Anatomy of the tibial nerve in relation to the tarsal tunnel: A cadaveric study.

BACKGROUND: Tarsal tunnel syndrome (TTS) is typically caused by an anatomical variant or mechanical compression of the tibial nerve (TN) with variable success after surgical treatment. METHOD: 40 lower-leg specimens were obtained. Dissections were appropriately conducted. Extremities were prepared under formaldehyde solution. The tibial nerve and branches were dissected for measurements and various characteristics. RESULTS: The flexor retinaculum had a denser consistency in 22.5% of the cases and the average length was 51.9 mm. The flexor retinaculum as an independent structure was absent and 77.2% of cases as an undistinguished extension of the crural fascia. The lateral plantar nerve (LPN) and abductor digiti minimi (ADM) nerve shared same origin in 80% of cases, 34.5% bifurcated proximal to the DM (Dellon-McKinnon malleolar-calcaneal line) line 31.2% distally and 34.3% at the same level. CONCLUSION: Understanding the tibial nerve anatomy will allow us to adapt our surgical technique to improve the treatment of this recurrent pathology.

Cystic degeneration of the tibial nerve: magnetic resonance neurography and sonography appearances of an intraneural ganglion cyst.

Extra- and intraneural ganglion cysts have been described in the literature. The tibial nerve ganglion is uncommon and its occurrence without intra-articular extension is atypical. The pathogenesis of cystic degeneration localized to connective and perineural tissue secondary to chronic mechanical irritation or idiopathic mucoid degeneration is hypothesized. Since the above pathology is extremely rare and the magnetic resonance imaging examination detects the defining characteristics of the intrinsic alterations of the tibial nerve, the authors illustrate such a case of tibial intaneural ganglion cyst with its magnetic resonance neurography and sonography appearances.

Neurorrhaphy techniques: comparative stereological and experimental axonal study / Técnicas de neurorrafia: estudio experimental estereológico axonal comparativo

There is a great variety of injuries that affect peripheral nerves derived from acquired or congenital degenerative diseases affecting the central nervous system that cause loss of sensorimotor functions. The objective of this work was to perform an end-to-side or side-to-side experimental axonal stereological study in order to compare volume density of axons, endouneuro and myelin sheath (and muscle mass) in peroneal and tibial nerves, with anastomosis contact from 0.25 cm to 0.50 cm. After approval of the Ethics Committe, 20 male Wistar rats were divided into four groups of five rats each (G1= end-to-side neurorrhaphy; G2= side-to-side neurorrhaphy of 0.25 cm; G3= side-to-side neurorrhaphy of 0 cm and G4= Control of normality). After 180 days, fragments of peroneal and tibial nerves were collected for histological and stereological study. In comparative stereological experimental study between neurorraphies, the volume density of axons, myelin sheath of tibial and fibular nerves, as well as the post-surgical muscle mass, remains the same in end-to-side and side-to-side neurorraphies, regardless of contact area of anastomosis. It can be inferred, as surgical repair options, both end-to-side neurorrhaphy to recover and prevents atrophy of the endplate as side-to-side neurorraphy that is independent of the distance between the nerve stumps.

Gran variedad de lesiones atingen a los nervios periféricos, derivadas de enfermedades adquiridas o degenerativas congénitas que afectan la parte central del sistema nervioso y que ocasionan pérdida de funciones sensoriomotoras. El objetivo de ese trabajo fue realizar un estudio experimental estereológico axonal post neurorrafias termino-lateral o latero-lateral para comparar densidad de volumen de axones, endoneuro y vaina de mielina (así como masa muscular) en nervios fibular y tibial, con unión de contacto entre 0,25 cm y 0,50 cm. Tras la aprobación del comité de ética, fueran utilizados 20 ratones machos de la raza Wistar divididos en cuatro grupos de 5 ratones cada uno (G1= Neurorrafia término lateral; G2= Neurorrafia latero lateral de 0,25 cm; G3= Neurorrafia latero lateral de 0,50 cm y G4= Control). Posteriormente, fragmentos de los nervios tibiales y fibulares fueron procesados para estudios histológicos y estereológicos. En el estudio experimental estereológico comparativo entre neurorrafias termino-lateral y latero-lateral, la densidad de volumen de axones, endoneuro y vaina de mielina de nervios tibial y fibular y también la masa muscular post quirúrgica se mantuvo equitativa, independientemente del área de unión de contacto. Podemos inferir como opciones de reparación quirúrgica, que el tratamiento de la neurorrafia termino-lateral y latero-lateral previnen la atrofia de placa motora, independiente de la distancia entre los muñones nerviosos.

