The Effect of Calcaneal Displacement Osteotomies on Tarsal Tunnel Pressures

Category: Basic Sciences/Biologics Introduction/Purpose: Calcaneal displacement osteotomies are frequently utilized procedures to correct hindfoot varus and valgus deformities and are frequently used in conjunction with other procedures to restore normal alignment of the foot. Complications associated with this procedure include overcorrection, undercorrection, iatrogenic fracture, wound dehiscence, and infection. Additionally, neurologic deficit associated with lateralizing calcaneal osteotomy has been documented in the literature. Changes in ankle alignment have been shown to significantly alter tarsal tunnel pressure and volume, and a MRI study by Bruce et. al showed that lateral osteotomy fragment displacement results in significant reduction of tarsal tunnel volume. We hypothesized that a lateral displacement calcaneal osteotomy would result in an increase in tarsal tunnel pressure compared baseline tarsal tunnel pressures or those with a medial displacement calcaneal osteotomy. Methods: We performed cadaveric dissections on five foot and ankle cadavers. The laciniate ligament covering the tarsal tunnel was visualized at 2 cm proximal to the medial malleolus and a nick incision was made to insert the ICP monitoring probe; the tunnel was left intact distally. A 45 degrees lateral incision was made in line with the osteotomy site and a calcaneal osteotomy was performed in line with the incision approximately 1 cm anterior to the attachment of the achilles tendon. A Codman ICP monitoring probe was then used to measure baseline tarsal tunnel pressure measurements prior to calcaneal displacement. The osteotomy was then displaced medially and laterally and fixed in place in place with a K-wire (Figure 1). Tarsal tunnel pressures were measured at 5 mm and 8 mm displacement in both directions. Results: Average tarsal tunnel pressures at baseline were 2.8 mmHg (range, 1-5 mmHg). Average tarsal tunnel pressures with 5 mm and 8 mm of medial calcaneal displacement were 1.0 mmHg (range, 0-4 mmHg) and 0.8 mmHg (range, 0-3 mmHg), and with lateral calcaneal displacement were 7.4 mmHg (range, 3-13 mmHg) and 14.4 mmHg (range, 10-22 mmHg). There was no significant difference in tarsal tunnel pressures with either 5 mm (p=.067) or 8 mm (P=.067) of medial calcaneal displacement compared to baseline. There was, however, a significant increase in tarsal tunnel pressures with both 5 mm (p=.039) and 8 mm (p=.001) of lateral calcaneal displacement compared to tarsal tunnel pressures at baseline and with 5 mm (p=.002) and 8 mm (p=.001) of medial calcaneal displacement. Conclusion: Tibial nerve palsy following lateral displacement calcaneal osteotomy has recently been shown to have an incidence as high as 34%. Osteotomies decreasing volume in the tarsal tunnel could cause iatrogenic compression of the tibial nerve. Based on the results of our study, displacing the calcaneus laterally increases the tarsal tunnel pressures on average five times above baseline tarsal tunnel pressures. Medial displacement, however, does not appear to have any significant effect on pressures within the tunnel. The findings in this study provide further clinical evidence in support of prophylactic tarsal tunnel release prior to performing a lateralizing calcaneal osteotomy.

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Morphological aspects of tympanic bulla after lateral osteotomy in cats

Acta Cirurgica Brasileira ◽

10.1590/s0102-86502008000200014 ◽

2008 ◽

Vol 23 (2) ◽

pp. 198-203

Author(s):

Adelina Maria da Silva ◽

Wilson Machado de Souza ◽

Roberto Gameiro de Carvalho ◽

Gisele Fabrino Machado ◽

Silvia Helena Venturoli Perri

Keyword(s):

