Search

Background and Aims: Comprehensive study of sural nerve biopsy utility based on individual histopathologic preparations is lacking. We aimed to quantify the value of different histologic preparations in diagnosis. Methods: One hundred consecutive sural nerves were studied by standard histological preparations plus graded teased nerve fibers (GTNF), immunohistochemistry, and epoxy‐semithin morphometry. Three examiners scored the individual preparations separately by a questionnaire of neuropathic and interstitial abnormalities, masked to the biopsy number, versus a gold‐standard of all preparations. Multivariate modeling was utilized to determine best approach versus the gold‐standard. Results: Highest confidence (range 8–9 of 10) and inter‐rater reliability (99%) for fiber abnormalities came from GTNF, and interstitial abnormalities from paraffin stains (range 7–8, 99%). Vasculitic neuropathy associated with GTNF axonal degeneration (moderate to severe 79%) with OR 3.8, 95% CI (1.001–14.7), p =.04, but not significantly with the other preparations. Clinicopathologic diagnoses associated with teased fiber abnormalities in chronic inflammatory demyelinating polyradiculoneuropathy, 80% (8/10); amyloidosis, 50% (1/2); adult‐onset polyglucosan disease 100% (1/1). GTNF and paraffin stains significantly correlated with fiber density determined by morphometric analysis (GTNF: OR 9.9, p <.0001, paraffin: OR 3.8, p =.03). GTNF combined with paraffin sections had highest accuracy for clinicopathologic diagnoses and fiber density with 0.86 C‐stat prediction versus morphometric analysis. Pathological results lead to initiation or changes of immunotherapy in 70% (35/50; initiation n = 22, reduction n = 9, escalation n = 4) with the remaining having alternative intervention or no change. Interpretation: Nerve biopsy paraffin stains combined with GTNF have highest diagnostic utility, confidence, inter‐rater reliability, improving accuracy for a pathologic diagnosis aiding treatment recommendations. Immunostains and epoxy preparations are also demonstrated useful supporting consensus guidelines. This study provides class II evidence for individual nerve preparation utility. [ABSTRACT FROM AUTHOR]

Background: Factors that may affect surgical decompression results in tarsal tunnel syndrome are not known.Methods: A retrospective single-center study included patients who had undergone surgical tibial nerve release. The effectiveness of decompression was evaluated according to whether the patient would or would not be willing to undergo another surgical procedure in similar preoperative circumstances.Results: The patients stated for 43 feet (51%) that they would agree to a further procedure in similar circumstances. Six feet with space-occupying lesions on imaging had improved results, but neurolysis failed in 9 feet with bone-nerve contact. Neurolysis was significantly less effective when marked hindfoot valgus (p = 0.034), varus (p = 0.014), or fasciitis (p = 0.019) were present.Conclusions: If imaging reveals a compressive space-occupying lesion, surgery has a good prognosis. In feet with static hindfoot disorders or plantar fasciitis, conservative treatment must be optimized. Bone-nerve contact should systematically be sought. [ABSTRACT FROM AUTHOR]

Case: An overall healthy 48-year-old man suffered a left foot mangled crush injury resulting in a post-transmetatarsal amputation and subsequently developing a painful neuroma on the plantar surface of the foot. To avoid the zone of injury, targeted muscle reinnervation was used to treat the neuroma by coapting the tibial nerve to the motor point of the flexor hallucis longus (FHL) muscle. At 1-year follow-up, the patient reported no pain at rest, returned to work, and could ambulate with an orthosis for 30 minutes., Conclusion: Rare tibial nerve coaptations to the FHL could serve as a treatment option for patients with neuromas in traumatic postmetatarsal amputation., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C418)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Summary: Treatment of painful neuromas has long posed a significant challenge for peripheral nerve patients. The regenerative peripheral nerve interface (RPNI) provides the transected nerve with a muscle graft target to prevent neuroma formation. Discrepancies in RPNI surgical techniques between animal models ("inlay" RPNI) and clinical studies ("burrito" RPNI) preclude direct translation of results from bench to bedside and may account for variabilities in patient outcomes. The authors compared outcomes of these 2 surgical techniques in a rodent model. Animals treated with burrito RPNI after tibial nerve neuroma formation demonstrated no improvement in pain assessment, and tissue analysis revealed complete atrophy of the muscle graft with neuroma recurrence. By contrast, animals treated with inlay RPNI had significant improvement in pain with viable muscle grafts. The results suggest superiority of the inlay RPNI surgical technique for the management of painful neuroma in rodents., Clinical Relevance Statement: RPNIs are currently being used to prevent and treat neuroma and phantom limb pain. This preclinical study suggests the superiority of one surgical technique over the other., (Copyright © 2023 by the American Society of Plastic Surgeons.)

This case report describes the treatment of a postoperative painful neuroma of the tibial nerve using an autologous nerve graft in a dog. The patient presented with sudden non-weight-bearing lameness 10 days after iatrogenic tibial nerve injury during preparation of a reverse saphenous conduit flap. The dog showed severe pain at the surgical site without nerve deficits. A magnetic resonance imaging examination revealed an enlarged tibial nerve at the injury site, consistent with a neuroma. Analgesics were administered over 11 days, but the patient remained in severe pain and non-weight-bearing. Therefore, surgical resection was recommended. The fusiform neuroma was resected microsurgically, and a saphenous nerve graft was transplanted using an epineural nerve repair technique. Histopathological examination was consistent with a neuroma. The dog showed immediate pain relief and weight-bearing the day after surgery with normal motor function. The dog made a full recovery by the last follow-up 6 mo after surgery. If patients develop pain and lameness following surgery or nerve injury, neuroma formation must be considered, even shortly after surgery. Microsurgical resection and autologous nerve transplantation using an epineural nerve repair technique is a viable method to treat painful neuromas and minimize the risk for recurrence in dogs., (© 2024 by American Animal Hospital Association.)

Purpose: Selective tibial neurotomy (STN) is a surgical procedure for treating spastic equinovarus foot. Hyperselective neurectomy (HSN) of tibial nerve is a modified STN procedure, which was rarely discussed. This study aimed to describe the branching patterns of the tibial nerve and propose an optimal surgical incision of HSN for treatment of spastic equinovarus foot., Methods: Sixteen lower limbs were dissected to determine the various branching patterns of the tibial nerve and categorized according to these branching patterns. The mean distances from the nerve entry points to the tip of femur's medial epicondyle were measured, as well as their percentage to the overall length of the leg. The surgical incision was designed according to the range of these nerve entry points., Results: The tibial nerve sent out proximal and distal motor branches based on their position relative to the soleus muscle's tendinous arch. For proximal motor branches, the branches innervating the medial gastrocnemius, lateral gastrocnemius and proximal soleus were categorized into types I (9/16), II (5/16) and III (2/16). Measurements from the medial epicondyle to the nerve entry points into the medial gastrocnemius, lateral gastrocnemius and proximal soleus ranged from 14 to 33 mm (4-9% of leg length), 22-45 mm (6-12%) and 35-81 mm (10-22%), respectively. Distal motor branches including the distal soleus, posterior tibialis, flexor digitorum longus and flexor hallucis longus, were classified as types A (8/14), B (4/14) and C (2/14), with the distances from their respective terminal points to the medial epicondyle were 67-137 mm (19-39%), 74-125 mm (20-35%), 116-243 mm (33-69%) and 125-272 mm (35-77%)., Conclusions: The motor branches of tibial nerve were classified into two groups and each subdivided into three types. Detailed location parameters may serve as an anatomical basis for designing incision of HSN., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: Metaphyseal fixation with porous titanium sleeves in revision knee surgery provides mechanical support to the implant, promotes biological fixation, and has shown satisfactory short- and mid-term results. Cement is commonly used to fix the tibial tray to the epiphyseal area. The objective of this study is to determine whether cement should be used to achieve fixation of the tibial tray with the hypothesis that metaphyseal sleeves would provide enough axial and rotational stability making cementation unnecessary. Material and methods: Prospective study of 60 patients undergoing knee replacement surgery with metaphyseal sleeves in type 2B defects in femur and tibia. Patients were divided into two groups according to the use of cement on the tibial component. Analysis included the American Knee Society Score (KSS) knee and functional scales, the Western Ontario and McMaster Universities (WOMAC) index, the Short Form 12 (SF-12) health survey, and radiographic assessment with a maximum follow-up of 5 years. Results: No statistically significant differences were found between the two groups in any of the parameters assessed. Conclusion: Metaphyseal sleeves showed a 100% survivorship at five years of followup. There were no differences in clinical and radiographic outcomes at five years of follow-up depending on whether or not cement was used for tibial platform fixation. Cementation of the tibial tray would therefore not be required to achieve satisfactory mid-term results. Level of evidence: Level II: prospective cohort study. Therapeutic. [ABSTRACT FROM AUTHOR]

