudalis were distributed in the thigh, while the N. ischiadica, which terminated as the tibial and fibular N.s that innervated the leg and foot. The tibial N. gave rise to the parafibular N. then divided to form the Nn. suralis medialis and lateralis. The N. suralis medialis continued as the N. metatarsalis plantaris medialis. The parafibular N. continued as the N. plantaris lateralis, which terminated as the R. digitalis of the fourth digit. The fibular N. terminated as the superficial and deep fibular N.s. The superficial fibular N. continued as the N. metatarsalis dorsalis lateralis and divided into two digital N.s to the third and fourth digits. The deep fibular N. crossed the ankle joint and continued as the N. metatarsalis dorsalis medialis that continued as the R. digitalis of the third digit. In general, the innervation of the pelvic limb of the ostrich was similar to the pelvic limbs of several different species of domesticated birds, including the chicken. We discuss the few differences as well as appropriate sites to perform nerve blocks for the lateral and medial dorsal and the lateral plantar N.s.

Are the feet of obese children fat or flat? Revisiting the debate

There is debate as to the effects of obesity on the developing feet of children. We aimed to determine whether the flatter foot structure characteristic of obese primary school-aged children was due to increased medial midfoot plantar fat pad thickness (fat feet) or due to structural lowering of the longitudinal arch (flat feet). Participants were 75 obese children (8.3 ± 1.1 years, 26 boys, BMI 25.2 ± 3.6 kg m(-2)) and 75 age- and sex-matched non-obese children (8.3 ± 0.9 years, BMI 15.9 ± 1.4 kg m(-2)). Height, weight and foot dimensions were measured with standard instrumentation. Medial midfoot plantar fat pad thickness and internal arch height were quantified using ultrasonography. Obese children had significantly greater medial midfoot fat pad thickness relative to the leaner children during both non-weight bearing (5.4 and 4.6 mm, respectively; P<0.001) and weight bearing (4.7 and 4.3 mm, respectively; P < 0.001). The obese children also displayed a lowered medial longitudinal arch height when compared to their leaner counterparts (23.5 and 24.5 mm, respectively; P = 0.006). Obese children had significantly fatter and flatter feet compared to normal weight children. The functional and clinical relevance of the increased fatness and flatness values for the obese children remains unknown.

Hypertrophic abductor hallucis muscle with nerve compression syndrome

A 13-year-old girl presented with a soft tissue swelling at the posteromedial side of the foot. This swelling had been present since birth but recently started to cause discomfort and radiating pain to the plantar aspect of the first and second toes. A magnetic resonance imaging (MRI) showed a soft tissue mass (2,6 x 3,7 x 13 centimetres) at the posteromedial side of the foot with signal-intensity similar to the intensity of muscle tissue on all the different sequences. There was no pathological contrast enhancement. Anatomically this mass was located at the abductor hallucis muscle (AH), representing a prominence or hypertrophy of the abductor hallucis muscle (Fig A). The diagnosis was made of a hypertrofic abductor hallucis muscle with narrowing the space for the medial plantar branches of the tibial nerve (circle) at the crossover between the flexor hallucis longus and flexor digitorum longus tendons (arrow), the quadratus plantae muscle (QP) and flexor digitorum brevis muscle (FDB) (Fig B). Example of a normal fibromuscular tunnel (Fig. C). Our patient was treated conservatively first and referred to a foot surgeon.

Colgajos de las perforantes del pie: problemas y posibles soluciones

Traditional medial plantar flap is widely described in the literature, but foot perforator flap is a relatively new subject which still needs more detailed a...

