Sural Nerve Lesions Research Articles

Value of ultrasound and magnetic resonance imaging in the assessment of Achilles tendon healing following percutaneous repair with the Dresden instrument.

Percutaneous Achilles tendon (AT) repair with the Dresden instrument is asafe and effective treatment for AT rupture within 15days after injury. Follow-up includes clinical examination and imaging to assess the healing process and detect possible complications. The findings of each control visit determine the progression of the rehabilitation of each patient. We assessed the postoperative findings of all patients who underwent AT with the Dresden technique from May 2022 to September 2023, during afollow-up period of 6months. The study population included 40male patients between 18and 59years of age. Ultrasound (US) and magnetic resonance imaging (MRI) were performed in all patients at day15 postoperatively and then monthly for 6months. All patients completed 6months follow-up and 2 (5%) presented with postoperative wound dehiscence. No sural nerve lesions, reruptures, reoperations or other complications were seen. Both imaging methods showed excellent correlation of findings at all time points. Both methods were effective to assess the hematoma and structural changes of the healing process during the first 3months. The use of US with Doppler was auseful tool to evaluate blood flow to the tendon stumps. After 3 months no significant morphological changes were observed but the US enabled adynamic functional assessment of the tendon. After 4 months tissues showed homogenization and decrease of volume without further major changes. Both US and MRI proved to be excellent methods to assess the healing process after percutaneous AT repair. The US performed by an experienced investigator showed advantages over MRI in evaluating the gap between the tendon stumps, the possibility of evaluating the vascularity with Doppler US and assessing the functionality of the healing tendon with dynamic examination, besides being acheap and easily accessible imaging method.

Minimally Invasive Approach for the Reconstruction of the Peroneal Brevis Tendon Using Semitendinosus Autograft: An Alternative Technique to Avoid Soft Tissue Complications

Surgical treatment of irreparable tears of the peroneal brevis tendon has been widely performed with reconstruction of the tendon using semitendinosus tendon allograft or autograft. However, it is carried out through a long lateral curved incision prone to soft tissue complications such as scar tenderness, sural nerve lesion, wound dehiscence, and swelling. We present a less invasive approach through 2 short incisions, preserving the lateral soft tissues of the hindfoot. It represents an effective and safe alternative to the long lateral curved approach. Besides that, it can be useful to treat patients at risk of wound healing complications such as smokers, vasculopaths and diabetics. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous Achilles tendon repair with the Dresden instrument. Clinical and MRI evaluation of 90 patients

BackgroundThis study aims at evaluating a substantial number of patients treated with a percutaneous, paratenon preserving technique for Achilles tendon repair using three different incisions with clinical follow-up and magnetic resonance imaging (MRI). MethodsNinety patients with percutaneous Achilles tendon repair using the Dresden technique for acute rupture were evaluated. Fifteen patients were treated using a central approach, 15 patients using a posterolateral approach and the original posteromedial approach was used in 60 patients. All patients were followed clinically and with MRI after 1 and 6 months post-operatively. ResultsUsing the standard posteromedial approach no complications were seen. With the central approach 4 (27%) wound healing problems were observed and with the posterolateral approach 2 (13%) sural nerve lesions occurred. One patient (1.1%) had a rerupture. MRI revealed an increased diameter at the rupture site and distal to it as well as an increasingly homogeneous signal over time. ConclusionsPercutaneous Achilles tendon repair with the Dresden technique yields excellent clinical results and a low complication rate. Modification of the original incision is discouraged.

Functional outcome and complication rate after percutaneous suture of fresh Achilles tendon ruptures with the Dresden instrument

BackgroundThe aim of this study was to evaluate the outcome of patients with a rupture of the Achilles tendon (ATR) treated percutaneously with the Dresden instrument in the hands of surgeons others than its inventors.Materials and methods118 patients (FU rate: 77.1%) with an acute ATR treated with the Dresden instrument were retrospectively evaluated. The following data were evaluated: pain intensity, functional limitation, Hannover score, Achilles tendon total rupture score (ATRS), AOFAS ankle-hindfoot score, Tegner activity score, complications, maximum calf circumference (MCC) on both sides, and the Matles test for tendon lengthening. The effect of the time point of the surgery after trauma was examined.ResultsHannover scores and ATRSs were good; AOFAS scores were excellent. Almost all patients returned to sporting activities postoperatively, and 66.1% were able to return to their previous level. The Tegner activity score revealed a slight posttraumatic decrease (p = 0.009) in the level of physical activity overall (pre-injury: 5.37 ± 0.15; postoperatively: 4.77 ± 0.15). The re-rupture rate was 2%. No sural nerve lesions and no infections were reported. Even after 3 years, there was still a difference in MCC that was correlated with inferior clinical score and AT lengthening. Patients treated within the first 2 days after ATR showed inferior clinical outcomes in terms of AOFAS score, ATRS, and functional limitations.ConclusionsPercutaneous ATR suture with the Dresden instrument is a safe and reliable method. Low complication and re-rupture rates, good clinical results, and a high rate of return to play support this fact. The time point of the operation may influence the outcome.

