Tibialis Posterior Research Articles

Does Kinesio taping of tibialis posterior or peroneus longus have an immediate effect on improving foot posture, dynamic balance, and biomechanical variables in young women with flexible flatfoot?

BackgroundFlexible flatfoot is common in young adults. One of its causes is the failure of dynamic stabilizers, which play an important role in the medial longitudinal arch support, and their appropriate function is necessary for the integrity of the lower extremity and the spine. ObjectiveThe study aimed to determine Kinesio taping on which extrinsic foot muscle provides greater benefit regarding enhancement of foot posture, dynamic balance, and biomechanical parameters in functional tasks immediately. MethodsThirty women were recruited for the study. They were randomly divided into groups (A = 15, B = 15). In group A, Kinesio taping was applied on the tibialis posterior (TP), and in group B, Kinesio taping was applied on the peroneus longus (PL) and remained for 30 min. Outcome measures were the navicular drop test (NDT), foot posture index (FPI), Y-balance test, and biomechanical parameters in functional tasks. Before/After within-group and between-group comparisons of outcome measures were performed. ResultsNDT and FPI decreased in both groups (p < 0.05) with no significant difference between groups. In group A, maximum total force of the stance phase (MaxTFSP) during running increased, and some temporal parameters were changed. (p < 0.05). In group B, Y-balance test improved in all directions, and the width of the gait line during walking increased. There were no significant differences in the postural stability parameters in the within-group comparison, except for mean center of pressure displacement in group B (p = 0.04). ConclusionKinesio taping of both muscles could improve foot posture. TP Kinesio taping can increase the MaxTFSP during running and alter some temporal parameters during walking and running tasks. PL Kinesio taping could lead to better dynamic stability and coordination during dynamic tasks. Each muscle can be considered a therapeutic target for a specific purpose.

A STUDY OF SHORT FOOT EXERCISE AND CRYO BALL THERAPY IN YOUNG INDIVIDUAL WITH FLEXIBLE FLAT FOOT: A CASE STUDY

Flatfoot, pes planus, or fallen arch is a common disorder that arises from a decrease of the medial longitudinal arch and it is commonly observed in clinical practice which causes pain and difficulty during physical activities. It is the result of the weakness of intrinsic and extrinsic foot muscles. In particular, the tibialis posterior muscle plays an essential role in maintaining the Medial Longitudinal Arch during dynamic weight bearing and balance. In addition, this muscle acts longer than other supination muscles during the stance phase in the gait cycle. So, the strengthening exercises of the tibialis posterior and cryotherapy improves pain and foot function among young adults with flat foot.

Management Of Spastic Equinovarus Foot in Children with Cerebral Palsy: An Evaluation of Anatomical Landmarks for Selective Nerve Blocks of the Tibial Nerve Motor Branches

To define the anatomical landmarks of tibial motor nerve branches for selective motor nerve blocks of the gastrocnemii, soleus and tibialis posterior muscles in the management of spastic equinovarus foot. Observational study. Twenty-four children with cerebral palsy with spastic equinovarus foot. Considering the affected leg length, motor nerve branches to the gastrocnemii, soleus and tibialis posterior muscles were tracked using ultrasonography, and located in the space (vertical, horizontal, deep) according to the position of fibular head (proximal/distal) and a virtual line from the middle of popliteal fossa to the Achilles tendon insertion (medial/lateral). Location of motor branches was defined as percentage of the affected leg length. Mean coordinates were: for the gastrocnemius medialis 2.5 ± 1.2% vertical (proximal), 1.0 ± 0.7% horizontal (medial), 1.5 ± 0.4% deep; for the gastrocnemius lateralis 2.3 ± 1.4% vertical (proximal), 1.1 ± 0.9% horizontal (lateral), 1.6 ± 0.4% deep; for the soleus 2.1 ± 0.9% vertical (distal), 0.9 ± 0.7% horizontal (lateral), 2.2 ± 0.6% deep; for the tibialis posterior 2.6 ± 1.2% vertical (distal), 1.3 ± 1.1% horizontal (lateral), 3.0 ± 0.7% deep. These findings may help the identification of tibial motor nerve branches to perform selective nerve blocks in patients with cerebral palsy with spastic equinovarus foot.