Weight-bearing plantar reconstruction using versatile medial plantar sensate flap

The medial plantar flap serves as an ideal tissue reserve for reconstructing the weight-bearing plantar areas as these areas require a sensate and glabrous skin. Furthermore, the flap provides tissue that is structurally similar to the plantar foot as it is also composed of thick glabrous plantar skin, shock-absorbing fibro-fatty subcutaneous tissue and plantar fascia. During the past 25 years, 20 patients (10 men, 10 women) with skin and soft-tissue defects over the weight-bearing plantar foot were treated. They ranged in age from 20 to 70 years (mean, 31.5 years). The causes of the defects were trauma (n=14) and malignant tumour (n=6); the defects were localised at the heel (n=16) and plantar forefoot (n=4). The medial plantar flap was transposed to the defects in three different ways: proximally pedicled sensorial island flaps (n =8), distally pedicled sensate island flaps based on the lateral plantar vessel (n =3) and neurovascular free flaps (n =9). Flap size varied from a width of 4-8cm and a length of 6-12cm. The mean size of the medial plantar flap was 49.5cm(2) (range, 28-96cm(2)). The follow-up period ranged from 6 to 80 months (mean, 19.9 months). Partial flap loss was observed in two proximally pedicled sensorial island flaps and one distally pedicled sensate island flap. Two free flaps restored normal sensation within 5 years of surgery. Minor skin graft loss at the donor site was observed in seven patients. However, no revision or re-grafting was performed. Hyperkeratosis was observed in one case. All patients achieved normal gait within 3 months after surgery and none noticed recurred ulceration. Durable, sensate coverage of the defects was achieved in all patients. We advocate variable sensate medial plantar flaps for the reconstruction of moderate-size defects of the weight-bearing plantar subunits.

Anatomy and application of free medial plantar perforator flap

Objective To reports to anatomy and clinical application of the medialis pedis perforator flap. Methods The origin, course, distribution and out diameter of medial plantar perforators, which were located at the septums between the abductor hallucis muscle and the flexor digitorum brevis, and between the abductor hallucis muscle and the skeleton, were observed on 10 sides adult feet specimens perfused with red latex. 11 free medialis pedis perforator flaps were transferred for soft-tissue defect in hand. The areas of tissue defect ranged from 2 cm x 2 cm - 9 cmx 4 cm. Results The medial plantar artery sends 2 perforators with regular anatomy through the septum between the abductor hallucis muscle and the flexor digitomm bre-vis, and 2 perforators with regular anatomy through the septum between the abductor hallucis muscle and nav-icluar bone and the medial cuneiform bone. These perforators supply the medial plantar flap and medialis pedis flap respectively. All of the 11 cases of free medialis pedis perforator flap survived uneventfully. The flap areas ranged from 2 cm × 3 cm - 11 cm× 5 cm. The appearance and functional results were satisfactory with following up for 6 to 24 months. Conclusion The free medialis pedis perforator flap is a good method in repairing soft-tissue defect in hand. Key words: Surgical flaps; Perforator flap; Transplantation; Microsurgery

New method to perform medial plantar proper digital nerve conduction studies

We describe a technique that records the sensory nerve action potential (SNAP) of the medial plantar proper digital nerve (MPPDN), which is the final sensory branch of the medial plantar nerve. We obtained antidromic MPPDN responses from 118 healthy volunteers, with surface recording electrodes placed on the medial side of the first metatarsal head of the great toe, with electrical stimulation applied at the 40% distance of the heel to great toe reference line. Antidromic SNAP parameters were recorded and normative reference values were obtained. The stimulation site that corresponded to 40% of the reference line was located at a mean distance of 8.7+/-1.2 cm from the recording electrodes. MPPDN responses were easily obtained in all but 9 limbs. The mean SNAP amplitudes obtained by our technique were 16.1+/-6.7 microV, and the lower and upper range values were 6.4 microV and 34.4 microV, respectively. Antidromic stimulation of the MPPDN at a distance of 8-10 cm from the medial side of the first metatarsal head of the great toe yields in reliable SNAP responses. This technique should be useful in the evaluation of the MPPDN involvement in Joplin's neuroma.

Modified retrograde‐flow medial plantar island flap for reconstruction of distal dorsal forefoot defects—Two case reports

Soft tissue reconstruction of the distal forefoot and toes poses a difficult problem. Skin grafts are not suitable when deep structures are exposed. Local flaps are not available, particularly for defects of the toes. Free flaps are spared for larger defects. Medial plantar flap has been widely used for plantar defects, especially weight-bearing surface of the heel. Distally based retrograde-flow design of this flap allows the transfer of the pedicled flap distally and provides coverage of soft tissue over the metatarsal heads. In this report, we further modified the retrograde-flow medial plantar island flap to extend its use for distal dorsal forefoot defects. The technique and outcomes of two patients are presented.

