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Background: There are several documented variations of the sural nerve noted within the literature. This cadaveric study was conducted to provide a surgical perspective to either directly addressing the sural nerve, or avoiding it depending on the injury or pathology being surgically addressed. Methods: Twenty-five preserved cadaveric limbs were dissected from the popliteal fossa to the foot. Three locations of the course of the sural nerve data were analyzed. The first location (M1) was from the head of the fibula to the sural nerve. The second location (M3) was from 2.54 cm proximal to the distal tip of the lateral malleolus to the sural nerve. The third location (M2) was from the shaft of the fibula at the halfway point between measurements 1 and 2 to the course of the sural nerve. The types of variations were noted as well, compared to previous studies, highlighting the abundance of sural nerve variations in the lower limb that clinicians and surgeons need to be aware of and ready to address. Results: The sural nerve courses 4.6 cm posterior from the fibula at the proximal fibula and mid fibula and 4.5 cm at the distal fibula. The 25 sural nerve variations are not reflective of what has been previously published in the literature. Conclusion: The data can be utilized in preoperative planning in addressing or avoiding the sural nerve involving the posterior superficial compartment of the leg.
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Recent reconstructive approaches to peripheral nerve surgery have been directed toward active approaches; one such approach is nerve grafting the injured nerve segment. Addressing a nerve injury proximal to the zone of injury has demonstrated reproducible results in preventing symptomatic neuroma formation. A 53-year-old woman with a history of an ankle fracture presented with neuritic symptoms that interfered with her activities of daily living. Her intractable pain was significantly but temporarily relieved with in-office nerve blocks to the superficial peroneal nerve and sural nerve. There were no identifiable zones of injury in the nerve conduction study. Orthopedic etiology was ruled out. Nerve allografts, each 3 cm in length, were utilized with conduits and placed at the location proximal to the zone of maximum tenderness. Once the neurotomy was performed, the nerve allografts and conduits were coapted to each nerve. The patient's intractable neuritic pain was relieved even 15 months postoperatively. The visual analog scale went from eight of 10 preoperatively to two of 10 postoperatively. Additional nerve conduction studies were not needed, and the patient returned to daily activities once the skin incisions healed. The reset neurotomy is an option for the microsurgical surgeon to have for patients with a nonidentifiable zone of injury or no identifiable neuroma but presents with intractable nerve pain relieved by local anesthetic nerve blocks.
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Approximately 20% of patients with diabetic peripheral neuropathy (DPN) endorse painful sensations such as prickling, stabbing, and burning pain that reflect small-fiber involvement. Although glycemic control is crucial to delay the onset and progression of DPN, there have been many reports on the use of decompression nerve surgery to aid in the treatment of DPN.
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Neuropatias Diabéticas , Humanos , Amputação Cirúrgica , Descompressão , Neuropatias Diabéticas/cirurgia , DorRESUMO
Background. The use of circular external fixation is a fundamental necessity in the armamentarium of a lower limb orthoplastic reconstructive surgeon. External fixation offers orthoplastic surgeons the ability to address soft tissue and osseous defects simultaneously. Using Ilizarov principles, the reconstructive surgeon must have the ability to address unique scenarios when performing orthoplastic principles. This article offers practical surgical management concepts based on experience using the TL-Hex Orthofix Truelok Hexapod System for acute shortening and relengthening. A soft tissue and osseous defect can be managed through this surgical approach as a limb salvage alternative to amputation. The information provided will lead to improved management strategies and outcomes for the practitioner and patient when presented with soft tissue and osseous defects.
