Consideration for Limb Salvage in Place of Amputation in Complex Tibial Fracture With Neurovascular Injury: A Case Report

High-energy tibial fractures often present with associated soft tissue injuries, including neuro-vascular damage, complicating the treatment decision. A 33-year-old male presented with Gustilo Anderson type IIIA fracture of the left distal tibia and fibula with associated closed calcaneus fracture and tibial nerve transection. Amputation was discussed, but the decision was made for limb salvage with nerve allograft. The patient displayed satisfactory functional recovery at 29 months postoperatively without need for major revision, grafting, arthrodesis, or amputation. This case report provides an example of successful limb salvage utilizing tibial nerve allograft in a complex high-energy lower extremity injury. Level of Evidence: IV.

Late Results of Early End-to-End Repair in Sciatic Nerve Injuries

OBJECTIVE

Mechanisms of sciatic nerve injury include gunshot injury, sharps injury, injection injury, contusion, femoral fracture injury, and iatrogenic injury due to fracture surgery. Regardless of the type of injury, patients undergoing sciatic nerve repair have poor motor and sensory outcomes. In this study, we compared the late outcomes of a group of patients in whom the author performed an early end-to-end anastomosis for sciatic nerve sharps injury and another group of patients with a similar injury who were not operated on but left to natural history.

METHODS

The sciatic nerve, comprising two primary divisions with distinct muscle innervations, was subject to separate examinations. Group 1 (n=10, study group) underwent tibial division anastomosis, while Group 2 (n=12, control group) received no surgical intervention involving the tibial division. Similarly, Group 3 (n=11, study group) underwent peroneal division anastomosis, while Group 4 (n=14, control group) encompassed subgroups that did not undergo peroneal division surgery.

RESULTS

In Group 1, the rate of gain in plantar flexion muscle strength was significantly higher (p < 0.05) compared to Group 2. Furthermore, the sensory examination gain level ratio within the tibial domain was significantly greater (p < 0.05) in Group 1 than in Group 2. Additionally, Group 1 exhibited a significantly higher rate (p < 0.05) of detection of regeneration and reinnervation findings in electromyography (EMG) compared to Group 2.

CONCLUSION

When evaluating the long-term outcomes following early end-to-end anastomoses of the sciatic nerve, it becomes evident that while significant improvements are observed when compared to individuals without anastomosis, the positive impact of surgical interventions on motor and sensory gains in daily life remains limited. Nevertheless, we contend that early surgical intervention holds potential advantages in terms of patient management.

Unrecognized tibial nerve injury in total-ankle arthroplasty: Two case reports

RATIONALE

Tibial nerve injury is a sustainable but rare complication during total-ankle arthroplasty (TAA). We outlined 2 previously unreported cases of tibial nerve injury in TAA, including the prognoses and possible causes.

PATIENT CONCERNS

First, a 63-year-old woman complained of a 5-month history of persistent tingling sensation and numbness on the medial and plantar aspects of her foot after TAA. Second, a 50-year-old woman complained of a 6-month history of tingling sensation and numbness on the plantar surface of her forefoot after TAA.

DIAGNOSIS

Explorations were performed on suspicion of tarsal tunnel syndrome; however, both patients exhibited complete laceration of tibial nerve with neuroma formation.

INTERVENTIONS

In both patients, we excised the neuroma and performed end-to-end nerve repair.

OUTCOMES

The sensory disturbance of the sole considerably improved at long-term follow-up over 8 years after the neurorrhaphy procedures.

LESSONS

Tibial nerve injury is rare following TAA, and is sometimes unrecognized or misdiagnosed. If tibial nerve injury is suspected, prompt surgical exploration should be performed; great precaution must also be taken to prevent injury of the tibial nerve during TAA.

Rate of Neurologic Injury Following Lateralizing Calcaneal Osteotomy Performed Through a Medial Approach

BACKGROUND

Calcaneal osteotomies are commonly used to correct varus hindfoot alignment in patients with symptomatic cavovarus deformity. Translational, closing wedge, and Malerba-type osteotomies have been implicated in the development of tarsal tunnel syndrome and neurologic injury to branches of the tibial nerve. The authors hypothesized that there would be minimal clinically important injury to the tibial nerve by performing a translational calcaneal osteotomy from a medial approach.

METHODS

All patients undergoing a cavovarus reconstruction by a single surgeon were identified. Patients were included if they underwent a lateralizing calcaneal osteotomy via medial approach. Demographics, operative reports, and clinic notes were reviewed to identify concomitant procedures performed, incidence of postoperative tarsal tunnel syndrome, complications, and preoperative and postoperative nerve examinations. Postoperative radiographs were reviewed for location of the osteotomy relative to the posterior tubercle.

RESULTS

Twenty-four patients underwent lateralizing calcaneal osteotomy via a medial approach. Of the osteotomies, 83.3% (20/24) were in the middle third of the calcaneus, with a mean of 11.6-mm translation. No patients developed postoperative tarsal tunnel syndrome or tibial nerve palsy.

CONCLUSION

Lateralizing calcaneal osteotomy performed via a medial approach had a clinically negligible incidence of neurologic injury. Adequate translation was achieved to obtain correction of varus hindfoot deformity. The authors believe that there is less direct and less percussive injury to branches of the tibial nerve when performing the osteotomy from medial to lateral. This technique may represent an operative strategy to minimize risk to the tibial nerve and reduce neurologic deficit following cavovarus reconstruction.

LEVEL OF EVIDENCE

Level IV, case series.

Challenging the catechism of therapeutics for chronic neuropathic pain: Targeting CaV2.2 interactions with CRMP2 peptides

Chronic neuropathic pain management is a worldwide concern. Pharmaceutical companies globally have historically targeted ion channels as the therapeutic catechism with many blockbuster successes. Remarkably, no new pain therapeutic has been approved by European or American regulatory agencies over the last decade. This article will provide an overview of an alternative approach to ion channel drug discovery: targeting regulators of ion channels, specifically focusing on voltage-gated calcium channels. We will highlight the discovery of an anti-nociceptive peptide derived from a novel calcium channel interacting partner - the collapsin response mediator protein 2 (CRMP2). In vivo administration of this peptide reduces pain behavior in a number of models of neuropathic pain without affecting sympathetic-associated cardiovascular activity, memory retrieval, sensorimotor function, or depression. A CRMP2-derived peptide analgesic, with restricted access to the CNS, represents a completely novel approach to the treatment of severe pain with an improved safety profile. As peptides now represent one of the fastest growing classes of new drugs, it is expected that peptide targeting of protein interactions within the calcium channel complex may be a paradigm shift in ion channel drug discovery.