Tibialis posterior muscle stiffness assessment in flat foot subjects by ultrasound based Shear-Wave Elastography

BackgroundFew methodologies are used to assess Tibialis Posterior muscle stiffness. Those present limitations leading to a lack of evidence. Muscle stiffness assessment can help in the injuries risk factors identification while coupling with Ultrasound based Shear-Wave Elastography for its management. However, a precise and reliable methodology needs to be utilized to increase stiffness accuracy among the entire Tibialis Posterior muscle. Therefore, this study aims to investigate the stiffness association between Tibialis posterior deep and superficial layer and between flat and neutral footed subjects. MethodsThe sample consisted of 18 participants, where 9 subjects represent the flatfoot group and 9 the neutral foot group. Only the subjects who presented a Navicular Drop Test value of > 9 mm were included in the flatfooted group. All participants were submitted to the Tibialis posterior stiffness assessment with the help of Ultrasound base Shear-Wave Elastography in a lying supine position. Association between Tibialis Posterior deep and superficial layers were determined by Pearson's correlation analysis and group differences were assessed using the U-Mann Whitney test in the comparison between flat foot and neutral foot group (p < 0.05). ResultsNo significant correlations between Tibialis Posterior layers stiffness were found (p = 0.194), nor in the comparison between both neutral and flat foot groups (p = 0.424/p = 0.258). ConclusionAmong participants, no associations between tibialis posterior layers stiffness were found. Also, we did not find any differences in the stiffness between flat and neutral foot groups. In this study, the stiffness did not differentiate flat-footed subjects from neutral subjects.

Investigation of the Characteristics and Mechanism of Interosseous Membrane Injuries in Typical Maisonneuve Fracture

Previous studies on the mechanism and scope of interosseous membrane injury in Maisonneuve fractures have been inconsistent. In order to better guide clinical treatment, the characteristics and mechanism of interosseous membrane injuries and proximal 1/3 fibular fracture in typical Maisonneuve fracture were investigated. The study comprised 15 patients between January 2019 and June 2021 with Maisonneuve fracture. All patients received X-ray and MRI examination of the calf and ankle joint, and CT scanning of the ankle joint. The injuries of medial structure, inferior tibiofibular syndesmosis, fibula, posterior malleolus, and interosseous membrane were evaluated. MR images of the calf showed that the injury of interosseous membrane (IOM) was from the syndesmosis to the proximal fibular fracture site in two patients, with a range of 32.3 and 29.8 cm, respectively. In the other 13 patients, the IOM rupture was not only confined to the distal third of the calf, but also close to the fibula fracture, and the IOM was intact between the two fracture sites. The range of distal IOM rupture was 3.7-12.2cm, with an average of 8.06 ± 2.35 cm. The proximal IOM was completely ruptured from the fibular side at the site of the fibular fracture and the range was 4.1-9.1 (average: 6.75 ± 1.64) cm. The average length of the integrate middle segment of the IOM was 14.55 ± 4.11 (5.6-20.3) cm. MR images of the calf also showed partial rupture of the posterior tibial muscle at the ending point on the fibula in 15 cases, partial rupture of soleus muscle and flexor hallucis longus in seven cases. The rupture of the IOM was caused by a combination of abduction and external rotation violence. It was manifested in two forms, most of which was not only distal end but also near fibular fracture site ruptures with the middle part intact, and a few were ruptures of the IOM from the ankle to the near fibular fracture site. The tibialis posterior muscle may be related to the location of the fibular fracture.

Clinical outcomes of posterior tibial tendon sheath ultrasound-guided corticosteroid injections.

The purpose of this study was to assess the safety of ultrasound-guided corticosteroid injections into the posterior tibial tendon sheath for posterior tibialis tendinopathy. Secondary outcomes include duration of pain relief, amount of pain relief, need for repeat injections and progression to surgery. We retrospectively reviewed all patients in our electronic medical record who underwent a posterior tibial tendon sheath (PTTS) steroid injection between 2015 and 2020 for the diagnosis of posterior tibial tendon dysfunction and/or posterior tibialis tendon insufficiency, and/or ankle pain. Demographic information was obtained from the patient record in addition to MRI data, clinical response to injection based on follow-up visits, number of total injections and progression to surgery. Thirty-eight posterior tibial tendon sheath ultrasound-guided injections were administered in 33 patients who met inclusion criteria during the 5-year study period. Thirty-three patients were included in the study with a total of 38 injections performed. Eighteen of 38 (47%) injections yielded good or better pain relief. Seven of 33 patients (21%) progressed to surgery. There were no reported complications with the 38 performed injections. Ultrasound-guided corticosteroid injection into the posterior tibial tendon sheath is a safe nonoperative treatment modality for progressive collapsing foot deformity. The efficacy of the injection appears highly variable with 47% of injections yielding 'good' or better clinical results. When evaluating body mass index (BMI), obese patients (BMI ≥30.0) were found to have a more sustained response to injection (P=0.029) and more pain relief (P=0.049) than non-obese patients.