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We present a novel technique for the management of intractable lower extremity pain, due to neuromas-in-continuity of two peripheral nerves, through combined neurectomies proximal to the zone of initial injury and subsequent bridging utilizing an allograft-coupled conduit construct. METHODOLOGY: A retrospective chart review of 36 patients (18 women and 18 men) with recalcitrant nerve pain secondary to neuromas-in-continuity of two peripheral nerves following lower extremity trauma was conducted. Subjects underwent superficial peroneal nerve (SPN) to deep peroneal nerve neurorrhaphy (19 patients) or SPN to sural nerve neurorrhaphy (17 patients) proximal to the zone of initial injury. Patient demographics, comorbidities, procedure details, complications, and preoperative and postoperative pain assessments using a visual analog scale were evaluated. RESULTS: Residual nerve pain from previous lower extremity trauma was included. Analysis of preprocedure and postprocedure visual analog scale scores demonstrated a mean decrease of 7.45 points (mean: pre 8.89, mean: post 1.44). All patients voiced satisfaction with postoperative ambulatory tolerance and pain relief at last follow-up (mean: 30.86 months). CONCLUSIONS: The sequelae of neuromas-in-continuity of the SPN, deep peroneal nerve, and sural nerves were noted to have significantly improved with proximal neurectomy and subsequent bridging utilizing a nerve allograft and conduit construct. We present this coaptation technique as a viable treatment option for reduction in neurogenic pain involving peripheral nerve injury of two dermatome distributions.
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This article provides the surgeon with a detailed technique guide using an alternating current biphasic waveform intraoperative nerve stimulator, such as the Checkpoint surgical nerve stimulator. The Checkpoint surgical nerve stimulator is an intraoperative hand-held biphasic device that is essential when performing nerve transfer techniques for the treatment of drop foot. This specific device provides the surgeon safe, accurate, reproducible, and continuous stimulation without fatigue or a decreased response to the nerve. An in-depth technique guide is provided while using this device while performing a nerve transfer for the treatment of drop foot.
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Transtornos Neurológicos da Marcha , Transferência de Nervo , Neuropatias Fibulares , Transtornos Neurológicos da Marcha/cirurgia , Humanos , Nervo Fibular/cirurgiaRESUMO
Morton's neuroma is a common painful pathology that occurs in the plantar forefoot. Many treatment options exist and surgical management is used after conservative treatment options fail. While within the literature, there is a high success rate with primary neurectomy procedures, the risk of recurrence of symptoms or "stump neuromas" remains difficult to treat and can lead to debilitating pain. This article expands on a previously published article to discuss an update on a nerve sparing, microneurosurgical, procedure for the management of Morton's neuromas.
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Doenças do Pé , Neuroma Intermetatársico , Neuroma , Pé , Doenças do Pé/cirurgia , Humanos , Neuroma Intermetatársico/diagnóstico por imagem , Neuroma Intermetatársico/cirurgia , Neuroma/cirurgia , DorRESUMO
Implantable peripheral nerve stimulators are used with the goal to decrease the neuropathic pain level and possibly the need for opioid analgesics. Peripheral nerve injuries and pathology must be thoroughly evaluated before implantation of neuromodulation devices. Ultrasound-guided nerve blocks and a peripheral nerve stimulator trial is performed before surgical implantation. In this article, the authors discuss indications, clinical and diagnostic examinations, and their surgical technique for implantation of the Bioventus StimRouter.
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Dor Crônica , Terapia por Estimulação Elétrica , Neuralgia , Dor Crônica/terapia , Humanos , Extremidade Inferior , Neuralgia/etiologia , Neuralgia/terapia , UltrassonografiaRESUMO
Dysfunction of the tibial nerve can progress to painful and potentially disabling conditions. There are multiple sites of entrapment along the course of the tibial nerve. Detailed knowledge of the anatomy and anatomic variations is critical for a surgeon to be able to properly diagnose and treat patients with tibial nerve injuries. Repair of tibial nerve injuries involves a thorough history, physical examination, diagnostic studies, and microsurgical techniques. This article discusses sites of tibial nerve entrapment and use of a surgical algorithm that provides a systematic approach that has been successful within the literature in treating chronic tibial neuritic pain.
