Anatomic Study of the Gastrocnemius–Soleus Junction and its Relationship to the Sural Nerve

2003 ◽  
Vol 24 (6) ◽  
pp. 473-476 ◽  
Author(s):  
Robert Z. Tashjian ◽  
A. Joshua Appel ◽  
Rahul Banerjee ◽  
Christopher W. DiGiovanni
Keyword(s):  
Sural Nerve ◽  
Average Distance ◽  
Average Width ◽  
Musculotendinous Junction ◽  
Lateral Border ◽  
Adjunct Treatment ◽  
Average Percentage ◽  
Vertical Extension ◽  
Fresh Frozen ◽  
Gastrocnemius Recession

Background: Gastrocnemius recession is performed for equinus contracture of the ankle and as an adjunct treatment for various foot pathologies. Successful release relies on many factors, including a thorough knowledge of the anatomy of the gastrocnemius-soleus junction and its relationship to the sural nerve which may be vulnerable to iatrogenic injury. Neither the average width of the tendon at the gastrocnemius-soleus junction, the anatomy of the sural nerve with respect to the gastrocnemius-soleus junction, nor appropriate landmarks for accurate incision placement at this level to avoid undesirable vertical extension, however, have yet to be acceptably defined. Methods: Fourteen fresh-frozen cadavers were dissected and the width of the tendon at the gastrocnemius-soleus junction, the distance of the sural nerve from the lateral border of the tendon at this level, the length of the fibula, and the distance from the distal tip of the fibula to the gastrocnemius-soleus junction were measured. Results: The average width of the gastrocnemius-soleus complex at the junction was 58 mm (range, 44–69 mm), the average distance of the sural nerve from the lateral border of the gastrocnemius-soleus complex at the level of the gastrocnemius-soleus junction was 12 mm (range, 7–17 mm), the average percentage of this distance as compared to the entire width of gastrocnemius-soleus junction was 20% (range, 13%-27%), and the ratio of the distance of the gastrocnemius-soleus junction from the distal tip of the fibula divided by the length of the fibula was 0.5 (range, 0.5–0.6). Conclusion: These results provide some guidelines as to the approximate size of the gastrocnemius–soleus complex at the site of gastrocnemius recession along with the location of the sural nerve at the musculotendinous junction. Also, the results indicate that the fibula can serve as a reproducible anatomic landmark to enable localization of the gastrocnemius–soleus junction at the time of gastrocnemius recession.

scholarly journals Cadaveric Anatomical Study of Sural Nerve: Where is The Safe Area for Endoscopic Gastrocnemius Recession?

2017 ◽  
Vol 11 (1) ◽  
pp. 1094-1098 ◽  
Author(s):  
Alvin Chin Kwong Tan ◽  
Zhi Hao Tang ◽  
Muhammad Farhan Bin Mohd Fadil
Keyword(s):  
Achilles Tendon ◽  
Sural Nerve ◽  
Anatomical Study ◽  
Lower Limbs ◽  
Lateral Border ◽  
Safe Area ◽  
Gastrocnemius Recession ◽  
The Mean ◽  
Tendon Insertion ◽  
Calcaneal Tuberosity

Purpose: To ascertain in cadavers where the sural nerve crosses the gastro-soleus complex and where the gastrocnemius tendon merges with the Achilles tendon in relation to the calcaneal tuberosities. Methods: Twelve cadaveric lower limbs (6 right and 6 left) were dissected. The distances between the calcaneal tuberosities and the lateral border of the Achilles tendon where the sural nerve crosses from medial to lateral, as well as to the gastrocnemius tendon insertion into the Achilles tendon, were measured. Results: The mean and median longitudinal distances from the calcaneal tuberosity to where the sural nerve crosses the lateral border of the Achilles tendon are 9.9cm and 10cm respectively (range 7cm to 14cm). The mean and median longitudinal distances from the calcaneal tuberosity to where the gastrocnemius tendon inserts into the Achilles tendon are 19.9cm and 18.5cm (range 17cm to 25cm) respectively. Conclusion: It is generally safe to place the posterolateral incision more than 14cm above the calcaneal tuberosity to avoid the sural nerve if surgeons plan to use a posterolateral incision for endoscopic recession. The distance between the calcaneal tuberosity to the gastrocnemius tendon insertion into the Achilles tendon is too highly variable to be used as a landmark for locating the gastrocnemius insertion.

