Effect of Lateral Sliding Calcaneus Osteotomy on Tarsal Tunnel Pressure

Background: Lateral sliding calcaneus osteotomies are common procedures to correct hindfoot varus deformities. Shifting the calcaneal tuberosity laterally (lateralization) can lead to tarsal tunnel pressure increase and tibial nerve palsy. The purpose of this cadaveric biomechanical study was to investigate the correlation of lateralization and pressure increase underneath the flexor retinaculum. Methods: The pressure in the tarsal tunnel of 12 Thiel-fixated human cadaveric lower legs was measured in different foot positions and varying degrees of calcaneal lateralization. Results: The mean pressure increased from plantarflexion (PF) to neutral position (NP) and from NP to hindfoot dorsiflexion (DF), and with increasing amounts of lateralization of the calcaneal tuberosity. The mean baseline pressure in PF was 1.5, in NP 2.2, and in DF 6.5 mmHg and increased to 8.1 in PF, 18.4 in NP, and 33.1 mmHg with 12 mm of lateralization. The release of the flexor retinaculum significantly lowered the pressure. Conclusion: Increasing pressures were found in the tarsal tunnel with increasing lateralization of the tuberosity and with both dorsiflexion and plantarflexion of the ankle. Clinical Relevance: A pre-emptive release of the flexor retinaculum for a lateralization of the calcaneal tuberosity of more than 8 mm should be considered, especially if specific patient risk factors are present. No tibial nerve palsy should be expected with 4 mm of lateralization.

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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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Schwannoma of the Posterior Tibial Nerve

Journal of the American Podiatric Medical Association ◽

10.7547/0003-0538-104.5.539 ◽

2014 ◽

Vol 104 (5) ◽

pp. 539-543 ◽

Cited By ~ 6

Author(s):

Tanya Judd ◽

Taunna Jones ◽

Lauren Thornberry

Keyword(s):

Soft Tissue ◽

Soft Tissue Mass ◽

Tibial Nerve ◽

Benign Tumors ◽

Tarsal Tunnel ◽

Posterior Tibial Nerve ◽

Nerve Branch ◽

Tissue Mass ◽

Posterior Tibial ◽

Flexor Retinaculum

Background Schwannomas are rare, slow-growing, benign tumors consisting of Schwann cells. They may cause pressure along a bony structure, resulting in increased pain and discomfort. Less than 1% of schwannomas become malignant, and localization in the foot is uncommon (2%–3% of reported cases). Methods We present a case of a schwannoma of a branch of the posterior tibial nerve sheath. The goal is to assist in recognition, diagnosis, and treatment of schwannoma in the foot and ankle. This is a case of a 51-year-old male soccer player with a soft-tissue mass along the medial ankle at the tarsal tunnel area with an insidious onset (2 years). Physical examination revealed a 3.0 × 2.5-cm mass; magnetic resonance imaging confirmed location, size, and depth. Results Surgical resection of the soft-tissue mass was performed under general anesthesia. The mass was found to be superior to the flexor retinaculum and attached by a small nerve branch of the posterior tibial nerve that traveled through the flexor retinaculum. A tissue specimen was sent to the pathology laboratory, and a schwannoma was confirmed histologically. Conclusions Schwannomas can occur after trauma, especially if the posterior tibial nerve or its branches are affected intrinsically or extrinsically, leading to discomfort, pain, and numbness along the tarsal tunnel. Also, unique to this case, a schwannoma may occur along the small branches of the posterior tibial nerve and present anatomically superior to the flexor retinaculum.

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Recurrent Tarsal Tunnel Syndrome and the Radial Forearm Free Flap

Foot & Ankle International ◽

10.1177/107110079601701010 ◽

1996 ◽

Vol 17 (10) ◽

pp. 641-643 ◽

Cited By ~ 3

Author(s):

David A. Novotny ◽

David B. Kay ◽

Michael G. Parker

Keyword(s):

Free Flap ◽

Tibial Nerve ◽

Treatment Options ◽

Deep Fascia ◽

Tarsal Tunnel ◽

Radial Forearm Free Flap ◽

Tarsal Tunnel Syndrome ◽

Flexor Retinaculum ◽

Radial Forearm ◽

Tunnel Syndrome

Tarsal tunnel syndrome results from posterior tibial nerve entrapment beneath the flexor retinaculum and the deep fascia. The syndrome consists of pain, paresthesias, and vasomotor changes. Surgical correction via release of the flexor retinaculum is the treatment of choice. There is however, a 10% to 20% failure rate, with little in the literature addressing treatment options in this subset of individuals. Two patients with recurrent tarsal tunnel syndrome were treated with re-release of the retinaculum, followed by nerve coverage with a radial forearm free flap. At 15 and 27 months, both patients were pain-free, ambulatory, and able to return to work.

