Anatomic lectures on structures at risk prior to cadaveric courses reduce injury to the superficial peroneal nerve, the commonest complication in ankle arthroscopy

High body mass index is not a contraindication for an arthroscopic ligament repair with biological augmentation in case of chronic ankle instability

PURPOSE

Obesity remains frequently mentioned as a contraindication for lateral ankle ligament repair. The aim of the study was to compare the clinical results of an arthroscopic lateral ligament repair with biological augmentation between patients with a body mass index (BMI) of more than 30 and less than 30.

METHODS

Sixty-nine patients with an isolated lateral ankle instability were treated with an arthroscopic anterior talofibular ligament (ATFL) repair with biological augmentation using the inferior extensor retinaculum (IER). Patients were divided into two groups according to their BMI: ≥ 30 (Group A; n = 26) and < 30 (Group B; n = 43). Patients were pre-and post-operatively evaluated, with a minimum of 2 years follow-up, and using the Karlsson Score. Characteristics of the patients, complications, ankle instability symptoms recurrence, and satisfaction score were recorded.

RESULTS

In group A, the median Karlsson Score increased from 43.5 (Range 22-72) to 85 (Range 37-100) at follow-up. Complications were observed in seven patients (27%). Nineteen patients (73%) reported that they were "very satisfied". One patient (4%) described persistent ankle instability symptoms. In group B, the median Karlsson Score increased from 65 (Range 42-80) to 95 (Range 50-100) at follow-up. Complications were observed in four patients (9%). Thirty-three patients (77%) reported that they were "very satisfied". Two patients (5%) described persistent ankle instability symptoms. Pre-operative and at last follow-up Karlsson Score, results were significantly different between the two groups. There was no significant statistical difference in favour of satisfaction score, complications and recurrence of ankle instability between the two groups.

CONCLUSION

ATFL repair with biological augmentation using IER gives excellent results for patients with BMI ≥ 30. Compared to patients with BMI < 30, they present a slightly lower preoperative and postoperative Karlsson score, however, with a similar satisfaction rate, but are at higher risk of transient superficial peroneal nerve dysesthesia.

LEVEL OF EVIDENCE

Level III.

Low to moderate risk of nerve damage during peroneus longus tendon autograft harvest

PURPOSE

This study aims to evaluate the proximity of the tendon stripper to both the peroneal and sural nerves during peroneus longus tendon (PLT) autograft harvesting.

METHODS

Ten fresh-frozen human cadaveric lower extremities were used to harvest a full-thickness PLT autograft using a standard closed blunt-ended tendon stripper. The distance to the sural nerve from the PLT (at 0, 1, 2 and 3 cm proximal to lateral malleolus (LM), and the distance to the peroneal nerve and its branches from the end of the tendon stripper were measured by two separate observers using ImageJ software.

RESULTS

The average distance from the PLT to the sural nerve increased significantly from 0 to 2 cm proximal to LM. The average distance to the sural nerve at the LM was 4.9 ± 1.5 mm and increased to 10.8 ± 2.4 mm (2 cm proximal to LM). The average distance from the tendon stripper to the deep peroneal nerve was 52.9 ± 11.4 mm. The average distance to the PLT branch of peroneal nerve was 29.3 ± 4.2 mm. The superficial peroneal nerve, which coursed parallel and deep to the tendon stripper, was on average 5.2 ± 0.7 mm from the end of the stripper. No transection injuries of the nerves were observed in any of the ten legs after harvesting.

CONCLUSION

This cadaver study found during a full-thickness PLT harvest, the distances between the tendon stripper and the nerves were greater than 5 mm with an initial incision at 2 cm proximal to LM which is recommended.

Anterocentral Portal in Ankle Arthroscopy

BACKGROUND

The anterocentral portal is not a standard portal in anterior ankle arthroscopy due to its proximity to the anterior neurovascular bundle. However, it provides certain advantages, including a wide field of vision, and portal changes become redundant. The purpose of this study was to evaluate the neurovascular complications after anterior ankle arthroscopy using the anterocentral portal.

METHODS

We retrospectively identified patients who had undergone anterior ankle arthroscopy with an anterocentral portal at our institution from 2013 to 2018. Medical record data were reviewed and patients were invited for clinical follow-up, where a clinical examination, quantitative sensory testing for the deep peroneal nerve, and ultrasonography of the structures at risk were performed. A total of 101 patients (105 arthroscopies) were identified and evaluated at a mean follow-up of 31.5 ± 17.7 months.

RESULTS

Leading indications to surgery were heterogeneous and included anterior impingement (48.6%), osteochondral lesions of the talus (24.8%), chronic ankle instability (14.3%), and fractures (8.6%). The overall complication rate was 7.6%, and no major complications were observed. In 1.9% (2/105) of the cases, the complications were associated with the anterocentral portal and included injury to the medial branch of the superficial nerve (1/105) and to the deep peroneal nerve (1/105). Injury to the deep peroneal nerve was associated with a loss of detection and nociception. There were no injuries to the anterior tibial artery. In 41.9% (44/105) of the cases, only 1 working portal was used in addition to the anterocentral portal, and in 19% (20/105) the anterolateral portal could be avoided. Ultrasonography confirmed the integrity of the deep peroneal nerve, the medial branch of the superficial peroneal nerve, and the anterior tibial artery in all patients. Patients with nerve injuries associated with the anterocentral portal showed no signs of neuroma or pseudoaneurysm.

