Neuroma of medial dorsal cutaneous nerve of superficial peroneal nerve after ankle arthroscopy

Complications of Hallux Rigidus Surgery

Hallux rigidus can be treated with a variety of surgical procedures, including joint preserving techniques, arthrodesis, and arthroplasty. The most commonly reported complications for joint preserving techniques consist of progression of arthritis, continued pain, and transfer metatarsalgia. Although good outcomes have been reported for arthrodesis overall, careful attention must be paid to technique and positioning of the toe to avoid nonunion or malunion. Arthroplasty preserves motion but in the case of failure can present the additional challenge of bone loss. In these scenarios, the authors recommend distraction bone block arthrodesis with structural autograft.

Anatomy of the superficial peroneal nerve: Can we predict nerve location and minimize iatrogenic lesion?

OBJECTIVE OF THE STUDY

Knowledge of anatomical variations of the superficial peroneal nerve (SPN) may minimize iatrogenic insults. The aim of the investigation was to perform an anatomical description of the SPN.

MATERIALS AND METHODS

Twenty-three embalmed cadaver lower limbs were dissected.

RESULTS

The SPN emerged from the crural fascia about 6.3±7.7mm anteromedial to the anterior border of the fibula and 26.8±12.6mm anteromedial and 113.6±43.9mm superior to the tip of the lateral malleolus. The median point of bifurcation into two terminal branches was 13.0mm anteromedial to the anterior border of the fibula and 34.9±14.7mm anteromedial and 81.0±69.0mm superior to the tip of the lateral malleolus. The SPN was found between 5.76% and 7.70% of the individual's height proximal to the tip of the lateral malleolus, with an unpredictable branching pattern over the intermalleolar line.

CONCLUSION

A lateral ankle approach over the posterolateral surface of the fibula (posterior to the tip of the lateral malleolus) minimizes the risk of iatrogenic nerve lesion.

The Use of Ultrasonography to Identify the Intersection of the Dorsomedial Cutaneous Nerve of the Hallux and the Extensor Hallucis Longus Tendon: A Cadaveric Study

Terminal branches of the superficial fibular nerve are at risk of iatrogenic damage during foot surgery, including hallux valgus rigidus correction, bunionectomy, cheilectomy, and extensor hallucis longus tendon transfer. One terminal branch, the dorsomedial cutaneous nerve of the hallux, is particularly at risk of injury at its intersection with the extensor hallucis longus tendon. Iatrogenic injuries of the dorsomedial cutaneous nerve of the hallux can result in sensory loss, neuroma formation, and/or debilitating causalgia. Therefore, preoperative identification of the nerve is of great clinical importance. The present study used ultrasonography to identify the intersection between the dorsomedial cutaneous nerve of the hallux and the extensor hallucis longus tendon in cadavers. On ultrasound identification of the intersection, dissection was performed to assess the accuracy of the ultrasound screening. The method successfully pinpointed the nerve in 21 of 28 feet (75%). The sensitivity, positive likelihood ratio, and positive and negative predictive values of ultrasound identification of the junction of the dorsomedial cutaneous nerve and the extensor hallucis longus tendon were 75%, 75%, 100%, and 0%, respectively. We have described an ultrasound protocol that allows for the preoperative identification of the dorsomedial cutaneous nerve of the hallux as it crosses the extensor hallucis longus tendon. The technique could potentially be used to prevent the debilitating iatrogenic injuries known to occur in association with many common foot surgeries.

Treatment of Foot and Ankle Neuroma Pain With Processed Nerve Allografts

BACKGROUND

Localized nerve pain in the foot and ankle can be a chronic source of disability after trauma and has been identified as the most common complication following operative interventions in the foot and ankle. The superficial location of the injured nerves and lack of suitable tissue for nerve implantation make this pain refractory to conventional methods of neuroma management. We describe a novel strategy for management using processed nerve allografts to bridge nerve gaps created by resection of both end neuromas and neuromas-in-continuity.

METHODS

A retrospective review of a prospectively maintained database was performed of all patients who received a processed nerve allograft for treatment of painful neuromas in the foot and ankle between May 2010 and June 2015. Patient demographic and operative information was obtained, as well as preoperative and postoperative pain assessments using a conventional ordinal scale and PROMIS (Patient Reported Outcomes Measurement Information System) Pain Behavior and Pain Interference assessments. Twenty-two patients were identified, with postoperative pain assessments occurring at a mean of 15.5 months after surgery.

RESULTS

Neuromas of the sural and superficial peroneal nerves were the most common diagnoses, with 3-cm nerve allografts being used as the interposition graft in the majority of cases. Eight patients had end neuromas and 18 patients had neuromas in continuity. Analysis of paired data demonstrated a mean ordinal pain score decrease of 2.6, with 24 and 31 percentage-point decreases in PROMIS Pain Behavior and Pain Interference measures, respectively. All changes were significant (P < .002).

CONCLUSION

The painful sequelae of superficial nerve injuries in the foot and ankle was significantly improved with complete excision of the involved nerve segment followed by bridging of the resulting nerve gap with a processed nerve allograft. This approach limits surgery to the site of injury and reconstitutes the peripheral nerve anatomy.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Ultrasound-Guided Interventional Procedures in Pain Medicine: A Review of Anatomy, Sonoanatomy, and Procedures: Part VI: Ankle Joint

Ultrasound-guided injections in pain medicine are emerging as a popular technique for pain interventions. Ultrasound can be applied for procedures of the ankle joint and surrounding structures. This review describes the anatomy and sonoanatomy of the ankle joint, subtalar joint, and surrounding extra-articular structures relevant for intra-articular injection. Second, it reviews injection techniques and the accuracy and efficacy of these intra-articular ankle injections.

Natural history of sensory nerve recovery after cutaneous nerve injury following foot and ankle surgery

Cutaneous nerve injury is the most common complication following foot and ankle surgery. However, clinical studies including long-term follow-up data after cutaneous nerve injury of the foot and ankle are lacking. In the current retrospective study, we analyzed the clinical data of 279 patients who underwent foot and ankle surgery. Subjects who suffered from apparent paresthesia in the cutaneous sensory nerve area after surgery were included in the study. Patients received oral vitamin B₁₂ and methylcobalamin. We examined final follow-up data of 17 patients, including seven with sural nerve injury, five with superficial peroneal nerve injury, and five with plantar medial cutaneous nerve injury. We assessed nerve sensory function using the Medical Research Council Scale. Follow-up immediately, at 6 weeks, 3, 6 and 9 months, and 1 year after surgery demonstrated that sensory function was gradually restored in most patients within 6 months. However, recovery was slow at 9 months. There was no significant difference in sensory function between 9 months and 1 year after surgery. Painful neuromas occurred in four patients at 9 months to 1 year. The results demonstrated that the recovery of sensory function in patients with various cutaneous nerve injuries after foot and ankle surgery required at least 6 months.