Purpose: To perform a detailed deformity analysis of patients with varus alignment and to define the ideal osteotomy level (tibial vs. femoral vs. double level) to avoid an oblique joint line. Methods: A total of 303 digital full-leg standing radiographs of patients aged 18–60 years and varus alignment [mechanical tibiofemoral varus angle (mFTA) ≥ 3°] were included. All legs were analyzed regarding mFTA, mechanical medial proximal tibia angle (mMPTA), mechanical lateral distal femur angle (mLDFA), and joint line convergence angle. Based on mFTA, varus alignment was categorized as "mild" (3°–5°), "moderate" (6°–8°), or "severe" (≥ 9°). Deformity location was determined according to the malalignment test described by Paley. Two osteotomy simulations were performed with different upper limits for mMPTA: anatomic correction (mMPTA ≤ 90°, mLDFA ≥ 85°) and overcorrection (mMPTA ≤ 95°, mLDFA ≥ 85°). If a single osteotomy exceeded these limits at the intended mFTA of 2° valgus, a double-level osteotomy was simulated. If even a double-level osteotomy resulted in deviations from the defined limits, the leg was categorized as "uncorrectable". Results: Mean mFTA was 6° ± 11° of varus (range 3°–15°). A tibial deformity was observed in 28%, a femoral deformity in 23%, a combined tibial and femoral deformity in 4%, and no bony deformity in 45%. The prevalence of a tibial deformity did not differ between varus severity groups, whereas a femoral and bifocal deformity was significantly more prevalent in knees with more distinct varus (p < 0.001). Osteotomy simulation revealed that isolated high tibial osteotomy (HTO) was appropriate in only 12% for anatomic correction, whereas a double-level osteotomy was necessary in 63%. If overcorrection of mMPTA was tolerated, the number of HTOs significantly increased to 57% (p < 0.001), whereas the number of double-level osteotomies significantly decreased to 33% (p < 0.001). Isolated DFO was considered ideal in 8% for both simulations. Significantly more knees were considered "uncorrectable" by simulating anatomic correction (18 vs. 2%; p < 0.001). A double-level osteotomy was significantly more often necessary in knees with "severe" varus (p < 0.001). Conclusion: Less than one-third of patients (28%) with mechanical varus ≥ 3° have a tibial deformity. If anatomic correction (mMPTA ≤ 90°) is intended, only 12% of patients can be corrected via isolated HTO, whereas 63% of patients require a double-level osteotomy. If slight overcorrection is accepted (mMPTA ≤ 95°), 57% of patients can be corrected via isolated HTO, whereas 33% of patients would still require a double-level osteotomy. Level of evidence: III, cross-sectional study. [ABSTRACT FROM AUTHOR]

Copyright of Turkish Journal of Trauma & Emergency Surgery / Ulusal Travma ve Acil Cerrahi Dergisi is the property of KARE Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) procedures have been shown to improve patient-reported outcomes for the treatment of symptomatic neuromas after amputation; however, the specific indications and comparative outcomes of each are unclear. The primary research questions were what complement of nerves most frequently requires secondary pain intervention after conventional amputation, whether this information can guide the focused application of TMR and RPNI to the primary amputation setting, and how the outcomes compare in both settings.Methods: We performed a retrospective review of records for patients who had undergone lower-extremity TMR and/or RPNI at our institution. Eighty-seven procedures were performed: 59 for the secondary treatment of symptomatic neuroma pain after amputation and 28 for primary prophylaxis during amputation. We reviewed records for the amputation level, TMR and/or RPNI timing, pain scores, patient-reported resolution of nerve-related symptoms, and complications or revisions. We evaluated the relationship between the amputation level and the frequency with which each transected nerve required neurologic intervention for pain symptoms.Results: The mean pain score decreased after delayed TMR or RPNI procedures from 4.3 points to 1.7 points (p < 0.001), and the mean final pain score (and standard deviation) was 1.0 ± 1.9 points at the time of follow-up for acute procedures. Symptom resolution was achieved in 92% of patients. The sciatic nerve most commonly required intervention for symptomatic neuroma above the knee, and the tibial nerve and common or superficial peroneal nerve were most problematic following transtibial amputation. None of our patients required a revision pain treatment procedure after primary TMR targeting these commonly symptomatic nerves. Failure to address the tibial nerve during a delayed procedure was associated with an increased risk of unsuccessful TMR, resulting in a revision surgical procedure (odds ratio, 26 [95% confidence interval, 1.8 to 368]; p = 0.02).Conclusions: There is a consistent pattern of symptomatic nerves that require secondary surgical intervention for the management of pain after amputation. TMR and RPNI were translated to the primary amputation setting by using this predictable pattern to devise a surgical strategy that prevents symptomatic neuroma pain.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Purpose: Defining a Minimal Clinically Important Difference (MCID) value for Patient-Reported Outcome Measures (PROMs) is crucial for determining the effectiveness of a procedure and calculating the sample size for trial planning. The purpose of this study was to determine the MCID of several PROMs (Knee injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS) and the SF-12) in patients who underwent medial opening-wedge High-Tibial Osteotomy (owHTO) with Patient-Specific Cutting Guides (PSCGs), using anchor-based methods. Methods: Patients undergoing isolated medial owHTO with PSCGs between January 2013 and January 2017 were enrolled in this single-center, prospective, observational study. Three outcome scores were collected pre-operatively and at the 2 years follow-up evaluation: KOOS, KSS and SF-12. The MCIDs were calculated using anchor-based method: at 2 years postoperatively: "Compared with before surgery, how would you rate operated joint now?" The responses were recorded using a five-point scale. Patients who answered "about the same" or "somewhat worse" were classified into the no change group, while those who answered "somewhat better" were classified into the minimal change group. A receiver operating characteristic (ROC) curve was used to define the cutoff point that best discriminated between the minimal change and no change groups for each PROMs Results: 196 patients were included, 75 (somewhat better) and 24 patients (about the same and somewhat worse) were, respectively, assigned to the "no change" and "minimal change" groups. There was no significant difference between the two groups in terms of baseline characteristics and postoperative complications. At 24 months follow-up all the PROMs (KOOS, KSS and SF-12) were significantly better for the "minimal change" group compared to the "no change" group. MCID was 15.4 for KOOS pain, 15.1 for KOOS symptoms, 17 for KOOS ADL, 11.2 for KOOS sports/recreation, 16.5 for KOOS QQL, 3 for KSS symptoms, 5.6 for KSS activity, 7.2 for SF-12 physical component and 6.3 for PCS mental component. Conclusion: This study determined the MCIDs of common used PROMs in patients undergoing owHTO. Level of evidence: Prospective Cohort Study, Level II [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to evaluate the long-term effectiveness of selective tibial neurotomy (STN) for the treatment of the spastic foot using a goal-centered approach., Methods: Between 2011 and 2018, adult patients with a spastic foot (regardless of etiology) who received STN followed by a rehabilitation program were included. The primary outcome was the achievement of individual goals defined preoperatively (T0) and compared at 1-year (T1) and 5-year (T5) follow-up by using the Goal Attainment Scaling methodology (T-score). The secondary outcomes were the presence of spastic deformities (equinus, varus, and claw toes), modified Ashworth scale (MAS) score for the targeted muscles, and modified Rankin Scale (mRS) score at T0, T1, and T5., Results: Eighty-eight patients were included. At T5, 88.7% of patients had achieved their goals at least "as expected." The mean T-score was significantly higher at T1 (62.5 ± 9.5) and T5 (60.6 ± 11.3) than at T0 (37.9 ± 2.8) (p < 0.0001), and the difference between T1 and T5 was not significant (p = 0.2). Compared to T0, deformities (equinus, varus, and claw toes; all p < 0.0001), MAS score (p < 0.0001), and mRS score (p < 0.0001) were significantly improved at T1 and T5. Compared to T1, MAS score increased slightly only at T5 (p = 0.05) but remained largely below the preoperative value. There was no difference between T1 and T5 regarding other clinical parameters (e.g., deformities, walking abilities, mRS score)., Conclusions: This study found that STN associated with a postoperative rehabilitation program can enable patients to successfully achieve personal goals that are sustained within a 5-year follow-up period.

