Management of an Early-Onset, Painful Tibial Nerve Neuroma Using an Autologous Nerve Graft.

This case report describes the treatment of a postoperative painful neuroma of the tibial nerve using an autologous nerve graft in a dog. The patient presented with sudden non-weight-bearing lameness 10 days after iatrogenic tibial nerve injury during preparation of a reverse saphenous conduit flap. The dog showed severe pain at the surgical site without nerve deficits. A magnetic resonance imaging examination revealed an enlarged tibial nerve at the injury site, consistent with a neuroma. Analgesics were administered over 11 days, but the patient remained in severe pain and non-weight-bearing. Therefore, surgical resection was recommended. The fusiform neuroma was resected microsurgically, and a saphenous nerve graft was transplanted using an epineural nerve repair technique. Histopathological examination was consistent with a neuroma. The dog showed immediate pain relief and weight-bearing the day after surgery with normal motor function. The dog made a full recovery by the last follow-up 6 mo after surgery. If patients develop pain and lameness following surgery or nerve injury, neuroma formation must be considered, even shortly after surgery. Microsurgical resection and autologous nerve transplantation using an epineural nerve repair technique is a viable method to treat painful neuromas and minimize the risk for recurrence in dogs.

Tarsal tunnel ganglion cyst: intraneural or extraneural site?

Intraneural ganglion cysts are very uncommon lesions, whose diagnosis has increased since the articular theory and the description of the MRI findings were established. We present a case report of a 59-year-old man with symptoms of tarsal tunnel syndrome. Foot and ankle MRI demonstrated the presence of an intraneural cystic lesion in the posterior tibial neve and its connection with the subtalar joint through an articular branch. The identification of the specific radiological signs like the «signet ring sign¼ allowed establishing an adequate preoperative diagnosis, differentiating it from an extraneural lesion and facilitating the articular disconnection of the nerve branch during surgery.

Tibial intraneural ganglion cysts at the superior tibiofibular joint treated with joint resection alone: a proof of concept.

BACKGROUND: Intraneural ganglion cysts involving the tibial nerve are rare. Recent evidence has supported an articular (synovial) theory to explain the joint-related origin of these cysts; however, optimal operative treatment for cysts originating from the STFJ remains poorly understood. Therefore, we present a novel strategy: addressing the joint itself without addressing the articular branch and/or the cyst. METHODS: Records of patients with tibial intraneural ganglion cysts with a connection to the STFJ who were treated with a joint resection alone at a single academic institution were reviewed. The clinicoradiographic features, operative intervention, and postoperative course were recorded. RESULTS: We identified a consecutive series of 7 patients. These patients (4/7 male, 57%) were 43 (range 34-61) years of age and all presented with symptoms of neuropathy. The patients underwent resection of the synovial surfaces of the STFJ without disconnection of the articular branch or decompression of the cyst. Postoperatively, three patients regained partial motor function (43%, n=7), although four patients noted continued sensory abnormality (57%, 4/7). All six patients with postoperative MRIs had some evidence of regression of the cyst. CONCLUSIONS: This novel surgical technique serves as a proof of concept-highlighting the fact that treating the primary source (the joint origin) can be effective in eliminating the secondary problem (the cyst itself). While this study shows that this simplified approach can be employed in select cases, we believe that superior results (faster, fuller recovery) can be achieved with combinations of disconnecting the articular branch, decompressing the cyst, and/or resecting the joint.

Rotationplasty with Tibial Nerve Coaptation: A Case Report.

CASE: We present the case of a 14-year-old adolescent boy with a distal femoral osteosarcoma partially encasing the tibial nerve. He underwent rotationplasty with resection and coaptation (end-to-end repair) of the tibial nerve. By 1 year postoperatively, he had recovered sensation on the plantar aspect of his foot and Medical Research Council scale 4+/5 gastro-soleus contraction that powered extension of the new knee. CONCLUSION: Tibial nerve resection is not an absolute contraindication for rotationplasty, even in an adolescent. Nerve coaptation allows for well-functioning rotationplasty as an alternative to endoprosthetic reconstruction or above-knee amputation.

