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.

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.

scholarly journals Endoscopic treatment of Achilles tendon enthesopathies: An anatomical and clinical feasibility study

2020 ◽  
Vol 8 (2_suppl) ◽  
pp. 2325967120S0000
Author(s):  
Olivier Boniface ◽  
Thomas Vervoort
Keyword(s):  
Achilles Tendon ◽  
Feasibility Study ◽  
Open Surgery ◽  
Wound Complications ◽  
Operating Technique ◽  
Clinical Series ◽  
Open Reconstruction ◽  
Tendon Insertion ◽  
Calcaneal Tuberosity

Background: One possible treatment for Achilles tendon enthesopathy is open reconstruction of the Achilles tendon insertion by resection of calcified enthesis and the calcaneal tuberosity followed by reinsertion of the tendon with anchors. Subcutaneous dissection of the tendon in open procedure is at risk of wound complications. We hypothesized that this procedure could be performed under endoscopy. Methods: An innovative operating technique was described. It consisted in removal and reinsertion of the Achilles tendon under endoscopy using five portals with resection of the calcaneal tuberosity and calcified enthesis. A feasibility study was first conducted on five cadaveric feet followed by an in vivo study on five patients. Results: In all cases, the Achilles tendon could be reinserted with the same technique than in open surgery. None of the ten surgical procedures technically failed. It was possible to correctly resect calcifications and the calcaneal tuberosity. Resection was performed under endoscopic and fluoroscopic control for the ten cases. Proper reinsertion was verified under endoscopy, by placement of the ankle in physiological equinus for clinical series and by dissection for cadaveric cases. There were no complications in the clinical series 3 months postoperatively. Conclusion: Achilles enthesopathies can be treated by detachment/reinsertion of the Achilles tendon under endoscopy with resection of calcified enthesis and the calcaneal tuberosity. This endoscopic technique should now be validated by analyzing longer-term clinical and anatomical results and comparing them with the results of open surgery.

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 Hindfoot Alignment of Adult Acquired Flatfoot Deformity

2017 ◽  
Vol 2 (2) ◽  
pp. 2473011416S0001
Author(s):  
Cesar de Cesar Netto ◽  
Shadpour Demehri ◽  
Apisan Chinanuvathana ◽  
Alireza Mousavian ◽  
Eric Tan ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Achilles Tendon ◽  
Clinical Assessment ◽  
Subtalar Joint ◽  
Hindfoot Alignment ◽  
Observer Reliability ◽  
Adult Acquired Flatfoot Deformity ◽  
The Mean ◽  
Valgus Alignment ◽  
Calcaneal Tuberosity

Category: Hindfoot Introduction/Purpose: Assessment of hindfoot alignment in adult acquired flatfoot deformity (AAFD) can be challenging. Clinical judgment and radiograph studies while important may not represent the accurate valgus alignment of the affected patients. Weightbearing (WB) ConeBeam CT (CBCT) is an emerging imaging modality that may potentially better demonstrate the three-dimensional (3D) deformity, facilitating visualization of important soft-tissue and bony landmarks and helping in surgical planning. Based on the relative position of bone and soft-tissue axes, different measurements of hindfoot alignment can be obtained with CT images. Therefore, we compared clinical assessment of hindfoot valgus alignment in AAFD patients with different possible measurements performed on WB CBCT images. Methods: In this prospective, IRB-approved study, 20 patients (20 feet, 15 right and 5 left) with clinical diagnosis of flexible AAFD were included. There were 12 males and 8 females, with a mean age of 52.2 years (range, 20 – 88 years of age), and average BMI of 30.35 kg/m2 (range, 19.00 – 46.09 kg/m2). Patients underwent clinical assessment of hindfoot alignment as well as WB CBCT. Two independent and blinded foot and ankle board-certified surgeons performed different hindfoot alignment measurements on the WB CBCT images that included: 3D “clinical” alignment; Achilles tendon axis/calcaneal tuberosity angle; angles formed between the tibial axis and the calcaneal tuberosity, calcaneal axis and line connecting midpoint of subtalar joint and most inferior part of calcaneal tuberosity. Positive values were considered valgus alignment. Mean differences between the measurements modalities were compared by paired T-test. Intra- and Inter-observer reliability for the WB CBCT measurements were calculated using Pearson correlation. Results: The mean clinical hindfoot valgus measured was 15.15o (SD 7.7o). It was found to be significantly different from the mean values of all WB CBCT angles modalities: 3D “clinical” alignment (10.42o, p < 0.015); Achilles tendon/calcaneal tuberosity angle (2.96o, p < 0.0001); tibial axis/calcaneal tuberosity angle (5.42o, p < 0.0001); tibial axis/subtalar joint angle (7.52o, p < 0.0001) and tibial axis/calcaneal axis angle (20.39o, p < 0.017). We found an excellent intra-observer agreement for all WB CBCT 3D measurements (range, 0.8863 – 0.9713, p < 0.0001). There was also good to excellent inter-observer reliability, with the exception of the 3D “clinical” alignment (r=0.450, p < 0.04), that showed moderate correlation. Conclusion: The use of 3D WB CBCT imaging can help characterize the valgus hindfoot alignment in patients with adult acquired flatfoot deformity. We found the different CBCT measurements modalities to be reliable and repeatable, and to significantly differ from the clinical evaluation of hindfoot valgus alignment.

