Ecografía para prevenir lesiones del nervio sural en la reparación del tendón de Aquiles. Estudio cadavérico / Ultrasound to prevent sural nerve injury in Achilles tendon repair. A cadaveric study

Introducción: Las técnicas mínimamente invasivas son las preferidas para tratar las roturas agudas del tendón de Aquiles. Representan una opción para evitar las complicaciones tegumentarias, y la lesión del nervio sural es uno de sus principales problemas. El objetivo de este estudio fue comprobar la utilidad de la ecografía para prevenir la lesión del nervio sural durante la reparación del tendón de Aquiles con técnicas percutáneas. materiales y métodos: Estudio en 12 piezas cadavéricas. Se recreó una lesión en el tendón de Aquiles 5 cm proximales de su inserción distal. En uno de los miembros del cadáver, se identificó el nervio sural o su vena satélite mediante ecografía. Se reparó el nervio sural por vía percutánea con dos agujas proximales y dos agujas distales a la lesión, y se representó el recorrido del nervio sural. En el miembro contralateral, no se identificó el nervio sural mediante ecografía. Se efectuó la reparación percutánea de las lesiones mediante la técnica de Ma y Griffith. Resultados: En el grupo ecográfico, no se identificaron lesiones del nervio sural. En el grupo de control, se observaron dos lesiones del nervio sural (p = 0,6). En todos los casos, la identificación del nervio sural mediante ecografía fue correcta. Conclusión: La asistencia ecográfica en el tratamiento percutáneo de las lesiones del tendón de Aquiles es un método eficaz y confiable para evitar las lesiones del nervio sural. Nivel de Evidencia: III

Introduction: Minimally invasive techniques are preferred to treat acute Achilles tendon ruptures. They represent an option to avoid integumentary complications, and sural nerve injury is one of its main problems. This study aims to verify the usefulness of ultrasound in preventing sural nerve injury during Achilles repair with percutaneous techniques. materials and methods: Study in 12 cadaveric pieces. We recreated an injury at the level of the Achilles tendon, 5 cm proximally to its distal insertion. In one of the cadaver limbs, the sural nerve and/or its satellite vein were identified by ultrasonography. We repaired the sural nerve percutaneously with two needles at the proximal level and two needles at the distal level of the lesion and represented the path of the sural nerve. In the contralateral limb, the sural nerve was not identified by ultrasound. We performed the percutaneous repair of the injuries using the Ma & Griffith technique. Results: In the ultrasound group, no sural nerve injuries were identified. In the control group, two sural nerve injuries were observed (p=0.6). In all cases, the identification of the sural nerve by ultrasound was correct. Conclusion: Ultrasound assistance in the percutaneous treatment of Achilles tendon injuries is an effective and reliable method to prevent sural nerve injuries. Level of Evidence: III

Avaliação da termoablação com endolaser da veia safena parva com anestesia local / Evaluation of endolaser thermoablation of the small saphenous vein under local anesthesia

Resumo Contexto Na insuficiência venosa crônica (IVC), a veia safena parva (VSP) é afetada em 15% dos casos. A cirurgia convencional é a técnica padrão para o tratamento da insuficiência da VSP, sendo a lesão no nervo sural uma complicação bastante temida. O tratamento de termoablação com endolaser tende a ser um método cirúrgico que diminui complicações da terapia cirúrgica da IVC. Objetivos Avaliar os pacientes com IVC submetidos à terapia por endolaser da VSP ao menos 30 dias após o procedimento. Métodos Foram analisados 54 membros inferiores de 46 pacientes submetidos à terapia por endolaser 1470 nm, sob anestesia local, para o tratamento da IVC em um hospital terciário. Os pacientes foram avaliados no período pré-operatório, intraoperatório e pós-operatório de 30 dias, através da clínica, exame físico e achados ecográficos. Resultados Nos 54 membros inferiores submetidos ao tratamento, comparando-se o período pré-operatório e o 30º dia pós-operatório, houve diferença significativa (p < 0,003) na redução do diâmetro da VSP tratada (6,37 mm pré-operatório e 5,15 mm no 30º dia pós-operatório) (IC95% 4,58-5,72) e na melhora do escore de gravidade clínica venosa (VCSS) (média de 8,02 pré-operatório e 6,11 no 30º dia pós-operatório) (IC95% 5,01-7,21) (p < 0,02). Complicações pós-operatórias, como parestesia e flebite, estiveram presentes e foram diagnosticadas em cinco e três pacientes, respectivamente, sem significar alteração na qualidade de vida e nas atividades de rotina. Conclusões A técnica de termoablação com laser da VSP mostrou-se segura e eficaz na redução dos sintomas clínicos e na melhora da qualidade de vida.