Connective Tissue ◽

Osteotomy Site ◽

Postoperative Results ◽

Morphological Aspects ◽

Mcnemar Test ◽

Lateral Osteotomy ◽

Significant Difference ◽

Adult Cats ◽

Macroscopic Examination ◽

Complete Regeneration

PURPOSE: To evaluate tympanic bulla healing after experimental lateral osteotomy in cats. METHODS: Twenty adult cats were submitted to unilateral lateral bulla osteotomy and divided into two groups: cats of B1 group (n=10) were euthanized at 8 weeks and cats of B2 group (n=10), at 16 weeks postoperative. RESULTS: Oblique lateral radiographs taken immediately postoperative showed interruption in the contour of the external acoustic meatus of the operated bullae in all cats of both groups (McNemar test: p=0.0010*). This feature was still observed in the radiographs taken after 8 and 16 weeks postoperative (McNemar test: B1 p=0.0020*; B2 p=0.0312*). Macroscopic examination showed that the operated bullae were similar to the normal ones, with preservation of the tympanic cavity. Connective tissue at the osteotomy site was significantly found in the operated bullae in both groups (McNemar test: B1 p=0.0020*; B2 p=0.0010*). The length of connective tissue at the osteotomy site was measured by histomorphometry. There was no statistically significant difference between the values of B1 group and B2 group (Mann-Whitney test: p=0.0524). CONCLUSIONS: Experimental lateral osteotomy did not alter significantly the tympanic bulla conformation and complete regeneration of the tympanic bulla frequently did not occur before 16 weeks of postoperative period.

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Cadaveric Study of the Neurovascular Bundle in Tarsal Tunnel Region among Sudanese - 2020

10.14293/s2199-1006.1.sor-.ppuprts.v1 ◽

2021 ◽

Author(s):

yasser seddeg ◽

Elfarazdag Ismail

Keyword(s):

Tibial Nerve ◽

Posterior Tibial Artery ◽

Neurovascular Bundle ◽

Medial Malleolus ◽

Tarsal Tunnel ◽

Nerve Blocks ◽

Bifurcation Points ◽

Posterior Tibial ◽

Tibial Artery ◽

Displacement Osteotomy

Abstract Background: Tarsal tunnel is situated medial to the ankle lying deep to the flexor retinaculum. Within which lies the neurovascular bundle in separate compartments. This study examines the level of bifurcation points of tibial nerve and posterior tibial artery, and the location of medial and lateral plantar nerves in the tarsal tunnel. As well as the origin of the medial calcaneal nerves. Methods: This study was a descriptive observational cross sectional study. Step by step dissections of the tarsal tunnel were performed on 30 Sudanese cadavers, the contents of the tarsal tunnel were explored. Results: The tibial nerve was found to bifurcate before the the medial malleolus calcaneal axis (MMCA) in (n=4/30, 13.3%) specimens , and inside the tunnel (n=26/30, 86.7%). The branching point of the posterior tibialartery was found before the MMCA in (n=10/28, 35.7%) of specimens, at the MMCA in (n=16/28, 57.1%), and after the MMCA in (n= 2/28, 7.1%). Medial calcaneal nerves were found to be derived from the LPN plus the TN in (n=13/30, 43.3%), while in (n=6/30, 20%) were derived from LPN plus MPN plus TN. only (n=5/30, 16.7 %) were derived from LPN alone. Conclusion: anatomical knowledge of the bifurcation points of tibial nerve and posterior tibial artery is of great importance in many medical procedures like external fixation of medial malleolus fractures, medial displacement osteotomy and nerve blocks in podiatric medicine.

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Tibial Nerve Palsy After Lateralizing Calcaneal Osteotomy

Foot & Ankle Specialist ◽

10.1177/1938640018816363 ◽

2018 ◽

Vol 12 (5) ◽

pp. 426-431 ◽

Cited By ~ 1

Author(s):

Are Haukåen Stødle ◽

Marius Molund ◽

Fredrik Nilsen ◽

Johan Castberg Hellund ◽

Kjetil Hvaal

Keyword(s):

