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Hirtler L, Bussek V, Kleinberger M, Willegger M. Anterolateral and accessory anterolateral portals are safe to avoid subcutaneous nerve injury during subtalar arthroscopy-Definition of safe zones for standard lateral portals. Knee Surg Sports Traumatol Arthrosc 2025; 33:1147-1155. [PMID: 39342497 PMCID: PMC11848959 DOI: 10.1002/ksa.12463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 08/19/2024] [Accepted: 08/30/2024] [Indexed: 10/01/2024]
Abstract
PURPOSE Injury to the superficial peroneal nerve (SPN) or the sural nerve (SN) is a common complication in subtalar arthroscopy. The purpose of this anatomical study was to evaluate the distance to surrounding subcutaneous nerves in the vicinity of three standard arthroscopic portals for subtalar joint arthroscopy and through actual portal placement for arthroscopic procedures, in order to define anatomical safe zones. METHODS Forty paired fresh-frozen foot-and-ankle specimens were used. Subtalar arthroscopy using a three-portal technique (anterolateral [AL], posterolateral [PL] and accessory anterolateral [AAL] portals) was performed. After completion of subtalar arthroscopy, the portals were marked, and all surrounding subcutaneous nerves, that is, the branches of the SPN and SN, were dissected. The distance of the nearest nerve at the level of the respective portal was measured and potential injury was recorded. RESULTS The nearest nerve at the level of the AL portal was the intermediate dorsal cutaneous nerve at a mean of 15.4 ± 5.1 mm medial to the portal. The nearest nerve at the level of the AAL portal was the lateral dorsal cutaneous nerve at a mean of 17.7 ± 4.8 mm, being lateral to the portal. The nearest nerve at the level of the PL portal was the SN at a mean of 6.7 ± 4.7 mm anterior to the portal. Based on the measurements, safe zones were defined. CONCLUSIONS Placement of the AL and AAL portals in subtalar arthroscopy is saved using standard anatomical landmarks and a thorough surgical technique. At the level of the PL portal, the SN is the most endangered structure in subtalar arthroscopy. Surgeons should be aware of the proximity of the SN to the PL portal and take the utmost care during portal placement and instrument insertion to avoid iatrogenic injury. The risk of nerve damage during portal placement may be reduced when positioning the portals in the defined safe zones. LEVEL OF EVIDENCE Not applicable.
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Affiliation(s)
- Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell BiologyMedical University of ViennaViennaAustria
| | - Vinzenz Bussek
- Division of Anatomy, Center for Anatomy and Cell BiologyMedical University of ViennaViennaAustria
| | - Markus Kleinberger
- Division of Anatomy, Center for Anatomy and Cell BiologyMedical University of ViennaViennaAustria
| | - Madeleine Willegger
- Department of Orthopedics and Trauma SurgeryMedical University of ViennaViennaAustria
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Nishikawa DRC, Duarte FA, Saito GH, de Cesar Netto C, Fonseca FCP, Miranda BRD, Monteiro AC, Prado MP. Minimally invasive tenodesis for peroneus longus tendon rupture: A case report and review of literature. World J Orthop 2020; 11:137-144. [PMID: 32190558 PMCID: PMC7063456 DOI: 10.5312/wjo.v11.i2.137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 11/21/2019] [Accepted: 12/23/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Peroneal tendon disorders are common causes of lateral hindfoot pain. However, total rupture of the peroneal longus tendon is rare. Surgical treatment for this condition is usually a side-to-side tenodesis of the peroneal longus tendon to the peroneal brevis tendon. While the traditional procedure involves a long lateral curved incision, this approach is associated with damage to the lateral soft tissues (up to 24% incidence).
CASE SUMMARY A 50-year-old female had developed pain at the lateral aspect of the hindfoot 1 mo after an ankle sprain while walking in the street. Previous treatments were anti-inflammatory drugs, ice, rest and Cam-walker boot. At physical exam, there was pain and swelling over the course of the peroneal tendons. Ankle instability and cavovarus foot deformity were ruled out. Eversion strength was weak (4/5). Imaging showed complete rupture of the peroneal longus tendon associated with a sharp hypertrophic peroneal tubercle. Surgical repair was indicated after failure of conservative treatment (physiotherapy, rest, analgesics, and ankle stabilizer). A less invasive approach was performed for peroneal longus tendon debridement and side-to-side tenodesis to the adjacent peroneal brevis tendon, with successful clinical and functional outcomes.
