Structures at Risk in the Arthroscopic Brostrom-Gould Procedure: A Cadaver Study

Category: Ankle, Arthroscopy, Basic Sciences/Biologics, Sports Introduction/Purpose: The Broström Gould procedure is the gold standard for repair of lateral ankle ligament injury and ankle instability. This procedure has demonstrated excellent short- and long-term outcomes in the orthopaedic literature. Arthroscopic Broström Gould techniques have become increasingly popular among some foot and ankle orthopaedic surgeons. Typically, this technique requires standard medial and lateral portals along with an accessory lateral working portal. The exact location of this portal is variable within the available described surgical techniques. The objective of this cadaveric study is to establish a standard entry point for and to assess the safety of the accessory lateral portal with respect to nearby anatomical structures. Methods: Ten fresh-frozen below-knee cadaver specimens were used. The location of the accessory portal was created 1.5 cm anterior to the distal tip of the fibula. A small vertical incision was made at this point, followed by insertion of a Kirschner wire into the joint. The wire was then gently impacted into the fibula. Superficial dissection was subsequently carried out around the entry point to identify the peroneal tendons, superficial peroneal nerve branches, and sural nerve branches. Structures were marked with colored push pins, and distance was measured between the nearest edge of the Kirschner wire and each of the three anatomic structures listed. Any instances of structural contact or damage were documented. Results: The average distance from the Kirschner wire to the peroneal tendon was 16.1 (±4.41) mm. The average distance from the wire to the superficial peroneal nerve and sural nerve was 13.11 (±6.79) mm and 12.33 (±4.08) mm, respectively. There were no instances of injury to any of the studied structures. However, there was a notable amount of variability in the proximity of structures in question for each cadaver. A branch of the superficial peroneal nerve was measured as close as 2 mm and as far as 24 mm in separate cadaver specimens. Conclusion: Arthroscopic Broström Gould procedures are a safe and effective method for lateral ankle ligamentous repair but are not without risk. Accessory lateral portal placement is relatively safe but should be meticulously executed to avoid damage to nearby anatomical structures.

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Keep it blunt: aberrations in the course of the superficial peroneal nerve during lateral ankle approach

European Orthopaedics and Traumatology ◽

10.1007/s12570-013-0165-7 ◽

2013 ◽

Vol 4 (1) ◽

pp. 59-61

Author(s):

Masroor A. Naveed ◽

Yousaf Khan ◽

Kopadda Raja Ratnam ◽

Jochen Fischer

Keyword(s):

Peroneal Nerve ◽

Superficial Peroneal Nerve ◽

Lateral Ankle

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Anomalous superficial peroneal nerve and variant cutaneous innervation of the sural nerve on the dorsum of the foot: a case report

Cases Journal ◽

10.1186/1757-1626-2-197 ◽

2009 ◽

Vol 2 (1) ◽

pp. 197 ◽

Cited By ~ 7

Author(s):

Somayaji Nagabhooshana ◽

Venkata Vollala ◽

Vincent Rodrigues ◽

Mohandas Rao

Keyword(s):

Case Report ◽

Sural Nerve ◽

Peroneal Nerve ◽

Superficial Peroneal Nerve ◽

Cutaneous Innervation

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Minimally Invasive Surgery for Correction of Adult Acquired Flat Foot Deformity: An Anatomic Study

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00446 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0044

Author(s):

Ademola I. Shofoluwe ◽

Erroll J. Bailey ◽

Gary W. Stewart

Keyword(s):

