Neurilemoma of the medial plantar nerve: a case report and literature review.

A neurilemoma is an uncommon, benign, encapsulated neoplasm whose origin is derived from the Schwann cells. Its incidence in the foot is uncommon. A review of the literature, etiology, incidence, clinical presentation, histology, differential diagnosis, and treatment are discussed. The authors present a case of a neurilemoma of the medial plantar nerve of the foot.     

Neurilemoma in the ankle as a cause of plantar foot pain: A report of one case

One case of posterior tibial nerve neurilemoma with chronic plantar foot pain is described. At the initial examination, the case was overlooked as plantar fasciitis; it was treated for long periods prior to operation. Neurilemomas in the foot and ankle can easily be overlooked and misdiagnosed as tarsal tunnel syndrome or plantar fasciitis because of the similarity of symptoms to those of other frequently encountered foot disorders, absence of palpable mass and the rarity. Magnetic resonance imaging is the imaging modality of choice for differential diagnosis. In this case, surgical excision of the tumours resulted in immediate and complete relief of chronic plantar foot and calf pain. Despite the rarity of the disease, surgeons should consider neurilemoma as a cause of persistent chronic plantar foot and calf pain.     

A Case of Posterior Tibial Nerve Injury After Arthroscopic Calcaneoplasty

We report the first case of distal posterior tibial nerve injury after arthroscopic calcaneoplasty. A 59-year-old male had undergone right arthroscopic calcaneoplasty to treat retrocalcaneal bursitis secondary to a Haglund's deformity. The patient complained of numbness in his right foot immediately after the procedure. Two years later and after numerous assessments and investigations, a lateral plantar nerve and medial calcaneal nerve lesion was diagnosed. In the operating room, the presence of an iatrogenic lesion to the distal right lateral plantar nerve (neuroma incontinuity involving 20% of the nerve) and the medial calcaneal nerve (complete avulsion) was confirmed. The tarsal tunnel was decompressed, and both the medial and the lateral plantar nerve were neurolyzed under magnification. To the best of our knowledge, our case report is the first to describe iatrogenic posterior tibial nerve injury after arthroscopic calcaneoplasty. It is significant because this complication can hopefully be avoided in the future with careful planning and creation of arthroscopic ports and treated appropriately with early referral to a nerve specialist if the patient's symptoms do not improve within 3 months.     

Risk of neurovascular injuries in flexor hallucis longus tendon transfers: an anatomic cadaver study

BACKGROUND: Flexor hallucis longus (FHL) tendon transfer is a frequently used treatment for both posterior tibial tendon insufficiency and chronic Achilles tendinopathy. We observed difficulties in harvesting the FHL tendon that may arise from cross-attachments with the flexor digitorum longus (FDL) tendon near the knot of Henry. The posterior tibial nerve is located nearby the decussation of these tendons. This study examined whether the difficult harvesting may be the cause of nerve injury. Methods: A cadaver study was performed on 24 foot specimens. In all feet, we used a double-incision technique. The FHL tendon was transected in the distal medial midfoot incision and retracted through the posteromedial hindfoot incision. After harvesting the FHL tendon, we exposed the posterior tibial nerve and its lateral and medial plantar branches to identify if any lesion had occurred. RESULTS: The retraction failed at the first attempt in all specimens because of the presence of cross-attachments between the FHL and FDL tendons. A more extensive dissection of the FHL and FDL tendons was therefore required. We found lesions in 33% of all foot specimens, including two complete ruptures of the medial plantar nerve. CONCLUSIONS: Harvesting of the FHL tendon when transection is made distal to the knot of Henry may cause injuries to the medial and lateral plantar nerves. Experience in this procedure may reduce the risk of nerve injuries but even then nerve lesions remain possible. The clinical significance of these nerve lesions is not described in literature and remains to be determined.     

Reconstruction of a painful post-traumatic medial plantar neuroma with a bioabsorbable nerve conduit: a case report.