Abstract Background The small saphenous vein (SSV) is affected in 15% of chronic venous insufficiency (CVI) cases. Conventional surgery is the standard technique for treatment of SSV insufficiency, but sural nerve injury is a complication of great concern. Endovenous laser ablation is a surgical technique for treatment of CVI that is considered likely to reduce morbidity and mortality. Objectives To evaluate patients with CVI undergoing endovenous laser ablation of the SSV at least 30 days after the procedure. Methods We analyzed 54 lower extremities in 46 patients scheduled for 1470-nm endovenous laser ablation under local anesthesia to treat CVI in a tertiary hospital. Patients were evaluated preoperatively, intraoperatively, and postoperatively over 30 days with clinical examination, physical examination, and ultrasound. Results In the 54 lower extremities treated, there was a significant difference (p < 0.003) in terms of reduction in the diameter of treated veins (6.37 mm preoperatively and 5.15 mm on the 30th postoperative day) and improvement in the venous clinical severity score (VCSS) (means of 8.02 preoperative and 6.11 on the 30th postoperative day) (95%CI, 5.01—7.21) (p < 0.02). Postoperative complications such as paresthesia and phlebitis were present and diagnosed in 5 and 3 patients, respectively, but did not affect their quality of life or routine activities. Conclusions Intravenous laser ablation of the SSV proved to be safe and effective for reducing clinical symptoms and improving quality of life.

Schwannomatosis del nervio plantar interno. Presentación de caso / Schwannomatosis of the internal plantar nerve. Case presentation

Introducción: Las Schwannomatosis Mononeurales de los Miembros son entidades muy poco frecuentes, escasamente conocidas y raramente publicadas en la bibliografía internacional, éstas se encuentran caracterizadas por la existencia de múltiples formaciones nodulares o plexiformes con compromiso exclusivo de un solo nervio, todas con diagnóstico patológico de schwannoma, excluyéndose a otras entidades tumorales y fuera del contexto de una neurofibromatosis. Aquí se presenta un caso con compromiso del nervio plantar medial o interno. Material y método: Se evaluó y analizo el caso clínico, a nivel semiológico y Neurorradiológico, Neurofisilógico. Se definió la conducta terapéutica y quirúrgica. Se evaluaron resultados mediante: análisis semiológico y seguimiento con imágenes. Descripción y resultados: Paciente sexo masculino de 45 años de edad consulta por presentar múltiples tumoraciones palpables en región retromaleolar interna y plantar derecho y disestesias al apoyo, con antecedente de cirugía de schwannoma plantar. Al examen neurológico: masas palpables en los sectores previamente indicados y Tinel a nivel retromaleolar interno y plantar. RMN: múltiples nódulos con captación intermedia de contraste, hipertensos en T2.Se practicó resección quirúrgica mediante amplio abordaje, se identificaron múltiples nódulos, uno de ellos de aspecto plexiforme que involucraba la totalidad del nervio plantar interno imposibilitando la preservación del tronco por lo cual se practicó microneurorrafia con interposición de puente de safeno interno. Discusión y conclusión: Las Schwannomatosis Mononeurales de los Miembros son entidades extremadamente raras, se han reportado con una frecuencia un poco mayor a aquellas que involucran a los nervios mediano y cubital, en sus características macroscópicas las lesiones fueron publicadas como pertenecientes a la variante nodular para esa escasa mayoría. La configuración plexiforme de los schwannomas es menos frecuente que la nodular per se y, en general. está asociada a troncos menores, fuera de estos territorios, su rareza es extrema. Este caso clínico resulta aún más especial por tratarse de una Schwannomatosis Mononeural del Plantar Medial con variante de tipo mixto, es decir nodular con una masa plexiforme dominante. Esta entidad no la hemos encontrado en la bibliografía internacional.Por otro lado, la resección quirúrgica de estos tumores, cuando son nodulares es compatible con la preservación del tronco nervioso, sacrificando solamente, su fascículo de origen. Este caso, dada la configuración descripta del tumor principal, el cual involucraba la totalidad del tronco, se hizo imposible la preservación del nervio, para lo cual debió realizarse microneurorrafia con puente. Como consideración final, creemos que es de capital importancia la adecuada exploración y planificación pre e intraoperatoria de estos pacientes

Introduction: Mononeural Schwannomatosis located at limbs are very infrequent entities, the knowledge about its are very poor, and there are just a few publications related to them. This articles make reference multiple nodular or plexiform lesions with involvement oh only one nerve, every one whit diagnosis of schwannoma, excluding fibromatosis. In this article, we describe a patient with who suffered the involvement of multiples tumours with nodular and plexiform configuration. Material y method: The clinical case was analysed by different media, clinical, neuro physiological and by neuroimages. By this approaches were defined and evaluated the surgical outcomes and results. Clinical case: Male, 45 years old. Multiples tumours at plantar region. Tinel Sign with multiple palpable masses al retromaleolar sulcus and plantar region, plantar schwannoma operated on previously.RMN: multinodular configuration at level of medial plantar nerve, with intermediate contrast reinforcement.An extended approach was performed, from retromaleolar sulcus to medial aspect of the foot, and finishing inside the digital-plantar sulcus. Complete resection was performed, multiples nodulos were found, the bigger had a plexiform configuration, was imposible the preservation of the nerve trunk and the, the interposition of sural nerve was realized. With good evolution. Conclusions: For this very rare entities, the bigger frequency was reported et limbs.The most frequent locations was at medial nerve, second place occupied by the ulnar nerve, we didn't find on international literature a plexiform tumour inside the medial plantar nerve.On the other hand, we think that the complete resection for this tumours when are nodular, the complete resection with preservation of the main trunk, is feasible. Ehen the tumour has a plexiform pattern; complete resection is only feasible with trunk nerve resection and interposition of nerve graft

