Medial Sural Cutaneous Nerve Research Articles

Morphological Variability of the Sural Nerve and Its Clinical Significance.

The sural nerve provides sensory innervation to the skin on the distal posterolateral third of the lower extremity. The morphological variants are characterized by high variability. However, it most commonly arises from a union of the medial sural cutaneous nerve and the peroneal communicating branch of the common fibular nerve. This article overviews the anatomical and clinical significance of the sural nerve. Despite the remarkable development of genetic diagnostics, sural nerve biopsy is still a very important tool to diagnose peripheral neuropathies such as diabetic, vascular and inflammatory neuropathies. Furthermore, the sural nerve is also commonly transplanted due to its characteristics. Such a procedure is applicable in cases of segmental nerve loss, but it is also used to restore potency in patients after radical prostatectomy. The knowledge of anatomical variants of the sural nerve is also crucial as it allows to minimize its damage during surgical procedures. Furthermore, during an ankle surgery, a nerve block can be used to complement anesthesia. The major aim of this work is to review contributions of the sural nerve to physiological and pathophysiological processes.

Modified Oblique Lobenhoffer (MOL) approach for posterolateral and posteromedial column access in tibial plateau fractures: a detailed cadaveric anatomical study

BackgroundTibial plateau fractures involving posteromedial (PM) and posterolateral (PL) columns are complex injuries that require an appropriate approach. The management of the PL column in these cases can be controversial, and limitations using deep posteromedial interval approaches have been referenced. In this paper, a modification of the Lobenhoffer approach, designed to optimize the access to the PL column, is described in detail. The aim of this study was to assess the feasibility of this approach in a cadaveric anatomical study.Materials and methodsIn total, five fresh-frozen cadaveric specimens were used for detailed anatomical study surrounding the approach. Relationships with cutaneous and deep neurovascular structures were evaluated. The exposure area of the PL and PM columns using this approach was assessed.ResultsThe cadaveric study showed safe and adequate exposure. Oblique skin and fascia incision just medial to the posterior midline was safe to protect the medial sural cutaneous nerve and the small saphenous vein. Elevation of the popliteus and tibialis posterior muscles offered safe protection of the anterior tibial artery and popliteal neurovascular bundle during retractor placement. Adequate full proximal exposure of the PM and PL columns, including the posterolateral lateral (PLL) and posterolateral central (PLC) segments, was obtained in all specimens.ConclusionsThe Modified Oblique Lobenhoffer (MOL) approach can be a feasible option to access PL and PM columns in tibial plateau fractures.Level of evidenceIV.

A Cadaveric Study of Two Uncommon Cases of Sural Nerve Complex Variation

Abstract Introduction The sural nerve is a sensitive nerve whose function is to provide sensory supply for the posterolateral aspect of the distal third of the leg and the lateral side of the dorsum of the foot. This nerve is formed in the upper third of the calf from the terminal branches of the tibial and common peroneal nerves and the communicating branch of the sural nerve. Objectives The aim of our study is to showcase two anatomical variants of the sural nerve. Materials and methods Two formalin-preserved cadavers, one male and one female, embalmed using formalin 4% were dissected with the intent of being used as teaching materials for the students attending anatomy classes at the “George Emil Palade” University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Romania. Results In both cases, less common anatomical variations of the formation of sural nerve were discovered. On the male cadaver, we identified the sural nerve as a continuation of the medial sural cutaneous nerve. The lateral sural cutaneous nerve and the communicating branch of the sural nerve were both absent. On the female cadaver, we identified both the medial sural cutaneous nerve and the lateral sural cutaneous nerve. The sural nerve was, however, a continuation of only the lateral sural cutaneous nerve, with the medial sural cutaneous nerve as an independent branch. Conclusions We described two anatomical variants of the sural nerve, which are less common than those documented in the literature.

Anatomical patterns of the sural nerve: a meta-analysis with clinical and surgical considerations.