Although nerve injuries to feet may be common, primary repair of a damaged nerve in the foot is rare. Secondary digital nerve reconstruction in the foot has not been previously reported. This report describes a patient with post-traumatic neuroma of medial plantar nerve who was treated by neuroma resection; the nerve defect was reconstructed with bioabsorbable nerve conduit. This case illustrates successful, secondary reconstruction of nerve injury in the foot using a new surgical technique. A bioabsorbable polyglycolic acid nerve conduit eliminated the need for a short nerve graft and was effective in relieving the neuroma pain by providing an appropriate distal site for neural regeneration.     

Tarsal tunnel syndrome secondary to neurilemoma of the medial plantar nerve

A neurilemoma of the medial plantar nerve was observed in a 52-year-old Caucasian female. She was diagnosed with tarsal tunnel syndrome by clinical and electromyographic examination. This case was followed up for 18 months and has been presented as a very rare cause of tarsal tunnel syndrome. Relevant literature was reviewed.     

The supramalleolar flap. Our experience in 35 cases

The authors report 35 cases of use of the supramalleolar flap described by Masquelet et al. in 1988. In 27 cases, the arterial blood supply was in a mixed (anterograde and retrograde) fashion since the perforating branch of the peroneal artery was spared. In eight cases the arterial blood supply was in a retrograde fashion due to the location of the skin loss. As described by Valenti et al. In 1991, the authors recommend the use of a distal subcutaneous pedicled to avoid skin grafting over the tendons at the distal part of the lag. In main cases of anterograde blood supply the superficial peroneal nerve could be spread. In 33 cases the plastic result was assessed as satisfactory. The coverage of the weight-bearing portion of the heel was done two times with no satisfactory result. Coverage of the medial malleolus area, Achilles tendon and dorsal skin of the foot represent the main indications and the best results. Five times, a venous congestion was observed with three cases of partial necrosis of the flap. The use of a large subcutaneous pedicle did not always prevent such venous problems, though this technical aspect improves the vascular reliability of the flap. The main local alternative is the distal pedicled sural flap that needs to divide the sural nerve and not allows coverage as distal as the supramalleolar flap. Except the distal coverage of the foot, the indications of these previous both flaps are similar. In case of foot coverage, the medial plantar flap based on the lateral plantar vascular bundle, as described by Martin et al. in 1991, is the other one local alternative. Free flaps are indicated for extensive skin losses, or when a poor distal vascularity of the leg does not allow reliability of distal pedicled flaps.     

跟骨内外侧经皮置针安全区解剖学研究

目的 划定国人跟骨内、外侧外固定针进针位置解剖学相对安全区.方法 解剖14具正常成年人足踝部标本.于跟骨内侧取跟骨最内下后点为A点,内踝最下点为B点,足舟骨结节为C点.解剖出跟骨内侧神经、足底外侧神经最后分支、足底外侧神经、足底内侧神经、胫后动脉、足底外侧动脉和足底内侧动脉.根据各结构行经AB、AC线的位置,确定跟骨内侧的相对安全区;于跟骨外侧取跟骨最外下后点为D点,外踝最下点为E点,解剖出跟骨外侧神经、腓肠神经、小隐静脉主干,同理确定跟骨外侧的相对安全区.结果 跟骨内侧神经、足底外侧神经最后分支、足底外侧神经、足底内侧神经、胫后动脉分别行经AB线后下22%、50%、56%、64%及58%处,跟骨内侧神经、足底外侧神经最后分支、足底外侧神经、足底内侧神经、足底外侧动脉、足底内侧动脉分别行经AC线后下14%、39%、49%、63%、41%及57%处.跟骨外侧神经、腓肠神经、小隐静脉分别行经DE线后下 19%、65%及61%处.结论 在跟骨内侧,AB线后1/2、AC线后1/3所在圆形区域为经皮置针相对安全区.在跟骨外侧,经DE线中点垂线后方的跟骨为经皮穿针相对安全区.     

Reconstruction of a child’s forefoot defect using a distally based pedicled medial plantar flap

This report describes a case of a 10-year-old boy who received a distally based, pedicled medial plantar artery flap to cover a defect on the distal lateral side of his right foot. The defect resulted from amniotic constriction. The flap served as defect coverage and was kept viable solely by the distal medial plantar vessels. Use of this particular kind of flap proves advantageous in that it provides good protection in the weight-bearing area of the foot, while causing only a minor donor site defect.     