Partial tibial nerve transfer for iatrogenic peroneal nerve palsy after endovenous laser ablation for varicose veins of the lower extremity: A case report.

Postprocedural peroneal nerve palsy after endovenous laser ablation (EVLA) for varicose veins is rare and is associated with poor functional recovery. There have been no reports using tibial nerve transfer for iatrogenic peroneal nerve palsy after EVLA. Herein, we present a case with peroneal nerve injury after EVLA, which was successfully treated by partial tibial nerve transfer for the first time. A 75-year-old female presented with a right foot drop immediately after EVLA of the lesser saphenous vein. The ankle and toe dorsiflexion had a muscle grade of M0 on the British Medical Research Council muscle scale, without voluntary motor unit action potentials (MUAP) in the tibialis anterior (TA) muscle on the needle electromyography. Three months after the injury, surgical nerve exploration revealed a damaged common peroneal nerve with discoloration and scarring at the fibular head. Intraoperative deep peroneal nerve stimulation confirmed the absence of compound muscle action potentials in the TA. The best functioning motor fascicles of the tibial nerve were transferred to the deep peroneal main trunk involving motor branches of the TA, extensor digitorum longus, and extensor hallucis longus (EHL) through the interosseous membrane. The postoperative course was uneventful, with no complications. After 3 months of surgery, nascent MUAP appeared in the TA. After 24 months, the patient regained the TA and EHL muscle function and ambulation without an ankle-foot orthosis and tibial nerve deficits. Thus, our procedure may serve as an alternative to nerve grafting, tendon transfer, and orthoses for better management of the major neural complications associated with EVLA.

Surgery and Behavioral Testing in the Tibial Neuroma Transposition Model in Rats.

The tibial neuroma transposition (TNT) is a rat model in which allodynia at the neuroma site (tibial nerve) can be independently evaluated from allodynia at the plantar surface of the hind paw innervated by the intact sural nerve. This TNT model is suitable to test therapies for neuroma pain, such as the potential superiority of certain surgical therapies that are already used in the clinic, or to evaluate new drugs and their effect on both pain modalities in the same animal. In this model, a distal lesion (neurotmesis) is made in the tibial nerve, and the proximal nerve end is transposed and fixed subcutaneously and pretibially to enable assessments of the neuroma site with a 15 g Von Frey monofilament. To assess allodynia over the sural nerve, Von Frey monofilaments can be used via the up-down method on the plantar lateral region of the hind paw. After cutting the tibial nerve, mechanical hypersensitivity develops at the neuroma site within 1 week after surgery and persists at least until 12 weeks after surgery. Allodynia at the sural innervated plantar surface develops within 3 weeks after surgery compared to the contralateral limb. At 12 weeks, a neuroma forms on the proximal end of the severed tibial nerve, indicated by dispersion and swirling of axons. For the TNT model surgery, multiple critical (micro)surgical steps need to be followed, and some surgery practice under terminal anesthesia is advised. Compared to other neuropathic pain models, such as the spared nerve injury model, allodynia over the neuroma site can be independently tested from sural nerve hypersensitivity in the TNT model. However, the neuroma site can be tested only in rats, not in mice. The tips and directions provided in this protocol can help research groups working on pain successfully implement the TNT model in their facility.

Unusual entrapment symptomatology treated in 115 cases by neurolysis of the common fibular nerve at the fibular head combined with neurolysis of the posterior tibial nerve at the tarsal tunnel.