Dexmedetomidine attenuates P2X4 and NLRP3 expression in the spine of rats with diabetic neuropathic pain

Abstract Purpose: To evaluate the effects of Dexmedetomidine (Dex) on spinal pathology and inflammatory factor in a rat model of Diabetic neuropathic pain (DNP). Methods: The rats were divided into 3 groups (eight in each group): normal group (N group), diabetic neuropathic pain model group (DNP group), and DNP model with dexmedetomidine (Dex group). The rat model of diabetes was established with intraperitoneal streptozotocin (STZ) injections. Nerve cell ultrastructure was evaluated with transmission electron microscopy (TEM). The mechanical withdrawal threshold (MWT) and motor nerve conduction velocity (MNCV) tests documented that DNP rat model was characterized by a decreased pain threshold and nerve conduction velocity. Results: Dex restored the phenotype of neurocytes, reduced the extent of demyelination and improved MWT and MNCV of DNP-treated rats (P=0.01, P=0.038, respectively). The expression of three pain-and inflammation-associated factors (P2X4, NLRP3, and IL-IP) was significantly upregulated at the protein level in DNP rats, and this change was reversed by Dex administration (P=0.0022, P=0.0092, P=0.0028, respectively). Conclusion: The P2X4/NLRP3 signaling pathway is implicated in the development and presence of DNP in vivo, and Dex protects from this disorder.

Cobertura de lesões em pé e terço inferior da perna com retalho fasciocutâneo reverso da panturrilha (Carriquiry) / Coverage of the lower third of the limb and foot injuries using reverse sural fasciocutaneous flap described by Carriquiry

Introdução: Lesões no terço distal dos membros inferiores, com exposição de ossos, articulações, tendões e vasos sanguíneos, não são passíveis do uso de enxertos de pele. Isto ocorre porque o leito vascular é exíguo e pela pobre granulação das feridas, podendo apenas ser corrigidas com retalhos musculares, miocutâneos, fasciocutâneos ou transferência microcirúrgica. Métodos: O retalho em seu limite inferior é demarcado a partir de 5 cm acima dos maléolos. Superiormente, é marcado num comprimento suficiente para cobertura total da lesão. Realizada incisão em demarcação prévia, e elevados pele e tecido subcutâneo juntamente com a fáscia muscular. O nervo sural é preservado em seu leito original. A elevação do retalho se dá até o ponto inferior marcado (o pedículo). Neste ponto, o retalho é transposto numa angulação suficiente para alcançar a lesão. Resultados: Oito casos foram operados utilizando o retalho descrito. Todos apresentavam exposição de ossos e tendões em região distal da perna, dorso do pé ou ambos, nos quais foram utilizados o retalho fasciocutâneo reverso da perna com a técnica proposta por Carriquiry. Os casos apresentaram resultados estético e funcional satisfatórios. Conclusão: O retalho utilizado se presta à correção de lesões do terço inferior da perna e do pé. É relativamente fácil de ser confeccionado, com bom suprimento vascular, e não há perda funcional do leito doador.

Introduction: Skin grafts are not effective to cover lesions in the distal third of the lower limbs that expose the bones, joints, tendons, and blood vessels due to a limited vascular bed and poor granulation of the wounds. These lesions can only be corrected with microsurgical transfer or muscle, myocutaneous, or fasciocutaneous flaps. Methods: The lower border of the flap was marked 5 cm above the malleolus. The upper border was marked after providing sufficient length for complete coverage of the lesion. The incision was performed at the marked upper border, and the skin and subcutaneous tissue were elevated together with muscle fascia. The sural nerve was preserved in its original bed. The flap was lifted to the marked lower border (the pedicle). At this point, the flap was transposed at a sufficient angle to cover the lesion. Results: Eight cases of surgery were conducted using the flap described above. All cases had exposed bones and tendons in the distal region of the limb, back of the foot, or both, in which the reverse sural fasciocutaneous flap with the technique proposed by Carriquiry was used. The cases showed satisfactory esthetic and functional results. Conclusion: The used flap can correct lesions of the lower third of the limbs and foot. It is relatively easy to make, with good vascular supply, and there is no functional loss of the donor area.

Lower Limb Reconstruction - Fasciocutaneous Sural Flap / Reconstrução de membro inferior- retalho fasciocutâneo sural

Abstract Objective The present study aims to evaluate the use of the reverse-flow sural fasciocutaneous flap to cover lesions in the distal third of the lower limb. Methods A total of 24 cases were analyzed, including 20 traumatic injuries, 3 sports injuries, and 1 case of tumor resection. Results Among the 24 evaluated medical records, 16 patients were male, and 8 were female. Their age ranged from6 to 75 years old. Most of the patients evolved with total healing of the flap (n= 21). There was only one case of total necrosis of the flap in an insulin-dependent diabetic, high blood pressure patient, evolving to subsequent limb amputation. In two cases, there was partial necrosis and subsequent healing by secondary intention; one of these patients was a heavy smoker. Complications were associated with comorbidities and, unlike other studies, no correlation was observed with the learning curve. There was also no correlation with the site or size of the lesion to be covered. Conclusion It is clinically relevant that the success rate of the reverse-flow sural fasciocutaneous flap technique was of 87.5%. This is a viable and effective alternative in the therapeutic arsenal for complex lower limb lesions.