The fibrotic tissue that appears following nerve damage can prevent axonal regeneration. Expanded polytetrafluor ethylene (ePTFE) is a synthetic polymer with antiadhesive properties and a safe history of use in neurosurgery. The aim of this study was to use ePTFE to prevent postsurgical adhesions in patients undergoing anastomosis surgery and report the results. Between January 2014 and May 2018, six patients with primary and secondary peripheral nerve cuts underwent anastomosis (one with allograft and five with autografts). The anastomotic region was wrapped with ePTFE to form a barrier. The mean follow-up period was 28 months (minimum 3 months, maximum 4 years). In three of six patients whose nerve integrity was lost due to various reasons, there was an improvement in electrophysiological recordings. The allograft was used in a patient with peroneal nerve injury; the sural nerve was used as a graft in other patients. In three patients, the defect was more than 4 cm. Early surgery and defect size are important factors to consider when treating peripheral nerve anastomosis. Development of intraneural and perineural adhesions postsurgery can be problematic. ePTFE is an inert polymer that prevents adhesions from forming after anastomosis surgery. [ABSTRACT FROM AUTHOR]

Background: This study aims to analyse the clinical results of ultrasound-guided surgery for the decompression of the tibial nerve, including its distal medial and lateral branches, to treat tarsal tunnel syndrome. These structures are the complete flexor retinaculum and the deep fascia of the abductor hallucis muscle, including individualised release of the medial and lateral plantar nerve tunnels. Method: This is a retrospective review of 81 patients (36 men and 45 women) with an average age of 41 years old (32–62) and an average clinical course of 31 months (8–96) compatible with idiopathic tarsal tunnel syndrome, who underwent ultrasound-guided decompression of the proximal and distal tarsal tunnel between February 2015 and November 2017 (both months included), with a minimum follow-up of 18 months. Results: Based on the Takakura et al. scale for the 81 patients, 76.54% obtained excellent results, 13.58% good results, and 9.87% poor results. The patients with the longest course of symptoms displayed the worst results. Conclusion: Although 9% of patients did not improve, ultrasound-guided tarsal tunnel release might be a viable alternative to conventional open approaches. [ABSTRACT FROM AUTHOR]

Background: The ansa cervicalis is useful for cranial nerve repair, and may be harvested without apparent morbidity. Herein we report an unusual and surgically relevant anatomic variant of the ansa cervicalis. Methods: An adult male with left parotid adenoid cystic carcinoma underwent parotidectomy with upper-division facial nerve resection and planned interposition repair using the ansa cervicalis. The ipsilateral hypoglossal nerve was identified, together with a descending branch producing strap muscle contraction when stimulated. This presumed descendens hypoglossi was unusually large in caliber; further dissection revealed continuity with the vagus nerve. Results: Ansa cervicalis harvest was aborted when its separation from vagus nerve epineurium was not possible. The sural nerve was alternatively harvested. The patient awoke with left vocal fold palsy, which completely resolved within 3 months. Conclusion: Anatomic variants of the ansa cervicalis exist that may preclude graft harvest and place the vagus nerve at risk of inadvertent injury. [ABSTRACT FROM AUTHOR]

Purpose: Neurovascular structures around the ankle are at risk of injury during arthroscopic all-inside lateral collateral ligament repair for the treatment of chronic ankle instability. This study aimed to evaluate the risk of damage to anatomical structures and reproducibility of the technique amongst surgeons with different levels of expertise in the arthroscopic all-inside ligament repair.Methods: Twelve fresh-frozen ankle specimens were used for the study. Two foot and ankle surgeons with different level of experience in the technique performed the procedure on 6 specimens each. The repair was performed following a standardized procedure as originally described. Then, an experienced anatomist dissected all the specimens to evaluate the outcome of the ligament repair, any injuries to anatomical structures and the distance between arthroscopic portals and the superficial peroneal nerve (SPN) and sural nerve.Results: Dissections revealed no injury to the nerves assessed. Mean distance from the anterolateral portal and the SPN was of 4.8 (range 0.0-10.4) mm. The mean distance from the accessory anterolateral portal to the SPN and sural nerve was of 14.2 (range 7.1-32.9) mm and 28.1 (range 2.8-39.6) mm, respectively. The difference between the 2 surgeons' groups was non-statistically significant for any measurement (mm). In all specimens both fascicles of the anterior talofibular ligament were reattached onto its original fibular footprint. The calcaneofibular ligament was not penetrated in any specimen.Conclusions: The all-inside arthroscopic lateral collateral ligament repair is a safe and reproducible technique. The clinical relevance of this study is that this technique provides a safe and anatomic reattachment of the anterior talofibular ligament, with minimal risk of injury to surrounding anatomical structures regardless of the level of experience with the technique. [ABSTRACT FROM AUTHOR]

Background: Tarsal tunnel syndrome (TTS) is a common entrapment neuropathy of the posterior tibial nerve. Surgery can be performed less invasively under local anesthesia. We adopted zig-zag skin incision to prevent postoperative wound complications., Methods: Between July 2022 and June 2023, we operated on 19 legs of 14 consecutive TTS patients (5 males, 11 females; average age 73.3 years). We made a 2- to 3-cm zig-zag skin incision on the tarsal tunnel. After posterior tibial nerve decompression by posterior tibial artery (PTA) transposition, the subcutaneous layer was tightly sutured with 4-0 PDS and the skin was closed with Dermabond Advanced. We investigated adverse events that developed during the first 30 postoperative days and recorded surgical outcomes at the final visit., Results: In all patients the nerves were successfully decompressed with PTA transposition. There were no intraoperative complications. During the 30 postoperative days there were no adverse events, including wound complications, and patients' symptoms improved significantly., Conclusion: Zig-zag skin incision was easy and convenient for surgical TTS treatment and may be useful for preventing postoperative wound complications.