CONCLUSION Peroneus longus tendon tenodesis can be performed through a less invasive approach with preservation of the lateral soft tissue integrity.
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Affiliation(s)
- Danilo Ryuko Cândido Nishikawa
- Department of Orthopedics, Foot and Ankle Surgery, Hospital of the Municipal Public Servant of São Paulo (HSPM), Aclimação 01532-000, São Paulo, Brazil
| | | | - Guilherme Honda Saito
- Department of Orthopaedics, Foot and Ankle Surgery, Hospital Israelita Albert Einstein, Jardim Leonor 05652-900, São Paulo, Brazil
| | - Cesar de Cesar Netto
- Department of Orthopedics, Foot and Ankle Surgery, University of Iowa, Iowa City, IA 52242, United States
| | - Fábio Correia Paiva Fonseca
- Department of Orthopedics, Foot and Ankle Surgery, Hospital of the Municipal Public Servant of São Paulo (HSPM), Aclimação 01532-000, São Paulo, Brazil
| | - Bruno Rodrigues de Miranda
- Department of Orthopedics, Foot and Ankle Surgery, Hospital of the Municipal Public Servant of São Paulo (HSPM), Aclimação 01532-000, São Paulo, Brazil
| | - Augusto César Monteiro
- Department of Orthopedics, Foot and Ankle Surgery, Hospital of the Municipal Public Servant of São Paulo (HSPM), Aclimação 01532-000, São Paulo, Brazil
| | - Marcelo Pires Prado
- Department of Orthopaedics, Foot and Ankle Surgery, Hospital Israelita Albert Einstein, Jardim Leonor 05652-900, São Paulo, Brazil
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Lehtonen EJ, Pinto MC, Patel HA, Dahlgren N, Abyar E, Shah A. Syndesmotic Fixation With Suture Button: Neurovascular Structures at Risk: A Cadaver Study. Foot Ankle Spec 2020; 13:12-17. [PMID: 30712382 DOI: 10.1177/1938640019826699] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The objective of this study was to describe the anatomic variations in the saphenous nerve and risk of direct injury to the saphenous nerve and greater saphenous vein during syndesmotic suture button fixation. METHODS Under fluoroscopic guidance, syndesmotic suture buttons were placed from lateral to medial at 1, 2, and 3 cm above the tibial plafond on 10 below-knee cadaver leg specimens. The distance and position of each button from the greater saphenous vein and saphenous nerve were evaluated. RESULTS The mean distance of the saphenous nerve to the suture buttons at 1, 2, and 3 cm were 7.1 ± 5.6, 6.5 ± 4.6, and 6.1 ± 4.2, respectively. Respective rate of nerve compression was as follows, 20% at 1 cm, 20% at 2 cm, and 10% at 3 cm. Mean distance of the greater saphenous vein from the suture buttons at 1, 2, and 3 cm was 8.6 ± 7.1, 9.1 ± 5.3, and 7.9 ± 4.9 mm, respectively. Respective rate of vein compression was 20%, 10%, and 10%. A single nerve branch was identified in 7 specimens, and 2 branches were identified in 3 specimens. CONCLUSION There was at least one case of injury to the saphenous vein and nerve at every level of button insertion at a rate of 10% to 20%. Neurovascular injury may occur despite vigilant use of fluoroscopy and adequate surgical technique. Further investigation into the use of direct medial visualization of these high-risk structures should be done to minimize the risk. Levels of Evidence: Therapeutic, Level II: Prospective, comparative study.