Síndrome del túnel del tarso: secundario a insuficiencia venosa. Reporte de un caso / Tarsal tunnel syndrome secondary to venous insufficiency: Case report

El síndrome del túnel del tarso se define como una neuropatía compresiva extrínseca y/o intrínseca del nervio tibial posterior o de una de sus ramas siendo una de sus causas la insuficiencia vascular. Caso clínico: femenina de 51 años, originaria de León, Guanajuato. Hipertensa, síndrome de Guillain-Barré hace ocho años, insuficiencia vascular y obesidad. Inicia con dolor en tobillo y talón izquierdo, manejada con AINES y rehabilitación con mejoría parcial, se realizan radiografías y resonancia magnética nuclear del tobillo izquierdo con datos de pinzamiento posterior, se realiza artroscopía y mejora un mes presentándose dolor intenso en el tobillo y la planta del pie y disestesias, se hace electromiografía con datos de lesión del tibial posterior. Cuenta con historia clínica, perfil prequirúrgico, dorsoplantar y lateral, se realiza una artroscopía encontrándose una tendinitis del Flexor Hallucis Longus (FHL), sinovitis y un pinzamiento posterior del tobillo, se hace sinovectomía, descompresión y un peinado del FHL. Mala evolución, se realiza electromiografía con axonotmesis de la rama plantar medial. Se realiza la liberación del nervio encontrándose el plexo venoso de Lazhortes tortuoso comprimiendo en todo su trayecto. Una de las causas es por la compresión intrínseca secundaria a tumores, modificaciones de la anatomía del túnel del tarso; sin embargo, menos frecuente, las várices pueden confundir el diagnóstico y llegar a producir un daño irreparable para el paciente si no se trata a tiempo. La paciente se encuentra actualmente sin dolor que le posibilita la marcha, con disestesias leves del primer dedo y movilidad limitada para su flexión.

Tarsal tunnel syndrome is defined as an extrinsic and/or intrinsic compressive neuropathy of the posterior tibial nerve or one of its branches. Its causes include venous insufficiency. Clinical case: 51 year-old female patient from León, Guanajuato. Hypertensive, with Guillain-Barré syndrome for eight years, vascular insufficiency and obesity. Her condition started with left ankle and heel pain; she was treated with NSAIDs and rehabilitation and achieved partial improvement. X-rays and MRI of the left ankle showed posterior impingement. She underwent arthroscopy and improved but one month later she presented with severe pain in the left ankle and sole and dysesthesias. Electromyography showed a lesion of the posterior tibial nerve. We had the patient's case history, preoperative tests, and dorsoplantar and lateral X-ray views. The arthroscopic diagnosis was flexor hallucis longus (FHL) tendinitis, synovitis and posterior ankle impingement. Synovectomy, decompression and smoothening of the FHL tendon were performed. The patient did poorly and underwent electromyography with axonotmesis of the medial plantar branch. After the nerve was released, Lazorthes venous plexus was found to be tortuous and compressing the entire nerve tract. The possible causes for this include intrinsic compression secondary to tumors, and anatomical changes of the tarsal tunnel. However, less often varices may confound the diagnosis and cause irreversible damage if not treated timely. The patient is currently pain free and can walk, has mild dysesthesias of the first toe and limited flexion.

[Tarsal tunnel syndrome secondary to venous insufficiency. Case report]. / Síndrome del túnel del tarso: secundario a insuficiencia venosa. Reporte de un caso.