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Síndromes de Compressão Nervosa , Nervo Tibial , Protocolos Clínicos , Humanos , Extremidade Inferior , Síndromes de Compressão Nervosa/diagnóstico , Síndromes de Compressão Nervosa/cirurgia , Nervos Periféricos , Nervo Tibial/cirurgiaRESUMO
Malunions, nonunions, avascular necrosis, neoplasms, and osteomyelitis of the tibia can be difficult limb salvage cases to manage, especially when large bone defects are present. This article aims to demonstrate the orthoplastic limb salvage options that the authors use with bone transport using the Orthofix TrueLok-Hexapod system (Orthofix Medical Inc, Lewisville, TX, USA).
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Osteomielite , Fraturas da Tíbia , Fixadores Externos , Humanos , Tíbia , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia , Resultado do TratamentoRESUMO
The management of pedal ulcerations is often challenging because of a failure to correct underlying biomechanical deformities. Without correcting the biomechanical driving force creating the increased plantar pressures, it is unlikely for routine wound care to provide lasting solutions to pedal ulcerations. Patients with diabetes often experience glycosylation of their tendons, leading to contracture and pursuant deformity, creating imbalanced pressure distributions and eventual plantar ulceration. This article evaluates the efficacy of various lower extremity tendon transfers to balance the foot and redistribute plantar pressures to prevent or heal ulceration.
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Pé Diabético/cirurgia , Neuropatias Diabéticas/cirurgia , Deformidades Adquiridas do Pé/cirurgia , Procedimentos Ortopédicos , Pé Diabético/etiologia , Neuropatias Diabéticas/complicações , Deformidades Adquiridas do Pé/etiologia , HumanosRESUMO
To date, more than 150 surgical techniques have been described for the treatment of intractable nerve pain. However, owing to their technical complexity, as well as the lack of comparative studies in the literature, there is currently no consensus on the appropriate management of this often debilitating condition. Therefore, we present our surgical algorithm, based on Seddon's classification to differentiate the degree of nerve injury, and subsequent treatment course for the management of lower extremity neurogenic pain.
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Extremidade Inferior/cirurgia , Neuralgia/cirurgia , Traumatismos dos Nervos Periféricos/cirurgia , Algoritmos , Denervação , Eletromiografia , Humanos , Extremidade Inferior/inervação , Transferência de Nervo , Neuralgia/etiologia , Exame Neurológico , Neuroma/cirurgia , Manejo da Dor , Traumatismos dos Nervos Periféricos/classificação , Neoplasias do Sistema Nervoso Periférico/cirurgia , Cuidados Pós-OperatóriosRESUMO
Foot drop represents a complex pathologic condition, requiring a multidisciplinary approach for appropriate evaluation and treatment. Multiple etiologic factors require recognition before considering invasive/operative intervention. When considering surgical management for the treatment of foot drop, it is first and foremost imperative to establish the cause of the condition. Not all causes resulting in clinical foot drop have surgical options. Establishing a cause allows the provider to more appropriately curtail a multidisciplinary approach to working-up, and ultimately, treating the patient. The authors offer an algorithm for evaluating and treating foot drop conditions associated with lumbar spine radiculopathy and peripheral nerve lesions.