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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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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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Interference Screw Versus Suture Anchors for Femoral Fixation in Medial Patellofemoral Ligament Reconstruction: A Biomechanical Study

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967121989282 ◽

2021 ◽

Vol 9 (3) ◽

pp. 232596712198928

Author(s):

Heath P. Gould ◽

Nicholas R. Delaney ◽

Brent G. Parks ◽

Roshan T. Melvani ◽

Richard Y. Hinton

Keyword(s):

Medial Patellofemoral Ligament ◽

Interference Screw ◽

Biomechanical Study ◽

Graft Fixation ◽

Mpfl Reconstruction ◽

Suture Anchors ◽

Femoral Fixation ◽

Significant Difference ◽

Load To Failure ◽

The Mean

Background: Femoral-sided graft fixation in medial patellofemoral ligament (MPFL) reconstruction is commonly performed using an interference screw (IS). However, the IS method is associated with several clinical disadvantages that may be ameliorated by the use of suture anchors (SAs) for femoral fixation. Purpose: To compare the load to failure and stiffness of SAs versus an IS for the femoral fixation of a semitendinosus autograft in MPFL reconstruction. Study Design: Controlled laboratory study. Methods: Based on a priori power analysis, a total of 6 matched pairs of cadaveric knees were included. Specimens in each pair were randomly assigned to receive either SA or IS fixation. After an appropriate reconstruction procedure, the looped end of the MPFL graft was pulled laterally at a rate of 6 mm/s until construct failure. The best-fit slope of the load-displacement curve was then used to calculate the stiffness (N/mm) in a post hoc fashion. A paired t test was used to compare the mean load to failure and the mean stiffness between groups. Results: No significant difference in load to failure was observed between the IS and the SA fixation groups (294.0 ± 61.1 vs 250.0 ± 55.9; P = .352), although the mean stiffness was significantly higher in IS specimens (34.5 ± 9.6 vs 14.7 ± 1.2; P = .004). All IS reconstructions failed by graft pullout from the femoral tunnel, whereas 5 of the 6 SA reconstructions failed by anchor pullout. Conclusion: In this biomechanical study using a cadaveric model of MPFL reconstruction, SA femoral fixation was not significantly different from IS fixation in terms of load to failure. The mean load-to-failure values for both reconstruction techniques were greater than the literature-reported values for the native MPFL. Clinical Relevance: These results suggest that SAs are a biomechanically viable alternative for femoral-sided graft fixation in MPFL reconstruction.

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Management of intended durotomy in minimally invasive intradural spine surgery

Journal of Neurosurgery Spine ◽

10.3171/2014.3.spine13719 ◽

2014 ◽

Vol 21 (2) ◽

pp. 279-285 ◽

Cited By ~ 14

Author(s):

Lee A. Tan ◽

Ippei Takagi ◽

David Straus ◽

John E. O'Toole

Keyword(s):