Resumo Objetivo Avaliar o uso do retalho fasciocutâneo sural de fluxo reverso na cobertura de lesões no terço distal dos membros inferiores. Métodos Foram analisados 24 casos, 20 de origem traumática, três por lesões esportivas e um por ressecção de lesão tumoral. Resultados Dos 24 prontuários avaliados, 16 eram homens e oito mulheres. A idade variou de seis a 75 anos. A maioria dos pacientes evoluiu com cicatrização total do retalho (21). Houve apenas um caso de necrose total do retalho em paciente diabético insulinodependente e hipertenso, evoluiu para posterior amputação do membro. Em dois casos, houve necrose parcial composterior cicatrização por segunda intenção, um desses pacientes era tabagista pesado. As complicações foram associadas às comorbidades e, ao contrário do evidenciado por outros estudos, não houve correlação com a curva de aprendizado. Também não houve correlação com o local ou o tamanho da lesão a ser coberta. Conclusão Tem-se como relevância clinica que a técnica de retalho fasciocutâneo sural de fluxo reverso usada obteve 87,5% de sucesso, é uma opção viável e eficaz no arsenal terapêutico das lesões complexas dos membros inferiores.

Avaliação crítica das técnicas cirúrgicas de correção do equino / Critical evaluation of the surgical techniques to correct the equinus deformity

RESUMO A deformidade em equino leva a diversos transtornos da marcha, ao causar alterações no apoio do pé e afetar regiões anatômicas mais distantes, como o joelho, quadril e tronco. Geralmente é secundária à retração, encurtamento ou espasticidade do tríceps sural, de modo que algumas intervenções cirúrgicas podem ser necessárias para corrigi-la. Trata-se de um dos procedimentos mais antigos da Ortopedia, antes realizado apenas no tendão calcâneo e que, ao longo do tempo, evoluiu com técnicas diferentes de acordo com o grau de deformidade, doença de base e perfil do paciente. Busca-se corrigir a deformidade, com a menor interferência possível na força muscular e, com isso, diminuir a incidência de complicações, como marcha agachada, arrastada e pé calcâneo. Do ponto de vista anatômico, o tríceps sural apresenta cinco regiões que podem ser abordadas cirurgicamente para correção do equino. Em virtude da complexidade do paciente com equino, os ortopedistas devem ter experiência com ao menos uma técnica em cada zona. Neste texto são abordadas e analisadas criticamente as técnicas mais importantes para correção do equino, principalmente de modo a evitar complicações. Foi realizada uma busca sobre técnicas cirúrgicas mais comuns de correção do equino em livros clássicos e identificação e consulta aos artigos originais. Em seguida, fez-se uma busca em bases de dados nos últimos dez anos.

ABSTRACT The equinus deformity causes changes in the foot contact and may affect more proximal anatomical regions, such as the knee, hip and trunk, potentially leading to gait disorders. The equinus is usually secondary to retraction, shortening and/or spasticity of the triceps surae, and it may require surgical correction. Surgery for the correction of equinus is one of the oldest procedures in Orthopedics, and it was initially performed only at the calcaneus tendon. The technique has evolved, so that it could be customized for each patient, depending on the degree of deformity, the underlying disease, and patient´s profile. The aim is to correct the deformity, with minimal interference in muscle strength, thus reducing the incidence of disabling complications such as crouch gait and calcaneus foot. We conducted a literature search for the most common surgical techniques to correct the equinus deformity using classic books and original articles. Further, we performed a database search for articles published in the last ten years. From the anatomical perspective, the triceps surae presents five anatomical regions that can be approached surgically for the equinus correction. Due to the complexity of the equinus, orthopedic surgeons should be experienced with at least one procedure at each region. In this text, we critically approach and analyze the most important techniques for correction of the equinus, mainly to avoid complications.

Ultrasound-guided minimal traverse-cross technique repair for acute closed Achilles tendon ruptures / 中国骨伤

OBJECTIVE@#To explore clinical effects of ultrasound-guided minimal traverse-cross technique repair for acute closed Achilles tendon ruptures.@*METHODS@#From January 2015 to March 2017, 20 patients with acute closed Achilles tendon rupture were treated by minimal traverse-cross technique repair with ultrasound guided. Among them, including 13 males and 7 females, aged from 28 to 49 years old with an average of(31.3 ±4.5) years old. All patients were single side injury. Fifteen patients on the left side and 5 patients were on the right side. The time from injury to operation ranged from 1 to 5 days with an average of (2.5±0.7) days. Operative time, postoperative complications were observed, and AOFAS score before and after operation at 12 months were compared.@*RESULTS@#All patients were followed up for 12 to 27 months with an average of(15.2±4.9) months. Operative time ranged from 33 to 65 min with an average of(43.7±5.6) min. Incision of one patient were continued oozing and improved after changing dressings, other patients were healed at stage I. No sural nerve irritation symptoms and palindromic rapture of heel tendon occurred. AOFAS score was improved from 65.2±7.4 before operation to 97.7±4.7 after operation at 12 months (t=22.5, <0.01); 18 patients got excellent results and 2 good.@*CONCLUSIONS@#Ultrasound-guided minimal traverse-cross technique repair for acute closed Achilles tendon ruptures, which promise minimal incision, protect sural nerve, ensure quality of tendon anastomosis and fixation, and is a ideal method for repairing acute closed Achilles tendon ruptures.