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Transtornos Neurológicos da Marcha/cirurgia , Transferência de Nervo , Neuropatias Fibulares/cirurgia , Anastomose Cirúrgica , Descompressão Cirúrgica , Transtornos Neurológicos da Marcha/etiologia , Humanos , Imageamento por Ressonância Magnética , Bloqueio Nervoso , Condução Nervosa , Exame Neurológico , Posicionamento do Paciente , Nervos Periféricos/diagnóstico por imagem , Cuidados Pós-Operatórios , Radiografia , Transferência Tendinosa , Estimulação Elétrica Nervosa Transcutânea , UltrassonografiaRESUMO
Medial plantar artery-based flaps have great value in healing full-thickness wounds of the foot and ankle. The goal of this study was to identify a common location for the origin of the medial plantar artery. Recognition of this anatomic marker will help improve incision placement and increase the success of preserving the artery when performing the medial plantar artery fasciocutaneous flap. This study examined the location of the origin of the medial plantar artery in 40 fresh cadavers. Results were obtained by dissection and macroscopic analysis to document the distance of the origin of the medial plantar artery from the intercollicular groove of the medial malleolus in centimeters. The mean distance was determined to be 3.2 ± 0.4 cm (range 2.7 to 4.5), with a low standard error of 0.0621. This suggests a high statistical probability that the common origin of the medial plantar artery is found 3.2 cm distal to the intercollicular groove of the medial malleolus in the general population.
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Tornozelo/irrigação sanguínea , Pé/irrigação sanguínea , Procedimentos de Cirurgia Plástica , Retalhos Cirúrgicos/irrigação sanguínea , Idoso , Idoso de 80 Anos ou mais , Tornozelo/cirurgia , Cadáver , Dissecação , Feminino , Pé/cirurgia , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
It is well-documented that individuals with longstanding diabetes mellitus are at risk for specific metabolic abnormalities; this includes but is not limited to increased glycation of collagenous soft-tissue structures. It is also apparent that such changes can manifest as thickening and increased stiffness of tendinous structures. What remains unknown are the biomechanical ramifications of these changes and how they should affect the surgical management of lower extremity injuries. Previous research suggests that the Achilles tendon demonstrates increased stiffness in the presence of diabetes. It is therefore reasonable to presume that increased collagen glycation and the resultant tendon stiffness can also lead to decreased extensibility and shortening of the peroneus longus and brevis tendons. The significance of this leads us to the conclusion that glycation of the peroneal tendons can create a deforming force in displaced lateral malleolar fractures because of the adjacent position of the peroneal tendons relative to the lateral malleolus. Complications stemming from this can lead to increased difficulty in reducing fibular fractures and subsequent shortening of the fibula. For the purpose of this article, we present 2 cases, 1 using open reduction with internal fixation and the other with external fixation. We will demonstrate that, in both reduction methods, lengthening of the peroneal tendons can be a useful adjunct procedure to aid in restoration of fibular length in diabetic ankle fractures.
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Fraturas do Tornozelo/cirurgia , Fixadores Externos , Fixação Interna de Fraturas , Redução Aberta , Tendões/cirurgia , Placas Ósseas , Parafusos Ósseos , Contratura/cirurgia , Diabetes Mellitus Tipo 2/complicações , Feminino , Humanos , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Limb length discrepancy (LLD) in the setting of concurrent hindfoot and ankle deformity poses an added level of complexity to the reconstructive surgeon. Regardless of etiology, a clinically significant LLD poses additional challenges without a forthright and validated solution. The purpose of the current study is to determine whether reconstructive hindfoot and ankle surgery with concurrent lengthening through a distal tibial corticotomy is comparable to other treatment alternatives in the literature. PATIENTS AND METHODS: A retrospective review of hindfoot and ankle deformity correction utilizing Ilizarov circular external fixation with concurrent distal tibial distraction osteogenesis from July 2009 to September 2014 was conducted. RESULTS: This study included 19 patients with a mean age of 47.47 ± 13.36 years with a mean follow up of 576.13 ± 341.89 days. The mean preoperative LLD was 2.70 ± 1.22 cm and the mean operatively induced LLD was 2.53 ± 0.59 cm. The mean latency period was 9.33 ± 3.47 days and distraction rate was 0.55 ± 0.16 mm/day. The mean distraction length was 2.14 ± 0.83 cm and mean duration of external fixation was 146.42 ± 58.69 days. The time to union of all hindfoot and ankle fusions was 121.00 ± 25.66 days with an overall fusion rate of 85.71%. CONCLUSIONS: The successful treatment of hindfoot and ankle deformity correction in the setting of LLD using the technique of a distal tibial corticotomy and distraction osteogenesis is reported and illustrates an additional treatment technique with comparable measured outcomes to those previously described. We urge that each patient presentation be evaluated with consideration of all described approaches and associated literature to determine the current best reconstructive approach as future studies may validate or replace the accepted options at present.