The sural nerve (SN) supplies the posterolateral aspect of the leg and the lateral aspects of the ankle and foot and descends through the gastrocnemius muscle along the lower third of leg. Because in-depth knowledge about SN anatomy is essential for clinical and surgical approaches, our study aims to review SN anatomical patterns. We searched the PubMed, Lilacs, Web of Science, and SpringerLink databases to find relevant articles for meta-analysis. We assessed the quality of the studies using the Anatomical Quality Assessment tool. We used proportion meta-analysis to analyze the SN morphological variables and simple mean meta-analysis to analyze the SN morphometric variables (nerve length and distance to anatomical landmarks). Thirty-six studies comprised this meta-analysis. Overall, Type 2A (63.68% [95% CI 42.36-82.64]), Type 1A (51.17% [95% CI 33.16-69.04]) and Type 1B (32.19% [95% CI 17.83-48.38]) were the most common SN formation patterns. The lower third of leg (42.40% [95% CI 32.24-52.86]) and middle third of leg (40.00% [95% CI 25.21-53.48]) were the most common SN formation sites. The pooled SN length from nerve formation to the lateral malleolus was 144.54mm (95% CI 123.23-169.53) in adults, whereas the SN length was 25.10mm (95% CI 23.20-27.16) in fetuses in the second trimester of gestation and 34.88mm (95% CI 32.86-37.02) in fetuses in the third trimester of gestation. The most prevalent SN formation pattern was the union of the medial sural cutaneous nerve with the lateral sural cutaneous nerve. We found differences regarding geographical subgroup and subject age. The most common SN formation sites were the lower and middle thirds of the leg.

ID:16076 IPG-Free Peripheral Nerve Stimulation Bilateral Sural Nerves for Chronic Pain in Lower Extremities

The sural cutaneous nerve consists of the fusion of the medial sural cutaneous nerve, which is a terminal branch of the tibial nerve, and the lateral sural cutaneous nerve from the peroneal nerve. These two branches are connected by the sural communicating branch and form the sural nerve. The nerve courses subcutaneously from the mid posterior popliteal fossa to just posterior to the lateral malleolus. It supplies sensation to the skin of the lateral foot, calf, and lower ankle.

Фетальна топографія шкірних нервів гомілкової ділянки

The purpose of the study was to determine the topographic and anatomical relationships of the cutaneous nerves of the lower leg in human fetuses of 4-6 months. Materials and methods. The study was performed on 27 preparations of human fetuses of 81.0-230.0 mm parietal-coccygeal length, using the methods of macromicroscopic preparation and morphometry. Results and discussion. In most of the studied fetuses, there was a classic variant of innervation of the skin of the lower leg region, both on the right and left. In other fetuses, variability in the number and length of cutaneous nerves in the lower leg region was found. The most interesting, from our point of view, were the anatomical variants of innervation of the skin of the lower leg region in the fetuses of 90.0, 158.0, 182.0, and 190.0 mm parietal-coccygeal length. Taking into account the individual and age anatomy of the cutaneous nerves of the leg in human fetuses provides not only the scientific value of the results, but also the rational use of knowledge in the practice of traumatologists, anesthesiologists and surgeons. The study of variants of innervation of the skin of the lower leg region in human fetuses from the standpoint of modern macroscopic anatomy is considered relevant and promising. The need to clarify the topographic and anatomical features of the innervation of the skin of the lower leg region in human fetuses of different ages is due to the search for ways to prevent iatrogenic damage to the cutaneous nerves of the shin when performing surgical and anesthetic manipulations on the structures of this area, since the establishment of the anatomical variability of the skin nerves and branches allows to choose the optimal tactics of surgical intervention. In the literature, there are fragmentary data on the fetal topography of the cutaneous nerves of the lower leg region. Conclusion. In fetuses of 90.0 mm and 158.0 mm parietal-coccygeal length, the innervation of the skin of the anterior-upper surface of the lower leg region was provided by two cutaneous branches from the tibial nerve. In the fetus of 190.0 mm parietal-coccygeal length lateral sural cutaneous nerve was not involved in the formation of the sural nerve, the area of its innervation was limited to the proximal two-thirds of the tibia. Innervation of the lateral border of the foot and lateral bone, in this case, provided only the medial sural cutaneous nerve from the tibial nerve. In the fetus of 182.0 mm parietal-coccygeal length medial sural cutaneous branches are represented by a single independent nerve trunk, from which at different angles short sensitive branches began

Anatomy of the sural nerve complex: Unaccounted anatomic variations and morphometric data