Neurological Deficit ◽

Nerve Palsy ◽

Tibial Nerve ◽

Case Series ◽

Tarsal Tunnel ◽

Retrospective Case ◽

Common Procedure ◽

Calcaneal Osteotomy ◽

The Mean

Background: Lateralizing calcaneal osteotomy (LCO) is a common procedure used to correct hindfoot varus. Several complications have been described in the literature, but only a few articles describe tibial nerve palsy after this procedure. Our hypothesis was that tibial nerve palsy is a common complication after LCO. Methods: A retrospective study of patients undergoing LCO for hindfoot varus between 2007 and 2013 was performed. A total of 15 patients (18 feet) were included in the study. The patients were examined for tibial nerve deficit, and all the patients were examined with a computed tomography (CT) scan of both feet. Patients with a preexisting neurological disease were excluded. The primary outcome was tibial nerve palsy, and the secondary outcomes were reduction of the tarsal tunnel volume, the distance from subtalar joint to the osteotomy, and the lateral step at the osteotomy evaluated by CT scans. Results: Three of the 18 feet examined had tibial nerve palsy at a mean follow-up of 51 months. The mean reduction in tarsal tunnel volume when comparing the contralateral nonoperated foot to the foot operated with LCO was 2732 mm3 in the group without neurological deficit and 2152 mm3 in the group with neurological deficit (P = .60). Conclusion: 3 of 18 feet had tibial palsy as a complication to LCO. We were not able to show that a larger decrease in the tarsal tunnel volume, a more anterior calcaneal osteotomy, or a larger lateral shift of the osteotomy is associated with tibial nerve palsy. Levels of Evidence: Level IV: Retrospective case series

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The Effect of Medial Displacement Calcaneal Osteotomy on Tarsal Tunnel Volume

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00248 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0024

Author(s):

Jae Young Kim ◽

Dong-II Chun ◽

Jaeho Cho ◽

Young Yi

Keyword(s):

Ct Scan ◽

Medial Malleolus ◽

Tarsal Tunnel ◽

Slice Thickness ◽

Cross Sectional ◽

Volume Increase ◽

Calcaneal Osteotomy ◽

Scout Image ◽

Tunnel Syndrome ◽

The Mean

Category: Hindfoot Introduction/Purpose: Tarsal tunnel volume is affected by position of the foot and the alignment of the ankle. Although medial displacement calcaneal osteotomy (MDCO) significantly alters the alignment of the hindfoot, the change of tarsal tunnel volume after this procedure has not yet been well documented. Therefore, authors investigated the volumetric change of tarsal tunnel after MDCO using Computed Tomography (CT) scan. Methods: This retrospective study involved 101 feet of 91 patients who underwent a MDCO at our institution from March 2016 to December 2018. We compared the tarsal tunnel volume from the preoperative and postoperative CT scan images under following protocols. On a sagittal scout image, the oblique axial plane was drawn parallel to the long axis of the calcaneus using talonavicular joint as a landmark. Serial oblique axial images were displayed using PACS (PathSpeed, GE Healthcare, Chicago, IL, USA) with both the soft tissue and the bone window settings. The volume of tarsal tunnel was evaluated from just distal to the tip of medial malleolus anterior colliculus to distance of 3 cm distal using 10 consecutive images by drawing the border of tarsal tunnel. The volume was calculated by adding 10 cross-sectional areas and then multiplying by 3 mm corresponding to slice thickness. Results: The mean preoperative and postoperative tarsal tunnel volume were 12229 mm3 (SD, 1842 mm3) and 12762 mm3 (SD, 1803 mm3), respectively. There was 4.6% (SD, 3.4%) of volume increase after MDCO (p <0.001). Results indicated high inter- and intraobserver reliability coefficients (r = 0.97, r = 0.98, respectively). Conclusion: MDCO increased the volume of tarsal tunnel. This finding might support clinicians performing MDCO as a conjunctive surgical option in treating patients with tarsal tunnel syndrome.