Adult Acquired Flatfoot Deformity: A Narrative Review about Imaging Findings.

Adult acquired flatfoot deformity (AAFD) is a disorder caused by repetitive overloading, which leads to progressive posterior tibialis tendon (PTT) insufficiency. It mainly affects middle-aged women and occurs with foot pain, malalignment, and loss of function. After clinical examination, imaging plays a key role in the diagnosis and management of this pathology. Imaging allows confirmation of the diagnosis, monitoring of the disorder, outcome assessment and complication identification. Weight-bearing radiography of the foot and ankle are gold standard for the diagnosis of AAFD. Magnetic Resonance Imaging (MRI) is not routinely needed for the diagnosis; however, it can be used to evaluate the spring ligament and the degree of PTT damage which can help to guide surgical plans and management in patients with severe deformity. Ultrasonography (US) can be considered another helpful tool to evaluate the condition of the PTT and other soft-tissue structures. Computed Tomography (CT) provides enhanced, detailed visualization of the hindfoot, and it is useful both in the evaluation of bone abnormalities and in the accurate evaluation of measurements useful for diagnosis and post-surgical follow-up. Other state-of-the-art imaging examinations, like multiplanar weight-bearing imaging, are emerging as techniques for diagnosis and preoperative planning but are not yet standardized and their scope of application is not yet well defined. The aim of this review, performed through Pubmed and Web of Science databases, was to analyze the literature relating to the role of imaging in the diagnosis and treatment of AAFD.

Tibialis Posterior Tendon Rupture Concomitant with Closed Bimalleolar Fracture

Introduction: Tibialis posterior rupture is rarely associated with ankle fractures, usually misdiagnosed, and leads to flatfoot deformity if untreated. Primary repair has been reported in most cases, with better outcomes regarding late deformity correction. Case Report: 22-years old female surgically treated for bimalleolar fracture, with intra-operative diagnosis of irreparable tibialis posterior tendon rupture, submitted to tenodesis to the flexor digitorum longus. Conclusion: Irreparable tibialis posterior rupture in acute fracture is a rare association with ankle fractures. Tenodesis to the flexor digitorum longus is a surgical option when primary repair is not possible.

Energy flow and functional behavior of individual muscles at different speeds during human walking.

Understanding the distinct functions of human muscles could not only help professionals obtain insights into the underlying mechanisms that we accommodate compromised neuromuscular system, but also assist engineers in developing rehabilitation devices. This study aims to determine the contribution of major muscle and the energy flow in the human musculoskeletal system at four sub-phases (collision, rebound, preload, push-off) during the stance of walking at different speeds. Gait experiments were performed with three self-selected speeds: slow, normal, and fast. Muscle forces and mechanical work were calculated by using a subject-specified musculoskeletal model. The functions of individual muscles were characterized as four functional behaviors (strut, spring, motor, damper), which were determined based on the mechanical energy. The results showed that during collision, hip flexors (iliacus and psoas major) and ankle dorsiflexors (anterior tibialis) were the most dominant muscles in buffering the stride with energy absorption; during rebound, the posterior muscles (gluteus maximus, gastrocnemius, posterior tibialis, soleus) contributed the most to energy generation; during preload, energy for preparing push-off was mainly absorbed by the muscles surrounding knee (vastus, semimembranosus, semitendinosus); during push-off, ankle plantar flexors (gastrocnemius, soleus, posterior tibialis, peroneus muscles, flexor digitorum, flexor hallucis) mainly behaved to generate energy for forward propulsion. With increased walking speed, additional energy (almost 400%) from harder stride was mainly absorbed by the flexor muscles. Hip extensors and adductors transferred more energy (around 150%) to the distal segments during rebound. Soleus and gastrocnemius muscles generated more energy (about 75%) to the proximal segments for propulsion. Along with our previous study of joint-level energy analysis, these findings could assist better understanding of human musculoskeletal behaviors during locomotion and provide principles for the bio-design of related assistive devices from motors performance enhancement to rehabilitation such as exoskeleton and prosthesis.