INTRODUCTION: Entrapment of the common fibular nerve (CFN) at the head of the fibula and entrapment of the posterior tibial nerve (PTN) at the tarsal tunnel are the most common nerve entrapment syndromes in the lower limb. Our aim was to study the results of combined neurolysis of the CFN and PTN for chronic lower limb pain. We hypothesized that combined neurolysis allowed a reduction of this chronic pain. MATERIAL AND METHOD: This bi-centric retrospective study took place from January 2015 to November 2018, with a single senior surgeon. The inclusion criteria were all patients operated on for an idiopathic entrapment syndrome with neurolysis of the PTN at the tarsal tunnel, combined with neurolysis of the CFN at the head of the fibula. The primary endpoint was the pain evolution assessed on a numerical analogue scale (NAS) preoperatively and postoperatively on D+21, and at the last follow-up. The secondary endpoint was to determine the prognostic factors on the clinical outcome of neurolysis. RESULTS: One hundred and fifteen neurolysis were included, comprising 64 women and 38 men with a mean age of 57±17.6 years. The preoperative pain (NAS0) was evaluated at 6±2.4 points. At D+21 postoperatively, there was a significant reduction in pain (NASD+21: 3±2.6 points, p<0.01). Similarly, at the last follow-up (with a mean follow-up of 37±8.4 months), there was a significant reduction in pain (NASLFU: 2±2.5, p<0.01). A history of systemic inflammatory disease was the only factor associated with a less significant decrease in pain at D+21, according to a multivariate analysis (p<0.01). There were 14 complications (12%) not requiring revision surgery. CONCLUSION: This study is the first to demonstrate the efficacy of combined neurolysis of the CFN at the head of the fibula and the PTN at the tarsal tunnel, in the treatment of idiopathic nerve entrapment syndrome of the lower limb. LEVEL OF EVIDENCE: IV; Retrospective comparative study.

Peripheral schwannomas of the tibial nerve: surgical results in a case series.

BACKGROUND AND AIM OF THE WORK: Schwannomas of the lower limb are uncommon benign tumors and those arising from Tibial Nerve are particularly rare. We report our experience on the topic, with particular attention to clinical presentation and lower limbs overall functionality before and after treatment. Our aim is to assess clinical impairment caused by the tumor and evaluate the effectiveness of surgical treatment. MATERIALS AND METHODS: Time between symptoms outbreak and diagnosis, as well as pre- operative tumor size were evaluated for each case. Pre-operative and post-operative overall lower limb functionality were assessed using both MSTS and LEFS scores. Sensitive symptoms and muscular strength were also evaluated before and after surgery. RESULTS: 7 patients were included in our study. The mean follow-up was 22.9 months. Average diagnostic delay was 8 months and tumor size was 29.3mm. Before surgery each patient had positive Hoffmann-Tinel sign and an at least mild paresthesia, 57% of our cases had slight reduction of muscular strength. Pre-operative MSTS score was 24.4 and LEFS score was 64.7. Tumor size and diagnostic delay were associated with pre-operative functionality. No major local complication was recorded during or after surgery. Each patient with pre-operative sensitive or motorial deficit benefited the effects of surgical treatment. CONCLUSIONS: Our cases suggest early diagnosis could reduce the impact of the disease on patients' activities of daily living and quality of life. Surgery, for its part, represents a safe and reliable approach to Tibial Nerve schwannomas with good chances of clinical and functional remission.

Modified Spared Nerve Injury Surgery Model of Neuropathic Pain in Mice.

Spared nerve injury (SNI) is an animal model that mimics the cardinal symptoms of peripheral nerve injury for studying the molecular and cellular mechanism of neuropathic pain in mice and rats. Currently, there are two types of SNI model, one to cut and ligate the common peroneal and the tibial nerves with intact sural nerve, which is defined as SNIs in this study, and another to cut and ligate the common peroneal and the sural nerves with intact tibial nerve, which is defined as SNIt in this study. Because the sural nerve is purely sensory whereas the tibial nerve contains both motor and sensory fibers, the SNIt model has much less motor deficit than the SNIs model. In the traditional SNIt mouse model, the common peroneal and the sural nerves are cut and ligated separately. Here a modified SNIt surgery method is described to damage both common peroneal and sural nerves with only one ligation and one cut with a shorter procedure time, which is easier to perform and reduces the potential risk of stretching the sciatic or tibial nerves, and produces similar mechanical hypersensitivity as the traditional SNIt model.