BackgroundThe sural nerve (SN) is a cutaneous sensory nerve innervating the posterolateral leg. The SN is formed from a highly variable set of contributing nerves called the sural nerve complex (SNC). The SNC is made up of the lateral sural cutaneous nerve, medial sural cutaneous nerve, sural communicating branch, and SN. The SN is frequently cited as the most common donor nerve graft and is commonly injured in procedures of the lower extremity. Recent meta-analysis standardized six morphologies of the SNC and established a required reporting criterion for the group of nerves forming the SN. Due to the inconsistencies in previous literature, this study will group observed SNC's by one of these six SNC morphologies to assess and validate the meta-analysis grouping criteria. This study will also collect the same morphometric data previously outlined in order to grow the number of samples that are reported in a standardized fashion. Methods100 formalin and 4 Theil preserved cadavers (n = 208) lower limbs were bilaterally dissected at Kansas City University and Creighton University School of Dentistry to observe the SNC in its entirety on the posterolateral leg. Anatomic data was captured utilizing the standardized morphologies types 1–6 with two sub-typing. Nerves that were found to be outside of this categorization were placed in an unassigned grouping. ResultsThe most prevalent SNCs were type 1 at 41.35% (n = 86) and type 3 nerves at 34.62% (n = 72). Type 2 was found 8.65% (n = 18), type 4 and 5 were found each at 0.48% (n = 1). Type 6 was not observed. When comparing the present studies frequency of nerve types 1–6 to the meta-analysis a sub-grouping of “North American” cadaveric studies a X2 = .903 p = .030 was found. Two distinct and previously unassigned formations of the SNC were 10.58% (n = 20) and 3.85% (n = 8) of data. These two SNC are termed type 7 & 8, these represent two formations of SN that are outside of what was previously reported. 15.87% (n = 33) did not match visual descriptions based on nerve origin of a type 1 SNC but met written definitions. These were termed type 1A1 and type 1A2. The SNC was asymmetrical in 57.69% (n = 120). The pooled mean length of the SN was 32.97 ± 14.12 cm (31.05–34.88), mean diameter was 2.31 ± 0.83 mm (2.20–2.42, and the distance of the posterior border of the lateral malleolus to the SN was found to be 1.72 ± 0.70 cm (1.63–1.80). ConclusionAnatomic variation in the SNC is highly variable, yet is consistent with previously observed literature. This study demonstrates two unaccounted formations of the SNC as well as two additional subcategories of SNC that were not included in the previous meta-analysis. These four variants warrant inclusion as standard formations of the SNC due to the high prevalence observed in this study as well as historical consistency observed in previous literature and case reports. These two SNC formations increase the risk of iatrogenic injury during surgical interventions of the lower extremity. Morphometric data describing the spatial relationship of this nerve complex on the posterolateral leg is consistent with previously reported data and aids in generating a large data set for future studies to characterize spatial properties of this nerve complex.

A unilateral anomalous muscle with an uncommon nerve supply interconnecting the biceps femoris and the gastrocnemius

This case study describes the morphology and embryology and hypothesizes the muscle action based on the morphology of an anomalous muscle that extends from the long head of the biceps femoris to the medial head of the gastrocnemius muscles. It has an uncommon nerve supply via the medial sural cutaneous nerve which is mainly sensory in humans. This variation is different from other similar variations involving the gastrocnemius and biceps femoris muscles. The case report will be of benefit to diagnosis, clinical training, and surgical procedures as well as contribute to knowledge on the type of nerve fiber carried by the medial sural cutaneous nerve or its components.

Sihler's staining of the cutaneous nerves of the leg and its implications for sensory reconstruction.