Tarsal tunnel syndrome is defined as an extrinsic and/or intrinsic compressive neuropathy of the posterior tibial nerve or one of its branches. Its causes include venous insufficiency. Clinical case: 51 year-old female patient from León, Guanajuato. Hypertensive, with Guillain-Barré syndrome for eight years, vascular insufficiency and obesity. Her condition started with left ankle and heel pain; she was treated with NSAIDs and rehabilitation and achieved partial improvement. X-rays and MRI of the left ankle showed posterior impingement. She underwent arthroscopy and improved but one month later she presented with severe pain in the left ankle and sole and dysesthesias. Electromyography showed a lesion of the posterior tibial nerve. We had the patient's case history, preoperative tests, and dorsoplantar and lateral X-ray views. The arthroscopic diagnosis was Flexor Hallucis Longus (FHL) tendinitis, synovitis and posterior ankle impingement. Synovectomy, decompression and smoothening of the FHL tendon were performed. The patient did poorly and underwent electromyography with axonotmesis of the medial plantar branch. After the nerve was released, Lazorthes venous plexus was found to be tortuous and compressing the entire nerve tract. The possible causes for this include intrinsic compression secondary to tumors, and anatomical changes of the tarsal tunnel. However, less often varices may confound the diagnosis and cause irreversible damage if not treated timely. The patient is currently pain free and can walk, has mild dysesthesias of the first toe and limited flexion.

Electrical stimulation of the posterior tibialis nerve improves symptoms of poststroke neurogenic overactive bladder in men: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of electrical stimulation of the posterior tibialis nerve in men with neurogenic overactive bladder secondary to ischemic stroke at 45 days and 12 months after treatment. MATERIALS AND METHODS: We studied 24 patients older than 18 years, with ischemic stroke that occurred between 6 months and 3 years previously and with no prior urinary symptoms. These patients were randomly allocated to receive electrical stimulation of the posterior tibialis nerve twice weekly for 6 weeks (treatment group, n = 12) or general advice and stretching sessions 1 to 3 times monthly for 6 weeks (control group, n = 12). Each session lasted 30 minutes in both groups. The primary outcomes were reduction in urinary frequency, reduction in urinary urgency, and overall improvement in voiding diary variables. RESULTS: Patients in the electrical stimulation group, in relation to baseline and to control group, experienced improvement in urinary symptoms, reducing urinary urgency and frequency, and reported subjective improvement after treatment. This effect persisted after 12 months of follow-up. The patients with lesion in right hemisphere, advanced age, and with higher body mass index presented more chance to develop urinary symptoms. CONCLUSION: Electrical stimulation of the posterior tibialis nerve is a safe and effective option for the treatment of poststroke neurogenic overactive bladder in men, reducing urinary frequency and urgency.

Fracturas de pilón tibial: estado actual de pacientes que ingresaron al Instituto Autónomo Hospital Universitario de Los Andes entre 1998-2007 aplicando la AOFAS: estudio observacional analítico prospectivo no concurrente / Tibial pilon fractures: currents status of patients admitted to the Instituto Autónomo Hospital Universitario de Los Andes between 1998-2007 using the AOFAS: prospective observacional study non-concurrent

Las fracturas de tibia distal han sido consideradas de difícil manejo debido a los resultados desalentadores descritos hasta el año de 1963 situación que comienza a cambiar a mediados de 1968 cuando se promulgan los principios de ORIF de la AO, sin embargo, actualmente sigue constituyendo un verdadero reto para el cirujano traumatólogo. En el presente estudio prospectivo no concurrente se evaluarán los pacientes adultos (mayores de 16 años de edad) que ingresaron al servicio de Ortopedia y Traumatología del Instituto Autónomo Hospital Universitario de Los Andes (IAHULA) entre 1998 y 2007 con fracturas de tibia distal (pilon tibial), constituyendo en total una población de 80 pacientes de la cual se toma una muestra de 40 pacientes. Para efectos de este estudio obtuvimos para las fracturas tipo A según la AO/ASIF un total de 33,3 por ciento de excelentes resultados, 33,3 por ciento de regulares resultados y 33,3 por ciento de malos resultados. Para las fracturas tipo B 71 por ciento de excelentes resultados, 15 por ciento de regulares resultados y 14 por ciento de malos resultados; mientras que para las fracturas de tipo C fue un 27 por ciento de excelentes resultados, 27 por ciento de regulares resultados y 46 por ciento de malos resultados, todos evaluados según la escala de evaluación de la AOFAS. A la luz de los estudios consultados, resulta evidente establecer como aspectos pronóstico determinantes el estado de las partes blandas la afectación metafisiaria y/o articular, así como la asociación a una lesión de peroné.