Blood Loss ◽

Minimally Invasive ◽

Length Of Hospital Stay ◽

Bed Rest ◽

Tubular Retractor ◽

Specific Patient ◽

Dural Closure ◽

Estimated Blood Loss ◽

The Mean ◽

Operative Notes

Object Minimally invasive surgery (MIS) has been increasingly used for the treatment of various intradural spinal pathologies in recent years. Although MIS techniques allow for successful treatment of intradural pathology, primary dural closure in MIS can be technically challenging due to a limited surgical corridor through the tubular retractor system. The authors describe their experience with 23 consecutive patients from a single institution who underwent MIS for intradural pathologies, along with a review of pertinent literature. Methods A retrospective review of a prospectively collected surgical database was performed to identify patients who underwent MIS for intradural spinal pathologies between November 2006 and July 2013. Patient demographics, preoperative records, operative notes, and postoperative records were reviewed. Primary outcomes include operative duration, estimated blood loss, length of bed rest, length of hospital stay, and postoperative complications, which were recorded prospectively. Results Twenty-three patients who had undergone MIS for intradural spinal pathologies during the study period were identified. Fifteen patients (65.2%) were female and 8 (34.8%) were male. The mean age at surgery was 54.4 years (range 30–74 years). Surgical pathologies included neoplastic (17 patients), congenital (3 patients), vascular (2 patients), and degenerative (1 patient). The most common spinal region treated was lumbar (11 patients), followed by thoracic (9 patients), cervical (2 patients), and sacral (1 patient). The mean operative time was 161.1 minutes, and the mean estimated blood loss was 107.2 ml. All patients were allowed full activity less than 24 hours after surgery. The median length of stay was 78.2 hours. Primary sutured dural closure was achieved using specialized MIS instruments with adjuvant fibrin sealant in all cases. The rate of postoperative headache, nausea, vomiting, and diplopia was 0%. No case of cutaneous CSF fistula or symptomatic pseudomeningocele was identified at follow-up, and no patient required revision surgery. Conclusions Primary dural closure with early mobilization is an effective strategy with excellent clinical outcomes in the use of MIS techniques for intradural spinal pathology. Prolonged bed rest after successful primary dural closure appears unnecessary, and the need for watertight dural closure should not prevent the use of MIS techniques in this specific patient population.

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Blood Pressure and Intraventricular Hemorrhage in Premature Infants

PEDIATRICS ◽

10.1542/peds.86.6.1006a ◽

1990 ◽

Vol 86 (6) ◽

pp. 1006-1007

Author(s):

EDWARD H. PERRY ◽

HENRIETTA S. BADA ◽

JOHN D. DAY ◽

SHELDON B. KORONES ◽

KRISTOPHER L. ARHEART ◽

...

Keyword(s):

Blood Pressure ◽

Birth Weight ◽

Premature Infants ◽

Intraventricular Hemorrhage ◽

Stability Boundary ◽

Mean Blood Pressure ◽

Pressure Increase ◽

Blood Pressure Increase ◽

The Mean

In Reply.— We appreciate the interest and comments of Drs Puccio and Soliani regarding our article "Blood Pressure Increase, Birth Weight Dependent Stability Boundary and Intraventricular Hemorrhage."1 In response, we address the following points: 1. Although mean blood pressure (BP) values greater than 100 mm Hg were observed in some of our patients, these were quite rare. The mean BP was found to be less than 60 mm Hg 99% of the time. Thus, unless one is recording BPs through long periods and sampling quite often, the brief spikes likely would not be observed.

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Obturator Nerve Transfer to the Branch of the Tibial Nerve Innervating the Gastrocnemius Muscle for the Treatment of Sacral Plexus Nerve Injury

Neurosurgery ◽

10.1227/neu.0000000000001166 ◽

2015 ◽

Vol 78 (4) ◽

pp. 546-551 ◽

Cited By ~ 4

Author(s):

Gang Yin ◽

Huihao Chen ◽

Chunlin Hou ◽

Jianru Xiao ◽

Haodong Lin

Keyword(s):

Nerve Injury ◽

Gastrocnemius Muscle ◽

Tibial Nerve ◽

Nerve Transfer ◽

Obturator Nerve ◽

Surgical Reconstruction ◽

Sacral Plexus ◽

Medial Head ◽

Anterior Branch ◽

The Mean

Abstract BACKGROUND: Lower-limb function is severely impaired after sacral plexus nerve injury. Nerve transfer is a useful reconstructive technique for proximal nerve injuries. OBJECTIVE: To investigate the clinical effectiveness and safety of transferring the ipsilateral obturator nerve to the branch of the tibial nerve innervating the medial head of the gastrocnemius muscle to recover knee and ankle flexion. METHODS: From 2007 to 2011, 5 patients with sacral plexus nerve injury underwent ipsilateral obturator nerve transfer as part of a strategy for surgical reconstruction of their plexuses. The mean patient age was 31.4 years (range, 19-45 years), and the mean interval from injury to surgery was 5.8 months (range, 3-8 months). The anterior branch of the obturator nerve was coapted to the branch of the tibial nerve innervating the medial head of the gastrocnemius muscle by autogenous nerve grafting. RESULTS: Patient follow-up ranged from 24 to 38 months. There were no complications related to the surgery. Three patients recovered to Medical Research Council grade 3 or better in the medial head of the gastrocnemius muscle. Thigh adduction function was not affected in any patient. CONCLUSION: Knee and ankle flexion can be achieved by transferring the anterior branch of the obturator nerve to the branch of the tibial nerve innervating the medial head of the gastrocnemius muscle, which is useful for balance. This procedure can be used as a new method for treating sacral plexus nerve injury.

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