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Branching pattern of tibial nerve in the tarsal tunnel - a cadaveric study

National Journal of Clinical Anatomy ◽

10.1055/s-0039-1700734 ◽

2017 ◽

Vol 06 (02) ◽

pp. 120-125

Author(s):

Kalpana Ramadoss ◽

Komala Nanjundaiah

Keyword(s):

Tibial Nerve ◽

Lower Limbs ◽

Medial Malleolus ◽

Tarsal Tunnel ◽

Terminal Branch ◽

Type I ◽

Medical College ◽

Lateral Plantar Nerve ◽

Tarsal Bones ◽

The Mean

Abstract Background and aims: Tibial nerve is the larger terminal branch of sciatic nerve, ends by dividing into medial and lateral plantar nerves beneath the flexor retinaculum [Tarsal tunnel]. The level of bifurcation of the tibial nerve is differently quoted in text books and articles. The aim of the present study is to localize the level of bifurcation of tibial nerve. Materials and methods: 50 lower limbs from 25 cadavers available in the Department of anatomy, M.S. Ramaiah medical college and Bangalore medical college were used for the study. A reference line of 1 cm width ‘Medio Malleolar Calcaneal axis’ [MMC axis] made with OHP sheet was placed from tip of the medial malleolus of tibia to the medial tubercle of calcaneus and used as grid to classify the level of bifurcation of tibial nerve into 3 types. Type I, II, III represented the bifurcation proximal to, deep to and distal to this axis respectively. Results: Tibial nerve bifurcation was found to be type I in 92%, type II in 6%, type III in 2% of specimens. Most of the cases [32.6%] bifurcated between 5.1 to 10 mm proximal to MMC axis. The median distance of medial plantar nerve from medial malleolus was 21.28mm on left side and 20.735mm on right side. The mean of lateral plantar nerve from medial tubercle of calcaneus was 29.61mm on left side, and 28.6mm on right side. Conclusion: Detailed anatomical knowledge of tibial nerve prevents the damage to tibial nerve during various surgical procedures like fixation of fractures with external nailing of tarsal bones, medial displacement osteotomies and in tarsal tunnel surgeries.

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Cavovarus Reconstruction Using a Lateralizing Calcaneal Osteotomy Via Medial Approach

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000050 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0000

Author(s):

David Jaffe ◽

Justin Kane ◽

Christian Royer ◽

David Vier

Keyword(s):

Tibial Nerve ◽

Lateral Approach ◽

Neurologic Deficit ◽

Tarsal Tunnel ◽

Tarsal Tunnel Syndrome ◽

Operative Strategy ◽

Medial Approach ◽

Calcaneal Osteotomy ◽

Patient Reported ◽

Tunnel Syndrome

Category: Hindfoot Introduction/Purpose: Calcaneal osteotomies are commonly used to correct a varus hindfoot alignment in a patient with symptomatic cavovarus deformity. Lateralizing osteotomies (i.e. translational, closing wedge, and Malerba) have been implicated in injury to branches of the tibial nerve. The incidence of neurologic deficit after lateralizing osteotomy was recently reported at 34%. These injuries may be due to decreased volume of the tarsal tunnel, but is also postulated that the tibial nerve may be subject to direct or percussive injury when creating an osteotomy from a lateral approach. The hypothesis of this study was there would be minimal clinically significant injury to the tibial nerve by performing the osteotomy from a medial approach and that adequate correction could still be obtained. Methods: A retrospective review of consecutive patients undergoing cavovarus reconstruction by a single fellowship trained foot and ankle surgeon were identified by CPT search from a billing database over a five-year period. Patients were included if they underwent a lateralizing calcaneal osteotomy via medial approach and excluded if a lateral approach was used. Patient demographics, operative reports, and postoperative clinic notes were collected. Presence of immediate postoperative tarsal tunnel syndrome, concomitant procedures performed, perioperative complications, and preoperative and postoperative neurologic examinations were reviewed. Postoperative radiographs were reviewed for location of the osteotomy relative to the posterior tubercle. Results: 24 patients underwent lateralizing calcaneus osteotomy via medial approach. 83.3% of the osteotomies were performed in the middle third of the calcaneus with a mean translation of 11.6 cm. No patients developed acute tarsal tunnel syndrome in the immediate postoperative period. No patients had a documented permanent postoperative tibial nerve palsy. One patient had late onset of lateral foot numbness that resolved by 12 months postoperatively. Another patient noted diffuse numbness of the entire foot. Neither patient reported functional limitations related to these deficits. Other complications included two incision-related complications (8.3%) that required irrigation and debridement, antibiotics, and plastic surgery closure. Three patients underwent removal of symptomatic calcaneal hardware (12.5%). One patient (4.2%) had delayed union of the osteotomy and broke the calcaneus screw. Conclusion: Lateralizing calcaneal osteotomy performed via medial approach has a clinically negligible incidence of neurologic injury and allows for powerful correction of hindfoot varus deformity. Utilizing a medial approach decreases risk of nerve transection and provides less percussive force to branches of the tibial nerve. This technique represents an operative strategy to minimize risk to the tibial nerve and reduce neurologic deficit while providing a powerful translational correction of the hindfoot during cavovarus reconstruction.