Tarsal tunnel syndrome (TTS) is a nerve entrapment of the posterior tibial nerve. This uncommon condition frequently goes undiagnosed or misdiagnosed even though it interferes with the daily activities of workers. Here we discuss the return to work status of a 37-year-old male patient who manages a manufacturing plant. He was identified as having Tarsal Tunnel Syndrome as a result of a foot abnormality and improper shoe wear. He had moderate pes planus and underwent tarsal tunnel release on his right foot. What are the determinant factors in defining a patient's status for returning to work after a tarsal tunnel release? We conducted a literature review using PubMed, Science Direct, and Cochrane. The Indonesian Occupational Medicine Association used the seven-step return-to-work assessment as a protocol to avoid overlooking the process. Duration of symptoms, associated pathology, and the presence of structural foot problems or a space-occupying lesion are factors affecting outcome. Post-operative foot scores, including Maryland Foot Score (MFS), VAS, and Foot Function Index, can be used to evaluate patient outcomes. Early disability limitation and a thorough return-to-work assessment are needed.

Introduction: Neuroenhancing therapies are desired because repair of nerve injuries can fail to achieve recovery. We compared two neuroenhancing therapies, electrical stimulation (ES) and systemic tacrolimus (FK506), for their capabilities to enhance regeneration in the context of a rat model.Methods: Rats were randomized to four groups: ES 0.5 mA, ES 2.0 mA, FK506, and repair alone. All groups underwent tibial nerve transection and repair, and outcomes were assessed by using twice per week walking track analysis, cold allodynia response, relative muscle mass, and nerve histology.Results: Electrical stimulation and FK506 groups demonstrated improved functional recovery and myelinated axon counts distal to the repair compared with repair alone. Electrical stimulation provided improvements in nerve regeneration that were not different from optimized FK506 systemic administration.Discussion: Providing ES after nerve repair improved regeneration and recovery in rats, with minimal differences in therapeutic efficacy to FK506, further demonstrating its clinical potential to improve management of nerve injuries. [ABSTRACT FROM AUTHOR]

Purpose: To determine the classification scheme for osteoarthritis severity grading that most closely correlates with postoperative clinical outcomes and to identify the positive and negative prognostic factors for medial open-wedge high-tibial osteotomy (OWHTO).Methods: Seventy-nine consecutive patients with primary varus osteoarthritis were treated using OWHTO. Arthritic grading was determined by arthroscopic assessment according to the modified Outerbridge classification and by radiographic classification according to the Kellgren-Lawrence (KL) grading scale on standing anteroposterior (AP) and 45° posteroanterior (PA) flexion weight-bearing radiography. Clinical outcome was assessed using the Oxford Knee Score (OKS), which was evaluated both preoperatively and at the postoperative 2-year follow-up after OWHTO. Multivariate regression analyses were used to explore and quantify the influence of baseline patient demographics, variables related to arthroscopic and radiological grades of arthritis, as well as postoperative alignment changes on the OKS.Results: At the 2-year follow-up, the mean OKS had improved from 20 ± 4 to 39 ± 5 points (p < 0.001). The average mechanical femorotibial and mechanical medial proximal tibial angle (MPTA) changed from 6.9° ± 3.4° to valgus 2.7° ± 2.8° and from 85.6° ± 2.4° to 92.9° ± 3.7° (all p < 0.001). The osteoarthritis severity grade based on the KL scale was 2.4 ± 0.9 on standing AP radiography, 2.8 ± 0.9 on 45° PA flexion weight-bearing radiography (p = 0.003), and 3.4 ± 0.7 according to the modified Outerbridge classification. In the multivariate analyses, the KL grade on 45° PA flexion weight-bearing radiography (p = 0.01) and postoperative MPTA (p = 0.01) showed significant negative correlations with postoperative OKS at the 2-year follow-up.Conclusion: The KL grading system based on 45° PA flexion weight-bearing radiography showed the strongest significant negative correlation with postoperative OKS after the OWHTO procedure using three different common OA classification schemes, which should be considered to determine the surgical indication of HTO. The KL grading system based on 45° PA flexion weight-bearing radiography showed the strongest correlation with high-tibial osteotomy-surgical indications and the counselling of patients with advanced osteoarthritis.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Purpose: Aim of this study is to document if combined meniscal allograft transplantation (MAT) and ACL reconstruction can improve knee function, reduce pain and allow patients with meniscal defect and ACL lesion to resume sport activities.Methods: Fifty MAT, arthroscopically performed without bone plugs and combined with one-stage primary or revision ACL reconstruction, with or without high tibial osteotomy (HTO), were included. Patients (aged 38.2 ± 10.6 years, 87% males) were evaluated at a mean follow-up of 5 years with Lysholm, Tegner and VAS scores. Patient satisfaction was also recorded, together with complications and failures.Results: VAS and Lysholm scores improved significantly (from 63.7 to 24.5 and from 60.6 to 82.7, respectively, p < 0.001), while the Tegner score did not reach pre-injury values (p < 0.001), but it improved significantly compared to pre-surgery values (from 2.8 to 4.6, p < 0.001). Medial MAT reported significantly better results compared to lateral MAT. Patients undergoing concomitant HTO reported a significantly higher decrease of VAS. Younger patients with higher pre-operative pain and lower activity level presented higher satisfaction. Eight patients needed a reoperation. Three patients were considered surgical failures while four were considered clinical failures, for a total of 15% failures.Conclusions: Meniscal allograft transplantation combined with ACL reconstruction represents a safe and suitable treatment, which should be considered as a suitable option in the clinical practice. All evaluated patient profiles, ACL injury in a patient with post-meniscectomy syndrome, failed ACL reconstruction in patients with a meniscus defect, and ACL reconstruction in patients with malalignment due to meniscal defect, benefited from the combined MAT procedure at medium-term follow-up.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

Background: Severe peripheral nerve injuries, such as deficits over long distances or proximal nerve trunk injuries, pose complex reconstruction challenges that often result in unfavorable outcomes. An innovative approach to repairing severe peripheral nerve damage involves using conduit suturing for nerve transposition repair. Cylindrical nerve guides are typically unsuitable for nerve transposition repair. Moreover, postsurgical adjuvant treatment is essential to promote the development of axonal lateral sprouts, proximal growth, and the restoration of neurostructure and function. The purpose of this research is to assess the impact of chitosan-based conduits with varying inner diameters on nerve transposition repair when combined with modified formula Radix Hedysari (MFRH)., Methods: Using chitosan, we created conduits with varying inner diameters on both ends. These conduits were then utilized to repair the distal common peroneal and tibial nerves in SD rats using the proximal common peroneal nerve. Subsequently, MFRH was employed as a supplementary treatment. The assessment of the repair's effectiveness took place 16 weeks postsurgery, utilizing a range of techniques, including the neurological nerve function index, neuroelectrophysiological measurements, muscle wet weight, and examination of nerve and muscle histology., Results: The outcomes of our study showed that following 16 weeks of postoperative treatment, MFRH had a significant positive impact on the recovery of neuromotor and nerve conduction abilities. Moreover, there was a significant increase in the ratio of wet weight of muscles, cross-sectional area of muscle fibers, quantity and structure of regenerated myelinated nerve fibers, and the count of neurons., Conclusions: A combination of chitosan-based chitin conduits possessing different inner diameters and MFRH can considerably promote the regeneration and functional recovery of damaged nerves, which in turn enhances nerve transposition repair efficacy., Competing Interests: The authors declare no conflict of interest., (© 2023 The Author(s). Published by IMR Press.)