Endoscopic Gastrocnemius Recession: Evaluation in a Cadaver Model

2003 ◽  
Vol 24 (8) ◽  
pp. 607-613 ◽  
Author(s):  
Robert Z. Tashjian ◽  
A. Joshua Appel ◽  
Rahul Banerjee ◽  
Christopher W. DiGiovanni
Keyword(s):  
Nerve Injury ◽  
Sural Nerve ◽  
Average Length ◽  
Average Distance ◽  
Knee Extension ◽  
Ankle Dorsiflexion ◽  
Lateral Incision ◽  
Incision Size ◽  
Gastrocnemius Recession ◽  
Portal Technique

The purpose of this study was to describe a new method of gastrocnemius recession using an endoscopic approach and to determine the accuracy of incision placement during gastrocnemius recession. Fifteen fresh-frozen cadaveric limbs underwent an endoscopic gastrocnemius recession utilizing a two-portal technique. All limbs were anatomically dissected after the procedure and each was examined for injury to the sural nerve. The ability to visualize the sural nerve intraoperatively, improvement in ankle dorsiflexion, time requirement for the procedure, incision size, and appropriateness of placement to facilitate recession were recorded for each specimen. An average of 83% of the gastrocnemius aponeurosis was transected in all 15 cadavers. After modifications of the technique, the final eight cadavers were noted to have had the entire (100%) gastrocnemius aponeurosis transected. Sural nerve injury occurred in one specimen (7%) in which the aponeurosis and the sural nerve were not well visualized. The sural nerve was definitively visualized during the procedure in 5 of 15 specimens (33%). No Achilles tendon injury was noted in any specimen. There was a mean improvement in ankle dorsiflexion of 20° (range, 10°–30°) during full knee extension. The average length of time to perform the procedure was 20 minutes (range, 10–35 minutes). The average medial and lateral incision lengths used in the two-portal technique were 18 mm (range, 14–22 mm) and 17 mm (range, 12–19 mm), respectively, and the average distance from the midpoint of the medial incision to the level of the gastrocnemius-soleus junction was 26 mm (range, 5–60 mm). These results indicate that a complete gastrocnemius aponeurosis transection may be obtained utilizing a modified endoscopic gastrocnemius recession, but visualization of the sural nerve is poor with possible risk of iatrogenic nerve injury.

Location of Vertical Limb of Extensile Lateral Calcaneal Approach and Risk of Injury of the Calcaneal Branch of Peroneal Artery

2018 ◽  
Vol 40 (2) ◽  
pp. 224-230 ◽  
Author(s):  
Norachart Sirisreetreerux ◽  
Paphon Sa-ngasoongsong ◽  
Noratep Kulachote ◽  
Theerachai Apivatthakakul
Keyword(s):  
Achilles Tendon ◽  
Average Distance ◽  
Skin Flap ◽  
Wound Complication ◽  
Calcaneal Fracture ◽  
Peroneal Artery ◽  
Lateral Edge ◽  
Vertical Incision ◽  
Fresh Frozen ◽  
The Right