Minimally Invasive Surgery ◽

Minimally Invasive ◽

Sural Nerve ◽

Peroneal Nerve ◽

Osteotomy Site ◽

Superficial Peroneal Nerve ◽

Deep Peroneal Nerve ◽

Dorsalis Pedis Artery ◽

Extensor Hallucis Longus ◽

Neurovascular Structures

Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is a complex and chronic debilitating condition characterized by a decrease in the medial arch height and, in advanced stages, a decrease in the talonavicular coverage angle as the forefoot drifts into pronation and abduction. Operative treatment of stage II deformity has changed significantly over the past few decades. Joint sparing procedures which aim to realign the hindfoot and augment the diseased tibialis posterior tendon with the flexor digitorum longus transfer are commonly performed. The introduction of minimally invasive surgery (MIS) has been associated with smaller incisions, less blood loss, and quicker recovery times. The purpose of this study was to qualitatively and quantitatively observe the tendinous and neurovascular structures at risk with MIS AAFD osteotomy procedures in cadaveric feet. Methods: MIS technique was used to perform medial displacement calcaneal, Evans, and Cotton osteotomies on nine cadaveric feet under fluoroscopic guidance. The sural nerve, superficial peroneal nerve and its branches, deep peroneal nerve, dorsalis pedis artery, saphenous vein, and peroneal and extensor hallucis longus tendons were carefully dissected from each cadaveric foot and evaluated for injuries following the MIS osteotomy cuts. The distance from the osteotomy cuts and these anatomic structures were measured and recorded. Results: On average, the sural nerve was 8.4 mm and 9 mm from the calcaneal and Evans osteotomy sites, respectively. The intermediate dorsal cutaneous nerve was on average 68.3 mm and 41.1 mm from the calcaneal and Evans osteotomy sites, respectively. The peroneal tendons were on average 16.7 mm and 0 mm from the calcaneal and Evans osteotomy sites, respectively. The extensor hallucis was an average of 1 mm from the Cotton osteotomy site. There was a partial tear injury to the peroneus brevis in four of the cadaveric specimens at the Evans osteotomy site without complete laceration. There was no injury to the sural nerve, superficial peroneal nerve and its branches, saphenous vein, deep peroneal nerve, dorsalis pedis artery, or extensor hallucis longus tendon. Conclusion: Tendinous and neurovascular structures are at risk with MIS AAFD osteotomy procedures. Care should be taken with soft tissue handling and blunt dissection to decrease iatrogenic injuries to these structures. Specifically, extra care and recognition of the peroneal tendons during the Evans osteotomy may prevent damage, as this structure was at greatest risk among the three osteotomy cuts. Future research studies evaluating this technique and the functional outcomes in patients in a clinical setting is warranted. Surgical technique studies are underway to implement smaller, yet appropriate bone grafts through mini incisions.

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The Relationship of the Lapidus Intramedullary Nail to Neurologic and Tendinous Structures in the Foot: An Anatomic Study

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00394 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0039

Author(s):

Ademola Shofoluwe ◽

Kurt Krautmann ◽

Lucas Marques ◽

Gary Stewart

Keyword(s):

At Risk ◽

Intramedullary Nail ◽

Tibialis Anterior ◽

Peroneal Nerve ◽

Average Distance ◽

Superficial Peroneal Nerve ◽

Tibialis Anterior Tendon ◽

Longus Tendon ◽

Extensor Hallucis Longus ◽

Nail Insertion

Category: Bunion, Midfoot/Forefoot Introduction/Purpose: The lapidus procedure is a longstanding operation performed for the treatment of hallux valgus deformity with a concomitant hypermobile first ray. Orthopaedic surgeons have a myriad of options to choose from in performing the lapidus procedure. The implantation of orthopaedic implants comes with the risk of iatrogenic injury to surrounding anatomy. Several cadaveric studies in the humerus and femur have described potential neurovascular structures at risk during placement of intramedullary nail systems. The purpose of this study was to determine the proximity of nail insertion and interlocking mechanisms in the Lapidus Phantom Intramedullary Nail System (Paragon 28, Inc.) to neurologic and tendinous structures in the foot. Methods: A titanium intramedullary nail was inserted from the first metatarsal to the medial cuneiform spanning the first tarsometatarsal joint in 10 fresh-frozen cadaver feet. K-wires were inserted in the proximal lateral, proximal medial, and distal medial-to-lateral interlock screw paths. The tibialis anterior tendon, extensor hallucis longus tendon, and superficial peroneal nerve were carefully dissected and exposed, and the distance from each of these anatomic landmarks were then measured and recorded from four different aspects of the nail: Proximal lateral interlocking screw path, proximal medial interlocking screw path, nail insertion, distal interlocking screw path. Distances were averaged, ranges were determined. Results: The tibialis anterior tendon was in closest proximity to the proximal medial interlock K-wire with an average distance of 0.4 mm. The proximal medial interlock bisected the tibialis anterior tendon in three of the specimens. The extensor hallucis longus tendon was in closest proximity to the nail insertion with an average distance of 1.2 mm. A branch of the superficial peroneal nerve was in closest proximity to the distal interlock K-wire with an average distance of 7.5 mm, however, the nerve came in direct contact with the proximal medial interlock K-wire in two of the specimens. Conclusion: The Lapidus intramedullary nail’s proximal medial interlock screw poses the greatest threat to the tibialis anterior tendon, with the distance from the tendon to the interlock K-wire being 3 mm or less in all specimens tested. The extensor hallucis longus tendon is at risk of injury with insertion of the nail. Medial to lateral interlocking poses the greatest danger to a branch of the superficial peroneal nerve. Blunt dissection should be performed using this system with a path to bone before instrumentation to reduce the risk of nerve and tendon injury in the foot.