This study aimed to reveal the entire cutaneous nerve distribution pattern of the leg and provide a morphological basis for sensory reconstruction during skin flap transplantation. Twelve adult cadavers were fixed with formalin, and the whole leg skin with subcutaneous fat was removed close to the muscle surface. The cutaneous nerves were visualized using modified Sihler's staining to reveal the distribution and innervation density of the cutaneous nerves. The saphenous nerve innervated the anterior part, 82.2% of the upper-middle region of the lateral part of the anterolateral leg, and the upper 63.4% of the medial posterior leg. The superficial peroneal nerve innervated 90.1% of the lateral lower one-third of the anterolateral leg. The medial sural cutaneous nerve covered 26.4% of the posterior leg. The lateral sural cutaneous nerve covered 42.3% (approximately 28.6% overlap with the saphenous nerve) of the upper-middle region of the anterolateral and posterolateral leg. The number of branches differed between certain cutaneous nerves in the leg. Communications were observed between the arborizations of the four cutaneous nerves mentioned above. The highest density of primary and secondary nerve branches was observed in the upper one-third of the lateral posterior leg. The upper one-third of the posteromedial leg contained the highest density of intracutaneous nerve branches and highest number of total nerve branches. These results may be used to map sensory regions when designing leg skin flaps for reconstruction surgery to obtain improved sensory 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.

Unusual anatomical variation in formation of sural nerve

Background: Sural nerve is formed by communication of medial sural cutaneous nerve, that arise from tibial nerve in popliteal fossa and peroneal communicating nerve, a branch directly from common peroneal nerve or from lateral sural cutaneous nerve.The objective of this study was described an unusual and few reported anatomical variation in formation of sural nerve.
 Materials and Methods: The anatomical variation described was found during routine dissection performed by medical students of second semester in two maleembalbed adult cadavers of 75 and 65 years of age, respectivelyin the laboratory of Morphology of the University of Pamplona.
 Results and Discussion: In the left lower limb, both medial sural cutaneous nerve, and lateral sural cutaneous nervewere absent. The sural nerve arose directly from the tibial nerve. It’s observed a communicating branch between tibial nerve and common peroneal nerve. In the right lower limb, lateral sural cutaneous nerve was absent. The sural nerve arose directly from the common peroneal nerve.Peroneal communicating nerve was considered as absent in the two cases.Motor fiber from sural nerve to gastrocnemius muscle was observed in both lower limbs
 Conclusions:The knowledge of the sural nerve (normal anatomy and variations in origin and course) is important in evaluating of the patients, as well explaining the different clinical findings necessary for accuracy treatment.
 Bangladesh Journal of Medical Science Vol.18(3) 2019 p.508-512

Sural Nerve Splitting in Reverse Sural Artery Perforator Flap: Anatomical Study in 40 Cadaver Legs.

The reverse sural artery perforator flap has been widely used in reconstruction of the lower extremity. However, along with the high rate of flap necrosis, sural nerve injury is one of the most frequent complications. This cadaveric study investigated a simple sural nerve preservation technique during reverse sural artery perforator flap surgery. Cadaver dissection was performed on 40 cadaver lower legs, to investigate the pattern of sural nerve distribution. The points where the lateral and medial sural cutaneous nerves penetrate the deep fascia were measured. The converging point of these nerves into the sural nerve was also recorded. Furthermore, the sural nerve was split until no tethering was observed, to simulate the sural nerve-sparing reverse sural artery perforator flap. Twenty-nine legs (72.5 percent) showed the lateral and medial sural cutaneous nerves converging to become the sural nerve (combined pattern); seven (17.5 percent) and four legs (10.0 percent) demonstrated the diminished and parallel types, respectively. The distances between the lateral malleolus and the fascia-penetrating point of the lateral and medial sural cutaneous nerves were 29.9 ± 3.3 cm and 18.8 ± 5.6 cm, respectively. In the combined type, the point of convergence was 13.6 ± 4.2 cm from the lateral malleolus. Nerve splitting was successfully performed in all combined cases, without injuring the nerve fascicles. The medial sural cutaneous nerve enters the deep fascia significantly more distally than does the lateral sural cutaneous nerve. Furthermore, using nerve splitting, the medial sural cutaneous nerve can be kept intact during reverse sural artery perforator flap surgery.