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Extra-tunnel Compression Mimicking Tarsal Tunnel Syndrome: Ultrasound Imaging for a Plantar Ganglion Cyst

Medical Ultrasonography ◽

10.11152/mu-1788 ◽

2018 ◽

Vol 20 (4) ◽

pp. 540

Author(s):

Ke-Vin Chang ◽

Wei-Ting Wu ◽

Levent Özçakar

Keyword(s):

Peripheral Nerve ◽

Ultrasound Examination ◽

Tibial Nerve ◽

Ganglion Cyst ◽

Surgical Excision ◽

Medial Malleolus ◽

Tarsal Tunnel ◽

Tarsal Tunnel Syndrome ◽

Tunnel Syndrome ◽

Tentative Diagnosis

We reported a 43-year-old man with right-foot numbness under the tentative diagnosis of tarsal tunnel syndrome. The initial ultrasound examination did not identify any remarkable findings at the level of the medial malleolus. Owing to the failure of conservative treatments, he was referred for US-guided injection of the tibial nerve. When tracking the entire course of the nerve, a ganglion cyst was observed on top of the tibial nerve, in proximity to the medial and lateral plantar branches. The symptom disappeared after surgical excision. The present case highlights the importance of sonoantomy and tracking of the entire course of affected nerve in peripheral nerve disorders and scout scanning prior to any perineural injections.

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Plexiform Neurofibroma of the Posterior Tibial Nerve Misdiagnosed as Proximal Tarsal Tunnel Syndrome: A Case Report

The Surgery Journal ◽

10.1055/s-0038-1632405 ◽

2018 ◽

Vol 04 (01) ◽

pp. e18-e22

Author(s):

Sang Nam ◽

Jung Kim ◽

Jaeki Ahn ◽

Yongbum Park

Keyword(s):

Peripheral Nerves ◽

Clinical Presentation ◽

Tibial Nerve ◽

Plexiform Neurofibroma ◽

Benign Tumors ◽

Medial Malleolus ◽

Tarsal Tunnel ◽

Tarsal Tunnel Syndrome ◽

Posterior Tibial ◽

Tunnel Syndrome

AbstractPlexiform neurofibromas of the foot are rare, benign tumors of the peripheral nerves. Diagnosis can be challenging if they present with symptoms mimicking other peripheral nerve pathologies. Tarsal tunnel syndrome is an entrapment syndrome of the entire tibial nerve behind the medial malleolus and under the flexor retinaculum. The clinical presentation typically includes posteromedial pain, positive Tinel's sign, and neurogenic signs, including both the sensation of numbness and the actual hypoesthesia and clawing of the toes.Here, we report the case of a 59-year-old female patient with plexiform neurofibroma with symptoms similar to those of tarsal tunnel syndrome. The plexiform neurofibroma was surgically excised and the nerve function was partially preserved.

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Predictive Outcome Modeling of Preoperative Clinical Symptoms and Electrodiagnostic Data in Tarsal Tunnel Surgery

Journal of Brachial Plexus and Peripheral Nerve Injury ◽

10.1055/s-0041-1731747 ◽

2021 ◽

Vol 16 (01) ◽

pp. e37-e45

Author(s):

Geoffrey K. Seidel ◽

Salma Al Jamal ◽

Eric Weidert ◽

Frederick Carington ◽

Michael T. Andary ◽

...