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Anatomic localization of motor entry point of superficial peroneal nerve to peroneus longus and brevis muscles

Clinical Anatomy ◽

10.1002/ca.21076 ◽

2010 ◽

Vol 24 (2) ◽

pp. 232-236 ◽

Cited By ~ 13

Author(s):

Je-Hun Lee ◽

Be-Na Lee ◽

Xiaochun An ◽

Rak-Hee Chung ◽

Seong-Oh Kwon ◽

...

Keyword(s):

Peroneal Nerve ◽

Entry Point ◽

Superficial Peroneal Nerve ◽

Peroneus Longus ◽

Motor Entry Point ◽

Anatomic Localization

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Peripheral Nerve Biopsy

10.1093/med/9780190617127.003.0013 ◽

2018 ◽

Author(s):

Miriana Popadich ◽

Thomas J. Wilson

Keyword(s):

Peripheral Nerve ◽

Surgical Procedure ◽

Sural Nerve ◽

Peroneal Nerve ◽

Chronic Inflammatory Demyelinating Polyneuropathy ◽

Nerve Biopsy ◽

Metastatic Tumor ◽

Tumor Infiltration ◽

Superficial Peroneal Nerve ◽

Inflammatory Demyelinating Polyneuropathy

Nerve biopsy is an important part of the diagnostic armamentarium in the evaluation of a number of diseases, including vasculitis, some hereditary neuropathies, toxic and metabolic neuropathies, inflammatory demyelinating conditions (such as chronic inflammatory demyelinating polyneuropathy), and neoplastic and nonneoplastic infiltrative diseases, such as sarcoidosis, amyloidosis, neurolymphomatosis, and other metastatic tumor infiltration. Options for nerve biopsy include whole-nerve biopsy (e.g., biopsy of the sural nerve, superficial peroneal nerve, or superficial sensory radial nerve) or targeted fascicular biopsy. This chapter identifies indications for nerve biopsy, discusses important considerations for choosing the biopsy target, and explains in detail the surgical procedure for common nerve biopsies.

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Anatomical Structures at Risk in Proximal Fifth Metatarsal Fracture Fixation: A Cadaver Study

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00058 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0005

Author(s):

Leonardo Vinicius de Matos Moraes ◽

Kelly Cristina Stéfani ◽

James T. McMurtrie ◽

Haley M. McKissack ◽

Jianguang Peng ◽

...

Keyword(s):