Competing Interests: None

Intraneural ganglion cysts are very uncommon lesions, whose diagnosis has increased since the articular theory and the description of the MRI findings were established. We present a case report of a 59-year-old man with symptoms of tarsal tunnel syndrome. Foot and ankle MRI demonstrated the presence of an intraneural cystic lesion in the posterior tibial neve and its connection with the subtalar joint through an articular branch. The identification of the specific radiological signs like the «signet ring sign» allowed establishing an adequate preoperative diagnosis, differentiating it from an extraneural lesion and facilitating the articular disconnection of the nerve branch during surgery., (Copyright © 2022 SERAM. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Percutaneous tibial nerve stimulation is a third-line treatment for overactive bladder and urgency urinary incontinence. During the procedure, a needle is inserted cephalad to the medial malleolus and posterior to the tibia. In recent years, permanent implants and leads have been developed for insertion into the medial ankle via a small incision. There are many important structures present in the medial compartment of the ankle, including the great saphenous vein, saphenous nerve, tibial nerve, posterior tibial vessels, and tendons of the posterior compartment leg muscles., Objective: The primary objective of this study was to identify the proximity of the percutaneous tibial nerve stimulation needle placed per Food and Drug Administration-approved device instructions to nearby important anatomic structures. The secondary objectives were to identify the proximity of the tibial nerve to the needle site, identify clinically relevant ankle anatomic structures, and confirm the tibial nerve and posterior tibial vasculature by histologic analysis., Study Design: Detailed medial ankle dissections were performed bilaterally on 10 female lightly embalmed anatomic donors (cadavers) obtained from the Willed Body Program at the University of Louisville. A pin was inserted at the percutaneous tibial nerve stimulation needle site, and the medial ankle was minimally dissected so the surrounding anatomic structures were visible but not disrupted. The shortest distance from the pin to the selected structures of the medial ankle region was measured. On completion of each dissection and set of measurements, tissue was harvested for histologic examination. The distances between the pin and each structure were assessed using means and standard deviations. A paired t test was used to assess the difference in the locations between the left and right ankles. Statistical analysis was performed on left-sided, right-sided, and combined measurements. An 80% prediction interval was found to represent the expected range of values for the measurement of a new cadaver or patient, and the 95% confidence interval of the mean was computed to characterize the average distance across all cadavers or patients., Results: The medial ankle of 10 adult female lightly embalmed cadavers were examined bilaterally. Dissections were completed from October 2021 to July 2022. Of note, 80% prediction intervals for the tibial nerve, the posterior tibial artery or vein, and the flexor digitorum longus tendon had a lower range of 0.0 mm from the pin and extending to 12.1, 9.5, and 13.9 mm, respectively. Moreover, 2 of the structures were found to be asymmetrical between the right and left ankles. The great saphenous vein was further from the pin on the left (20.5 mm [standard deviation of 6.4 mm] on the left vs 18.1 mm [standard deviation of 5.3 mm] on the right; P=.04). The calcaneal (Achilles) tendon was further from the pin on the right side (13.2 mm [standard deviation of 6.8 mm] vs 7.9 mm [standard deviation of 6.7 mm]; P=.04). Tibial neurovascular structures were confirmed with microscopic analysis., Conclusion: The anatomic structures within the medial ankle lie unexpectedly close to the percutaneous tibial nerve stimulation needle site as noted per Food and Drug Administration-approved device instructions. There is a possibility that some medial ankle structures are not symmetrical. It is crucial that practitioners understand medial ankle anatomy when performing percutaneous tibial nerve stimulation or permanent device insertion., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The Radiographic Union Score for Tibial fractures (RUST) and the modified version of the system, mRUST, are popular standards for assessing fracture-healing progress with use of radiographs. To our knowledge, this is the first study to experimentally validate the ability of RUST and mRUST to accurately assess bone-healing progression with use of both micro-computed tomography (micro-CT) scanning and biomechanical testing.Methods: Adult male rats (n = 29) underwent osteotomy with a midshaft fracture gap repaired with use of a polyetheretherketone plate. Anteroposterior and lateral radiographs were made of the repaired femora prior to rat death at end points of 5, 6, 7, 8, 9, and 17 weeks, and 2 fellowship-trained orthopaedic trauma surgeons independently assigned RUST and mRUST scores to repaired femora. The repaired and intact contralateral femora were then dissected. Bones underwent dissection, micro-CT scanning, and biomechanical torsion testing at the end points.Results: RUST scores ranged from 5 to 12 and mRUST scores ranged from 5 to 16. Intraclass correlation coefficients (ICCs) were 0.89 (95% confidence interval [CI]: 0.78 to 0.94) for RUST and 0.86 (95% CI: 0.74 to 0.93) for mRUST, which fall within the "almost perfect agreement" category for ICCs. Spearman rank correlation coefficients (RS) showed correlation of RUST (RS range, 0.456 to 0.818) and mRUST (RS range, 0.519 to 0.862) with micro-CT measurements of mineralized callus volume (BV), total callus volume (TV), and BV/TV ratio, but less so with bone mineral density (BMD). Additionally, RUST (RS range, 0.524 to 0.863) and mRUST (RS range, 0.434 to 0.850) were correlated with some biomechanical properties. A RUST score of 10 or an mRUST score of 15 may be considered the threshold above which a plated bone is "healed" because, at these scores, 120% or 140% of failure torque, respectively, was achieved by the repaired femora as compared with the intact contralateral femora.Conclusions: RUST and mRUST both show strong statistical correlations with micro-CT and biomechanical parameters.Clinical Relevance: RUST and mRUST scoring systems provide clinicians with validated, reliable, and available tools to assess the progress of fracture-healing. [ABSTRACT FROM AUTHOR]

A hypertrophied peroneal tubercle can present as a bony prominence at the lateral aspect of the foot and a peroneal tenosynovitis or tear. We report a case of a 52-year-old man complaining of lateral foot tingling pain and numbness. The sural nerve entrapment and peroneus longus tenosynovitis by hypertrophied peroneal tubercle were confirmed. Good results were obtained after excision of the hypertrophied peroneal tubercle and sural nerve release. [ABSTRACT FROM AUTHOR]

People with a transtibial amputation have numerous secondary health conditions, including an increased prevalence of low back pain. This increased prevalence may be partially explained by altered low back biomechanics during movement. The purpose of this study was to compare trunk kinematics and L4-L5 lumbar loads in people with and without a transtibial amputation during sit-to-stand. Motion capture, ground reaction force and electromyographic data were collected from eight people with a unilateral transtibial amputation and eight people without an amputation during five self-paced sit-to-stand motions. A musculoskeletal model of the torso, lumbar spine, pelvis, lower limbs, and 294 muscles was used in a static optimization framework to quantify L4-L5 loads, low back muscle forces, and trunk kinematics. Participants with an amputation had greater peak and average L4-L5 loading in compression compared to control participants, with peak loading occurring shortly after liftoff from the chair. At the instant of peak loading, participants with an amputation had significantly greater segmental trunk lateral bending and trunk-pelvis axial rotation toward the intact side, and significantly greater segmental trunk axial rotation toward the prosthetic side compared to control participants. Participants with an amputation also had greater peak frontal plane and transverse plane segmental trunk angular velocity. The postural differences observed in people with a transtibial amputation were consistent with their ground reaction force asymmetry. The cumulative effects of the altered movement strategy used by people with an amputation may result in an increased risk for low back pain development over time. [ABSTRACT FROM AUTHOR]