Application of free medial sural artery perforator flap for repair of severe thumb web scar contracture

Objective To explore the clinical effect of free medial sural artery perforator (MSAP) flap for repair of severe thumb web scar contracture. Methods From October 2012 to March 2015, 14 cases of severe thumb web scar contracture were repaired with free MSAP flap after scar excision. The flap areas ranged from 5 cm×4 cm to 9 cm×6 cm. The clinical outcomes were evaluated by the appearance of transplanted flaps, sensory recovery, opening angle and width of thumb web and donor site recovery at postoperative follow-up. Results All 14 flaps survived uneventfully. The thumb webs were well-stacked with satisfactory shapes. There was no secondary contracture. Primary healing was achieved at donor sites. Postoperative follow-up ranged from 12 to 18 months, with an average of 14 months. Postoperative angle of repaired thumb webs was enlarged to (80±6)° from preoperative angle of (15±5)°. And the width was enlarged to (45.0±5.6) mm from (20.0±3.5) mm. Thumb functions of abduction, adduction and opposition were all improved obviously. All flaps restored protective sensation. Six cases with anastomosis of medial sural cutaneous nerve recovered to S3. No functional damage was observed at donor sites. Conclusion MSAP flap is an effective way to repair severe thumb web contracture because of its constant perforator, satisfactory shape of repaired thumb webs and minor damages to donor sites. Key words: Surgical flaps; Transplantation; Medial sural artery perforator; Thumb web contracture

The Relationship of Superficial Cutaneous Nerves and Interperforator Connections in the Leg: A Cadaveric Anatomical Study.

The lower limb is a source of many flaps both for closure of local defects and for free transfer. Fasciocutaneous flap techniques have been progressively refined, although the vascular basis for their success needs clarification. Archival studies of 48 lower limbs were reviewed and combined with 20 studies of lower limbs from fresh cadavers, making a total of 68 investigations. Lower limbs were injected with a dilute lead oxide solution; the integument was removed and radiographed; and the cutaneous nerves were dissected, tagged with wire, radiographed again, and their paths traced on the original images. The major cutaneous nerves in the leg are paralleled by a longitudinal vascular axis often comprising long branches with large-caliber true anastomotic connections between perforators. The most highly developed vascular axes followed the medial sural cutaneous and saphenous nerves, together with their accompanying veins, immediately superficial to the deep fascia. The intervening areas were characterized by shorter branches usually connected by small-caliber choke anastomotic connections. These findings provide the anatomical basis for the observed reliability of longitudinal flaps in the leg. The superficial cutaneous nerves of the leg, especially the saphenous and medial sural cutaneous nerves, are paralleled by a vascular axis on or beside the nerve comprising long perforator branches connected usually but not always by large-caliber true anastomotic connections. This emphasizes the importance of understanding the characteristics of interperforator anastomoses when designing and raising flaps.

Anatomical Variability of the Sural Nerve in South Indian Population: A Foetal Study

Sural nerve (SN) is clinically important and is employed in nerve conduction studies, nerve biopsies and also used for nerve grafting. Therefore the anatomical variations of the sural nerve are imperative. SN is formed by either continuation of medial sural cutaneous nerve (MSCN) or by joining with peroneal communicating branch (PCB) of common peroneal nerve. It innervates the posterolateral region of leg and dorsolateral aspect of the foot. Various studies have been carried out worldwide to study the anatomical variations of the sural nerve in adults and fetus alike; however there is a dearth in the literature from India in this regard. Further the percentage of variability does change in different populations. Therefore to study the variability of the sural nerve in the leg in fetuses, 13 full term formalin fixed foetuses were dissected to expose the sural nerve. The sural nerve was classified into three types based on its formation Type A- Formation of SN by the union of MSCN & PCB; Type B- SN as continuation of MSCN; Type C- SN as continuation of PCB. The level of formation of the nerve was also identified with relation to the leg. Based on the variability in the formation of the SN, 23 out of 26 limbs (88.46%) were included under type A, two under type B (7.69%). Type C was noted in a single case (3.85%). The level of formation of the SN in the leg was at the upper one-third in three cases, middle one-third in five cases and lower one-third in the remaining 18 cases. The current study is an attempt to present the variations in the anatomy of the SN, the knowledge of which is essential as the SN is important clinically.