scholarly journals sSural nerve: anatomical study and clinical aspects.

1969 ◽  
Vol 40 (3) ◽  
pp. 252-258
Author(s):  
José Luis Nieto ◽  
Enrique Vergara Amador ◽  
José Armando Amador
Keyword(s):  
Sural Nerve ◽  
Peroneal Nerve ◽  
Anatomical Study ◽  
Common Peroneal Nerve ◽  
Lateral Malleolus ◽  
Cutaneous Nerve ◽  
Clinical Aspects ◽  
Lateral Border ◽  
Communicating Branch ◽  
The Common

Introduction: An anatomical study of the sural nerve in 20 fresh cadavers was carried out, with the main aim of knowing the anatomy of the sural nerve and the relationships with the anatomical points to facilitate its identification in different clinical and surgical procedures. Materials and methods: From fresh cadavers with ages between 20 and 40 years and less than 48 hours of death, 20 legs were studied. Through a posterior incision the sural nerve was dissected from the popliteal region until the lateral malleolus, identifying the medial sural cutaneous nerve and the communicating branch of the common peroneal nerve. Measures were made in centimeters. Results: In 70% of the cases, the sural nerve was composed by the connection of the medial sural cutaneous nerve and the communicating branch of the common peroneal nerve and in 30% only by the medial sural cutaneous nerve. This branch was present in 100% of the cases. The communicating branch was present without connection with the medial sural cutaneous nerve in 15%, and in the other 15% this branch was absent. In 57% the nervous connection was proximal to the miotendinous union of the gastrocnemius The width of the miotendinous union of the gastrocnemius were between 5 to 8 cm (average 6.5 cm). The sural nerve was found 2.6 cm on average medial to the lateral border of the union. In the 6 cases of connection distal to the miotendinous union, the sural medial nerve passed 2 cm in average medial to the lateral border of the union, and the sural lateral to 0.8 cm medial of the same reference mentioned. Regarding the insertion of the Achilles’ tendon, the sural nerve passed 2.25 cm previous to the same and in relation to the most prominent and posterior part of the lateral malleolus it passed 2 cm in average. Discussion: This study showed that is possible to find the sural nerve with security if the anatomical points are identified well to preserve it in different surgeries or to harvest the flaps in neurological studies and harvesting it for grafting or nerve biopsy.

Outcomes and Complications of Open Versus Minimally Invasive Repair of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Randomized Controlled Trials

2021 ◽  
pp. 036354652110536
Author(s):  
Ahmed Khalil Attia ◽  
Karim Mahmoud ◽  
Pieter d’Hooghe ◽  
Jason Bariteau ◽  
Sameh A. Labib ◽  
...  
Keyword(s):  
Achilles Tendon ◽  
Functional Outcomes ◽  
Sural Nerve ◽  
Open Repair ◽  
Meta Analysis ◽  
Deep Infection ◽  
Surgical Time ◽  
Significant Difference ◽  
Tendon Ruptures ◽  
The Mean