Distal tibia fracture have been considered difficult to use because of the disappointing results described until the years 1963 which begins to change in mid-1968 when it enacted the principles of ORIF of AO, however, currently still be a real challenge to the trauma surgeon. This prospective study will assess the concurrent non-adult patients (older than 16 years of age) who entered the service of Orthopedics and Traumatology Institute of the University Hospital of Los Andes (IAHULA) between 1998 and 2007 with fractures distal tibia (tibia pylon), constituting a total population of 80 patients of which took a sample of 40 patients. For purposes of this study, we obtained for type A fractures according to AO/ASIF a total of 33,3 percent of excellent results, 33,3 percent of regular results, and 33,3 percent poor results. For fractures type B 71 percent of excellent results, 15 percent regular results, and 14 of poor results, whereas for type C fractures was 27 percent excellent results, 27 percent of regular results, and 46 percent of poor results all assessed according to the scale of assessement of the AOFAS. In light of the studies consulted, as is evident establish prognostic determinants respects the status of soft tissue involvement, metaphyseal and/or joints, as well as the association of a fibula injury.

Neuroma de Morton: diagnóstico ecográfico / Sonographic diagnosis of Mortons neuroma

Objetivo: El neuroma de Morton es una causa frecuente de metatarsalgia en el adulto. El objetivo del presente trabajo es describir la experiencia de nuestro servicio en el diagnóstico ultrasonográfico de ésta entidad. Material y métodos: Se evaluaron retrospectivamente 14 ecografías pertenecientes a 13 pacientes (12 mujeres y 1 varón) con neuroma de Morton confirmado por anatomía patológica. Las edades oscilaron entre los 38 y los 72 años, con una media de 53,8 años. Los estudios fueron realizados con un ecógrafo ATL Ultramark HDI equipado con transductor lineal de banda ancha de 5-10 mHz, o con un ecógrafo Toshiba SSA 270 con transductor lineal de 7,5 mHz. Los pacientes fueron examinados en decúbito dorsal, desde la planta del pie, rastreándose cada espacio intermetatarsiano en sentido transversal y longitudinal, al tiempo que se ejercía presión en forma intermitente con un dedo, en el mismo espacio, en el dorso del pie. Resultados: En todos los casos las lesiones detectadas fueron descriptas como imágenes redondeadas, hipoecoicas, de aspecto sólido y límites bien definidos, sin evidencia de calcificaciones ni vascularización detectable con Doppler. El 92,8 por ciento (N13) se halló en el tercer espacio. El 7,2 por ciento (N1) se halló en el segundo espacio. El diámetro mayor medio fue de 10.85 mm. +/- 4.05 mm. El diámetro menor medio fue de 6.85 mm. +/- 2.55 mm. Conclusiones: En coincidencia con la bibliografía consideramos que el ultrasonido es un método eficaz para diagnosticar neuromas de Morton (AU)

Relationship between functional deficiencies and the contribution of myelin nerve fibers derived from L-4, L-5, and L-6 spinolumbar branches in adult rat sciatic nerve.

The distribution and relative intrafascicular contribution of myelin fibers derived from spinal segments L-4 to L-6 were analyzed in adult rat sciatic nerve and its main branches, using 200-kDa neurofilament subunit immunodetection in previously injured nerve sections in the L-4 or L-5 spinal branch or both. These branches' functional contribution was evaluated 16 days after the injury, using the method of J. Bain, S. Mackinnon, and D. Hunter (1988, Plast. Reconstr. Surg. 83: 129-136). A common topographic intrafascicular distribution was found in 69% of cases, with notable segregation of L-4 and L-5 fibers and a random distribution for L-6 fibers. At sciatic nerve main branch level, L-4 contributes almost entirely to the peroneal nerve, L-5 to the tibial nerve, and L-6 and other branches to the sural nerve. After injury to L-4, a significant reduction in peroneal nerve functional index (PFI) was observed, as was a reduction in print length (PL). Injury to L-5 caused a significant reduction in the sciatic (SFI) and tibial (TFI) functional nerve indices, an increase in PL, and a reduction in the spread between opposite toes (TS). Finally, transection of both L-4 and L-5 was followed by a significant reduction in all functional indices measured, an increase in PL, and a reduction in intermediate toe (ITS) and opposite toe spread (TS). The results indicate a direct relationship between the distribution and contribution of the spinal nerve fibers forming the sciatic nerve and the alteration in functional indices for sciatic, tibial, and peroneal nerves.