Treatment of Displaced Intra-articular Calcaneal Fractures with the Intramedullary Nail

Category: Trauma Introduction/Purpose: In 2010, a new closed reduction, internal fixation procedure for displaced intra-articular calcaneus fractures (DIACF) was developed with an intramedullary nail introduces through a channel in the calcaneal tuberosity. The goal was to reduce the rate of skin complications following principles of open reduction procedures. The aim of this prospective mono-centric study was to assess the occurrence of complications and the functional results using the AOFAS-AHS score. The secondary objectives were to assess first the restoration of the Böhler and Gissane angles on X-ray and shape of the calcaneus (Height, length, width) on CT scans, then thalamic reduction on 3D CT scans based on Goldzak’s global articular reduction classification. Methods: 26 Patients were included prospectively between 2014 and 2016 with analysis of X-rays and CT scans. Two were lost to follow-up and 2 patients sustained a secondary subtalar arthrodesis. After positioning a distractor and drilling, reduction was done with tamps and spatula. The nail was then introduced and locked with screws in the tuberosity and the constant fragment. After 3 weeks of non-weight bearing and 3 weeks with hindfoot off-loading shoe, full weight bearing was allowed. The functional outcome and restoration of the radiographic angles were evaluated postoperatively, at 3 months, 1 year and at the last follow-up. Global calcaneal shape and thalamic surface were evaluated postoperatively, at 1 year and at the last follow-up. The following early complications (delayed healing, infection, annoyed material, sural nerve lesion) and later complications (painful stiffness of the subtalar joint, hindfoot varus malalignment and calcaneofibular conflict) were recorded. Results: Mean follow up was 2.4 years. The mean AOFAS-AHS score was 79 ± 12 [100; 61] in the 22 patients examined. The mean Böhler angle rose from -1.29°± 18° [-35; 28] pre-operatively to 33°± 6° [22; 44] post-operatively. The mean calcaneal height index and length rose respectively from 0.44± 0,18 [0,12; 0,83] to 0.86± 0,22 [0,46; 1,1] and 82,4± 5,4 [72; 93] mm to 86,7mm ±4,6 [76; 97], and the width decreased from 49,8± 4,8 [38; 59] to 46,3± 3,7 [38; 55] mm. The Goldzak global articular reduction assessment was excellent in 39% of cases, good in 42% of cases and poor in 19% of cases. One case of deep infection was reported. Three patients needed device removal and two sustained a secondary subtalar arthrodesis. Conclusion: Our prospective study on this new device has the longest time of follow-up. The results confirm the effectiveness and the reliability over time of the procedure to restore the global shape and the thalamic surface with a low rate of complications and quick return to activities. It appears to be an excellent compromise between the respect of the principles of reduction as applied in the ORIF procedures, and the low cutaneous risk of percutaneous procedures. A subsequent study, with a larger number of patients, will enable analysis of the correlation between the radiological markers and the AOFAS-AHS.

Two minimally invasive surgical treatments for Achilles tendon rupture: Achillon versus sponge forceps

Objective To compare 2 mini-invasive surgical treatments, Achillon versus sponge forceps, for acute Achilles tendon rupture. Methods Between December 2010 and January 2015, 35 patients with acute Achilles tendon rupture were treated at our department. They were 32 males and 3 females, with an average age of 36.4 years (range, 21 to 64 years) . The interval between injury and operation was 1 to 13 days (average, 3.2 days) . Sixteen of them were treated by Achillon while 19 by sponge forceps. The 2 groups were compatible with no significant differences in general clinical data (P>0.05) . Rehabilitation was carried out 4 weeks after immobilization with brace. American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scoring system was used to evaluate the function of the affected foot at the last follow-up. The 2 groups were compared in terms of surgery time, hospital stay, AOFAS score, decrease in leg circumference, complications and rerupture rate. Results All the patients were followed up for an average of 9.6 months (from 6 to 19 months) . There were no significant differences between the Achillon and sponge forceps groups regarding average AOFAS score (91.8 ±4.4 versus 93.2±5.8) , surgery time (38.3±13.2 min versus 42.5±9.8 min) , hospital stay (3.9±1.5 d versus 4.1±1.6 d) , or decrease in leg circumference (2.1±0.5 cm versus 2.3±0.3 cm) (P>0.05) . No re-ruptures or sural nerve lesion was observed in either group. One case of delayed wound healing occurred in each group. Conclusions Both Achillon and sponge forceps can lead to limited complications and a very low rate of re-rupture in surgical treatment of acute Achilles tendon rupture. Compared with the Achillon technique, sponge forceps may have the advantages of simplicity and lower cost. Key words: Achilles tendon; Tendon injuries; Surgical procedures, minimally invasive