Predictive factors of effective tibial nerve release in tarsal tunnel syndrome.

BACKGROUND: Factors that may affect surgical decompression results in tarsal tunnel syndrome are not known. METHODS: A retrospective single-center study included patients who had undergone surgical tibial nerve release. The effectiveness of decompression was evaluated according to whether the patient would or would not be willing to undergo another surgical procedure in similar preoperative circumstances. RESULTS: The patients stated for 43 feet (51%) that they would agree to a further procedure in similar circumstances. Six feet with space-occupying lesions on imaging had improved results, but neurolysis failed in 9 feet with bone-nerve contact. Neurolysis was significantly less effective when marked hindfoot valgus (p = 0.034), varus (p = 0.014), or fasciitis (p = 0.019) were present. CONCLUSIONS: If imaging reveals a compressive space-occupying lesion, surgery has a good prognosis. In feet with static hindfoot disorders or plantar fasciitis, conservative treatment must be optimized. Bone-nerve contact should systematically be sought.

Tarsal Tunnel Syndrome: Outcome According to Etiology.

Surgical results in tarsal tunnel syndrome are variable, and etiology seems to be a factor. Three possible etiologies can be distinguished. The aim of the present study was to compare surgical results according to etiology. Three continuous retrospective series (45 patients overall) of tarsal tunnel syndrome were compared. Group 1 presented a permanent intra- or extra-tunnel space-occupying compressive structure. Group 2 presented intermittent intra-tunnel venous dilatations. Group 3 comprised idiopathic tarsal tunnel syndrome. The mean follow-up was 3.6 +/- 1.8 years. The main endpoint was subjective postoperative improvement on Likert scale. Group 1 reported greater improvement than groups 2 and 3. Preoperative neuropathy on ultrasound was associated with poorer improvement, which was not the case for neuropathy on electromyography. Surgical treatment of tarsal tunnel syndrome provides better results in etiologies involving structural compression.

Outcomes of Tibial Nerve Repair and Transfer: A Structured Evidence-Based Systematic Review and Meta-Analysis.

Although nerve transfer and repair are well-established for treatment of nerve injury in the upper extremity, there are no established parameters for when or which treatment modalities to utilize for tibial nerve injuries. The objective of our study is to conduct a systematic review of the effectiveness of end-to-end repair, neurolysis, nerve grafting, and nerve transfer in improving motor function after tibial nerve injury. PubMed, Cochrane, Medline, and Embase libraries were queried according to the PRISMA guidelines for articles that present functional outcomes after tibial nerve injury in humans treated with nerve transfer or repair. The final selection included Nineteen studies with 677 patients treated with neurolysis (373), grafting (178), end-to-end repair (90), and nerve transfer (30), from 1985 to 2018. The mean age of all patients was 27.0 ± 10.8 years, with a mean preoperative interval of 7.4 ± 10.5 months, and follow-up period of 82.9 ± 25.4 months. The mean graft repair length for nerve transfer and grafting patients was 10.0 ± 5.8 cm, and the most common donor nerve was the sural nerve. The most common mechanism of injury was gunshot wound, and the mean MRC of all patients was 3.7 ± 0.6. Good outcomes were defined as MRC ≥ 3. End-to-end repair treatment had the greatest number of good outcomes, followed by neurolysis. Patients with preoperative intervals less than 7 months were more likely to have good outcomes than those greater than 7 months. Patients with sport injuries had the highest percentage of good outcomes in contrast to patients with transections and who were in MVAs. We found no statistically significant difference in good outcomes between the use of sural and peroneal donor nerve grafts, nor between age, graft length, and MRC score.