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Affiliation(s)
- Eva J Lehtonen
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Martim C Pinto
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Harshadkumar A Patel
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nicholas Dahlgren
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Eildar Abyar
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashish Shah
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Ultrasound Imaging in the Management of a Rare Superficial Fibular Nerve Injury. Am J Phys Med Rehabil 2018; 95:e185-e186. [PMID: 27088475 DOI: 10.1097/phm.0000000000000503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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A review of main anatomical and sonographic features of subcutaneous nerve injuries related to orthopedic surgery. Skeletal Radiol 2018; 47:1051-1068. [PMID: 29549379 DOI: 10.1007/s00256-018-2917-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 02/08/2018] [Accepted: 02/09/2018] [Indexed: 02/02/2023]
Abstract
Lesion to subcutaneous nerves is a well-known risk of orthopedic surgery and a significant cause of postoperative pain and dissatisfaction in patients. High-resolution ultrasound can be used to visualize the vast majority of small subcutaneous nerves of the upper and lower limbs. Ultrasound detects nerve abnormalities such as focal hypoechoic thickening, stump neuroma, and scar encasement, and provides information not only about the peripheral nerve itself but also about its relationship to adjacent anatomical structures. The purpose of this review is to provide an overview of the anatomy of the main subcutaneous nerves damaged during orthopedic surgery, recall at-risk procedures, and offer useful anatomic landmarks to help the sonographer identify and follow the nerves when an iatrogenic lesion is suspected.
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Rbia N, van der Vlies CH, Cleffken BI, Selles RW, Hovius SER, Nijhuis THJ. High Prevalence of Chronic Pain With Neuropathic Characteristics After Open Reduction and Internal Fixation of Ankle Fractures. Foot Ankle Int 2017; 38:987-996. [PMID: 28670914 DOI: 10.1177/1071100717712432] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Unstable ankle fractures require treatment with open reduction and internal fixation (ORIF). Long-term functional outcome is satisfying in most patients; however, a number of patients have persistent complaints. Superficial nerve complications following ankle surgery may be the cause of chronic pain and disability. METHODS In this observational retrospective survey, a cohort of 527 women and men, who underwent ORIF in the period from January 2007 to January 2014, were invited to an online questionnaire. Pain symptoms were assessed using the McGill Pain Questionnaire (MPQ) and the Douleur Neuropathic en 4 Questions (DN4) Questionnaire. Descriptive statistics were used to present patient characteristics; a logistic regression model was used to analyze prognostic factors of neuropathic pain. A total of 271 patients completed the questionnaire. Mean follow-up period was 5.8 years (±1.9). RESULTS Persistent neuropathic pain symptoms were present in 61 of all patients, and 51 of these patients reported an impaired quality of life caused by their symptoms. In univariate analysis, the following parameters were associated with neuropathic pain: age, hypertension, a thyroid disorder, lower back pain, fracture dislocations, and late complications such as nonunion, posttraumatic arthritis, or osteochondral injury. In multivariate analysis, an age between 40 and 60 years was found to be a significant predictor of neuropathic pain. Hypertension, dislocation, and late complications were significant predictors of persistent pain without neuropathic characteristics. CONCLUSION The present study demonstrated a prevalence of persistent neuropathic pain symptoms after ORIF for ankle fractures in 23% of the respondents, which caused an impaired health-related quality of life. We identified 4 significant predictors of chronic and neuropathic pain after ORIF. This knowledge may aid the treating surgeon to identify patients who are at increased risk of persistent postoperative neuropathic pain and may affect the treatment of pain in these patients. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Nadia Rbia
- 1 Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Berry I Cleffken
- 2 Department of Trauma Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Ruud W Selles
- 1 Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands.,3 Department of Rehabilitation Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Steven E R Hovius
- 1 Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Tim H J Nijhuis
- 1 Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands.,2 Department of Trauma Surgery, Maasstad Hospital, Rotterdam, the Netherlands
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Rbia N, Nijhuis THJ, Roukema GR, Selles RW, van der Vlies CH, Hovius SER. Ultrasound assessment of the sural nerve in patients with neuropathic pain after ankle surgery. Muscle Nerve 2017; 57:407-413. [PMID: 28710794 DOI: 10.1002/mus.25744] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 06/28/2017] [Accepted: 07/09/2017] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The sural nerve may be damaged after ankle injury. The aim of our study was to determine the diagnostic utility of high-resolution sonography in patients with ankle fractures treated by open reduction and internal fixation in whom there was a clinical suspicion of sural neuropathy. METHODS We examined the ultrasound (US) characteristics of patients with and without postsurgical sural neuropathic pain and healthy volunteers. Cross-sectional area (CSA), echogenicity, and vascularization of the sural nerves were recorded. RESULTS Fourteen participants and all sural nerves were identified. CSA (P < 0.001) and vascularization (P = 0.002) were increased in symptomatic patients when compared with asymptomatic patients and healthy volunteers. There were no significant differences in nerve echogenicity (P = 0.983). DISCUSSION US may be a valuable tool for evaluating clinically suspected sural nerve damage after ankle stabilization surgery. Sural nerve abnormalities are seen in patients with postsurgical neuropathic pain. Muscle Nerve 57: 407-413, 2018.