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Articulação do Tornozelo/anormalidades , Articulação do Tornozelo/cirurgia , Calcanhar/anormalidades , Calcanhar/cirurgia , Osteogênese por Distração/métodos , Tíbia/cirurgia , Adulto , Idoso , Articulação do Tornozelo/diagnóstico por imagem , Feminino , Calcanhar/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Osteogênese por Distração/instrumentação , Estudos Retrospectivos , Tíbia/diagnóstico por imagemRESUMO
OBJECTIVES: The purpose of the study was to determine whether ultrasound (US)-guided surgery is a viable type of surgery for performing an effective release/decompression of the constricting structures that are responsible for focal nerve compression in tarsal tunnel syndrome. METHODS: Ultrasound guidance was used on cadaveric specimens to delineate the anatomic course of the nerves and vessels in the medial ankle that comprise the structures involved in tarsal tunnel syndrome. Ultrasound guidance was used on cadaveric specimens and assisted in delineating a safe surgical zone to adequately and effectively release these constrictive structures of the proximal and distal tarsal tunnels. The US-guided tarsal tunnel release/decompression was performed through 2 small 1- to 2-mm portals. After US-guided release, anatomic dissection was used to check the efficacy (release of the flexor retinaculum and deep abductor hallucis muscle) and safety (absence of neurovascular or tendon injury) of the procedure. RESULTS: In 12 fresh cadaveric specimens, US-guided release of the tibial nerve (proximal tarsal tunnel) and its branches (distal tarsal tunnel) at the medial ankle was effective in all 12 specimens (100% release rate), without any signs of compromise or injury into the neurovascular structures. CONCLUSIONS: Ultrasound-guided tarsal tunnel release is a feasible surgical procedure that can be safe and effective with the proper training, although further investigation is warranted. This type of surgery may promote faster recovery with less postoperative morbidity, including pain, but this will be the subject of a further investigation.
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Síndrome do Túnel do Tarso/diagnóstico por imagem , Síndrome do Túnel do Tarso/cirurgia , Nervo Tibial/diagnóstico por imagem , Nervo Tibial/cirurgia , Ultrassonografia de Intervenção/métodos , Cadáver , Humanos , Estudos ProspectivosRESUMO
The purpose of this study was to demonstrate use of a distally based peroneus brevis muscle flap in high-risk patients with diabetes and peripheral vascular disease for limb salvage of nonhealing heel ulcerations. Seventeen patients were referred for a below-knee amputation because of nonhealing heel ulcerations and peripheral vascular disease. As a last resort, 17 distally based peroneus brevis muscle flaps were elevated in 17 patients with full-thickness heel ulcerations measuring an average defect size of 14.11 cm2. All flaps were supplemented with concentrated bone marrow aspirate, negative pressure wound therapy, bilayer wound matrix, and static external fixation for an average time of 10.3 weeks. Split-thickness skin graft was delayed by an average of 17.5 days. All procedures were performed on patients diagnosed with diabetes, advanced peripheral arterial disease and a nonhealing heel ulcer present >1 year. All flaps survived at 1.5 years follow-up. The average time to healing was 10.3 weeks. No major amputations were performed to date. Partial tip necrosis occurred in 2 patients and healed uneventfully with local wound care. Distally based peroneus brevis muscle flaps in patients with diabetes and peripheral vascular disease offer a reliable alternative to limb salvage for full-thickness heel ulcerations measuring up to 7â¯×â¯6 cm. Combinatorial procedures are necessary to improve outcomes in high-risk patients whose alternative is a major amputation.