Double Arthrodesis, Postero-Medial Release and Posterior Tibial Transfer in One Step in Paralytic Inveterate Equine Varus Foot

Introduction: Varus equine foot deformity is common in developing countries. The management of these deformities is surgical in adults. Several surgical techniques have been described with more or less satisfactory results. To our knowledge, no study has been performed on the simultaneous association of double arthrodesis, posteromedial release, and posterior tibial transfer in a single operation in inveterate paralytic varus equines feet. The purpose of this work was to evaluate the results obtained. Patients and Method: This was a retrospective descriptive study from January 01, 2018 to December 31, 2021. It concerned inveterate paralytic varus equines feet operated on by the simultaneous association in a single operative time of double arthrodesis of the foot, posteromedial release of the back foot and transfer of the posterior tibial muscle to the lateral cuneiform. We identified seven patients with a mean age of 22.1 years with extremes of 11 years and 36 years. There were three males and four females. The cause of the deformity was neurological in all cases. All patients had painful walking discomfort and shoeing difficulties. The average time to management was 13.3 years with extremes of 4 and 25 years. The chronology of the interventional steps was posteromedial release, arthrodesis, and transfer of the posterior tibial muscle to the lateral cuneiform. The average postoperative follow-up was 21.7 months with extremes of 6 and 48 months. The parameters studied were the duration of the procedure, complications related to the procedure, muscle strength at the last recoil, consolidation of the arthrodesis, residual pain, patient activity, gait perimeter, stepping, ankle mobility, residual deformity, footwear, protrusion of the transferred tendon, and the possibility of walking on the heel. Final results were graded according to the Angus and Cowell criteria. Results: No intraoperative complications were noted. An early superficial infection of the surgical site was noted. It was treated with local care and healed without sequel. Residual pain was present in one case. Tibiotalar osteoarthritis was observed in one case, which required a tibiotalar arthrodesis. At the last follow-up, consolidation of the arthrodesis was effective in all patients. The posterior tibial muscle was side 5 (n = 4) and 4 (n = 3). The patients’ activity was normal without assistance in all cases. The walking perimeter was greater than 1 km in six patients. Patient activity was normal without assistance in all cases. Stepping was absent in all patients. No difficulty with footwear was noted. According to the Angus and Cowell criteria, the result was good (n = 6), i.e. 85.7% and bad (n = 1), i.e. 14.3% of cases. Conclusion: This study suggests that double arthrodesis associated with posteromedial release and transfer of the posterior tibial in one step in inveterate paralytic varus equines feet, gives satisfactory results. It allows for easy shoeing and plantigrade walking without stepping. Complications are essentially represented by the absence of fusion of the arthrodesis and tibiotalar arthrosis.

EXERCISES AND NEUROMUSCULAR ELECTRIC STIMULATION FOR MEDIAL LONGITUDINAL ARCH: CLINICAL TRIAL.

The extrinsic muscles, such as the posterior tibialis and long flexor of the hallux and the intrinsic of the foot, are part of the active subsystem of the central system of the foot and play an essential role in the control of the medial longitudinal arch resulting from difficulty in contracting the muscle, neuromuscular electrostimulation (NMES) becomes a resource combined with strengthening and recommended for rehabilitation. T this work aims to evaluate the effectiveness of NMES associated with exercise in deforming the medial longitudinal arch. This is a randomized blind clinical trial. 60 asymptomatic participants were divided into three groups: NMES, exercise and control. The NMES and exercise group performed seven exercises for the intrinsic and extrinsic muscles twice a week for 6 weeks, and the NMES group used an NMES associated with five exercises. Navicular height and medial longitudinal arch angle were taken before and after the intervention period. No statistically significant differences existed between groups for navicular height and medial longitudinal arch angle. NMES associated with exercise does not change the characteristics of the medial longitudinal arch in association with asymptomatic. Level of Evidence I; Randomized clinical trial.

