Accessory soleus muscle as a cause of resistance to correction in congenital club foot: a case report

Symptomatic accessory soleus muscle: A cause for exertional compartment syndrome in a young soldier: A case report

BACKGROUND

Accessory soleus muscle (ASM) is a rare congenital variation that is almost asymptomatic, but several papers have recently described symptomatic ASM. The clinical features of this condition are similar to tarsal tunnel syndrome (TTS) and include pain and numbness around the medial side of the ankle. ASM commonly originates from the fibula or soleus muscle and inserts into the Achilles tendon or calcaneus. Usually, it is identified as posteromedial swelling and definitely diagnosed by magnetic resonance imaging. In most cases, treatment is observation, but surgical excision can be considered if symptoms are severe.

CASE SUMMARY

A 23-year-old male Korean soldier presented with complaints of bilateral foot and ankle pain and a swelling medial to the Achilles tendon that was more pronounced on the right side. Symptoms first occurred after playing soccer 10 mo before this presentation, worsened after physical exertion, and were relieved by rest. He had no medical history, and no one in his family had the condition. Laboratory results were non-specific. Several tests were performed to exclude common diseases such as tumors or TTS. However, MRI revealed a bulky accessory soleus muscle in both feet, though the patient complained of more severe pain on the right side during physical activity. Accordingly, surgical resection was adopted. At surgery, a large accessory soleus muscle was noted anterior to the Achilles tendon with distinctive insertion from a normal soleus muscle. At 12 mo after surgery, there was no pain, numbness, or swelling of the right foot or ankle, no evidence of recurrence, and the patient could do all sports activities.

CONCLUSION

Accessory soleus muscle should be added to the list of differential diagnosis if a patient has pain, sole numbness or swelling of the posteromedial ankle.

Whole genome sequencing identifies ANXA3 and MTHFR mutations in a large family with an unknown equinus deformity associated genetic disorder

The aim of this study was to characterize a previously uncharacterized genetic disorder associated with equinus deformity in a large Chinese family at the genetic level. Blood samples were obtained and whole genome sequencing was performed. Differential gene variants were identified and potential impacts on protein structure were predicted. Based on the control sample, several diseases associated variants were identified and selected for further validation. One of the potential variants identified was a ANXA3 gene [chr4, c.C820T(p.R274*)] variant. Further bioinformatic analysis showed that the observed mutation could lead to a three-dimensional conformational change. Moreover, a MTHFR variant that is different from variants associated with clubfoot was also identified. Bioinformatic analysis showed that this mutation could alter the protein binding region. These findings imply that this uncharacterized genetic disorder is not clubfoot, despite sharing some similar symptoms. Furthermore, specific CNV profiles were identified in association with the diseased samples, thus further speaking to the complexity of this multigenerational disorder. This study examined a previously uncharacterized genetic disorder appearing similar to clubfoot and yet having distinct features. Following whole genome sequencing and comparative analysis, several differential gene variants were identified to enable a further distinction from clubfoot. It is hoped that these findings will provide further insight into this disorder and other similar disorders.

An unusual aberrant muscle in congenital clubfoot: an intraoperative finding

Congenital clubfoot is a common congenital deformity, characterized by equinus of the hindfoot and adduction of the midfoot and forefoot, with varus through the subtalar joint complex. A cavus deformity will also be present. The etiology of this congenital deformity remains elusive. Muscle anomalies are not commonly found in patients with idiopathic clubfoot, and, when present, their significance is not clear. The presence of a flexor digitorum accessorius longus muscle and an accessory soleus muscle found at surgical correction of clubfoot deformity has been previously reported. Our case was a female child, aged 2 years, 3 months, who developed bilateral relapsed congenital clubfoot. She was found to have an unusual aberrant muscle in both legs. This was discovered accidentally during surgical correction of her deformity through posteromedial soft tissue release. This muscle might have contributed to the hindfoot varus and equinus in the clubfoot deformity, because the latter were completely corrected after release of the muscle from its insertion. Awareness of such a new anatomic variant, with the other anatomic variants found in clubfoot deformity, will not only improve our understanding of normal lower limb development, but could also lead to improved genetic counseling and diagnostic and treatment methods of such a common congenital deformity.

Achilles tenotomy as an office procedure: safety and efficacy as part of the Ponseti serial casting protocol for clubfoot

BACKGROUND

Ponseti demonstrated the correction of clubfoot in infants using manipulation followed by the application of well-molded long-leg plaster casts. Percutaneous Achilles tenotomy was recommended to correct residual equinus contracture in approximately 80% of cases. In the current study, we evaluated the safety of this practice for the treatment of clubfoot when performed as an "office procedure" without sedation or general anesthesia during the final stage of the serial casting protocol.

PATIENTS AND METHODS

We retrospectively collected data regarding babies who underwent serial manipulation and casting according to the Ponseti protocol for the treatment of clubfoot. All babies managed in the outpatient clinic between 2006 and 2010 were included. Tenotomy was indicated when the forefoot was completely corrected and if the hind-foot showed rigid equinus. Tenotomy was performed by a single scalpel stab in the outpatient clinic, using topical and local anesthesia (without general anesthesia or sedation). The cast was then applied and kept on for 3 weeks. Babies were discharged home after 1 hour of supervision. Surgical reports regarding Achilles tenotomy were reviewed, and data were collected from postoperative notes. We specifically looked for perioperative complications, recovery unit notes, and hospital readmission.