Background: The extensile lateral calcaneal approach is a standard method for accessing a joint depression calcaneal fracture. However, the operative wound complication rate is high. Previous studies showed a calcaneal branch of the peroneal artery contributing to the calcaneal flap blood supply. This study focuses on the location of the vertical limb in this approach correlating to the aforementioned artery and flap perfusion. Methods: Ten pairs of fresh-frozen cadaveric lower extremities were used. Extensile lateral calcaneal approach (ELCA) was carried out on both calcanei, where the vertical limb was placed at the line between the posterior border of lateral malleolus and lateral edge of the Achilles tendon for the right side (standard ELCA; sELCA) and at the lateral edge of the Achilles tendon for the left side (modified ELCA; mELCA). The identified vessel in the vertical limb incision was ligated and cut, and the horizontal limb of the incision was carried out as usual. After completion of flap elevation, 80°C water was injected into the popliteal vessel. In addition, thermal images were taken pre- and postinjection. Dye was injected subsequently, and perfusion was recorded in video format. Results: Mean pre- and postinjection skin flap temperature difference was significantly higher in mELCA (5.36°C vs 0.72°C, P = .0002). Dye perfusion patterns were significantly better in mELCA ( P = .0013). The calcaneal branch of peroneal artery was found in the vertical incision in 9 of 10 sELCA, with average distance 22.04 mm anterior to the calcaneal tuberosity and 8.22 mm proximal to superior border of the calcaneus, whereas one was found in mELCA, in which perfusion tests still appeared normal. Conclusion: The vertical limb of incision during extensile lateral calcaneal approach should be placed at the lateral edge of the Achilles tendon to avoid injuring the calcaneal branch of peroneal artery, which supplies the lateral calcaneal flap. However, further clinical research might be needed to confirm the results of this study. Clinical relevance: This study demonstrates a likely safest position for the proper incision for exposing the lateral calcaneus.

Anatomy of the sural nerve and its relation to the Achilles Tendon

2000 ◽  
Vol 21 (6) ◽  
pp. 475-477 ◽  
Author(s):  
Jonathan Webb ◽  
Narain Moorjani ◽  
Mike Radford
Keyword(s):  
Achilles Tendon ◽  
Nerve Injury ◽  
Individual Variation ◽  
Sural Nerve ◽  
Proximal Part ◽  
Lower Limbs ◽  
Lateral Border

Sural nerve injury is a complication of Achilles Tendon (TA) rupture. We dissected 30 cadaveric lower limbs to describe the course of the sural nerve in relation to the TA. At the level of insertion of the TA into the calcaneum, the sural nerve was a mean 18.8 mm from the lateral border of the TA. The proximal course of the nerve was towards the midline such that it crossed the lateral border of the TA at a mean distance of 9.8 cm from the calcaneum. The significant individual variation in the position of the sural nerve in relation to the achilles tendon should be borne in mind when placing sutures in the proximal part of the achilles tendon. Percutaneous sutures should not be placed in the lateral half of the TA.

Adjunct treatment in snakebite envenoming: a systematic review of randomised controlled trials

2020 ◽  
Vol 114 (11) ◽  
pp. 847-857
Author(s):  
Chaturaka Rodrigo ◽  
Ariaranee Gnanathasan
Keyword(s):  
Systematic Review ◽  
Randomised Controlled Trials ◽  
Fresh Frozen Plasma ◽  
Cochrane Library ◽  
Controlled Trials ◽  
Adjunct Therapy ◽  
Adjunct Treatment ◽  
Fresh Frozen ◽  
Randomised Controlled ◽  
Frozen Plasma