Morphological examination and clinical significance of the tibialis posterior: A cadaver study

Morphological examination and clinical significance of the tibialis posterior: A cadaver study

Changing a Reflex Motor Pattern Using the Allyane Technique: Case Report of a Dancer’s Chronic Ankle Instability

The treatment of chronic ankle instability (CAI) is quite long and problematic. In dance, about 53% of dancers have CAI. CAI is a major cause of musculoskeletal disorders such as sprains, posterior ankle impingement, and shin splints. Moreover, CAI leads to a loss of confidence and becomes a key factor for reducing or stopping dance. This case report assesses the effectiveness of the Allyane technique on CAI. Furthermore, it provides a better understanding of this pathology. The Allyane process is a neuromuscular reprogramming method based on the scientific background of neuroscience. Its aim is to strongly activate the afferent pathways of the reticular formation, responsible for voluntary motor learning. It uses mental skill imagery, afferent kinaesthetic sensations, and specific sequences of low-frequency sounds coming from a patented medical device. A. Is a 15-year-old female dancer who practices ballet 8 h per week. She has suffered from CAI for 3 years, with repeated sprains as well as a loss in confidence, with a direct implication on her career. Despite physiotherapy rehabilitation, her CAI tests were still deficient and she still felt strongly apprehensive while dancing. After 2 h of the Allyane technique, we notice a 195% gain of strength of the peroneus, 266% for the posterior tibialis, and 141% for the anterior tibialis muscles. Side hop test and the functional test (Cumberland Ankle Instability tool) normalized. 6 week later, the control assessment confirms this screening and gibes an idea of the durability of the technic. This neuroreprogramming method could not only open the door to interesting perspectives in the treatment of CAI, but it can also help in the understanding of this pathology in case of central muscle inhibitions.

The crural interosseous membrane re-visited: Part II, new biomechanical concepts

Demonstrate movement of the Interosseous Membrane (IM) when tensile loading was applied to the Tibialis Anterior (TA) and Tibialis Posterior (TP). Postulate new roles for IM in running. Nine IMs were assessed by 2 examiners. Dissections exposed the TA and TP. Posterior IM was palpated under TP as tensile loading of TA applied. Anterior IM was palpated under TA, as tensile loading of TP applied. Tensile loading was measured via a spring scale attached to distal tendons of TA and TP. TA tensile loading caused movement of IM anteriorly. TP tensile loading caused movement of IM posteriorly. T-test revealed no statistically significant difference between two examiners. The IM moves when TA and TP muscles undergo tensile loading. Rapid TA contraction during running pulls on the IM, pre-stretching TP and resulting in a forceful TP contraction. The IM is an important factor in pre-stretching of TA and TP. Nerve endings found in IM in our previous publication can increase afferent signal input and coordinate muscle activation of anterior and posterior IM muscles; IM acts as both a tendon and ligament; IM can coordinate muscular activity at heel strike and toe-off; IM limits separation of the distal tibio-fibular joint at heel strike; IM attenuates vertical ground reaction forces.

Foot Muscle Strength, Muscle Shortness, Balance, and Shoe Preferences in Different Foot Postures

Objective: The aim of this study was to investigate the foot muscle strength, muscle shortness, tibialis posterior endurance, balance, and the shoe preference differences between the neutral and pronated foot posture.&#x0D; Methods: Forty-nine participants consisting of 23 women and 26 men, and age of between 18 and 45 years were participated in the study. Foot posture, medial longitudinal arch height, height, gastrocnemius and hamstring muscle shortness, foot and ankle muscle strength, tibialis &#x0D; posterior muscle endurance, static balance, and shoe preferences of the participants were evaluated. Subjects were recruited into two groups according to their foot posture evaluated with Foot Posture Index: as those with neutral and pronated foot posture.&#x0D; Results: Navicular drop, gastrocnemius, and hamstring muscle shortness were significantly higher in participants with pronated foot posture compared to those with neutral foot (p0.05).&#x0D; Conclusion: Flexibility of gastrocnemius and hamstring muscles were reduced, but foot muscle strength, tibialis posterior muscle endurance, and balance remained unaffected in young individuals with excessive foot pronation. Moreover, shoe preferences may not affect the foot posture in young people. Although all age-related biomechanical effects of foot pronation are not well known yet, muscle shortness seems to arise earlier than muscle weakness and reduced balance in pronated foot posture

Surgical Treatment Options for Buerger's Disease (Experience with 315 Cases in Iran).