Sural Nerve Tuberculoma: A Case Report / 대한족부족관절학회지

Nearly one third of the world's population have active or latent tuberculosis, resulting in 1.5 million deaths annually. Tuberculosis involving the peripheral nerve is difficult to detect. Sural nerve tuberculoma is an extremely rare case of tuberculous involvement of the peripheral nerve that has attracted the attention of physicians. This paper reports a patient with sural nerve tuberculoma. A 58-year-old female patient presented with a palpable mass on the posterolateral calf with progressive tingling sensation on the distal area. The patient had no history of trauma and it was unclear whether the patient had any contact with individuals with active tuberculosis. The histopathologic findings revealed a granuloma-like lesion with caseous necrosis that was compatible with tuberculoma.

Could Ultrasound-Guided Stimulation of Sural Nerve Affect Nerve Conduction Study?

OBJECTIVE: To determine anatomical variation of the sural nerve (SN) by ultrasonography (US) and compare sensory nerve action potential (SNAP) of the SN obtained by a control method to that obtained with adjusted method using US. METHODS: Eighty legs of 40 healthy volunteers were enrolled. The location and formation of SN were investigated through US. Two methods of nerve conduction study (NCS) were then performed. In the control method, the cathode was placed 14 cm proximal to the lateral malleolus and the greatest SNAP amplitude was obtained by moving the cathode medially or laterally from just lateral to the calf-mid line. In adjusted NCS, the exact SN union site was stimulated in type 1. In other SN types, the stimulation was done directly over the nerve and the distance from the lateral malleolus was set to be 14 cm. RESULTS: It was found that 73.8% of the SNs were type 1, 22.5% were direct continuation of MSCN (type 2), and 3.8% were MSCN and LSCN without communicating (type 4). However, type 3 was not found. The union point in type 1 SN was 12.6±2.5 cm proximal to the lateral malleolus and 1.4±0.7 cm lateral to the calf-midline. After stimulation adjustment, SNAP amplitude in type 1 SN was significantly increased (20.7±5.5 μV vs. 27.1±6.7 μV). CONCLUSION: Anatomical variation of SN and its location were verified by US. US provides additional information for conducting sural NCS and helps obtain more accurate results.

Use of the cross-leg distally based sural artery flap for the reconstruction of complex lower extremity defects

Cross-leg flaps are a useful reconstructive option for complex lower limb defects when free flaps cannot be performed owing to vessel damage. We describe the use of the extended distally based sural artery flap in a cross-leg fashion for lower extremity coverage in three patients. To maximise the viability of these extended flaps, a delay was performed by raising them in a bipedicled fashion before gradual division of the tip over 5 to 7 days for cross-leg transfer. Rigid coupling of the lower limbs with external fixators was critical in preventing flap avulsion and to promote neovascular takeover. The pedicle was gradually divided over the ensuing 7 to 14 days before full flap inset and removal of the external fixators. In all three patients, the flaps survived with no complications and successful coverage of the critical defect was achieved. One patient developed a grade 2 pressure injury on his heel that resolved with conservative dressings. The donor sites and external fixator pin wounds healed well, with no functional morbidity. The cross-leg extended distally based sural artery flap is a reliable reconstructive option in challenging scenarios. Adequate flap delay, manoeuvres to reduce congestion, and postoperative rigid immobilization are key to a successful outcome.

A possible role of endoneurial fibroblast-like cells in the resolution of endoneurial oedema following nerve crush injury / El posible rol de los fibroblastos endoneurales en la resolución del edema endoneural después de una lesión por aplastamiento nervioso

SUMMARY: Endoneurial oedema is a salient feature of all types of neuropathy. Its elimination is crucial during the complications of nerve recovery. The objective was to study a possible role of the endoneurial fibroblasts in the resolution of nerve edema. Forty-two albino male rats aged between 30 and 40 days (weight 200 g to 250 g) were used in this study. The left sural nerves of 36 rats were subjected to crush injury at one to three-week intervals with six animals per interval. The right and left sural nerves of the remaining six rats were used as controls. At the end of the second week after crush injury, the endoneurium showed channel-like spaces that were lined by fibroblast-like cells and collagen bundles that contained degenerated myelin, and were connected to the subperineurial spaces. Flattened fibroblast-like cells were arranged in several layers in the subperineurial, forming barrier-like cellular sheets localizing to the endoneurial oedema in the space. Fibroblast-like cells also wrapped around the regenerating nerve fibres with their branching cytoplasmic processes. During the third week, the flattened fibroblast-like cells formed nearly continuous cellular sheets in the subperineurial spaces. Macrophages were frequently observed between these cellular barrier-like sheets and in the subperineurial. The endoneurial fibroblast-like cells form barrier-like cellular sheets that probably localise the endoneurial oedema in the subperineurial space. It also appear to create endoneurial channel-like spaces containing degenerated myelin and endoneurial oedema, which may be helpful in localizing and resolving such oedema.