Anatomic and Ultrasonic Study Based on Selective Tibial Neurotomy

Selective tibial neurotomy (STN) was considered as an effective procedure for the treatment of spastic feet. It is also widely used for treating obese calves in some Asian countries. This study aimed to provide morphologic measurement data and theoretical support for the operation and intraoperative localization. Fifty lower legs from 20 embalmed cadavers and 5 fresh corpses were dissected to observe and record the relationship of 4 branches of the tibial nerve, as well as the length, width, and thickness of the triceps surae. An ultrasonic transducer was also used to measure the thickness of muscles of 50 volunteers and acquire the ultrasonic image of muscles and nerve branches. Anatomic results showed that the tibial nerve gave off 4 branches in a proximal to distal direction: the medial sural cutaneous nerve, the motor branches innervating the medial and lateral gastrocnemius, and the motor branch innervating the soleus. These nerve branches had 8 patterns of origin. A significant finding was that the nerve innervating the soleus consisted of 2 branches. Ultrasonic measurement results showed that the thickness of the gastrocnemius and the soleus were positively related to the circumference of the calf. The calf circumference was positively related to the thickness of the soleus and the gastrocnemius. Diverging patterns of tibial nerve branches were multiple, and caution should be used to prevent damaging other branches. Tibial nerve, branches, and diverging sites could be seen clearly in the ultrasonic image. A preoperational ultrasonic examination is recommended.

Operative Anatomy of the Medial Gastrocnemius Recession vs the Proximal Medial Gastrocnemius Recession.

Isolated gastrocnemius contracture (IGC) is associated with various foot and ankle pathologies. To address the problem of IGC, a number of gastrocnemius lengthening procedures have been described. Although proximal medial gastrocnemius recession (PMGR) has shown to be an effective operative treatment for IGC, it poses risks to various anatomic structures around the knee joint and requires the patient to be positioned prone. As an alternative, we proposed to release the medial gastrocnemius at the division between the proximal one-third and distal two-thirds of the gastrocnemius muscle to correct equinus contracture, while minimizing risk to other structures. The aim of this study was to describe an anatomic basis for a medial gastrocnemius recession (MGR) and to investigate the anatomic structures at risk in comparison to PMGR. Eight cadaveric lower leg specimens were used in the study. The standard PMGR and the novel MGR were performed on each specimen. After completion of the 2 procedures, complete dissection was performed to investigate the distances between surgically released fascia margins and surrounding anatomic structures, including the greater saphenous vein, small saphenous vein, saphenous nerve, medial sural cutaneous nerve, semimembranosus tendon, tibial nerve, and popliteal artery. The mean distances were calculated and the shortest distances for each structure were reported. Proximities of anatomic structures to surgically released gastrocnemius fascia at the medial and lateral margins were notably different between the 2 techniques. For the PMGR, the semimembranosus tendon (95% confidence interval of 2.4-7.4 mm), small saphenous vein (3.4-10.0 mm), popliteal artery (3.9-9.3 mm), and tibial nerve (5.0-11.1 mm) were in greater proximity to the operative margin. For the MGR, the greater saphenous vein (5.3-17.6 mm) and saphenous nerve (5.1-18.6 mm) were at greater risk. MGR at the proximal one-third of the gastrocnemius muscle may be a safe alternative for operative treatment of IGC. We identified the major structures at risk when performing the proximal medial gastrocnemius release and propose a novel, possibly safer alternative for the medial gastrocnemius release.

Accessory maxillary ostia: A morphological study on cadavers

Selective tibial neurotomy (STN) was considered as an effective procedure for the treatment of spastic feet. It is also widely used for treating obese calves in some Asian countries. This study aimed to provide morphologic measurement data and theoretical support for the operation and intraoperative localization.Fifty lower legs from 20 embalmed cadavers and 5 fresh corpses were dissected to observe and record the relationship of 4 branches of the tibial nerve, as well as the length, width, and thickness of the triceps surae. An ultrasonic transducer was also used to measure the thickness of muscles of 50 volunteers and acquire the ultrasonic image of muscles and nerve branches.Anatomic results showed that the tibial nerve gave off 4 branches in a proximal to distal direction: the medial sural cutaneous nerve, the motor branches innervating the medial and lateral gastrocnemius, and the motor branch innervating the soleus. These nerve branches had 8 patterns of origin. A significant finding was that the nerve innervating the soleus consisted of 2 branches. Ultrasonic measurement results showed that the thickness of the gastrocnemius and the soleus were positively related to the circumference of the calf.The calf circumference was positively related to the thickness of the soleus and the gastrocnemius. Diverging patterns of tibial nerve branches were multiple, and caution should be used to prevent damaging other branches. Tibial nerve, branches, and diverging sites could be seen clearly in the ultrasonic image. A preoperational ultrasonic examination is recommended.