A Minimally Invasive Full Endoscopic Approach to Tibial Nerve Neurolysis in Diabetic Foot Neuropathy: An Alternative to Open Procedures.

BACKGROUND: Dellon et al. have reported that chronic nerve compression of the tibial nerve inside the tarsal tunnel, caused by diabetes mellitus, can be relieved following open decompression surgery. However, the large skin incision resulting from Dellon's procedure may cause wound healing problems. The authors report the possibility of a minimally invasive full endoscopic procedure. METHODS: Operations were performed under local anesthesia without a pneumatic tourniquet. An anesthetic agent was applied at the proximal part of the flexor retinaculum of the foot, and a hypodermic needle was advanced into the tarsal tunnel. Tarsal tunnel pressure and blood circulation of the tibial nerve using indocyanine green assessment were measured preoperatively. One 1-cm portal skin incision was made at the anesthetized area and the Universal Subcutaneous Endoscope system was inserted into the tarsal tunnel. The flexor retinaculum, tibial nerve, blood vessels, and abductor hallucis muscle fascia were identified under endoscopic observation. After decompression of the tarsal tunnel, the authors measured tarsal tunnel pressure and blood circulation of the tibial nerve for analysis of the effectiveness of the endoscopic decompression during the procedure. RESULTS: Fourteen operations were compiled and analyzed. Postoperative clinical status was improved based on the preoperative modified Toronto Clinical Neuropathy Score. The mean tarsal tunnel pressure dropped to 4.5 mmHg during surgery from the initial preoperative 49.4 mmHg in resting position. Endoscopic indocyanine green assessment showed more than 30 percent improvement of the vascularity surrounding the tibial nerve. CONCLUSION: The authors' minimally invasive full endoscopic procedure is a viable alternative approach for tarsal tunnel syndrome patients with diabetic foot neuropathy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Effect of Nimodipine and Botulinum Toxin A on Peripheral Nerve Regeneration in Rats: A Pilot Study.

BACKGROUND: Peripheral nerve damage is a frequent problem, with an estimated 2.8%-5.0% of trauma admissions involving peripheral nerve injury. End-to-end, tension-free microsurgical repair (neurorrhaphy) is the current gold standard treatment for complete transection (neurotmesis). While neurorrhaphy reapproximates the nerve, it does not address the complex molecular regenerative process. Evidence suggests that botulinum toxin A (BTX) and nimodipine (NDP) may improve functional recovery, but mechanisms of action remain unknown. METHODS: This research investigates BTX and NDP for their novel capacity to improve neural regeneration in the setting of neurorrhaphy using a Lewis rat tibial nerve neurotmesis model. In a triple-masked, placebo-controlled, randomized study design, we compared functional (rotarod, horizontal ladder walk), electrophysiological (conduction velocity, duration), and stereological (axon count, density) outcomes of rats treated with: NDP+saline injection, BTX+NDP, Saline+placebo, and BTX+placebo. Additional controls included sham surgery +/- BTX. RESULTS: NDP+saline outperformed other treatment groups in the ladder walk. This group had the fewest deep slips (15.07% versus 30.77% in BTX+NDP, P = 0.122), and the most correct steps (70.53% versus 55.58% in BTX+NDP, P = 0.149) in functional testing. NDP+saline also had the fastest nerve conduction velocity (0.811m/s versus 0.598m/s in BTX+NDP, P = 0.126) among treatment groups. BTX+NDP had the highest axon count (10,012.36 versus 7,738.18 in NDP+Saline, P = 0.009). CONCLUSION: This study is the first to test NDP with BTX in a multimodal assessment of nerve recovery following neurotmesis and neurorrhaphy. NDP outperformed BTX+NDP functionally. Future work will focus on nimodipine in an effort to improve nerve recovery in trauma patients.

Exercise induced neuropathic lower leg pain due to a tibial bone exostosis.