RESUMEN: El edema endoneural es una característica destacada de todos los tipos de neuropatía. Su eliminación es importante durante las complicaciones de la recuperación nerviosa. El objetivo fue estudiar un posible papel de los fibroblastos endoneurales en la resolución del edema nervioso. En este estudio se utilizaron 42 ratas macho albinas con edades entre los 30 y 40 días (peso 200 a 250 g). Los nervios surales izquierdos de 36 ratas se sometieron a lesiones por aplastamiento en intervalos de una a tres semanas con seis animales por intervalo. Se usaron los nervios surales derecho e izquierdo de las seis ratas restantes como controles. Al final de la segunda semana después de la lesión por aplastamiento, el endoneuro mostró espacios en forma de canal que estaban revestidos por células similares a fibroblastos y haces de colágeno que contenían mielina degenerada y se conectaron a los espacios subperineurales. Las células aplanadas de fibroblastos se dispusieron en varias capas en el subperineuro, formando láminas celulares de tipo barrera que se localizaban en el espacio del edema endoneural. Las células similares a fibroblastos también envolvían las fibras nerviosas regeneradoras con sus procesos citoplásmicos ramificados. Durante la tercera semana, las células aplanadas de fibroblastos formaron láminas celulares casi continuas en los espacios subperineurales. Los macrófagos se observaron con frecuencia entre estas láminas similares a barreras celulares y en el subperineuro. Las células de tipo fibroblasto endoneural formaban láminas celulares de tipo barrera que probablemente localizan el edema endoneural en el espacio subperineural. También parece que crea espacios en forma de canal endoneural que contienen mielina degenerada y edema endoneural, que pueden ser útiles para localizar y resolver este edema.

Caso Clínico: Cirugía Reconstructiva de Tobillo / Case Report: Reconstructive Ankle Surgery

INTRODUCCIÓN: La diabetes mellitus es un importante problema de salud pública, según la Organización Mundial de la Salud, 422 millones de adultos en todo el mundo en 2014. En 2012 provocó 1.5 millones de muertes a nivel mundial; es la primera causa de amputación no traumática en miembros inferiores y las infecciones del pie ocurren con alta frecuencia en pacientes mal controlados. Este caso muestra la reconstrucción de defectos de partes blandas en el tercio inferior pierna, talón, maléolos y pie a través de la descripción del colgajo sural reverso. En este estudio se discuten las ventajas y desventajas de la utilización de esta técnica. CASO CLÍNICO: Paciente de sexo femenino 56 años de edad con antecedentes de Diabetes Mellitus tipo 2 mal controlada, que sufrió una fractura de tobillo izquierdo tratada con osteosíntesis; durante el postoperatorio acudió a emergencia, por presentar dolor de gran intensidad en tobillo izquierdo, fiebre, dehiscencia de herida quirúrgica, acompañada de secreción serosa. EVOLUCIÓN: La paciente luego de varias limpiezas quirúrgicas y cambios de terapia de cierre asistido por presión negativa, se consigue controlar la infección, con persistencia del defecto de cobertura ósea y del material de osteosíntesis. Se presentaron complicaciones adicionales como la rigidez articular, atrofia muscular; se decidió realizar reconstrucción del tercio distal del pie usando colgajo fasciocutáneo sural de flujo reverso, que evolucionó satisfactoriamente, consiguiendo cubrir el defecto con tejido biológico. CONCLUSIÓN: El colgajo sural de flujo reverso, es una técnica reproducible, que permite cubrir defectos de cobertura en tercio distal de pierna y tobillo; acortar los tiempos de hospitalización, especialmente cuando hay exposición ósea o de material de osteosíntesis.

BACKGROUND: Diabetes mellitus is a major public health problem, according to the World Health Organization, 422 million adults worldwide in 2014. In 2012, it caused 1.5 million deaths worldwide. Diabetes is the leading cause of non-traumatic amputation in lower limbs and foot infections occur with high frequency in poorly controlled patients. This case shows the reconstruction of soft tissue defects in the lower third leg, heel, malleoli and foot through the description of the reverse sural flap. In this study the advantages and disadvantages of the use of this technique are discussed. CASE REPORT: A 56-year-old female patient with a poorly controlled history of Diabetes Mellitus type 2, who suffered a fracture of the left ankle treated with osteosynthesis, and who during the postoperative period attended emergency orthopedics and traumatology, due to severe pain in the left ankle, fever, dehiscence of surgical wound, accompanied by serous secretion. EVOLUTION: The patient, after several surgical cleanings and changes in closure therapy assisted by negative pressure, manages to control the infection, with persistence of the bone coverage defect and the osteosynthesis material. There were additional complications such as joint stiffness, muscle atrophy; it was decided to reconstruct the distal third of the foot using a reverse flow sural fasciocutaneous flap, which evolved satisfactorily, managing to cover the defect with biological tissue. CONCLUSIONS: The sural flap of reverse flow is a reproducible technique that allows to cover coverage defects in the distal third of the leg and ankle; shorten hospitalization times, especially when there is bone exposure or osteosynthesis material.