Abstract Adjunct therapy in snakebite may be lifesaving if administered appropriately or can be harmful if non-judicious use leads to avoidable delays in administering antivenom. This systematic review analyses the evidence from randomised controlled trials (RCTs) on the efficacy of adjunct treatment administered with antivenom. PubMed, EMBASE, Scopus, Cochrane library and CINAHL were searched for RCTs enrolling patients with snakebite envenoming where a treatment other than antivenom has been assessed for its efficacy within the last 25 y. Fifteen studies met the inclusion criteria. The interventions assessed were categorised as adjunct therapies (heparin or fresh frozen plasma) to reverse haemotoxicity (three studies), antibiotics to prevent local infections (three studies), steroids to reduce local swelling (one study), premedication (adrenaline, steroids and antihistamines, either alone or in combination) to reduce hypersensitivity reactions to antivenom (five studies) and other interventions (three studies). Apart from a beneficial effect of low-dose adrenaline (1:1000, 0.25 ml administered subcutaneously) in preventing antivenom-induced hypersensitivities (OR: 0.54, 95% CI 0.32 to 0.93, two RCTs, 354 participants, moderate certainty evidence) in Sri Lanka, evidence for any other adjunct therapy is either non-existent or needs confirmation by larger better designed trials.

Minimally Invasive Dorsal Cheilectomy of the First Metatarsal: A Cadaveric Study

2018 ◽  
Vol 39 (12) ◽  
pp. 1497-1501 ◽  
Author(s):  
Kar Hao Teoh ◽  
Esten Konstad Haanaes ◽  
Saud Alshalawi ◽  
Hiro Tanaka ◽  
Kartik Hariharan
Keyword(s):  
Minimally Invasive ◽  
Average Distance ◽  
Cadaveric Study ◽  
Invasive Technique ◽  
Optimal Position ◽  
First Metatarsal ◽  
Below The Knee ◽  
Fresh Frozen ◽  
Stab Incision ◽  
Relationship Of

Background: Minimally invasive dorsal cheilectomy (MIDC) for hallus rigidus is gaining in popularity. The optimal position for the stab incision for MIDC is dorsomedial to allow an ergonomic sweeping movement of the burr, potentially putting the dorsomedial cutaneous nerve (DMCN) to the hallux at risk. We aimed to quantify the risk of using this minimally invasive technique with a cadaveric study. Methods: A total of 13 fresh-frozen cadaveric specimens amputated below the knee were obtained for this study. After the procedure, the specimens were dissected, and structures were inspected for damage. Results: The DMCN to the hallux was cut completely in 2 specimens (15%). All the extensor hallucis longus tendons were intact, although in 1 specimen, the tendon showed some fraying on the underside of the tendon. The average distance of the stab incision from the first metatarsophalangeal (MTP) joint was 17.7 (range, 10-23) mm. The relationship of the DMCN to the stab incision was variable. The average distance of the DMCN to the incision was 3.8 (range, 0-7) mm. The danger zone for damaging the DMCN was at one-third the length of the first metatarsal proximal to the first MTP joint. Conclusion: The DMCN has been well studied by several authors and has a variable course. This nerve was damaged in 15% of our specimens following MIDC. Clinical Relevance: We believe patients should be made aware of this risk when considering surgery. A carefully made working capsular pocket for the burr and marking this nerve before making the incision if palpable could mitigate this risk.

Percutaneous, Intra-articular, Chevron Osteotomy (PeICO) for the Treatment of Hallux Valgus: A Cadaveric Study

2019 ◽  
Vol 40 (5) ◽  
pp. 586-595 ◽  
Author(s):  
Jorge Javier Del Vecchio ◽  
Mauricio Esteban Ghioldi ◽  
Anuar Emanuel Uzair ◽  
Lucas Nicolás Chemes ◽  
María Cristina Manzanares-Céspedes ◽  
...  
Keyword(s):  
Sagittal Plane ◽  
Metatarsophalangeal Joint ◽  
Cadaveric Study ◽  
Percutaneous Surgery ◽  
Lateral Border ◽  
Iatrogenic Injuries ◽  
Orthopedic Surgeons ◽  
Chevron Osteotomy ◽  
Extensor Hallucis Longus ◽  
Fresh Frozen