Background: Buerger's disease (thromboangiitis obliterans) may be a rare peripheral vascular disease that sometimes affects young male smokers. This study presents surgical treatment options for 315 Buerger's patients during a period of 18 years from 2002 to 2020. Methods: In this cross-sectional study, 315 newly diagnosed Buerger patients in a period of 18 years (by Census sampling) were evaluated. Data included age, sex, cigarette smoking status, clinical presentation, the affected limb (right or left, upper or lower extremities), and the performed therapeutic procedures such as angiography of limb arteries, amputation, sympathectomy, and vascular bypass surgery, which were collected in a data sheet. Vascular reconstruction was done if there were suitable inflow and outflow arteries. Sympathectomy was performed for the patients who were unsuitable for revascularization. All analyzes were performed using SPSSV.18 software package (SPSS Inc., Chicago, IL). Data are presented as frequency, mean ± variance (SD). Results: The mean age of patients was 42.6±9 years old, ranging from (26-75). There were 309 (98.1%) males and 6 (1.9%) females. The most common symptom was ulcer 252 (80%), and the most commonly involved arteries were the dorsal pedis (N=231; 73.4%) and posterior tibialis (N=225; 71.5%). Vascular bypass surgery, sympathectomy, and amputation were performed for patients who met surgical indications. Aortofemoral (N=9) and femoropopliteal (N=24) bypass procedures were done in 2.8% and 7.6% of patients respectively. Of nine patients who underwent aorto-femoral bypass procedure, 6 cases presented with leg claudication, 3 with an ulcer, and 3 with the Raynaud phenomenon. The digital loss rate was 9.6% (N=9) in toes and 1% (N=3) in fingers. Conclusion: As most of the Buerger patients have multi arterial involvement, bypass surgery or sympathectomy can't help treat these patients more than cigarette smoking or pharmaceutical therapy.

Relation of Flatfoot Severity with Flexibility and Isometric Strength of the Foot and Trunk Extensors in Children.

Flatfoot is a deformity in which the foot is flattened due to a decrease in or loss of the medial longitudinal arch. Few studies have investigated the relationship between the severity of flat feet, trunk strength, and joint flexibility. The aim of this study is to investigate the relationship between the severity of flatfoot and joint flexibility and foot and trunk strength in children with flexible flatfoot. This study included 16 children (boys, 12; girls, 4; age, 4~8 years) with flexible flatfeet. We examined the resting calcaneal stance position angle (RCSPA) and foot posture index (FPI) scores for clinical severity and radiographic parameters, such as calcaneal pitch angle, talometatarsal angle (TMA), and talocalcaneal angle (TCA). Muscle thicknesses of the tibialis posterior (TP), peroneus longus (PL), and L1 multifidus were measured by sonography. Isometric contraction of ankle inversion, eversion in a seating position, and lumbar extension at a prone position were induced using a handheld dynamometer to measure the maximum muscle strength for each muscle. Beighton's scoring system was used to assess joint flexibility by evaluating the hyperextension of the joint for each category when performing stretching motion. Spearman's rank correlation coefficient for nonparametric data was used. The FPI showed a moderately negative correlation with the muscle thickness of TP (r = -0.558, p = 0.009) and L1 multifidus (r = -0.527, p = 0.012), and the strength of the ankle inverter (r = -0.580 p = 0.005) and lumbar extensor (r = -0.436 p = 0.043). RCSPA showed a moderately positive correlation with TCA (r = 0.510, p = 0.006). Beighton's score showed no significant correlation with all parameters. In children with flatfoot, FPI reflected the clinical severity; thus, the more severe the symptoms, the weaker the ankle inverter and lumbar extensor.

Digital Ischemia Associated with Profound Anemia: A Concerning Consequence of Treatment without Transfusions