Patterns of Nerve Conduction Abnormalities in Patients with Type 2 Diabetes Mellitus According to the Clinical Phenotype Determined by the Current Perception Threshold

BACKGROUND: Clinical manifestations of diabetic peripheral neuropathy (DPN) vary along the course of nerve damage. Nerve conduction studies (NCS) have been suggested as a way to confirm diagnoses of DPN, but the results have limited utility for evaluating clinical phenotypes. The current perception threshold (CPT) is a complementary method for diagnosing DPN and assessing DPN symptoms. We compared NCS variables according to clinical phenotypes determined by CPT measurements. METHODS: We retrospectively enrolled patients with type 2 diabetes mellitus who underwent both NCS and CPT tests using a neurometer. CPT grades were used to determine the clinical phenotypes of DPN: normoesthesia (0 to 1.66), hyperesthesia (1.67 to 6.62), and hypoesthesia/anesthesia (6.63 to 12.0). The Michigan Neuropathy Screening Instrument (MNSI) was used to determine a subjective symptom score. DPN was diagnosed based on both patient symptoms (MNSI score ≥3) and abnormal NCS results. RESULTS: A total of 202 patients (117 men and 85 women) were included in the final analysis. The average age was 62.6 years, and 71 patients (35.1%) were diagnosed with DPN. The CPT variables correlated with MNSI scores and NCS variables in patients with diabetes. Linear regression analyses indicated that hypoesthesia was associated with significantly lower summed velocities and sural amplitudes and velocities, and higher summed latencies, than normoesthesia. Sural amplitude was significantly lower in patients with hyperesthesia than in patients with normoesthesia. CONCLUSION: NCS variables differed among patients with diabetes according to clinical phenotypes based on CPT and decreased sural nerve velocities was associated with hyperesthesia.

Sural Nerve Entrapment and Tenosynovitis of Peroneus Longus by Hypertrophied Peroneal Tubercle: A Case Report / 대한족부족관절학회지

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.

Comparative Study of Clinical Outcome of Three Surgical Techniques in the Achilles Tendon Rupture: Open Repair, Percutaneous Repair, and Minimal Incision Repair by Achillon / 대한족부족관절학회지

PURPOSE: This study compared the clinical outcomes of open repair, percutaneous repair, and minimal incision repair by Achillon in ruptured Achilles tendon. MATERIALS AND METHODS: The outcomes of 12 patients with open repair (group 1), 8 patients with percutaneous repair (group 2), and 10 patients with minimal incision repair by Achillon (group 3) from February 2013 to March 2016 were analyzed retrospectively. The postoperative clinical evaluations were done by the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Arner-Linholm scale, mid-calf circumference difference, one-leg heel raise difference, visual analogue scale (VAS) for postoperative scarring, time to return to work, and complications. RESULTS: No significant difference in the AOFAS ankle-hindfoot score, Arner-Linholm scale, and time to return to work was observed among three groups (p=0.968, 0.509, and 0.585). The mean differences in the mid-calf circumference in groups 1, 2, and 3 were 1.09, 0.73, and 0.58, respectively; groups 2 and 3 were significantly higher than group 1 (p=0.002). In addition, the mean VAS scores for postoperative scarring in groups 1, 2, and 3 were 7.0, 9.1, and 9.1, respectively; groups 2 and 3 were significantly higher than group 1 (p=0.001). The mean differences in one-leg heel raising in groups 1, 2, and 3 were 2.03, 1.91, and 1.33, respectively; group 3 was significantly higher than groups 1 and 2 (p=0.010). The complications encountered were one case of deep infection in group 1 and one case of sural nerve hypoesthesia in group 2. CONCLUSION: Minimal incision repair by Achillon is recommended as an effective surgical treatment for Achilles tendon rupture because it minimizes the risk of complications, leads to an improved tendon strength and healing, and achieves cosmetic satisfaction.

Per-oral cross-facial sural nerve graft for facial reanimation / 대한악안면성형재건외과학회지

BACKGROUND: Cross-facial nerve graft is considered the treatment of choice for facial reanimation in patients with unilateral facial palsy caused by central facial nerve damage. In most cases, a traditional parotidectomy skin incision is used to locate the buccal and zygomatic branches of the facial nerve. METHODS: In this study, cross-facial nerve graft with the sural nerve was planned for three patients with facial palsy through an intraoral approach. RESULTS: An incision was made on the buccal cheek mucosa, and the dissection was performed to locate the buccal branch of the facial nerve. The parotid papillae and parotid duct were used as anatomic landmarks to locate the buccal branch. CONCLUSIONS: The intraoral approach is more advantageous than the conventional extraoral approach because of clear anatomic marker (parotid papilla), invisible postoperative scar, reduced tissue damage from dissection, and reduced operating time.