Channel-assisted minimally invasive repair of acute Achilles tendon rupture.

BackgroundPercutaneous (minimally invasive) suturing is a promising option for Achilles tendon (AT) repair with low rerupture and infection rates. Sural nerve lesions are the major problem to avoid with the technique. A new device was therefore designed for suturing the AT, resulting in channel-assisted minimally invasive repair (CAMIR). The purpose of this study was to compare the clinical and functional outcomes of CAMIR with traditional open techniques.MethodEighty two patients with AT rupture were included: 41 for CAMIR, 41 for open repair. All patients followed a standardized rehabilitation protocol. Follow-ups were at 12 and 24 months after surgery. Functional evaluation was based on the clinical American Orthopaedic Foot & Ankle Society score associated with neurologic deficit (sural nerve), calf circumference, range of motion (ROM), and isometric testing.ResultsThere was no difference between groups regarding plantar flexor strength, ankle ROM, or calf circumference. CAMIR significantly decreased the operative time compared to open repair (17 vs. 56 min, P < 0.0001). Mean scar length was greater in the open repair group (10 vs. 2 cm, P < 0.0001). There were no wound complications in the CAMIR group but four in the open repair group (P < 0.0001). No deep vein thrombosis, rerupture, or sural nerve injury occurred.ConclusionCAMIR and open repair yielded essentially identical clinical and functional outcomes. Sural nerve injuries can be minimized using CAMIR by carefully placing the suture channel with a stab incision and special trocar based on a modified Bunnell suture technique.

Reconstruction in chronic lateral ligament injuries of ankle with Colville’s technique

We evaluated the results of Colville’s technique in young patients with chronic instabilities of the ankle lateral ligaments.Reconstruction with Colville augmented technique was performed in seven male and one female patients (median age 27; age range 23-35 years) with chronic lateral ankle instability at Mugla Sitki Kocman Universty Orthopaedic Clinic between 2010-2013. The mean interval time between injury and operation was 29 months (range 21-33 months). The patients were followed up for mean 24 months (range 12-36 months). Excellent results were achieved in all cases. Recurrent instability was not observed in any patient. Complications such as infection, non-healing wound and suralnerve lesion were not encountered. By means of Colville’s technique, stability can be obtained in nearly 100% while the subtalar joint motions are protected.

Avoiding Sural Nerve Injuries during Percutaneous Achilles Tendon Repair

Background Sural nerve injury is a reported risk during percutaneous repair of the Achilles tendon. Hypothesis Exposure of the sural nerve during percutaneous repair can minimize the risk of nerve injury. Study Design Case control study; Level of evidence, 3. Methods The authors retrospectively examined the results of 84 patients who were treated for acute Achilles tendon rupture at 2 different hospitals. Both hospitals used the same percutaneous repair technique, except that the sural nerve was exposed in the 38 patients (mean age, 38 years; range, 23-68 years) of one hospital; the nerve was not exposed in the 46 patients (mean age, 42 years; range, 24-71 years) of the other hospital (the nonexposure group). Results All patients recovered and returned to work after 44 days (range, 5-202 days). All patients returned to their previous sports levels within 1 year. On the 100-point Hannover Achilles Tendon Score, the mean score was 81 points (range, 44-100 points). The overall incidence of sural nerve related complications was 18%. All sural nerve lesions occurred in the nonexposure group. In the total study population, there were 3 cases of deep vein thrombosis, 1 rerupture, and 1 case of infection. Conclusion Sural nerve injuries can be minimized during surgery by carefully placing the stab incisions to expose the nerve so as to avoid it during repair. If the sural nerve is exposed, percutaneous repair of the ruptured Achilles tendon is a safe and reliable method of treating Achilles tendon ruptures.

Ectopic activity in cutaneous regenerating afferent nerve fibers following nerve lesion in the rat.