Objectives: The differential diagnosis of chronic exercise induced lower leg pain in sporters includes compartment syndrome and medial tibial stress syndrome. However, severe discomfort may also be caused by nerve entrapment.Methods: Here we present a marathon runner who reports pain day and night in the lower leg. Deep palpation suggested the presence of a bony tumor deep in the calf musculature, and digital pressure on the soleal sling was painful and elicited paresthesias in the foot. A swab test indicated a hypo-esthetic sole of the foot. Imaging revealed the presence of a tibial exostosis that was hypothesized to narrow the soleal tunnel and irritate the tibial nerve.Results: Via a medial infragenual approach, the soleal tunnel was opened. A bony prominence was found in direct contact to the tibial nerve. Resection of the exostosis with tibial nerve neurolysis completely abolished all of his symptoms.Conclusion: An awkward lower leg discomfort that is present at night and worsens during exercise combined with altered foot sole skin sensation in the presence of a tibial bone exostosis may suggest tibial nerve neuropathy. If conservative therapies fail, resection and neurolysis is advised.

Impacts of Rehabilitation Gait Training on Functional Outcomes after Tibial Nerve Transfer for Patients with Peroneal Nerve Injury: A Nonrandomized Controlled Trial.

BACKGROUND: Although there was initial success using tibial nerve transfer to restore ankle dorsiflexion following peroneal nerve injury, results from later series were less promising. A potential reason is coactivation of the much stronger antagonistic muscles during gait. The purpose of this study was to test the hypothesis that gait training would improve functional performance following tibial nerve transfer. METHODS: Using a prospective, nonrandomized, controlled study design, patients were divided into two groups: surgery only or surgery plus gait training. Of the 20 patients who showed reinnervation in the tibialis anterior muscle, 10 were assigned to the gait training group, and an equal number were in the control group. Those in the treatment group began training once reinnervation in the tibialis anterior muscle was detected, whereas those in the control group continued to use their ankle-foot orthosis full time. Differences in ankle dorsiflexion were measured using the Medical Research Council scale, and quantitative force measurement and functional disability was measured using the Stanmore Scale. RESULTS: Patients in the gait training group attained significantly better functional recovery as measured by the Stanmore Scale (79.5 ± 14.3) (mean ± SD) versus (37.2 ± 3.5) in the control group (p = 0.02). Medical Research Council grades were 3.8 ± 0.6 in the training group versus 2.5 ± 1.2 in the surgery only group (p < 0.05). Average dorsiflexion force from patients with above antigravity strength (all from the training group) was 31 percent of the contralateral side. CONCLUSION: In patients with successful reinnervation following tibial nerve transfers, rehabilitation training significantly improved dorsiflexion strength and function. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Practice Patterns and Pain Outcomes for Targeted Muscle Reinnervation: An Informed Approach to Targeted Muscle Reinnervation Use in the Acute Amputation Setting.