Severe anemia is associated with increased mortality and adverse cardiovascular events, but documentation of other clinical sequelae is not well known. It is rare to witness prolonged, life-threatening anemia in a clinically stable patient because it is largely prevented and treated with transfusions. In this case, we are presenting a patient with extreme anemia who cannot receive blood transfusions due to religious beliefs and is struggling with acute limb ischemia as an associated consequence. According to current literature, anemia is prevalent in patients with peripheral vascular disease, but it is not recorded as a cause. Additionally, longitudinal studies have demonstrated an association between cardiac arrests, acute myocardial infarctions, and congestive heart failure from having hemoglobin levels less than 7 g/dL but other adverse events were not studied. This unique clinical case contributes to optimizing bloodless management and treatment as well as identifying sequelae from severe anemia that has not been recorded in current research to the best of our knowledge. Patient is a 43-year-old African American female who is a Jehovah's Witness with a past medical history of delusional disorder, previous malaria infection 10 years ago, and recent travel to Ghana who presented with generalized myalgias and weakness for one week. She was transferred to our hospital for septic shock. She was also COVID-19 positive with severe thrombocytopenia, lactic acidosis, and disseminated intravascular coagulation. Physical examination was significant for scleral icterus, generalized jaundice, and tachycardia. On admission, peripheral smear confirmed 15.7% parasitemia. She was initiated on atovaquone/proguanil and artesunate for the malarial infection. Her hemoglobin on arrival was 7 g/dL (normal 12-15 g/dL) but shortly, her hemoglobin dropped to 5.5 g/dL and continued to decline. Given her religious status, she did not consent to blood transfusion products. Decision was made to maximize anemia treatment with iron infusions, B12, folate, and epoetin 20,000 units. She was also placed on a non-rebreather mask for supplemental therapy. Once the parasitemia resolved on repeated smears, the patient's hemoglobin slowly began to show improvement. Her lowest recorded hemoglobin throughout admission was 3.5 g/dL. Although she achieved resolution of her coagulation disorders and septic shock, her hospital course was complicated by the development of blue discoloration of her metatarsals bilaterally. This developed one week into her hospitalization without history of vasopressors use or history of previous vascular disease. Vascular evaluation revealed intact posterior tibialis and dorsalis pedis pulses bilaterally. Interestingly, arterial dopplers did not show thrombosis or stenosis but did reveal significantly decreased flow in the right dorsalis pedis artery. It was highly suspected that the digital ischemia is secondary to hypoperfusion from critical anemia. She is currently not a surgical candidate but is otherwise doing well, hemodynamically stable, and currently awaiting rehabilitation placement. This specific case highlights the dilemma between medical necessity and honoring religious decisions. It provides rare insight into a patient with stable, profound anemia. It also raises the question if blood transfusions could have definitively prevented or reversed the limb ischemia. Supplemental oxygen delivery, iron infusions and erythropoiesis-stimulating agents (ESAs) are the standard of care in bloodless management of Jehovah's Witnesses. However, the dosing of epoetin continues to be studied in the setting of severe anemia without blood transfusions. Furthermore, this patient brings awareness to vascular complications and introduces a new clinical outcome that can be investigated in the future. Currently, our patient continues to defy the odds with statistically unviable hemoglobin levels and remains faithful to her spirituality. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Histoarchitecture of the fibrillary matrix of human fetal posterior tibial tendons

Adult tendons are highly differentiated. In mature individuals, tendon healing after an injury occurs through fibrotic tissue formation. Understanding the intrinsic reparative properties of fetal tendons would help to understand the maturation tissue process and tendon tissue repair. The present study evaluated the evolution of histoarchitecture, cellularity and the distribution of collagens I, III and V in the posterior tibial tendon in human fetuses at different gestational ages. Morphological profiles were assessed in nine fresh spontaneously aborted fetuses (Group I: five fetuses aged between 22 and 28 weeks of gestation; Group II: four fetuses aged between 32 and 38 weeks of gestation), characterized by a combination of histology, fluorescence and immunohistochemistry. In Group I, the posterior tibial tendon showed statistically significant greater cellularity and presence of collagen III and V than in Group II tendon, which showed a predominance of collagenous I and a better organization of the extracellular matrix compared with Group I tendons. In addition, a statistically significant higher rate of CD90, a marker of mesenchymal cells, was found in Group I tendons. In fetuses with gestational age between 22 and 28 weeks, the posterior tibialis tendons showed a thin and disorganized fibrillar structure, with an increase in collagen III and V fibers and mesenchymal cells. In the posterior tibialis tendons of fetuses with gestational age between 32 and 38 weeks, the fibrillar structure was thicker with a statistically significant increase in type I collagen and decreased cellularity.