At Risk ◽

Sural Nerve ◽

Guide Wire ◽

Articular Surface ◽

Average Distance ◽

Cadaver Study ◽

Percutaneous Fixation ◽

Peroneus Longus ◽

Peroneus Brevis ◽

The Wire

Category: Sports, Trauma, Cadaver study Introduction/Purpose: Jones fractures are fractures of the proximal fifth metatarsal involving the metaphyseal-diaphyseal junction. They have an increased risk for refracture, delayed union and nonunion secondary to poor blood supply to this área. They are usually treated conservatively, but when chosen for surgical treatment percutaneous fixation with screws is the most used. Few studies have evaluated the complications of injury to nearby structures during the percutaneous fixation. It has been shown, however, that the peroneal brevis and longus, the cuboid, and the sural nerve lie in close proximity to this starting point and are, therefore, at theoretical risk of injury. The study aims to evaluate the presence of injury of the structures at risk and to measure the distance of these structures to the entry point. Methods: Eleven fresh-frozen below-the-knee specimens underwent standard operative fixation for a Jones fracture via the “High and inside” percutaneous technique. A guide wire was placed through the medullary canal and confirmed on fluoroscopy. The cannulated drill with drill sleeve was then placed over the wire and advanced to the diaphysis. The guide wire was left and the skin and subcutaneous tissues were carefully removed from the lateral midfoot to fully expose the structures at risk. The guidewire was then removed, and then the solid screw was placed. Neurovascular and tendinous structures were assessed for any injury. The distance of the wire in the base of fifth metatarsal and these structures was measured and documented, including the branches of the sural nerve, cuboid, fourth metatarsal, peroneus longus, and peroneus brevis tendons. Results: The structure with the shortest average distance from the pin was the peroneus brevis, measuring 0.91 mm (±1.22 mm S.D.), followed by the cuboid articular surface, sural nerve, peroneus longus, and base of the fourth metatarsal, respectively. The pin had damaged the peroneus brevis in 5 of 11 cadavers. However, it did not damage at the tendon insertion point in any specimen. The average distance from the tendon insertion point was 7.2 mm. The furthest measured distance was 10 mm, while the closest was 3 mm. The screw head contacted the articular surface of the cuboid in 3 of 11 cadavers. There were no instances of pin contact with or damage to the peroneus longus, sural nerve, or fourth metatarsal head. Conclusion: This is the only study that evaluated the risk of injury the structures after a procedure that simulated an actual surgical act. It is also the only one that was aware of the risk of tendon injury not only in its insertion but also in its path during the placement of the wire and drill. We conclude that percutaneous fixation of fractures of the base of the fifth metatarsus presents a risk of partial lesion of the peroneus brevis tendon and lateral aspect of the cuboid. Therefore, specific care with these structures can be taken during the procedure.

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Anatomic Structures at Risk When Utilizing an Intramedullary Nail for Distal Fibular Fractures

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000181 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0001

Author(s):

David Goss ◽

Christopher Reb ◽

Terrence Philbin

Keyword(s):

Relative Risk ◽

High Risk ◽

Sural Nerve ◽

Peroneal Nerve ◽

Percutaneous Technique ◽

Superficial Peroneal Nerve ◽

Distal Fibula ◽

Peroneal Tendons ◽

Distal Locking ◽

Peroneus Brevis

Category: Ankle Introduction/Purpose: Distal fibula fractures are most commonly fixated with plate and screw constructs. Conversely, modern generation fibular intramedullary nails are load-sharing devices that offer rigid internal fixation via percutaneous technique with only transaxial screws residing subcuticularly. The relative risk of damage to nearby structures is well characterized for plate and screws constructs; however, no such data is available for fibular nails. As a result, the purpose of this anatomic study was to assess the relative risk to nearby anatomic structures when implanting a current generation retrograde locked intramedullary fibular nail. Methods: This was an IRB-exempt study. Ten human cadaveric lower extremities were instrumented with a contemporary retrograde locked intramedullary fibular nail with three distal locking and two syndesmotic fixation options. The cadavers were then dissected by a single experienced orthopedic foot and ankle surgeon in a standardized fashion. The shortest distance, in millimeters (mm), between the site of procedural steps and nearby named structures of interest (i.e. sural nerve, superficial peroneal nerve and the peroneal tendons) was measured and recorded. Levels of risk were then assigned based on observed distances as high (0 to 5 mm), moderate (5.1 to 10 mm) and low (greater than 10 mm). Results: The peroneus brevis tendon was at high risk when making the distal skin incision in all specimens (Table). When reaming and inserting the nail through the distal fibula aperture, the peroneus brevis was at high risk in 7 specimens. The peroneus longus tendon was at moderate to high risk when inserting both the proximal and distal syndesmotic screws in 9 specimens. The superficial peroneal nerve was at high risk when inserting an anterior to posterior distal locking screw in 7 specimens. The sural nerve was at low risk for all procedural steps. Of note, no structures were observed to have been directly damaged. Conclusion: The current findings indicate that strict adherence to sound percutaneous technique is needed in order to minimize iatrogenic damage to neighboring structures when performing retrograde locked intramedullary fibular nail insertion. This includes making skin-only incisions, thorough blunt spreading down to bone, and maintaining close approximation between tissue protection sleeves and bone at all times. The current findings indicate that the peroneal tendons and superficial peroneal nerve are at the highest risk, and should be considered when performing relevant clinical outcomes studies.

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