First Metatarsal Dorsal Close Wedge Osteotomy Combined with Medial Cuneiform Plantar Open Wedge Osteotomy for the Treatment of a Cavus Foot

Purpose: We wanted to analyze the results of the 1st metatarsal dorsal close wedge osteotomy (MTDW) combined with medical cuneiform plantar open wedge (MCPOW) for treating forefoot deformity of a cavus foot. Materials and Methods: We retrospectively analyzed 30 patients. Their mean age was 21.5 years (SD 10.6 years) and the average follow-up period was 2.3 years. Thirty-four cases of thirty patients were classified as group A, as classified by the 1st MTDW combined with the MCPOW, 16 feet (14 patients) were group B by the 1st MTDW or MCPOW, 12 feet (10 patients), and group C by triple arthrodesis, 6 feet (6 patients). We evaluated the ankle dorsiflexion, plantarflexion, heel alignment, and the Maryland foot score (MFS) preoperatively and the last follow-up, and we analyzed the radiologic Hibb, Meary, calcaneal pitch and tibiotalar angles. Results: The ankle dorsiflexion (p=0.01), plantar flexion (p=0.03) and heel alignment (p=0.02) of group A were significantly improved more than that of groups B and C. The MFS of group A revealed better than group B and C (p=0.01). The Meary (p=0.01), Hibb (p=0.02) and calcaneal pitch angle (p=0.02) of group A were significantly improved more than that of groups B and C. Conclusion: 1st MTDW combined with MCPOW osteotomy that focuses at the apex of the deformity for correction of a cavus foot can obtain better clinical and radiological results than other surgical procedures.

Tibial Nerve Decompression in Patients with Tarsal Tunnel Syndrome: Pressures in the Tarsal, Medial Plantar, and Lateral Plantar Tunnels

The anatomical basis for the surgical techniques used to treat tarsal tunnel syndrome is not well studied. The authors sought to evaluate their hypotheses that (1) pronation and pronation with plantar flexion of the intact foot would have higher pressures than the intact foot in other positions; (2) decompression surgery would significantly lower the pressure in all three tunnels in all foot positions, and roof incision plus septum excision would lower the pressure further in some positions; and (3) the pressures in symptomatic patients would be significantly higher than those in an analogous cadaver study. In 10 patients with tarsal tunnel syndrome, the authors intraoperatively measured pressures in the tarsal, medial plantar, and lateral plantar tunnels in multiple foot positions before and after excision of the tunnel roofs and intertunnel septum. The authors found that (1) pronation and plantar flexion significantly increased pressures in the medial and lateral plantar tunnels, to levels sufficient to cause chronic nerve compression; (2) tunnel release and septum excision significantly decreased those pressures; and (3) compared with cadaver pressures, patients had similar tarsal tunnel pressures but higher lateral plantar tunnel pressures in some positions. Many surgeons operating on patients with tarsal tunnel syndrome do not decompress the respective medial plantar and lateral plantar nerves and excise the septum. The authors' study validates the hypotheses that patients who are clinically suspected of having chronic compression of the tibial nerve and its branches at the ankle have higher tunnel pressures and that releasing these structures decreases the pressures.

Reliability of Superficial Peroneal, Sural, and Medial Plantar Nerve Conduction Studies

The reliability of medial plantar, sural, and superficial peroneal nerve conduction studies (NCS) has not been widely studied. These nerves are usually involved in distal sensory neuropathies and their serial study is relevant in the clinical setting. To determine the inter- and intrarater reliability of superficial peroneal, sural, and medial plantar NCS in healthy participants. Two raters performed the bilateral NCS twice in 20 healthy participants (23.5 +/- 3.5 years). Reliability was analyzed by the Bland-Altman method and intraclass correlation coefficient (ICC). Variability was established by the coefficient of variation. The Bland-Altman method showed a good level of intra- and interrater agreement for all nerves. The amplitude (rater 1) and latency of the medial plantar nerve and the amplitude of the sural nerve (rater 2) had an intrarater ICC of >or=0.75. Interrater analysis showed concordance levels between moderate and very low. The highest coefficients of variations were found for amplitude and the lowest for nerve conduction velocity. Although the Bland-Altman method confirmed a good intra- and interrater reliability of the studied nerves, ICC analyses showed mixed results. These statistical approaches are complementary, and each one has advantages and disadvantages that must be considered in their application and interpretation.