Background: Percutaneous surgery is experiencing sustained growth based on third-generation techniques. This cadaveric study was designed with the main goal of exploring the risk of iatrogenic tendon and neurovascular lesions and defining the safe zones in a percutaneous, intra-articular, chevron osteotomy (PeICO) procedure, as well as assessing the accuracy of the osteotomy itself. Methods: Eight feet from below-knee fresh-frozen specimens were selected. After the procedure, the specimens were dissected, and structures were inspected for damage. Results: The results of the safety measurements were as follows: (1) distance between portal 1 (P1) and the lateral border of the extensor hallucis longus (EHL) tendon: average 17.6 mm (range 12.7-21.3); (2) distance between P1 and the dorsomedial digital nerve (DMDN): average 7.2 mm (range 1.6-10.4); (3) distance between P1 and the metatarsophalangeal joint: average 15.7 mm (range 9.4-20.5); distance between portal 2 (P2), or the osteosynthesis portal, and the metatarsophalangeal joint: average 25.5 mm (range 22-30.4); distance between P2 and the lateral border of the EHL tendon: average 12.7 mm (range 8-16.7); and distance between P2 and the DMDN: average 4.1 mm (range 1.7-8.2). There were no iatrogenic injuries. The osteotomy angulation in the sagittal plane (reproducibility) average was 85.6 degrees. Conclusion: There were no iatrogenic injuries on this cadaveric study of PeICO. Clinical Relevance: This study will help orthopedic surgeons understand the risks of performing percutaneous surgery by mimicking an accepted open technique (chevron).

Soft Tissue Structures at Risk With Percutaneous Posterior to Anterior Screw Fixation of the Talar Neck

2018 ◽  
Vol 39 (10) ◽  
pp. 1237-1241
Author(s):  
Lauren E. Roberts ◽  
Martim Pinto ◽  
Jackson R. Staggers ◽  
Alexandre Godoy-Santos ◽  
Ashish Shah ◽  
...  
Keyword(s):  
At Risk ◽  
Soft Tissue ◽  
Sural Nerve ◽  
Injury Rate ◽  
Optimal Placement ◽  
Anatomic Structure ◽  
Shortest Distance ◽  
Fresh Frozen ◽  
Tissue Structures ◽  
Percutaneous Screws

Background: Fractures of the talar neck and body can be fixed with percutaneously placed screws directed from anterior to posterior or posterior to anterior. The latter has been found to be biomechanically and anatomically superior. Percutaneous guidewire and screw placement poses anatomic risks for posterolateral and posteromedial neurovascular and tendinous structures. The objective of this study was to determine the injury rate to local neurovascular and tendinous structures using this technique in a cadaveric model. In addition, we aimed to determine the number of attempts at passing the guidewires required to achieve acceptable placement of 2 parallel screws. Methods: Eleven fresh frozen cadaver limbs were used. Two 2.0-mm guidewires were placed under fluoroscopic guidance, posterior to anterior centered within the talus. The number of attempts required was recorded. A layered dissection was then performed to identify injury to any local anatomic structure. The shortest distance between the closest guidewire and the soft tissue structures was measured. Results: The mean total number of guidewires passed to obtain optimal placement of 2 parallel screws was 2.9 ± 0.7. Direct contact between the guidewire and the sural nerve was seen in 100% of the specimens, with the nerve impaled by the guidewire in 3 of 11 (27.2%) cases. The peroneal tendons were impaled in 1 of 11 (9%) specimens and the Achilles tendon was in contact with the guidewire in 8 of the 11 (72.7%) specimens, and impaled at its most lateral border with the guidewire in 2 specimens (18.2%). Conclusion: The placement of posterior to anterior percutaneous screws for talar neck fixation is technically demanding, and multiple guidewires are needed. Our cadaveric study showed that important tendinous and neurovascular structures were in proximity with the guidewires and that the sural nerve was injured in 100% of the cases. Clinical Relevance: Given the risk of injury to these structures, we recommend a formal posterolateral incision for proper visualization and retraction of the anatomic structures at risk.