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Affiliation(s)
- Nadia Rbia
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus University Medical Center, Postal Box 2040, 300 CA, Rotterdam, The Netherlands
| | - Tim H J Nijhuis
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus University Medical Center, Postal Box 2040, 300 CA, Rotterdam, The Netherlands.,Department of Trauma Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Gert R Roukema
- Department of Trauma Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Ruud W Selles
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus University Medical Center, Postal Box 2040, 300 CA, Rotterdam, The Netherlands.,Department of Rehabilitation Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Steven E R Hovius
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus University Medical Center, Postal Box 2040, 300 CA, Rotterdam, The Netherlands
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Pirozzi KM, Creech CL, Meyr AJ. Assessment of Anatomic Risk During Syndesmotic Stabilization With the Suture Button Technique. J Foot Ankle Surg 2015; 54:917-9. [PMID: 25940637 DOI: 10.1053/j.jfas.2015.04.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Indexed: 02/03/2023]
Abstract
The suture button technique represents an accepted method of fixation for acute or chronic injury to the tibiofibular syndesmosis. The objective of the present investigation was to assess the anatomic risk to the superficial medial neurovascular structure with insertion of a syndesmotic suture button and to measure the distance of the button to the greater saphenous vein during a standardized insertion. A syndesmotic suture button was inserted with a standardized technique in 20 fresh frozen cadaveric limbs. Of 20 suture buttons, 14 (70.0%) were inserted posterior to the greater saphenous vein, 2 (10.0%) were inserted anterior to the greater saphenous vein, and 4 (20.0%) were inserted directly onto the greater saphenous vein. A total of 11 suture buttons (55.0%) were inserted with some entrapment of a medial neurovascular structure. The absolute mean ± standard deviation distance of the suture button to the greater saphenous vein was 4.88 ± 4.44 mm. The results of the present investigation have indicated that a risk of entrapment of superficial medial neurovascular structures exists with insertion of a suture button for syndesmotic fixation and that a medial incision should be used to ensure that structures are not entrapped.
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Affiliation(s)
| | - Corine L Creech
- Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA
| | - Andrew J Meyr
- Associate Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
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Tzika M, Paraskevas G, Natsis K. Entrapment of the superficial peroneal nerve: an anatomical insight. J Am Podiatr Med Assoc 2015; 105:150-9. [PMID: 25815655 DOI: 10.7547/0003-0538-105.2.150] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Entrapment of the superficial peroneal nerve is an uncommon neuropathy that may occur because of mechanical compression of the nerve, usually at its exit from the crural fascia. The symptoms include sensory alterations over the distribution area of the superficial peroneal nerve. Clinical examination, electrophysiologic findings, and imaging techniques can establish the diagnosis. Variations in the superficial peroneal sensory innervation over the dorsum of the foot may lead to variable results during neurologic examination and variable symptomatology in patients with nerve entrapment or lesions. Knowledge of the nerve's anatomy at the lower leg, foot, and ankle is of essential significance for the neurologist and surgeon intervening in the area.
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Affiliation(s)
- Maria Tzika
- Department of Anatomy, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Paraskevas
- Department of Anatomy, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Natsis
- Department of Anatomy, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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