Background: An acute Achilles tendon rupture is one of the most common sports injuries, affecting 18 per 100,000 persons, and its operative repair has been evolving and increasing in frequency since the mid-1900s. Traditionally, open surgical repair has provided improved functional outcomes, reduced rerupture rates, and a quicker recovery and return to activities at the expense of increased wound complications such as infections and skin necrosis compared with nonoperative management. In 1977, Ma and Griffith introduced the percutaneous approach, and over the following decades, multiple improved techniques, and modifications thereof, have been described with comparable outcomes with open repair. Purpose: The current study aimed to provide updated level 1 evidence comparing open repair with minimally invasive surgery (MIS) through a comprehensive search of the literature published in English, Arabic, Spanish, Portuguese, and German while avoiding limitations of previous studies such as heterogeneous study designs and a small number of included trials. Study Design: Meta-analysis; Level of evidence, 1. Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases to identify randomized controlled trials (RCTs) comparing open repair and MIS of Achilles tendon ruptures. The primary outcomes were (1) functional outcomes, (2) reruptures, (3) sural nerve injuries, and (4) infections (deep/superficial), whereas the secondary outcomes were (1) skin complications, (2) adhesions, (3) other complications, (4) ankle range of motion, and (5) surgical time. Results: There were 10 RCTs that qualified for the meta–analysis with a total of 522 patients. Overall, 260 (49.8%) patients underwent open repair, while 262 (50.2%) underwent MIS. The mean postoperative AOFAS score was 94.8 and 95.7 for open repair and MIS, respectively, with a nonsignificant difference (mean difference [MD], –0.73 [95% CI, –1.70 to 0.25]; P = .14; I2 = 0%). The pooled mean total complication rate was 15.5% (0%-36.4%) for open repair and 10.4% (0%-45.5%) for MIS, with a nonsignificant statistical difference (odds ratio [OR], 1.50 [95% CI, 0.87-2.57]; P = .14; I2 = 40%). The mean rerupture rate was 2.5% (0%-6.8%) for open repair versus 1.5% (0%-4.6%) for MIS, with a nonsignificant statistical difference (OR, 1.56 [95% CI, 0.42-5.70]; P = .50; I2 = 0%). No cases of sural nerve injuries were reported in the open repair group. The mean sural nerve injury rate was 3.4% (0%-7.3%) in the MIS group, which was statistically significant (OR, 0.16 [95% CI, 0.03-0.46]; P = .02; I2 = 0%). The mean overall superficial infection rate was 6.0% (0%-18.2%) and 0.4% (0%-4.5%) for open repair and MIS, respectively, with a statistically significant difference (OR, 5.70 [95% CI, 1.80-18.02]; P < .001; I2 = 0%). The mean overall deep infection rate reported in the open repair group was 1.4% (0%-5.0%), while no deep infection was reported in the MIS group, with no statistically significant difference (OR, 3.14 [95% CI, 0.48-20.54]; P = .23; I2 = 0%). There were no significant differences between the open repair and MIS groups in the skin necrosis and dehiscence rate, adhesion rate, or keloid scar rate. The mean surgical time was 51.0 and 29.7 minutes for open repair and MIS, respectively, with a statistically significant difference (MD, 21.13 [95% CI, 15.50-26.75]; P < .001; I2 = 15%). Conclusion: Open Achilles tendon repair was associated with a longer surgical time, higher risk of superficial infections, and higher risk of ankle stiffness, while MIS was associated with a greater risk of temporary sural nerve palsy. The rerupture rate and functional outcomes were mostly equivalent. We found MIS to be a safe and reliable technique. However, high–quality standardized RCTs are still needed before recommending MIS as the gold standard for managing Achilles tendon ruptures.

The Anatomic Features of the Sural Nerve With an Emphasis on its Clinical Importance

2005 ◽  
Vol 26 (7) ◽  
pp. 560-567 ◽  
Author(s):  
'Z. Asli Aktan iKiZ ◽  
Hülya üÇerler ◽  
Okan Bilge
Keyword(s):  
Sural Nerve ◽  
Clinical Importance ◽  
Lateral Malleolus ◽  
Lower Limbs ◽  
Cutaneous Nerve ◽  
Lateral Side ◽  
Fifth Toe ◽  
The Mean ◽  
Clinically Significant ◽  
Lateral Cutaneous Nerve

Background: The sural nerve is formed by the union of the medial and lateral cutaneous nerves of the leg that originate from the tibial and common peroneal nerves. Operative procedures and traumatic injuries to the popliteal fossa, leg, ankle and foot place the sural nerve and its branches at risk. The aim of this study was to describe the course, variations and some clinically significant relations of the sural nerve. Methods: The sural nerve was dissected in 30 lower limbs (leg-ankle-foot) of 15 cadavers. The specimens were measured, drawn and photographed. Results: In 18 specimens (60%) the sural nerve originated from the union of the medial and lateral cutaneous nerves of the leg in the upper two-thirds of the leg (classic type). The union of the medial and lateral cutaneous branches was in the distal third of the leg in three specimens (10%). The lateral cutaneous nerve was absent in five (16.7%), and the medial cutaneous nerve was absent in 2 (6.7%) specimens. In two specimens (6.7%) the nerves had separate courses. The mean distance between the most prominent part of the lateral malleolus and the sural nerve was 12.76 ± 8.79 mm. The mean distance between the tip of the lateral malleolus and sural nerve was 13.15 ± 6.88 mm. The most common distribution of the sural nerve in the foot was to the lateral side of the fifth toe (60%), followed by the lateral two and a half toes (26.7%). Conclusions: These described variations and measurements should be helpful for planning operative approaches that minimize the risk of sural nerve injury.