Spontaneous activity, and mechanical and thermal sensitivity were investigated in regenerating afferent nerve fibers within 4-21 days post sural nerve lesion (crush or transection and resuturing) in anaesthetized rats. About 33-40% of the myelinated (A) and 22-27% of the unmyelinated (C) fibers excited by electrical nerve stimulation exhibited at least one of these ectopic discharge properties. In total 177 A- and 169 C-fibers with ectopic activity were analysed. Most A-fibers (161/177) were mechanosensitive. Spontaneous activity (median 1 imp/s) was present in 23/177 and thermosensitivity in 14/177 A-fibers (13 of them being activated by heat stimuli). Almost all A-fibers (159/177) exhibited only one type of ectopic discharge property. Most C-fibers (94/169) were thermosensitive responding either to cold (n = 45) or to heat stimuli (n = 33) or to both (n = 16). Eighty-four of 169 C-fibers were spontaneously active (median 0.3 imp/s) and 75/169 C-fibers were mechanosensitive. Both the proportion and the discharge rate of spontaneously active C-fibers were significantly higher after crush than after section and resuturing of the nerve. About 60% of the C-fibers (101/169) had only one ectopic discharge property and 40% two or three. In conclusion, regenerating cutaneous afferent A- and C-fibers may develop mechano- and/or thermosensitivity as well as spontaneous activity. We suggest that spontaneous and evoked ectopic activity in regenerating cutaneous afferents are a function of the intrinsic functional properties of these neurons and of the interaction between the regenerating nerve fibers and non-neural cells during Wallerian degeneration in the nerve distal to the nerve lesion.

Foot pain due to sural nerve conduction block at the calf

Summary Foot pain related to sural nerve lesion is rare. The origin of the pain was unrecognized in one patient for at least 10 months and was thought to be an S1 root disease, as the pain was associated with paresthesiae of the external border of the ankle and foot and a positive Lasegue manoeuvre. Electrodiagnosis (EDX) demonstrated a sensory conduction block at calf which corresponded with the sural nerve entrapment where the nerve pierces the deep fascia. The surgical release of the nerve provided rapid relief from the complaint.

Neurophysiological and ultrasound findings in sural nerve lesions following stripping of the small saphenous vein

We describe the neurophysiological and ultrasound (US) findings in two patients with right sural nerve lesions following stripping of the small saphenous vein for varicose vein treatment. In the first case, US showed a tear of the nerve proximal to the lateral malleolus and a hypoechoic swelling of the proximal stump, likely related to a terminal bulb neuroma. A sural conduction study performed distally and proximally to the lesion through a near-nerve needle technique showed absent responses. In the second case, US showed a deep subcutaneous extension of a postsurgical scar placed behind the lateral malleolus close to the sural nerve, but no nerve discontinuity. Sural conduction study showed absent responses distal to the scar. Sural stimulation immediately above the scar yielded a small response at the sciatic nerve. A subsequent investigation performed 15 months after the operation showed absent proximal and distal responses. The combination of US and sural conduction study, including recording at the sciatic nerve, to our knowledge has not been described previously, and may yield important complementary information in the diagnosis of sural nerve lesions. © 1999 John Wiley & Sons, Inc. Muscle Nerve 22: 1724–1726, 1999

Peripheral nerve pathological findings in familial amyloid polyneuropathy: A correlative study of proximal sciatic nerve and sural nerve lesions

To analyze the peripheral nerve pathological abnormalities in familial amyloid polyneuropathy, a correlative pathological study was carried out on the spinal nerve roots, proximal sciatic nerves, sural nerves, and brachial plexuses from 3 patients with the disease in Japan. The spinal nerve roots appeared to be unaffected except for amyloid deposition on the epineurium. In sciatic nerves and brachial plexuses the nerve lesions had a multifocal distribution, showing prominent interstitial edema in the endoneurium frequently adjacent to deposits of amyloid; in these regions the nerve fibers were severely depleted. A teased-fiber study revealed that segmental demyelination was the predominant type of nerve fiber abnormality. However, these findings were not seen in the sural nerves; instead a diffuse fiber loss with axonal degeneration was observed. It is suggested that multifocal lesions in the proximal portions of the long extremity nerves could summate distally to produce a symmetrical polyneuropathy in the disease. In addition to a space-occupying effect of amyloid deposits in the endoneurium, severe endoneurial edema associated with amyloid deposition in blood vessels and the endoneurial interstitium may induce ischemia in nerve fibers, thus causing the progressive polyneuropathy in this disorder.