Surgical Anatomy of a Novel Medial Gastrocnemius Recession versus the Proximal Medial Gastrocnemius Recession

Category: Hindfoot Introduction/Purpose: Isolated gastrocnemius contracture (IGC) is associated with various foot and ankle pathologies. To address the problem of IGC, a number of gastrocnemius lengthening procedures have been described. Decreased power and endurance with plantar flexion activities have been reported in patients after the Strayer procedure. Although proximal medial gastrocnemius recession (PMGR) has shown to be an effective surgical treatment for IGC, it poses risks to various anatomic structures around the knee joint and requires the patient to be positioned prone. The aim of this study was to describe an anatomic basis for a novel medial gastrocnemius recession (MGR) at the mid-level of the gastrocnemius muscle and to investigate the anatomical structures at risk in comparison to PMGR. Methods: Ten fresh frozen cadaveric lower leg specimens were employed for the study. The standard PMGR and the novel MGR were performed on each specimen. For the MGR procedure, we made a 2 cm incision over the mid-level of the medial gastrocnemius muscle region and performed complete release of the medial gastroncnemius fascia. After completion of the two procedures, complete dissection was performed to investigate the distances between surgically released fascia margins and surrounding anatomic structures including the greater saphenous vein, small saphenous vein, saphenous nerve, medial sural cutaneous nerve, semimembranosus tendon, tibial nerve and popliteal artery. These distances were recorded and compared statistically. Results: Proximities of anatomic structures to surgically released gastrocnemius fascia were significantly different between the two techniques. Major neurovascular structures were closer to the surgical margin than anticipated and at greater risk with the PMGR. In particular, popliteal artery (average distance 6.62 mm) and the tibial nerve (8.04 mm) were in close proximity with the PMGR margin, whereas these structures were deeply embedded and farther away from the MGR margin. For the PMGR, the semimembranosus tendon (average distance of 4.16 mm), small saphenous vein (6.71 mm), medial sural cutaneous nerve (3.66 mm), were also in close proximity to the surgical margin. For the MGR, the structures closer to the surgical margin and thus at greater risk of injury were the greater saphenous vein (12.22 mm) and saphenous nerve (11.87 mm). Conclusion: Medial gastrocnemius recession (MGR) at the central level of the gastrocnemius muscle may be an attractive surgical option and method when addressing IGC associated with various foot and ankle disorders. It can easily be performed in either the supine or prone position and may allow for less risk of injury to major surrounding neurovascular structures than a more proximal release. The biomechanical and clinical efficacies of the proposed MGR warrant further investigation.

The sural nerve: Sonographic anatomy, variability and relation to the small saphenous vein in the setting of endovenous thermal ablation.

Background Neurological complications are well documented in association with both surgical stripping or disconnection and thermal ablation of the small saphenous vein. The sural nerve (medial sural cutaneous nerve) is most vulnerable due to its close relationship to the small saphenous vein. Objective This is a cross-sectional observational study of the sonographic anatomy of 115 Australian patients to determine the course of the sural nerve and its relationship to the small saphenous vein, and to identify its relevance in the thermal ablation of the small saphenous vein. Method Sonographic mapping of the right sural nerve was performed with a Philips L12.5 and Sonosite 10.5 MHz ultrasound machine on 115 patients. The sural nerve was traced proximally from the level of the lateral malleolus to the popliteal fossa in order to measure its distance from the small saphenous vein at four reference points in the lower leg. Results A total of 115 patients were studied (females 82, males 33). The sural nerve was identified in 100% of patients; 64 patients (55.7%) showed usual sural nerve anatomy, while 51 patients (44.3%) demonstrated a range of anatomical variations, including the sural nerve becoming epifascial at a higher point than usual. Conclusion The sural nerve was identifiable on duplex ultrasound in 100% of cases. Classic anatomical relations and the perceived protection of the sural nerve conferred by the deep fascia of the upper calf are unreliable. Preoperative strategies can help to approach and protect the sural nerve in the endovenous ablation setting.