Post-traumatic pseudoaneurysm of the medial plantar artery combined with tarsal tunnel syndrome: two case reports

Pseudoaneurysms in the foot are more often reported in the lateral plantar artery than the medial plantar artery, most likely because of its more superficial location. There are no reports of pseudoaneurysm of the medial plantar artery after trauma. We present two cases of pseudoaneurysm of the medial plantar artery after blunt foot trauma and foot laceration. This pseudoaneurysm compressed a posterior tibial nerve, resulting in tarsal tunnel syndrome. The patients were treated successfully using transcatheter embolization without the need for surgical intervention. The tarsal tunnel syndrome also subsided. Here, the authors report these cases and provide a review of literature.     

三维CT血管造影辅助设计足内侧隐神经营养血管皮瓣修复足远端软组织缺损

目的探讨三维CT血管造影技术(three-dimensional computerized tomography angiography,3D-CTA)辅助设计足内侧隐神经营养血管皮瓣,逆行修复足远端皮肤软组织缺损的临床效果。方法2013年11月至2018年2月,潍坊市益都中心医院收治19例足远端缺损患者,男12例,女7例,年龄16~45岁,平均29.6岁。术前行同侧足3D-CTA检查,了解供区血管情况,明确FDA2趾底内侧动脉浅支的位置、走行、长度、与周围邻近组织关系,设计足内侧隐神经营养血管皮瓣逆行修复足远端皮肤软组织缺损创面。随访时根据Sanders等的Maryland足功能评分标准评定足、踝部功能,根据Swanson等的周围神经损伤临床效果评价标准对感觉恢复情况进行评估。结果术前采用3D-CTA均能检测到FDA2趾底内侧动脉浅支,术中所见穿支血管情况与检查图像结果显示基本一致。术后皮瓣全部成活,所有病例均得到随访,时间为6~12个月,平均8个月,皮瓣外观较好,血运可靠,足、踝部功能基本正常,穿鞋及负重无明显影响。足、踝部功能恢复达优者8例,良10例,中1例。足远端皮肤感觉恢复达S45例,S310例,S24例;感觉恢复范围达R43例,R39例,R27例。结论术前行3D-CTA检查,可以明确供区FDA2趾底内侧动脉浅支解剖情况,指导设计足内侧隐神经营养血管皮瓣逆行修复足远端皮肤软组织缺损,血供可靠,创伤小,效果满意。     

Anterior tibial artery injury is not the contraindication of medial plantar flap: digital subtraction angiography evidence and clinical application

The medial plantar artery (MPA) is often sacrificed as the vascular pedicle of the medial plantar flap (MPF). However, for patients with ankle soft tissue defect caused by traffic accident, the anterior tibial artery (ATA) could be damaged and the blood supply of the distal foot would only come from the MPA and the lateral plantar artery (LPA). In this case, sacrificing the MPA for the MPF means that the LPA will become the mainly source of blood supply of the distal foot. Whether the blood supply of the distal foot is adequately guaranteed remains to be discussed. A total of seven patients with ankle soft tissue defect and ATA injury were enrolled in the study. The digital subtraction angiography (DSA) was performed to observe the hemodynamics of the ipsilateral foot. The MPF was harvested only when the foot arterial network consisting of the MPA, the LPA, the deep plantar arch, and the deep plantar artery of DPA, and the blood redistribution existed. DSA results showed the blood from the posterior tibial artery was redistributed to the ipsilateral foot and the MPA is not the dominant artery in the foot. Seven MPFs were harvested, and all flaps survived completely. No complications, such as pain, ulcer, and necrosis, occurred in the ipsilateral toes. The DSA could accurately and intuitively evaluate the hemodynamics of foot in patients with ATA injury. The DSA data and clinical practice proved that the ATA injury is not the contraindication of the MPF.     

A touch pressure sensory assessment of the surgical treatment of the tarsal tunnel syndrome

Background

Decompressive tarsal tunnel surgery may improve dysfunctional plantar foot sensation in, patients with tarsal tunnel syndrome and peripheral neuropathy. However, quantitative sensory, assessment is lacking.