CONCLUSION

Using a standardized technique, the anterocentral portal in ankle arthroscopy is safe with a low number of neurovascular injuries and can be recommended as a standard portal. The anterolateral portal remains associated with a high number of injuries to the superficial peroneal nerve.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The distribution pattern of the dorsal cutaneous nerves of the foot and its clinical implications

Iatrogenic injury to subcutaneous nerves on the dorsum of the foot is an established risk factor during the surgical procedures resulting in postoperative pain, sensation loss and painful neuroma. Previous studies have reported on the distribution pattern of the superficial peroneal, deep peroneal and sural nerves (SNs) and their branches with various classifications about specific populations. The purpose of the present study was to evaluate the distribution pattern and classification of the nerves on the dorsum of the foot and analyze the location of these nerves into five zones with clinical implications. Fifty-four lower limbs of fresh frozen cadavers were used in the present study. The anatomical patterns of the superficial peroneal, deep peroneal, SN and their branches were classified into eight, two and five patterns respectively. Type VI pattern, a classic distribution pattern of the superficial peroneal nerve was the most frequent type with a prevalence of 13 limbs (25.00%). In Zone 5, where the arthroscopic portal placements for the first metatarsophalangeal joint arthrodesis, 29 limbs (55.77%) showed three nerve branches located in this zone. The results of the present study provide anatomical knowledge that may help the surgeon to choose the appropriate treatment for their patients and reducing the rate of complications in surgery.

What should we be careful of ankle arthroscopy?

PURPOSE

Ankle arthroscopy has been used as a standard tool by foot and ankle surgeons. To overcome the narrowness of ankle joint, a noninvasive distraction technique is used for the successful visualization in ankle arthroscopy. The aim of this study was to investigate the incidence and type of complications associated with ankle arthroscopy using a noninvasive distraction technique and to report a troublesome complication.

METHODS

We reviewed 514 patients' charts from 2003 to 2011. The same noninvasive distraction technique was used. Patients' demography, duration of follow-up, diagnoses, procedures, and complications related to ankle arthroscopy were analyzed.

RESULTS

There were 388 male and 126 female; mean age was 37.2 years; mean follow-up duration was 33 months. The diagnoses were osteochondral lesion of talus, chronic ankle instability, anterolateral soft tissue impingement syndrome, and anterior bony impingement. We performed arthroscopic synovectomy, osteochondral procedure, bony spur excision, and loose body removal. The mean time of arthroscopic procedure was 47 min. There were neurologic complications (eight cases), skin necrosis of posterior thigh (three cases), instrument breakage (two cases), and superficial wound infection (one case). All complications were well resolved. The total duration of distraction plus tourniquet inflation exceeded 120 min in the three cases of skin necrosis. Skin necrosis was deemed to be resulted from the long tourniquet time.

CONCLUSION

The noninvasive distraction technique is safe and effective for ankle arthroscopy. However, the distraction plus tourniquet requires attention because it can cause high pressure on posterior thigh resulting in soft tissue injury.

Potential Lack of Association Between Three Vestigial Muscles in Humans: A Willed Body Donor Study

PURPOSE

Anatomical agenesis within a population is not well understood, with variations including but not limited to complete absence, unilateral presence, or bilateral presence. Agenesis of human vestigial muscles including the palmaris longus (PL), fibularis tertius (FT), and psoas minor (PM) has been studied; however, the relationship between their presence and absence has not been examined. The purpose of this study is to analyze the prevalence of the PL, FT, and PM muscles, investigate any relationship of prevalence based on sex or race, and investigate any correlation between the presence or absence of each muscle within individual donors.

METHODS

Twenty-three willed body donors were comprehensively dissected by medical students, and the presence or absence of the PL, FT, and PM muscles was recorded.

RESULTS

The PL was present bilaterally in 87% of donors and absent bilaterally in 13%. The FT was present bilaterally in 96% of donors, and present unilaterally in 4% of donors. There was no evidence of total agenesis of the FT within our sample. The PM was present bilaterally in 39% of donors, and absent bilaterally in 61% of donors. No statistically significant relationship was indicated between muscle presence and the sex or race of the donors. No correlation between the presence or absence of each of the muscles was found.

CONCLUSION

In this sample of willed body donors, there was no relationship between muscular agenesis of the vestigial muscles. This suggests that muscle agenesis is a local genetic developmental event at each muscle, and that there is not a single developmental event that leads to agenesis of multiple vestigial muscles. Further understanding of the agenesis of vestigial structures within populations and subpopulations can aid in physician diagnosis and understanding of the anatomical makeup of individuals.

Fibularis tertius muscle in women & men: A surface anatomy cross-sectional study across countries

The fibularis tertius muscle (FTM) is a rare anatomic variation. The prevalence of this exclusively human structure, which is found in the anterior compartment of the leg, is often underestimated, and it is believed that foot and ankle conditions are more difficult to manage in patients with an FTM. The aim of this study was to assess the presence of the FTM palpation and determine whether its presence is associated with an individual’s sex, because the exact prevalence in males and females is unclear. An observational cross-sectional study was carried out. The study included 481 people (23.49% men and 76.51% women) with a mean age of 23.51±5.369 years, who were recruited from a Podiatric Medicine and Surgery Clinic (Spain). Data on routine demographic and clinical factors were recorded, and the presence or absence of the FTM was determined based on surface visual or palpated localization of the tendon (using a consistent protocol). The FTM was present in 38.25% (184/481) of the participants. Furthermore, FTM were present in 38.6% (142/481) of females and 37.2% (42/481) of males. The study revealed that the presence of the FTM varies between individuals and does not depend on an individual’s sex. Significant differences in the prevalence of the FTM between countries should be carefully evaluated rather than generalizing the results of this Spanish study to other non-Spanish populations. Larger numbers of participants should be enrolled in future studies in order to meet the statistical criteria.