RESULTS

Fifty-six babies (83 feet) were included in the current study. There were 40 males and 16 females, and 27 of them had bilateral clubfoot. Three babies (0.5%) had complex (syndrome-related) clubfoot; familial risk was known in 6 (11%) babies. Forty-one (73%) babies were indicated for Achilles tenotomy. Tenotomy was performed after an average of 5 casts (range, 3 to 9). No adverse events were related to local anesthesia and/or the procedure itself, and there was no delay in discharge in any of the operated babies. One baby was evaluated in the emergency room 3 days after the procedure because of (unfounded) parental concern of swelling inside the cast. All other babies had an uneventful course. Retenotomy was performed in 7 babies (12 feet); 2 of them (4 feet) had complex clubfoot. All of these babies (ie, their parents), except 1, had moderate to poor compliance with the treatment protocol.

CONCLUSIONS

Tenotomy as an office procedure using topical and local anesthesia is a safe procedure. It does not incur a substantial rate of readmission to the emergency room, either because of parental concern or because of actual complications. The need for retenotomy is related to a low compliance with the treatment protocol.

LEVEL OF EVIDENCE

Level II.

The co-existence of the gastrocnemius tertius and accessory soleus muscles

A bilateral gastrocnemius tertius muscle and a unilateral accessory soleus muscle were encountered during the routine educational dissection studies. The right gastrocnemius tertius muscle consisted of one belly, but the left one of two bellies. On the left side, the superficial belly of the gastrocnemius tertius muscle had its origin from an area just above the tendon of the plantaris muscle, the deep belly from the tendon of the plantaris muscle. The accessory soleus muscle originated from the posteromedial aspect of the tibia and soleal line of the tibia and inserted to the medial surface of the calcaneus. On the right side, the gastrocnemius tertius muscle had its origin from the lateral condyle of the femur, and inserted to the medial head of the gastrocnemius muscle. The co-existence of both gastrocnemius tertius and accessory soleus muscle has not, to our knowledge, been previously reported.

Accessory soleus in the athletes: literature review and case report of a massive muscle in a soccer player

Accessory soleus is a rare congenital anatomical variant, which may manifest in the second/third decade of life as an exertional ankle pain and swelling or as an asymptomatic postero-medial mass. The incidence of this condition ranges from 0.7 to 5.5%. Many treatment options have been described in literature, including conservative treatment, excision, fasciotomy, release and closure of blood supply. We report a symptomatic massive accessory soleus (17 x 5 x 4 cm) in an 18-year-old male semi-professional soccer player. Excision of the accessory soleus was performed. The patient went back to the game 3 months after surgery. The literature review stated that either fasciotomy or excision of the muscle produce good results in the athletes.

Accessory soleus muscle in clubfoot deformity: a report in four feet

The commonest presentation of accessory soleus muscle is a swelling at the posteromedial aspect of the ankle in adolescents or young adults. Accessory soleus is rarely encountered in children undergoing surgical release for congenital clubfoot, and only a few isolated reports are available in the literature. The purpose of this study is to heighten awareness about the role of accessory soleus muscle in clubfoot deformity. Four cases of accessory soleus muscle in patients undergoing surgical release for clubfoot deformity are reported here in which, a distinct anomalous muscle deep to the tendoachilles was identified. Hindfoot varus and equinus persisted in each of these cases despite an adequate posteromedial soft tissue release, which could be corrected only on tenotomizing the tendon of the accessory soleus muscle at its insertion. An awareness about the accessory soleus muscle is important, particularly when non-operative methods of clubfoot management with tendoachilles tenotomy or limited surgery are employed. Failure to recognize this muscle if present in patients with congenital clubfoot may lead to persistent hindfoot deformity. A high index of suspicion should be maintained in cases in which hindfoot deformity persists despite an otherwise adequate soft tissue correction.

Anomaly of anatomical origin of soleus muscle: a mouse model

In the laboratory mouse, the soleus muscle arises at the head of the fibula and inserts via the Achilles tendon on the tuber calcanei together with the gastrocnemius muscle. During routine dissection of mice from the BXD recombinant inbred (RI) strains, we found that the soleus often originated from the lateral epicondyle of the femur instead of the head of the fibula. This soleus femoral attachment anomaly (SFAA) changes the soleus from being a single-joint to a two-joint muscle. The incidence of SFAA was 45% in the BXD38 RI strain. Bilateral inspection indicated that SFAA may be present unilaterally or bilaterally within an individual mouse. We explored the effect of SFAA on muscle weight in mice with unilateral expression. The weight of SFAA soleii was significantly less (P < 0.01) than that of the soleii with normal attachment by 6% (females) and 14% (males). Similar anatomical anomalies of the soleus muscle have been noted in humans. The mouse model will provide the means to explore the physiological consequences and genetic basis for such anomalies.