A Systematic Review of Lower Extremity Muscle Synergies During Gait: Identifying Potential Nerve and Tendon Donors for Functional Reconstruction

PURPOSE: Technical advances in functional tendon and nerve transfers, most recently in the lower extremity, have improved patient outcomes following limb salvage. However, rigorous research defining and comparing clinical outcomes for the multiple available surgical options remains lacking. In the absence of such data to guide surgical decision making, we aim to gain a better understanding of the neuromuscular organization of gait (i.e. muscle synergies) to glean insights into donor-recipient pairings for functional lower extremity reconstruction aiming to restore walking. METHODS: A MEDLINE search (2000-2020) was performed using terms such as ‘motor module’, ‘synergy’, and ‘walking’. Studies with extractable data on muscle synergies in healthy human subjects during a walking gait were included. RESULTS: Thirty-eight studies were included, incorporating data from 416 participants. Muscle activity was measured using surface EMG in all but two studies. Muscle synergies were extracted using several computational techniques, including non-negative matrix factorization, principal component analysis, torque decomposition, and factor analysis. Each study identified between three and seven muscle synergies, with an average of 4.5 +/- 0.9. 82% of studies reported four or five synergies. The synergies observed across studies could be reclassified into four temporally-independent synergies. Synergy A was active at weight acceptance and included vastus lateralis (reported in 63% of studies), rectus femoris (63%), gluteus medius (58%), vastus medialis (53%), and gluteus maximus (39%). Synergy B, active during late stance, included soleus (87%), medial (79%) and lateral (53%) heads of the gastrocnemius, and peroneus (37%). Synergy C, active at early swing, included tibialis anterior (84%), rectus femoris (41%), erector spinae (32%), and adductors (27%). Synergy D, active at late swing, included biceps femoris (86%), semitendinosus (65%), semimembranosus (24%), and tibialis anterior (22%). CONCLUSIONS: This is the first study to systematically review the neuromuscular organization of gait and apply these findings to surgical decision making. In cases of quadriceps weakness, obturator to femoral nerve transfers have been described with favorable reliability in outcomes.1,2 The obturator nerve plays an important role in hip stabilization and thus fires synergistically in early stance with the quadriceps during synergy A. In deficiencies of plantar flexion, the ankle cannot stabilize against natural dorsiflexion in late stance. The peroneus, providing ankle stability and firing synergistically with plantar flexors in synergy B, may serve as a donor nerve/tendon to reconstruct injuries of the superficial posterior compartment. Even in the absence of obvious synergies, built-in redundancy in lower extremity function provides several expendable donors that may restore range of motion and stability; these data inform which pairings are least antagonistic and most likely to be successful. For example, while transfers of the tibialis posterior,3 FDL/FHL,4 and gastrocenemius5 have been described in cases of foot drop, we prefer simultaneous nerve/tendon transfer of the lateral gastrocnemius because it is expendable, leaving the medial head and soleus intact, and less antagonistic than other transfers, allowing the tendon to more naturally and effectively dorsiflex. Surgical plans aiming to restore the four basic synergies identified herein could allow for restoration of independent gait following significant lower extremity injury. REFERENCES: 1. Dubois E, Popescu IA, Sturbois Nachef N, Teboul F, Goubier JN. Repair of the femoral nerve by two motor branches of the obturator nerve: A case report. Microsurgery. Mar 2020;40(3):387-390. doi:10.1002/micr.30527 2. Rastrelli M, Tocco-Tussardi I, Tropea S, Rossi CR, Rizzato S, Vindigni V. Transfer of the anterior branch of the obturator nerve for femoral nerve reconstruction and preservation of motor function: A case report. Int J Surg Case Rep. 2018;51:58-61. doi:10.1016/j.ijscr.2018.08.004 3. Agarwal P, Gupta M, Kukrele R, Sharma D. Tibialis posterior (TP) tendon transfer for foot drop: A single center experience. J Clin Orthop Trauma. May-Jun 2020;11(3):457-461. doi:10.1016/j.jcot.2020.03.007 4. Movahedi Yeganeh M. Triple Tendon Transfer for Correction of Foot Deformity in Common Peroneal Nerve Palsy. Foot Ankle Int. Jun 2016;37(6):665-9. doi:10.1177/1071100716629779 5. Leclere FM, Badur N, Mathys L, Vogelin E. Neurotized lateral gastrocnemius muscle transfer for persistent traumatic peroneal nerve palsy: Surgical technique. Neurochirurgie. Aug 2015;61(4):292-7. doi:10.1016/j.neuchi.2014.08.001