Method

Quantitative sensory threshold evaluation of 42 feet in 37 consecutive (29 non-diabetic and 8 diabetic) patients was done before and after surgical decompression for tarsal tunnel syndrome. Insensitivity was documented quantitatively (grams force) before and after surgery using a graded series of twenty Semmes–Weinstein monofilaments applied to the anatomic nerve regions of the plantar aspect of the foot.

Results

Sensory evaluation at an average of 12 months after surgery showed significant improvement, of mean sensory threshold, compared with preoperative values, for medial calcaneal, medial plantar, and lateral plantar nerves.

Conclusion

Quantitative sensory assessment with a graded series of twenty Semmes–Weinstein, monofilaments showed significant sensory improvement in the medial calcaneal, medial plantar, and, lateral plantar nerves after posterior tibial nerve decompression.     

Medial Plantar Artery Common Origin to Determine Incision Placement for the Fasciocutaneous Flap: A Cadaveric Study

Medial plantar artery–based flaps have great value in healing full-thickness wounds of the foot and ankle. The goal of this study was to identify a common location for the origin of the medial plantar artery. Recognition of this anatomic marker will help improve incision placement and increase the success of preserving the artery when performing the medial plantar artery fasciocutaneous flap. This study examined the location of the origin of the medial plantar artery in 40 fresh cadavers. Results were obtained by dissection and macroscopic analysis to document the distance of the origin of the medial plantar artery from the intercollicular groove of the medial malleolus in centimeters. The mean distance was determined to be 3.2 ± 0.4 cm (range 2.7 to 4.5), with a low standard error of 0.0621. This suggests a high statistical probability that the common origin of the medial plantar artery is found 3.2 cm distal to the intercollicular groove of the medial malleolus in the general population.     

Misdiagnosis of plexiform neurofibroma of the medial plantar nerve: Case report

Plexiform neurofibromas are benign tumors of the peripheral nerve. Diagnosis may be challenging, if they present mimicking other peripheral nerve pathologies.We report the case of a patient who had severe foot pain, which progressively hampered her walking ability, erroneously attributed to recurrent Morton's neuroma. Diagnosis of plexiform neurofibroma of her right medial plantar nerve was made 15 years after the appearance of symptoms.Pain and function recovered after radical neurotomy of the medial plantar nerve. A correct diagnosis is an essential starting point in the treatment of neurofibromas and a misdiagnosis may lead to an inappropriate treatment.     

足部逆行血管蒂皮瓣修复前足皮肤缺损

目的 探讨足逆行血管蒂皮瓣修复前足皮肤缺损的效果。方法足底内侧皮瓣以足底内侧动脉浅支为蒂逆行转移,足踝背皮瓣以足背动脉分支第一或第二跖背动脉为蒂逆行转移。转移皮瓣均行浅静脉及皮神经吻合修复。结果转移皮瓣全部成活。其中1例未行浅静脉吻合术后出现静脉危象,经减张及药物治疗后存活。术后1年随访皮瓣感觉功能恢复。结论足部逆行血管蒂皮瓣转移修复前足皮肤缺损,具有于术简捷、创伤小、功用好、并发症少等优点。     

Strain and excursion of the sciatic, tibial, and plantar nerves during a modified straight leg raising test.

A modified straight leg raising (SLR) in which ankle dorsiflexion is performed before hip flexion has been suggested to diagnose distal neuropathies such as tarsal tunnel syndrome. This study evaluates the clinical hypothesis that strain in the nerves around the ankle and foot caused by ankle dorsiflexion can be further increased with hip flexion. Linear displacement transducers were inserted into the sciatic, tibial, and plantar nerves and plantar fascia of eight embalmed cadavers to measure strain during the modified SLR. Nerve excursion was measured with a digital calliper. Ankle dorsiflexion resulted in a significant strain and distal excursion of the tibial nerve. With the ankle in dorsiflexion, the proximal excursion and tension increase in the sciatic nerve associated with hip flexion were transmitted distally along the nerve from the hip to beyond the ankle. As hip flexion had an impact on the nerves around the ankle and foot but not on the plantar fascia, the modified SLR may be a useful test to differentially diagnose plantar heel pain. Although the modified SLR caused the greatest increase in nerve strain nearest the moving joint, mechanical forces acting on peripheral nerves are transmitted well beyond the moving joint.