The Usefullness of Medial Plantar and Lateral Dorsal Cutaneous Branch of Sural Nerve Conduction Studies in Diabetic Patients

The Usefullness of Medial Plantar and Lateral Dorsal Cutaneous Branch of Sural Nerve Conduction Studies in Diabetic Patients

Free Medial Plantar Artery Perforator (MPAP) Flap for the Resurfacing of Finger Defect-Report of Two Cases

Background: Finger destruction secondary to trauma represents a much more significant influence on the activity of daily living. Various surgical techniques contribute to cover the distal defect of the finger. Aim and Objectives: We would like to introduce a find-designed perforator skin flap to reconstruct the finger defects. Material and Method: Two patients received free medial plantar artery perforator (MPAP) flaps to resurface the palmar defects of fingers. The flaps were harvested without interrupting the circulation of the medial plantar artery. The flap perforator was anastomosed to proper digital artery and the superficial vein of the MPAP flap was anastomosed to dermal vein of the injured finger which had no severe length discrepancy or metacarpophalangeal joint injury. Results: One male and one female patient were arranged for free MPAP flap reconstruction in March and August 2007. The mobility of the fingers was not restricted after surgery. One flap survived completely with no vascular compromise. Another flap encountered venous congestion and only partially failed (30% loss) after salvage. Conclusion: The MPAP flap is a suitable choice to reconstruct defect of the finger with less donor site morbidity. The cushiony characteristic of the MPAP flap is anatomically similar to the pulp tissue of fingers. Technical difficulty is focused on anastomosis of perforators (diameter≦ 0.8mm) and limited access of concomitant vein. With the many advantages of the MPAP flap, it is worthy of application to more reconstruction needs, particularly for finger defects.

Compartment Syndrome of the Lower Leg and Foot

Compartment syndrome of the lower leg or foot, a severe complication with a low incidence, is mostly caused by high-energy deceleration trauma. The diagnosis is based on clinical examination and intracompartmental pressure measurement. The most sensitive clinical symptom of compartment syndrome is severe pain. Clinical findings must be documented carefully. A fasciotomy should be performed when the difference between compartment pressure and diastolic blood pressure is less than 30 mm Hg or when clinical symptoms are obvious. Once the diagnosis is made, immediate fasciotomy of all compartments is required. Fasciotomy of the lower leg can be performed either by one lateral incision or by medial and lateral incisions. The compartment syndrome of the foot requires thorough examination of all compartments with special focus on the calcaneal compartment. Depending on the injury, clinical examination, and compartment pressure, fasciotomy is recommended via a dorsal and/or medial plantar approach. Surgical management does not eliminate the risk of developing nerve and muscle dysfunction. When left untreated, poor outcomes with contractures, toe deformities, paralysis, and sensory neuropathy can be expected. In severe cases, amputation may be necessary. Level III. See Guidelines for Authors for a complete description of levels of evidence.

PO1.15 The Changes in the Mixed Nerve Conduction with Age in the Medial and Lateral Plantar Nerves

PO1.15 The Changes in the Mixed Nerve Conduction with Age in the Medial and Lateral Plantar Nerves

PO1.5 Medial Plantar Sensory Nerve Conduction Studies in Diabetics; Comparisons of Three Different Methods

PO1.5 Medial Plantar Sensory Nerve Conduction Studies in Diabetics; Comparisons of Three Different Methods

Reconstruction of a child’s forefoot defect using a distally based pedicled medial plantar flap

This report describes a case of a 10-year-old boy who received a distally based, pedicled medial plantar artery flap to cover a defect on the distal lateral side of his right foot. The defect resulted from amniotic constriction. The flap served as defect coverage and was kept viable solely by the distal medial plantar vessels. Use of this particular kind of flap proves advantageous in that it provides good protection in the weight-bearing area of the foot, while causing only a minor donor site defect.