REVERSIBILITY OF VITAMIN E DEFICIENCY NEUROLOGIC SYNDROME DURING CHRONIC CHILDHOOD CHOLESTASIS

To determine the reversibility of neurologic abnormalities due to vitamin E (E) deficiency, we prospectively studied the effects of E repletion on 14 children with chronic cholestasis, well-documented E deficiency, and characteristic sural nerve or muscle lesions: Group A(n=2)- both age 20 mo., no neurologic signs; Group B(n=3)- age <3 yrs., with characteristic neurologic signs; Group C(n=9)- ages 5-17 yrs., with neurologic signs. E repletion was achieved by oral (n=4; 60 to 90 IU/kg/day) or intramuscular (n=10;1.0-1.5 IU/kg/day) dl-a-tocopherol. Child neurologists performed serial neurologic exams each 6-12 mo., assigning a neurologic score based on rating each of 12 neurologic signs from 0 (normal) to 3+ (severely abnormal). The mean neurologic scores for each group at 6 month time intervals were (Table): Conclusion: Vitamin E repletion reverses or prevents neurologic abnormalities when begun prior to age 3 years, whereas only partial improvement occurs when therapy is begun after age 5 years. We recommend surveillance for and treatment of E deficiency prior to age 3 years in children with chronic cholestasis.

Vitamin E deficiency during chronic childhood cholestasis: Presence of sural nerve lesion prior to 2½ years of age

Vitamin E malabsorption and deficiency during chronic childhood cholestasis has been associated with a progressive ataxic neurologic syndrome. Hyporeflexia, the first sign of neurologic dysfunction, may begin prior to age 2 years, but severe symptoms do not develop until age 5 to 10 years. To establish the age of onset of neuropathologic lesions, we prospectively evaluated four young children with severe cholestasis. Malabsorption and deficiency of vitamin E were documented by low serum vitamin E concentrations, low serum vitamin E to total serum lipids ratios, elevated hydrogen peroxide hemolysis, and impaired absorption of a pharmacologic dose of alpha-tocopherol. Abnormal neurologic findings in two patients were limited to areflexia, ptosis, mild truncal ataxia, and hypotonia; two patients had minimal signs of neurologic dysfunction. Sural nerve histology at age 6 to 25 months revealed a degenerative axonopathy involving large-caliber myelinated fibers, but without quantitative axonal loss. Muscle histology and histochemistry tests yielded normal results. Our study suggests that neurologic injury may occur during the first two years of life in vitamin E-deficient children with cholestatic hepatobiliary disease, obligating aggressive attempts at correcting this deficiency state at a very young age.

Sural nerve lesions in a case of hypertyrosinemia

A sural nerve obtained three hours after death from a patient with hypertyrosinemia due to 4-hydroxyphenylpyruvic acid oxidase deficiency was examined. The diameter of the myelinated fibers, as seen on the histogram, was similar to those in an age matched control. However, the number of smaller fibers was greater. Electron-microscopically, the findings of de- and hypomyelination were noted, and occasional dense bodies and multimembranous bodies were seen in some axoplasms. Since his mother was also suffering from hypertyrosinemia, the serum tyrosine level during the fetal and newborn infant periods seemed to be constantly elevated, which may have caused the abnormalities of nerve fibers observed in the present case.

Ultrastructural pathology of peripheral nerves in patients with diabetic neuropathy.

Sural nerve lesions in patients with clinically manifest diabetic neuropathy were investigated electron microscopically. Myelinated nerve fibers were reduced in all the diabetic patients. Axonal degeneration of both myelinated and unmyelinated nerve fibers was most conspicuous finding in the diabetic sural nerves. Structural changes of the axons were represented by axonal dwindling, depletion of axoplasmic organelles, vacuolarization and an increase in neurofilaments. Accumulation of glycogen-like particles and deposition of electron homogeneous amorphous materials were noted within a few axons. On the other hand, there could also be found degenerative changes of myelin sheaths, various kinds of cytoplasmic inclusion bodies (crystalloid, lamellar inclusion bodies and lipids-like droplets), aggregates of glycogen particles in the Schwann cell cytoplasm and basement membrane hyperplasia of Schwann cells in all the subjects. Furthermore, multiplication and thickening of the basement membrane of vasa nervorum were constant findings of the diabetic sural nerves. The vascular changes, demyelination and axonal degeneration of the cases were not apparently correlated with each other. There was no special relationship between nerve tissue changes and clinical symptoms or laboratory findings. These results indicated that the peripheral nerve lesions in human diabetics were mainly due to metabolic impairment of nerve fibers, accompanying dysmetabolism of Schwann cells and diabetic microangiopathy, and that these changes proceeded independently.