The soleus arcade syndrome is a rare compression neuropathy of the tibial nerve that often remains undiagnosed due to low clinical awareness and difficult diagnosis. We present the case of a female patient admitted with acute worsening of a pre-existing sensory tibial neuropathy and acute tibial nerve palsy after knee joint injection. After a knee magnetic resonance imaging remained non-diagnostic, dynamic ultrasonography was performed. Constriction by the soleus arcade and proximal swelling of the tibial nerve could be demonstrated during plantarflexion of the ankle by means of a dynamic examination in the standing patient. The patient underwent surgery and recovered fully. This proposed diagnostic approach can be used to identify soleus arcade syndrome by ultrasound. [ABSTRACT FROM AUTHOR]

Background: Injury to the common peroneal nerve disrupts the motor control pathway to ankle dorsiflexors and evertors, as well as toe extensors, resulting in pathological gait and foot drop. Direct external compression on the fibular head is the most frequent cause of peroneal nerve impairment and has poor prognosis. Methods and Patients: Here, we report the surgical outcome of 21 patients with foot drop (9 males and 12 females) who underwent nerve transfer procedure of either the superficial peroneal nerve or the tibial nerve fascicles to the motor branch of the tibialis anterior and to the deep peroneal nerve. They had at least 6 months postoperative follow-up (mean = 17; range, 6-32 months). Results: Among 21 patients who had no ankle dorsiflexion (BMRC 0/5) preoperatively, 9 patients had successful restoration of ankle dorsiflexion (BMRC 4 to 4+/5), 7 patients had BMRC 2 to 3+/5, and 4 patients had no or poor restoration of dorsiflexion (BMRC 0 to 1+/5) but achieved good ankle eversion (BMRC 3 to 4+/5). Overall statistically significant clinical improvement of ankle dorsiflexion and eversion from preoperative BMRC grade 2.6 ± 0.5 to postoperative BMRC grade 3.6 ± 0.7 (P = .0000004) was achieved. Conclusion: Overall statistically significant clinical improvement of ankle dorsiflexion and eversion was achieved in 80% of our study patients. Most of these patients gained antigravity and were able to walk with minimal steppage gait. In the other 4 patients (20%), there was good improvement in ankle eversion but poor or no ankle dorsiflexion. [ABSTRACT FROM AUTHOR]

Background: Intraneural ganglion cysts involving the tibial nerve are rare. Recent evidence has supported an articular (synovial) theory to explain the joint-related origin of these cysts; however, optimal operative treatment for cysts originating from the STFJ remains poorly understood. Therefore, we present a novel strategy: addressing the joint itself without addressing the articular branch and/or the cyst., Methods: Records of patients with tibial intraneural ganglion cysts with a connection to the STFJ who were treated with a joint resection alone at a single academic institution were reviewed. The clinicoradiographic features, operative intervention, and postoperative course were recorded., Results: We identified a consecutive series of 7 patients. These patients (4/7 male, 57%) were 43 (range 34-61) years of age and all presented with symptoms of neuropathy. The patients underwent resection of the synovial surfaces of the STFJ without disconnection of the articular branch or decompression of the cyst. Postoperatively, three patients regained partial motor function (43%, n=7), although four patients noted continued sensory abnormality (57%, 4/7). All six patients with postoperative MRIs had some evidence of regression of the cyst., Conclusions: This novel surgical technique serves as a proof of concept-highlighting the fact that treating the primary source (the joint origin) can be effective in eliminating the secondary problem (the cyst itself). While this study shows that this simplified approach can be employed in select cases, we believe that superior results (faster, fuller recovery) can be achieved with combinations of disconnecting the articular branch, decompressing the cyst, and/or resecting the joint., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Introduction: Entrapment of the common fibular nerve (CFN) at the head of the fibula and entrapment of the posterior tibial nerve (PTN) at the tarsal tunnel are the most common nerve entrapment syndromes in the lower limb. Our aim was to study the results of combined neurolysis of the CFN and PTN for chronic lower limb pain. We hypothesized that combined neurolysis allowed a reduction of this chronic pain., Material and Method: This bi-centric retrospective study took place from January 2015 to November 2018, with a single senior surgeon. The inclusion criteria were all patients operated on for an idiopathic entrapment syndrome with neurolysis of the PTN at the tarsal tunnel, combined with neurolysis of the CFN at the head of the fibula. The primary endpoint was the pain evolution assessed on a numerical analogue scale (NAS) preoperatively and postoperatively on D+21, and at the last follow-up. The secondary endpoint was to determine the prognostic factors on the clinical outcome of neurolysis., Results: One hundred and fifteen neurolysis were included, comprising 64 women and 38 men with a mean age of 57±17.6 years. The preoperative pain (NAS0) was evaluated at 6±2.4 points. At D+21 postoperatively, there was a significant reduction in pain (NASD+21: 3±2.6 points, p<0.01). Similarly, at the last follow-up (with a mean follow-up of 37±8.4 months), there was a significant reduction in pain (NASLFU: 2±2.5, p<0.01). A history of systemic inflammatory disease was the only factor associated with a less significant decrease in pain at D+21, according to a multivariate analysis (p<0.01). There were 14 complications (12%) not requiring revision surgery., Conclusion: This study is the first to demonstrate the efficacy of combined neurolysis of the CFN at the head of the fibula and the PTN at the tarsal tunnel, in the treatment of idiopathic nerve entrapment syndrome of the lower limb., Level of Evidence: IV; Retrospective comparative study., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

The long history of regeneration nerve research indicates many clinical problems with surgical reconstruction to be resolved. One of the promising surgical techniques in specific clinical conditions is end-to-side neurorrhaphy (ETS), described and then repeated with different efficiency in the 1990s of the twentieth century. There are no reliable data on the quality of recipient nerve regeneration, possible donor nerve damage, and epineural window technique necessary to be performed. This research attempts to evaluate the possible regeneration after end-to-side neurorrhaphy, its quality, potential donor nerve damage, and the influence of epineural windows on regeneration efficiency. Forty-five female Wistar rats were divided into three equal groups, and various surgical technics were applied: A-ETS without epineural window, B-ETS with epineural window, and C-free graft reconstruction. The right peroneal nerve was operated on, and the tibial nerve was selected as a donor. After 24 weeks, the regeneration was evaluated by (1) footprint analysis every two weeks with PFI (peroneal nerve function index), TFI (tibial nerve function index), and SFI (sciatic nerve function index) calculations; (2) the amplitude and latency measurements of motor evoked potentials parameters recorded on both sides of the peroneal and tibial nerves when electroneurography with direct sciatic nerve electrical stimulation and indirect magnetic stimulation were applied; (3) histomorphometry with digital conversion of a transverse semithin nerve section, with axon count, fibers diameter, and calculation of axon area with a semiautomated method were performed. There was no statistically significant difference between the groups investigated in all the parameters. The functional indexes stabilized after eight weeks (PFI) and six weeks (TFI and SFI) and were positively time related. The lower amplitude of tibial nerve potential in groups A and B was proven compared to the non-operated side. Neurophysiological parameters of the peroneal nerve did not differ significantly. Histomorphometry revealed significantly lower diameter and area of axons in operated peroneal nerves compared to non-operated nerves. The axon count was at a normal level in every group. Tibial nerve parameters did not differ from non-operated values. Regeneration of the peroneal nerve after ETS was ascertained to be at the same level as in the case of free graft reconstruction. Peroneal nerves after ETS and free graft reconstruction were ascertained to have a lower diameter and area than non-operated ones. The technique of an epineural window does not influence the regeneration result of the peroneal nerve. The tibial nerve motor evoked potentials were characterized by lower amplitudes in ETS groups, which could indicate axonal impairment.