Endoscopic Flexor Hallucis Longus Decompression: A Cadaver Study

2007 ◽  
Vol 28 (7) ◽  
pp. 810-814 ◽  
Author(s):  
John J. Keeling ◽  
Gregory P. Guyton
Keyword(s):  
Sural Nerve ◽  
Significant Risk ◽  
Cadaver Study ◽  
Flexor Hallucis Longus ◽  
Lateral Plantar Nerve ◽  
Endoscopic Release ◽  
Incision Size ◽  
Large Joint ◽  
Fresh Frozen ◽  
Neurovascular Structures

Background New indications for arthroscopy are being considered because arthroscopy limits incision size and potentially decreases operative morbidity. This cadaver study investigated the utility of performing an all-endoscopic flexor hallucis longus (FHL) decompression. Methods Eight fresh-frozen cadaver legs were used. In the simulated prone position with large joint arthroscopic equipment, posterolateral and posteromedial portals were used to perform posterolateral talar process bony excision and FHL sheath debridement and release. We noted the integrity of the sural nerve, FHL tendon, and medial tibial neurovascular bundle. After open dissection, values for sural nerve distance to the posterolateral portal, the amount of FHL sheath released and the proximity of the arthroscopic instrumentation to the medial tibial neurovascular structures were recorded. Results Three of eight FHL tendons were injured during the attempted FHL release. Furthermore, no FHL sheath was completely released down to the level of the sustentaculum. Although posterolateral portal placement was on average 12.1 mm from the sural nerve, it was only 6.1 mm from the lateral calcaneal branch of the sural nerve. Moreover, in all cases the medial calcaneal nerve and first branch of the lateral plantar nerve were closely juxtaposed and in some cases adherent to the FHL fibro-osseous sheath. Conclusions Although os trigonum or posterolateral talar process excision was performed without difficulty, endoscopic release of the FHL tendon proved technically demanding with significant risk to the local neurovascular structures. Given the reliability and low morbidity of open techniques, this cadaver study calls into question the clinical use of complete endoscopic FHL release to the level of the sustentaculum. Moreover, hindfoot endoscopic surgery should be performed by surgeons familiar with open posterior ankle anatomy and experienced in hindfoot endoscopy.

Endoscopic Plantar Fascia Release: A Cross-sectional Anatomic Study

1997 ◽  
Vol 18 (7) ◽  
pp. 398-401 ◽  
Author(s):  
Fredrick Reeve ◽  
Richard T. Laughlin ◽  
Douglas G. Wright
Keyword(s):  
Average Distance ◽  
Plantar Fascia ◽  
Anatomic Study ◽  
Abductor Hallucis ◽  
Cross Sectional ◽  
Abductor Hallucis Muscle ◽  
Fresh Frozen ◽  
Abductor Digiti Minimi ◽  
The Relationship ◽  
Plantar Fascia Release

Endoscopic plantar fascia release is a new procedure proposed to treat heel pain and plantar fasciitis. The purpose of this study was to assess the structures at risk during plantar fascia release using this method. Ten fresh-frozen cadaver feet were divided into two groups. All specimens underwent cannula placement inferior to the plantar fascia. Five of the specimens had plantar fascia release using the endoscopic technique. Six of the specimens were then frozen and cut in transverse, sagittal, and coronal sections to visualize the relationship between the cannula and plantar fascia and surrounding structures. Gross dissection was performed on the remaining four specimens. The amount of plantar fascia released, the relationship to the nerve to abductor digiti minimi, and the fascia of the abductor hallucis muscle were assessed. The average distance from the cannula margin to the nerve to the abductor digiti minimi was 6 mm at the medial border of the plantar fascia. The average amount of plantar fascia released was 90%. Although a complete release was attempted, the fascia to the abductor hallucis was not released in any of the specimens. The nerve to the abductor digiti minimi was not damaged in any of the specimens. On coronal sections, the nerve was closer to the cannula and plantar fascia release than previously reported.

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