Intraoperative Ultrasound-Guided Percutaneous Repair of a Ruptured Achilles Tendon: A Comparative Study with Open Repair / 대한정형외과학회잡지

PURPOSE: To compare the clinical outcomes of ultrasound-guided percutaneous repair (USPR) and open repair in a ruptured Achilles tendon. MATERIALS AND METHODS: The outcomes of 12 patients with USPR (group A) and 18 patients with open repair (group B) from January 2015 to February 2017 were analyzed retrospectively. The postoperative clinical evaluations were performed using the Arner-Lindholm scale, American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, Achilles tendon total rupture score (ATRS), and visual analogue scale for the overall satisfaction and cosmetic satisfaction with the scar, and the starting time of single heel raises. The complications were also evaluated. RESULTS: The Arner-Lindholm scale, AOFAS ankle-hindfoot score, ATRS, starting time of single heel raises were similar in both groups (all p>0.05). Group A showed a significantly higher overall patient's satisfaction and cosmetic satisfaction in than group B (all p < 0.05). Two cases of Achilles tendon elongation were encountered in group A, and 1 case of re-rupture with deep infection and 1 case of superficial infection were experienced in group B. CONCLUSION: USPR showed good clinical outcomes and high satisfaction as well as a low rate of complications, such as sural nerve injury. Therefore, USPR can be considered as an effective surgical treatment option for Achilles tendon ruptures.

Endoscopic Sural Nerve Removal in Obstetric Brachial Plexopathy Using Basic Endoscopy Instruments: Technical Note

Introduction The sural nerve (SN) is commonly used for grafting following resection of a neuroma-in-continuity in neonatal brachial plexus lesions (NBPL). The main drawbacks of the current open techniques are large scars and contractures in the late postoperative stage, which may, in severe cases, cause equinovarus contractures. Objective To describe the feasibility and the technical aspects of endoscopic SN harvesting with the use of basic endoscopy instruments and small incisions. Methods Prospective observational study of NBPL subjected to endoscopic nerve harvesting between February of 2012 and February of 2014 in a consecutive series. Patients were operated at the Felício Rocho Hospital (Hospital Felício Rocho) and the Clinical Hospital, Federal University of Minas Gerais (Hospital das Clínicas UFMG), Belo Horizonte/MG, in Brazil. The study outcomes assessed were: scar size, presence or absence of contractures in the calf, bleeding volume (measured by the number of gauzes used) and number of incisions. Only patients with a follow-up longer than 6 months were included. Results Seven patients were selected and twelve endoscopic nerves were endoscopically harvested. The average surgery time was 45 minutes. Nine SNs were harvested through two incisions, and three nerves through three incisions. The estimated bleeding was less than 5ml and there were no complications or contractures during the follow-up period of 6 months to 4 years. Conclusion Sural nerve harvesting in children with NBPL is feasible and it offers the advantage of needing only two or three small incisions using basic endoscopy instruments.

Introdução O nervo sural é a melhor opção para enxertia nas reconstruções microcirúrgicas da plexopatia braquial obstétrica. O método clássico aberto com incisão longitudinal desde o tornozelo até a fossa poplítea ou em incisões em degraus possuem as desvantagens de cicatrizes amplas e contraturas em equinovarus (pé torto). Atualmente, o emprego de endoscópios específicos para a retirada de enxertia de nervos e vasos mostra resultados satisfatórios em relação ao encurtamento do tempo cirúrgico e à redução no tamanho das incisões, mas tem como inconveniente o alto custo de aquisição e manutenção. Objetivo Discutir a viabilidade e descrever nota técnica da retirada do nervo sural utilizando instrumental básico de endoscopia e pequenas incisões. Métodos Estudo observacional prospectivo em pacientes com plexopatia braquial obstétrica submetidos a retirada do nervo sural por endoscopia no período de fevereiro de 2012 a fevereiro de 2014 no Hospital Felicio Rocho e no Hospital das Clinicas UFMG, Belo Horizonte/MG, Brasil. Resultados Sete pacientes foram selecionados e foram retirados doze nervos surais por endoscopia. O tempo médio da cirurgia foi de 45 minutos. Nove nervos surais foram retirados por duas incisões, e três nervos foram retirados por três incisões. O sangramento foi inferior a 5ml e não houve complicações no pós-operatório imediato e tardio em acompanhamento entre 6 meses e 4 anos. Não foram observadas contraturas no período observacional. Conclusão O nervo sural pode ser retirado utilizando duas ou três pequenas incisões por meio de instrumental endoscópico básico em crianças com plexopatia braquial obstétrica.

Ischemic Sciatic Neuropathy in a Patient with Liposarcoma

BACKGROUND: Various etiologies are the causative agents for sciatic neuropathy. We present here a case of ischemic sciatic neuropathy in a patient with liposarcoma. CASE REPORT: A 55-year-old woman presented with severe pain and weakness of the left leg. She had a history of recurred retroperitoneal liposarcoma, and was being administered chemotherapy. Examination revealed weakness in ankle dorsiflexion, plantar flexion and hamstring. Complaints also included dysesthesia, and numbness in the sole and dorsum of the foot. Nerve conduction study showed low compound muscle action potentials and slow motor conduction velocity of left peroneal and tibial nerves, with indiscernible sensory nerve action potentials of the left superficial peroneal and sural nerves. Computed tomography angiography revealed occlusion of the left common iliac artery. Commencement of intravenous infusion of heparin resulted in skin color change and progression of the weakness. Hence, the patient underwent an emergency thrombectomy. CONCLUSIONS: Ischemia should be considered as a cause of sciatic neuropathy in cancer patients, which requires management with timely treatment.