CASE DESCRIPTION 4 horses were examined because of signs of chronic hind limb lameness. CLINICAL FINDINGS 3 horses had a history of lameness for > 6 months; specific duration was un-known for 1 horse. On initial evaluation, grade 3 to 4 (on a scale from 1 to 5) hind limb lameness was present in all 4 horses. Radiography of the stifle joint of the affected limb revealed medial femoral condyle subchondral lu-cencies or subchondral cystic lesions (SCLs) in all 4 horses, medial femoro-tibial osteoarthritis in 3 horses, and medial tibial condyle SCLs in 3 horses. TREATMENT AND OUTCOME 2 horses were treated medically (stall rest and oral NSAID administration), and 2 horses were treated surgically by means of medial femoral transcondylar lag screw placement through the medial femoral condyle SCLs. The 2 horses treated medically did not improve and were euthanized. Necropsy confirmed the presence of medial femoral condyle and medial tibial condyle SCLs. Surgical treatment did not resolve the lameness in 1 horse with SCLs in the medial tibial condyle and medial femoral condyle, and euthanasia was performed 150 days after surgery. In the second horse, a medial tibial condyle SCL was evident on radiographs obtained 3 months after surgery; however, this was not addressed surgically, and signs of lameness resolved 11 months after surgery. CLINICAL RELEVANCE Results of this small case series suggested that SCLs in the medial tibial condyle can occur in association with SCLs of the medial femoral condyle, with a poor prognosis for return to athletic function in affected horses. Further investigation is indicated. [ABSTRACT FROM AUTHOR]

Introduction: High tibial osteotomy (HTO) is an important treatment alternative in isolated single compartment knee osteoarthritis. To achieve adequate mechanical axis corrections in the lower extremity fibula is also osteotomized concomitantly. The aim of this study was to compare the union rates of proximal and diaphyseal fibular osteotomies accompanying high tibial osteotomies.Method: Sixty-seven knees of sixty-three patients who had undergone HTO were retrospectively evaluated. The patients were grouped according to the level of the fibular osteotomy (FO). In group I, the level of FO was proximal, and in group II, it was at the level of junction of middle and distal third of diaphysis. The union rates of FOs at two different levels were compared. The influence of the presence of displacement at the osteotomy site and apposition between bone ends on union was also evaluated.Results: Fifty-nine of sixty-seven FOs (88.06 %) were united. The union rate of proximal FOs was significantly greater than diaphyseal osteotomies (p < 0.0001); 97.9 % of proximal FOs were united, whereas this ratio was 65 % for the diaphyseal FOs. The presence of displacement at the FO and apposition between bone ends significantly influenced the bony union rate (p values 0.035 and <0.0001, respectively).Conclusion: Union rates and nonunion characteristics of FO might differ according to its level, apposition of bone ends, and contact area. The fate of FO might also affect the union of HTO. [ABSTRACT FROM AUTHOR]

Objective To evaluate the objective and subjective functional effectiveness of tibial nerve neurotomy (TNN) in post-stroke spastic equinovarus foot (SEF). Methods In an open study, 23 hemiplegic patients were assessed immediately before TNN and then 5 months after TNN. The main outcome measure was the Lower Limb Function Assessment Scale (LL-FAS), which provided an ecologic assessment of impairments in standing and walking (i.e. kinematic abnormalities) and their impacts on activities of daily living. Patients were also assessed for global clinical impression of change, fear of falling, neuromotor impairments, spatiotemporal and video gait parameters and walking capacities. Results TNN had a very marked effect on the level of spasticity and the range of motion in dorsiflexion (p < 10 − 3 ). These changes resulted in better foot positioning when standing and walking (particularly in stance), which was perceived very favorably by the patients. There was a clear, patient-perceived improvement in activities performed when standing and walking (LL-FAS (p < 0.01)), the global clinical impression of change (p < 10 − 3 ) and the fear of falling (p = 0.022) that was not revealed by conventional, objective measurements (New Functional Ambulation Classification, Rivermead Mobility Index). Conclusion TNN is an effective treatment for post-stroke SEF; it is associated with a patient-reported improvement in standing and walking abilities during activities of daily living. Further research must now assess the long-term subjective efficacy of TNN. [ABSTRACT FROM AUTHOR]

The aim of this study was to analyze the displacements of center of pressure (COP) using an in-shoe recording system (F-Scan) before and after motor nerve block and neurotomy of the tibial nerve in spastic equinovarus foot. Thirty-nine patients (age 45 +/- 15 yr) underwent a motor nerve block; 16 (age 38 +/- 15.2 yr) had tibial neurotomy, combined with tendinous surgery (n = 9). The displacement of the COP (anteropos-terior [AP], lateral deviation [LD], posterior margin [PM]) was compared between paretic and nonparetic limbs before and after block and surgery. At baseline, the nonparetic limb had a higher AP (17.3 vs 12.3 cm,p < 0.001) and LD (4.0 vs 3.3 cm, p = 0.001) and a smaller PM (2.9 vs 4.7 cm,p = 0.001). For the paretic limb, a significant increase of AP was observed after block (13.5 vs 12.3 cm, p = 0.02) and after surgery (13.7 vs 12.3 cm, p = 0.03). A significant decrease of PM was observed after surgery (4.5 vs 3.3 cm, p < 0.001) with no more difference between two limbs (2.8 vs 3.3 cm, p = 0.44). This study shows that the F-Scan system can be used to quantify impairments and be useful to evaluate the effects of treatment for spastic foot. It suggests that changes in AP displacement following block may predict the effects of neurotomy. [ABSTRACT FROM AUTHOR]

Case: We present the case of a 14-year-old adolescent boy with a distal femoral osteosarcoma partially encasing the tibial nerve. He underwent rotationplasty with resection and coaptation (end-to-end repair) of the tibial nerve. By 1 year postoperatively, he had recovered sensation on the plantar aspect of his foot and Medical Research Council scale 4+/5 gastro-soleus contraction that powered extension of the new knee., Conclusion: Tibial nerve resection is not an absolute contraindication for rotationplasty, even in an adolescent. Nerve coaptation allows for well-functioning rotationplasty as an alternative to endoprosthetic reconstruction or above-knee amputation., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C33)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

The tibial neuroma transposition (TNT) is a rat model in which allodynia at the neuroma site (tibial nerve) can be independently evaluated from allodynia at the plantar surface of the hind paw innervated by the intact sural nerve. This TNT model is suitable to test therapies for neuroma pain, such as the potential superiority of certain surgical therapies that are already used in the clinic, or to evaluate new drugs and their effect on both pain modalities in the same animal. In this model, a distal lesion (neurotmesis) is made in the tibial nerve, and the proximal nerve end is transposed and fixed subcutaneously and pretibially to enable assessments of the neuroma site with a 15 g Von Frey monofilament. To assess allodynia over the sural nerve, Von Frey monofilaments can be used via the up-down method on the plantar lateral region of the hind paw. After cutting the tibial nerve, mechanical hypersensitivity develops at the neuroma site within 1 week after surgery and persists at least until 12 weeks after surgery. Allodynia at the sural innervated plantar surface develops within 3 weeks after surgery compared to the contralateral limb. At 12 weeks, a neuroma forms on the proximal end of the severed tibial nerve, indicated by dispersion and swirling of axons. For the TNT model surgery, multiple critical (micro)surgical steps need to be followed, and some surgery practice under terminal anesthesia is advised. Compared to other neuropathic pain models, such as the spared nerve injury model, allodynia over the neuroma site can be independently tested from sural nerve hypersensitivity in the TNT model. However, the neuroma site can be tested only in rats, not in mice. The tips and directions provided in this protocol can help research groups working on pain successfully implement the TNT model in their facility.