Keyword(s):

Surgical Outcome ◽

Clinical Symptoms ◽

Tibial Nerve ◽

Outcome Measurement ◽

Tarsal Tunnel ◽

Patient Reported ◽

Peripheral Polyneuropathy ◽

Tunnel Syndrome ◽

Phalen's Test ◽

Surgical Release

Abstract Background The relationship between tarsal tunnel syndrome (TTS), electrodiagnostic (Edx) findings, and surgical outcome is unknown. Analysis of TTS surgical release outcome patient satisfaction and comparison to Edx nerve conduction studies (NCSs) is important to improve outcome prediction when deciding who would benefit from TTS release. Methods Retrospective study of 90 patients over 7 years that had tarsal tunnel (TT) release surgery with outcome rating and preoperative tibial NCS. Overall, 64 patients met study inclusion criteria with enough NCS data to be classified into one of the following three groups: (1) probable TTS, (2) peripheral polyneuropathy, or (3) normal. Most patients had preoperative clinical provocative testing including diagnostic tibial nerve injection, tibial Phalen's sign, and/or Tinel's sign and complaints of plantar tibial neuropathic symptoms. Outcome measure was percentage of patient improvement report at surgical follow-up visit. Results Patient-reported improvement was 92% in the probable TTS group (n = 41) and 77% of the non-TTS group (n = 23). Multivariate modeling revealed that three out of eight variables predicted improvement from surgical release, NCS consistent with TTS (p = 0.04), neuropathic symptoms (p = 0.045), and absent Phalen's test (p = 0.001). The R 2 was 0.21 which is a robust result for this outcome measurement process. Conclusion The best predictors of improvement in patients with TTS release were found in patients that had preoperative Edx evidence of tibial neuropathy in the TT and tibial nerve plantar symptoms. Determining what factors predict surgical outcome will require prospective evaluation and evaluation of patients with other nonsurgical modalities.

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The Safety of the Esmarch Tourniquet

Foot & Ankle ◽

10.1177/107110079301400508 ◽

1993 ◽

Vol 14 (5) ◽

pp. 278-283 ◽

Cited By ~ 17

Author(s):

William C. Biehl ◽

James M. Morgan ◽

F. William Wagner ◽

Rodney A. Gabriel

Keyword(s):

Learning Curve ◽

Clinical Application ◽

Medial Malleolus ◽

Foot And Ankle ◽

Surgical Case ◽

Significant Difference ◽

Mean Pressure ◽

Continued Use

The use of an Esmarch bandage as a tourniquet in surgery has been criticized. Many authors claim that the pressures under the Esmarch are inconsistent and may be extremely high. We have seen few, if any, problems from the use of an Esmarch in surgery of the foot and ankle. The purpose of this study was to evaluate the pressures generated under the Esmarch tourniquet in a situation that mimics its clinical application, and to determine whether pressures of appropriate magnitude and consistency are obtained in order to recommend its continued use in surgery. Ten volunteers performed numerous applications of the Esmarch. The number of wraps and the width of the Esmarch bandage used were varied. The Esmarch was applied as it would be for a surgical case. Pressures directly beneath the Esmarch were recorded 8 cm proximal to the distal tip of the medial malleolus. Considering all volunteers and all pressures generated, a 3-in Esmarch applied with three wraps gave a mean pressure (±SD) of 225 ± 46 mm Hg. A 3-in Esmarch applied with four wraps gave a mean pressure of 291 ± 53 mm Hg. A 4-in Esmarch applied with three wraps gave a mean pressure of 233 ± 35 mm Hg, and a 4-in Esmarch with four wraps gave a mean pressure of 284 ± 42 mm Hg. The maximum pressures generated by any individual were as follows: 3-in three wraps, 321 mm Hg; 3-in four wraps, 413 mm Hg; 4-in three wraps, 328 mm Hg; and 4-in four wraps, 380 mm Hg. There was no significant difference in the magnitude or consistency of pressures generated between the experienced and inexperienced wrappers. There did not appear to be a learning curve for the application of the Esmarch bandage. We conclude that an Esmarch bandage, used as a tourniquet, can generate safe and reliable pressures. Either a 3-in or 4-in Esmarch bandage applied above the ankle with three circumferential overlapping wraps consistently results in pressures that are in a safe range.

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