Modified pedicled tongue-like skin extension fasciocutaneous flaps for heel reconstruction; a versatile technique

Soft-tissue reconstruction for isolated heel defects represents a challenging surgical dilemma due to tight inelastic tissue and inevitable acute angulations of the fibro-vascular pedicle of local flaps. A modified pedicled flap with a tongue-like skin extension has been designed to eliminate tunnel tightness to avoid traction injury and kinking of the blood vessel. Between 2003 and 2005, eight patients with isolated heel defects were analysed (six men, two women). Their age ranged from 5 to 47 years (median age = 31). Six were traumatic while two were neuropathic. Reversed sural (n = 4), medial planter (n = 3) and one dorsalis pedis artery fasciocutaneous flap were used. The average follow-up period was 1 year during which the flaps were monitored for venous congestion, ischemia, superficial epidermolysis and partial or total flap loss. Only one modified pedicle flap showed mild venous congestion; on the other hand, no other ischemic events such as superficial epidermolysis or flap loss were experienced. The modified tongue-like process extension is considered a valuable tool to increase the versatility of these flaps.

Limiar de sensibilidade cutânea dos pés em pacientes diabéticos através do pressure specified sensory device: uma avaliação da neuropatia

Neuropathy is a severe progressive loss of protective sensation in the feet, increasing patient vulnerability to mechanical trauma and consequently more prone to development of chronic wounds, major distortion of the foot bone architecture and to eventual limb amputation. Prophylaxis should be enforced to avoid foot ulceration and for this purpose, evaluation of the degree of loss of sensation on the skin is essential. The PSSD (Pressure Specified Sensory Device) was developed to quantify the threshold of pressure applied to the skin that the patient might recognize as positive. Pressure of one or two points is tested both statically and with movement, thus assessing the function of fast and slow response nerve fibers. 33 diabetic patients, type II, with no previous history of wounds on the lower extremity were studied. The tests used were, one point static, one point moving and two points, static and moving on the cutaneous territory of the fibular nerve and posterior tibial nerve (two territories - medial plantar and calcaneous nerves). Altered values were observed for the static and dynamic tests over the three nerve territories studied. Differences were statically significant (p < 0.05). This numeric quantification of the threshold of pressure supports the evaluation of the status of the fiber/receptor structures as well as the functional deficit subsequent to diabetic neuropathy.

Cadaveric Simulation of a Pes Cavus Foot

The pes cavus deformity has been well described in the literature; relative bony positions have been determined and specific muscle imbalances have been summarized. However, we are unaware of a cadaveric model that has been used to generate this foot pathology. The purpose of this study was to create such a model for future work on surgical and conservative treatment simulation. We used a custom designed, pneumatically actuated loading frame to apply forces to otherwise normal cadaveric feet while measuring bony motion as well as force beneath the foot. The dorsal tarsometatarsal and the dorsal intercuneiform ligaments were attenuated and three muscle imbalances, each similar to imbalances believed to cause the pes cavus deformity, were applied while bony motion and plantar forces were measured. Only one of the muscle imbalances (overpull of the Achilles tendon, tibialis anterior, tibialis posterior, flexor hallucis longus and flexor digitorum longus) was successful at consistently generating the changes seen in pes cavus feet. This imbalance led to statistically significant changes including hindfoot inversion, talar dorsiflexion, medial midfoot plantar flexion and inversion, forefoot plantar flexion and adduction and an increase in force on the lateral mid- and forefoot. We have created a cadaveric model that approximates the general changes of the pes cavus deformity compared to normal feet. These changes mirror the general patterns of deformity produced by several disease mechanisms. Future work will entail increasing the severity of the model and exploring various pes cavus treatment strategies.