Surgical Treatment of Achilles Tendinitis by Decompression of the Retrocalcaneal Bursa and the Superior Calcaneal Tuberosity

2002 ◽  
Vol 30 (3) ◽  
pp. 318-321 ◽  
Author(s):  
Marilyn L. Yodlowski ◽  
Arnold D. Scheller ◽  
Lampros Minos
Keyword(s):  
Surgical Treatment ◽  
Achilles Tendon ◽  
Nonoperative Treatment ◽  
Achilles Tendinitis ◽  
Lateral Border ◽  
Pain Scores ◽  
Retrocalcaneal Bursa ◽  
Calcific Deposits ◽  
Calcaneal Tuberosity

Background Initial nonoperative treatment of pain at the Achilles tendon, often referred to as “tendinitis,” is not always successful. Hypothesis Surgical treatment is effective for patients with insertional tendinitis unrelieved by nonoperative measures. Study Design Retrospective cohort study. Methods Thirty-five patients (41 feet) who had painful Achilles tendon syndrome unrelieved by 6 months of nonoperative measures were treated surgically. The technique consisted of a single incision along the lateral border of the Achilles tendon. The dissection exposed the retrocalcaneal bursa and fat pad, which were completely excised along with any scarred and thickened paratenon. A partial calcaneal exostectomy of the tubercle was performed. Results At a minimum follow-up of 20 months (average, 39), the patients’ pain scores (rated from 0 to 6) improved from 4.7 (SD, 1.1) preoperatively to 1.5 (SD, 1.3); 90% had complete or significant relief of symptoms, 10% felt improved, and none felt unchanged or worse. Conclusions Surgical treatment of chronic Achilles tendon pain with resection of the prominent tuberosity, complete debridement of the bursa, excision of thickened, scarred paratenon, and removal of accessible calcific deposits within the tendon is an effective treatment.

scholarly journals Anatomical study of anterior supramalleolar artery and its potential application to design a bi-foliate fasciocutaneous flap

2015 ◽  
Vol 48 (01) ◽  
pp. 017-021
Author(s):  
Ji-Yin He ◽  
Shih-Heng Chen ◽  
Kannan Karuppiah Kumar ◽  
Zhi-Hong Fan ◽  
Jie Lao ◽  
...  
Keyword(s):  
Anatomical Study ◽  
Type A ◽  
Fasciocutaneous Flap ◽  
Lower Limbs ◽  
Anterior Tibial Artery ◽  
Medial Branch ◽  
Flap Transfer ◽  
Type D ◽  
Pedicle Length ◽  
The Mean

ABSTRACT Purpose: A further understanding of the anterior supramalleolar artery (ASMA) and its potential applications in reconstructive surgery. Materials and Methods: A total of 24 fresh lower limbs from fresh cadavers were injected with red latex for dissection. The type of origin, course, diameter of the pedicle, and the distance between the origin of the ASMA from the anterior tibial artery to the extensor retinaculum (O-R) were recorded. Bi-foliate fasciocutaneous flaps were harvested using the branches of the ASMA. Results: We found four types of origin of the ASMA, and we have accordingly classified them into four types. 10 of them were type A, 7 were type B, 6 were type C and 1 was type D. The mean O-R (origin of ASMA to retinaculum) distance was 2.0 ± 0.8 cm. The diameter of the medial branch (D1), the diameter of the lateral branch (D2), and the diameter of artery stem (D3) (only in type A) were 1.0 ± 0.2 mm, 0.8 ± 0.3 mm, 1.1 ± 0.2 mm, respectively. The mean pedicle length of the lateral flap (L1) and medial flap (L2) were 5.1 ± 1.0 cm and 3.7 ± 0.6 cm, respectively. Conclusions: The ASMA exists constantly with four different types of origin. Its sizable diameter and lengthy pedicle make it suitable for bi-foliate fasciocutaneous flap transfer.

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