Kinematics-based studies before and after selective tibial neurotomy (STN) gait have not been performed. It is very important for spastic patients before and after STN to evaluate quality of gait motion. We examined the quantitative changes in kinetic and kinematic parameters in the gait of a hemiplegic patient after STN. A patient with stroke-related hemiplegia who did not require aids to walk underwent a three-dimensional gait analysis (3DGA) before and after STN. 3DGA system was used to obtain spatiotemporal, kinetic and kinematic parameters of the lower extremities. Postoperative increases in walking speed and the single leg support ratio were detected in the paralyzed limb. Kinetic and kinematic analyses of the stance phase performed after STN detected dorsiflexion in the ankle, the appearance of generation power during plantar flexion, an extension of the range of hip movement during the gait cycle, and the disappearance of genu recurvatum. The acquisition of a normalized ankle joint gait pattern after STN might result in coordinated improvements in the kinetic and kinematic parameters of other joints. The measurement of spatiotemporal, kinetic, and kinematic gait parameters using 3DGA systems might aid decisions regarding the optimal post-STN rehabilitation strategies for spastic patients who hope to improve their gaits. [ABSTRACT FROM AUTHOR]

Loosening and migration of tibial prostheses have been identified as causes of early total knee replacement (TKR) failure. The problem is made more complex when defects occur in the proximal tibia compromising fixation and alignment. Clinical studies using metal augments have shown these to be an alternative to other means of defect treatment. Finite element (FE) analysis can be used to identify regions that may be prone to loosening and migration. In the current work, 3D FE models of TKR uncontained type-2 defects treated with block augments have been constructed and analysed. It has been shown that a metal augment is the most suitable. The use of bone cement (PMMA) to fill proximal defects is not considered suitable as stresses carried by the cement block exceed those of the fatigue limit of bone cement. It has been shown that the stresses in the proximal cancellous bone of block-augmented models are significantly below levels likely to cause damage due to overloading. Furthermore, the use of stem extensions has been shown to reduce the cancellous bone stresses in the proximal region thus increasing the likelihood of bone resorption. Given this, it is recommended that stem extensions are not required unless necessary to mitigate some other problem. [ABSTRACT FROM AUTHOR]

Objective The aim of the study was to compare the effect of diagnostic motor nerve block with anaesthetics and of selective tibial neurotomy in the treatment of spastic equinovarus foot in hemiplegic adults. Methods In this prospective observational study, 30 hemiplegic adults with spastic equinovarus foot benefited from a diagnostic nerve block with anaesthetics followed by a selective tibial neurotomy performed at the level of the same motor nerve branches of the tibial nerve. Spasticity (Ashworth scale), muscle strength (Medical Research Council scale), passive ankle dorsiflexion (ROM), gait parameters (10 meters walking test) and gait kinematics (video assessment) were assessed before and after the nerve block and two months and two years after selective tibial neurotomy. Results The decrease in spasticity and the improvement in gait kinematics were similar after the diagnostic nerve block and two months and two years after neurotomy. The diagnostic nerve block did not revealed the slight increase in gait speed and in tibialis anterior muscle strength that was observed two years after neurotomy. Conclusion This study suggests that diagnostic nerve block with anaesthetics and selective neurotomy equally reduce spasticity and improve gait in case of spastic equinovarus foot in hemiplegic adults. Diagnostic nerve block can be used as a valuable screening tool before neurotomy. [ABSTRACT FROM AUTHOR]

Background The aim of our study is to evaluate retrospectively the prognostic factors affecting the final outcome of surgical treatment of tarsal tunnel syndrome. Material and methods Surgical decompression were performed on 31 patients. All patients had EMG and anesthetic test confirmation. The results were evaluated according to VAS scale and modified AOFAS score. Follow-up was after 12 months. Results 22 patients received very good or good (71%), 7 satisfactory (22%), 2 poor (7%) results in the subjective and objective patient's assessment. The outcomes decreased from 5.19 (SD 1.01) points to 1.19 (SD 0.83) points according to VAS scale, and modified AOFAS increased from 31.77 (SD 9.08) points to 57.58 (SD 9.90). Patients with diagnosed cause, short period of time between onset of disease till surgery, and positive Tinel's sign achieved the best results. Conclusion Etiology of the tarsal tunnel syndrome has influence on the results. Immediate diagnosis and short period between occurrences of symptoms in surgical treatment improves the outcomes. Tinel's sign may be used as a prognostic factor. [ABSTRACT FROM AUTHOR]

Background Complete nerve regeneration and clinical healing remain a challenge despite considerable advances in the treatment of peripheral nerve injuries. To improve nerve regeneration, several experimental molecular procedures have been attempted. This study aimed to investigate the effects of folic acid on peripheral nerve healing after transection and end-to-end suture repair of the tibial nerve in rats. Methods In this study, 20 adult male Wistar Albino rats weighing 225 to 250 g were used. The right tibial nerves of 20 rats were explored, transected, and sutured using the end-to-end technique. The rats were randomly allocated to either the intraperitoneally administered folic acid group (test group) or the control group. Preoperative and 6-week postoperative neurophysiological studies were performed by the same researcher. Myelin-sheathed axons were counted. Results The results demonstrated that the folic acid-treated group exhibited improved electromyographic results compared with the control group. Histological evaluation revealed that the axons were well preserved and that the axon quantity and density were increased in the test group compared with the control group. Quantitative results also increased in the test group compared with the control group (p = 0.001). Conclusion In this study, 6-week intraperitoneal administration of 80 µg/kg of folic acid significantly improved peripheral nerve healing. Histological analysis of the group that received folic acid revealed increased axonmyelination with little granular tissue or fibrosis. We propose that folic acid supplementation may be an effective component of peripheral nerve injury treatment. [ABSTRACT FROM AUTHOR]

Background: Sole sensation is essential for standing and walking. Moreover, lack of protective sensation of sole increases the risk of fall-related injuries. In the light of recent developments in nerve transfer, reconstruction of sole sensation can be achieved even in sciatic nerve injuries. Few researchers have addressed the problem of lack of potential donor nerve in proximal sciatic nerve injuries. The saphenous nerve has sufficient sensory fibers and is anatomically feasible to be used as a donor nerve to reconstruct sensation., Objective: To outline a new approach to restore the sensation of the sole using terminal branches of the saphenous nerve., Methods: In an attempt to restore sole sensation, 4 patients underwent saphenous nerve transfer to medial plantar and calcaneal branches. Highet-Zachary system scoring was used to evaluate sensory recovery in target regions (heel, metatarsal heads, and big toe)., Results: Of the study population, heel sensation recovered up to S3 in 1 case, S2 in 2 cases, and S1 in 1 case. Partial recovery of the metatarsal heads and the big toe was achieved in 2 cases., Conclusion: The findings of this study indicate that the saphenous nerve is a suitable and available donor to restore sole sensation in sciatic or posterior tibial nerve injuries., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Surgical results in tarsal tunnel syndrome are variable, and etiology seems to be a factor. Three possible etiologies can be distinguished. The aim of the present study was to compare surgical results according to etiology. Three continuous retrospective series (45 patients overall) of tarsal tunnel syndrome were compared. Group 1 presented a permanent intra- or extra-tunnel space-occupying compressive structure. Group 2 presented intermittent intra-tunnel venous dilatations. Group 3 comprised idiopathic tarsal tunnel syndrome. The mean follow-up was 3.6 +/- 1.8 years. The main endpoint was subjective postoperative improvement on Likert scale. Group 1 reported greater improvement than groups 2 and 3. Preoperative neuropathy on ultrasound was associated with poorer improvement, which was not the case for neuropathy on electromyography. Surgical treatment of tarsal tunnel syndrome provides better results in etiologies involving structural compression., (Copyright © 2021 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)