BACKGROUND: Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) procedures have been shown to improve patient-reported outcomes for the treatment of symptomatic neuromas after amputation; however, the specific indications and comparative outcomes of each are unclear. The primary research questions were what complement of nerves most frequently requires secondary pain intervention after conventional amputation, whether this information can guide the focused application of TMR and RPNI to the primary amputation setting, and how the outcomes compare in both settings. METHODS: We performed a retrospective review of records for patients who had undergone lower-extremity TMR and/or RPNI at our institution. Eighty-seven procedures were performed: 59 for the secondary treatment of symptomatic neuroma pain after amputation and 28 for primary prophylaxis during amputation. We reviewed records for the amputation level, TMR and/or RPNI timing, pain scores, patient-reported resolution of nerve-related symptoms, and complications or revisions. We evaluated the relationship between the amputation level and the frequency with which each transected nerve required neurologic intervention for pain symptoms. RESULTS: The mean pain score decreased after delayed TMR or RPNI procedures from 4.3 points to 1.7 points (p < 0.001), and the mean final pain score (and standard deviation) was 1.0 ± 1.9 points at the time of follow-up for acute procedures. Symptom resolution was achieved in 92% of patients. The sciatic nerve most commonly required intervention for symptomatic neuroma above the knee, and the tibial nerve and common or superficial peroneal nerve were most problematic following transtibial amputation. None of our patients required a revision pain treatment procedure after primary TMR targeting these commonly symptomatic nerves. Failure to address the tibial nerve during a delayed procedure was associated with an increased risk of unsuccessful TMR, resulting in a revision surgical procedure (odds ratio, 26 [95% confidence interval, 1.8 to 368]; p = 0.02). CONCLUSIONS: There is a consistent pattern of symptomatic nerves that require secondary surgical intervention for the management of pain after amputation. TMR and RPNI were translated to the primary amputation setting by using this predictable pattern to devise a surgical strategy that prevents symptomatic neuroma pain. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Saphenous nerve to posterior tibial nerve transfer: A new approach to restore sensations of sole in diabetic sensory polyneuropathy.

BACKGROUND: Loss of sensations in the sole following diabetic sensorimotor polyneuropathy (DSPN) leads to diabetic foot ulcers and its sequelae. We hypothesized that sensory reinnervation of sole by transfer of saphenous nerve (SN) to sensory fascicles of posterior tibial nerve (PTN) in these patients may reverse the neuropathy. METHODS: This prospective interventional case series included patients with advanced DSPN and intact sensory supply of SN. PTN was neurotized by transfer of SN nerve in the tarsal tunnel and postoperatively sensations of the sole were tested. Any existing ulcers on sole were noted and their healing was monitored. FINDING: A total of 17 patients (22 feet), 9 male and 8 female, were included. Seven patients had ulcers in the feet. At 6 months follow-up all patients developed protective sensation in the sole. The average 2 PD improved from 60 mm to 45.5 mm, average vibration perception improved from 34.12 V to 24.33, Medical Research Council (MRC) score improved from S0 in 12 feet and S1 in 10 feet to S3+ in 13 feet, S3 in 5 feet, and S2 in 2 feet at 6 months along with healing of ulcers in all 7 feet. INTERPRETATION: Transfer of SN to PTN for sensory neurotization is an innovative and simple option to prevent complications of DSPN. This procedure has the potential to change the natural history of DSPN.

Outcome following neurectomy of the deep branch lateral plantar nerve and plantar fasciotomy for hindlimb proximal suspensory desmopathy in western performance horses: 21 cases.

OBJECTIVE: To report the outcome of horses used in western performance disciplines after deep branch lateral plantar neurectomy/fasciotomy surgery for hind limb proximal suspensory desmopathy (PSD). STUDY DESIGN: Retrospective analysis. SAMPLE POPULATION: Twenty-one client-owned horses. METHODS: Medical records were reviewed (2009-2019) for horses involved in western performance disciplines that had been treated with deep branch lateral plantar neurectomy and plantar fasciotomy for lameness due to hind limb PSD. Follow-up was obtained by reexamination and/or verbal interviews with owners >2 years postoperatively. RESULTS: Sixteen quarter horses and five paints were used for western pleasure (14/21), barrel racing (2/21), cutting (1/21), steer wrestling (1/21), working cow horse (1/21), team roping (1/21) and reining (1/21). A median duration of 8 months was required before horses were able to resume training or athletic work. Nine horses were able to return to a similar or higher level of athletic use, nine horses returned to a lower level of athletic performance, and three horses could not return to intended function. Owner satisfaction with outcome after the procedure was high (16/21), average (3/21), and low (2/21). CONCLUSION: Deep branch lateral plantar neurectomy and plantar fasciotomy allowed most horses to resume some athletic function as western performance horses. CLINICAL SIGNIFICANCE: These results provide evidence of potential outcomes when considering surgical treatment of hind limb PSD in western performance horses.