Histologic peripheral nerve changes in rats induced by deltamethrin.

Synthetic pyrethroid insecticides have been used in the last two decades largely because of their high activity as an insecticide and low mammalian toxicity. Some studies have demonstrated that these products, especially compounds with an alpha-cyano group, are toxic to the mammalian central nervous system (CNS) in acute intoxications. However, morphological studies are scarce. In the present work the histopathologic changes of the sciatic and tibial nerves of rats submitted to acute intoxication with the cyanopyrethroid deltamethrin were studied. For 3 consecutive days male Wistar rats received by oral gavage deltamethrin at a dose of 45 mg/kg body wt. On the 4th day fragments of sciatic and tibial nerves were studied by transmission electron microscopy (TEM) and teasing of individual nerve fibers. In addition, another group of rats were allowed to recover until the 10th day. Teasing of nerves of animals sacrificed on the 4th day revealed myelin ovoids, which are indicative of axonal damage. TEM demonstrated rare degenerated axons completely filled with organelles, in particular mitochondria, and with electron-dense lamellar bodies that resemble myelin figures. In addition, great cytoplasmic vacuolization caused by proliferation and dilation of the rough and smooth endoplasmic reticulum and Golgi apparatus was observed in some Schwann cells. No lesion was found 7 days after discontinuation of the treatment (group2). Since these histologic changes are transitory and scarce, the question arises: Are they related to the changes in NA(+), K(+)-ATPase activity or Na(+) channels caused by pyrethroid compounds?

Compression of the peripheral branches of the sciatic nerve by lipoma.

The authors report two female patients with chronic sensitive and motor findings in lower limbs caused by compression of distal branches of sciatic nerve by lipoma. Similar cases were not described on literature. Nerve conduction studies allowed to localize the exact site of compression. At surgery, lipomas compressing the deep peroneal nerve (case 1) and the posterior tibial nerve (case 2) were observed. Histologic studies of tumors confirmed the diagnoses.

Reaçäo hansênica tipo I na hanseníase borderline tuberculóide durante a poliquimioterapia: época de aparecimento e nervos acometidos / Type I reaction in borderline tuberculoid leprosy under multidrug therapy: time of onset and nerves affected

FUNDAMENTOS - A reaçäo tipo I é pouco estudada na literatura. OBJETIVOS - Descrever a época de aparecimento da reaçäo tipo 1 e os nervos acometidos, nos pacientes portadores de hanseníase borderline tuberculóide (BT), durante a poliquimioterapia(PQT). PACIENTES E MÉTODOS - Estudo longitudinal realizado no Ambulatório de Dermatologia da Faculdade de Medicina da UFMG. Setenta e um pacientes com hanseníase BT foram incluídos no estudo de agosto de 1989 a agosto de 1993. RESULTADOS - 89,3 por cento dos pacientes hansenianos BT com reaçäo tipo 1 apresentaram esse surto atá a sexta dose de tratamento. O nervo ulnar foi o mais acometido nas reaçöes tipo 1 (37,0 por cento). CONCLUSÃO - A reaçäo tipo 1 nos pacientes hansenianos BT ocorre mais frequentemente até a sexta dose de PQT. O nervo ulnar foi o mais acometido

Exame palpatório de nervos periféricos (espessados na hansenáse) e suas vias anatômicas / Palpations of peripheral nerves (thickened in leprosy) and their anatomical pathways

Este trabalho demonstra, por meio de dissecçäo, o trajeto superficial dos nervos comprometidos na hanseníase. Nessa doença, as lesöes ocorrem com mais frequência em determinados nervos que, nesses casos, se tornam mais espessos do que o normal. Esses nervos específicos säo superficiais em alguma parte de seus trajetos anatômicos e, aí, mais facilmente palpáveis