Relation of the Sural Nerve and Medial Neurovascular Bundle With the Achilles Tendon in Children With Cerebral Palsy Treated by Percutaneous Achilles Tendon Lengthening.
Journal
Journal of pediatric orthopedics
ISSN: 1539-2570
Titre abrégé: J Pediatr Orthop
Pays: United States
ID NLM: 8109053
Informations de publication
Date de publication:
01 Feb 2022
01 Feb 2022
Historique:
entrez:
7
1
2022
pubmed:
8
1
2022
medline:
12
1
2022
Statut:
ppublish
Résumé
One of the most common treatment options for a short Achilles tendon (AT) in cerebral palsy is percutaneous AT lengthening using 3 hemisections. Because of proximity of neurovascular structures around the tendon, iatrogenic injury to them have been a concern about this technique. The sural nerve (SN) is under risk of injury at the site of the lateral incomplete cut, especially if it is done proximally. The medial neurovascular bundle is under injury risk at medial cuts. The aim of the article was to study the anatomical relations of the SN and medial neurovascular bundle to the AT, and define dangerous levels for injury with the help of magnetic resonance imaging (MRI). Patients operated for percutaneous Achilles lengthening were called for MRI investigation of the SN and medial neruvascular bundle integrity and their anatomical relation with the AT. The distance of 5 mm was taken as the threshold for increased risk of injury. Measurements were done on MRI at each cm from the insertion of the tendon on both medial and lateral sides, and at the level of the middle cut. Thirty ankles operated and followed at least 1 year were included to the study. On the medial side, the tibial nerve, and the posterior tibial artery lied more than 5 mm away from the tendon at all levels in all patient. On the lateral side, the first 4 cm were relatively safe for the middle lateral cut, while increased risk of SN damage was detected in more proximal levels. Overall, 6 of 30 ankles had radiographically detectable SN injury. The first 4 cm of the AT on the lateral side was detected to be safe for the middle lateral directed cut, while whole tendon length were found to be safe for the first and the third cuts of the percutaneous Achilles lengthening surgery using 3 hemisections in children with cerebral palsy. Level III.
Sections du résumé
BACKGROUND
BACKGROUND
One of the most common treatment options for a short Achilles tendon (AT) in cerebral palsy is percutaneous AT lengthening using 3 hemisections. Because of proximity of neurovascular structures around the tendon, iatrogenic injury to them have been a concern about this technique. The sural nerve (SN) is under risk of injury at the site of the lateral incomplete cut, especially if it is done proximally. The medial neurovascular bundle is under injury risk at medial cuts. The aim of the article was to study the anatomical relations of the SN and medial neurovascular bundle to the AT, and define dangerous levels for injury with the help of magnetic resonance imaging (MRI).
METHODS
METHODS
Patients operated for percutaneous Achilles lengthening were called for MRI investigation of the SN and medial neruvascular bundle integrity and their anatomical relation with the AT. The distance of 5 mm was taken as the threshold for increased risk of injury. Measurements were done on MRI at each cm from the insertion of the tendon on both medial and lateral sides, and at the level of the middle cut.
RESULTS
RESULTS
Thirty ankles operated and followed at least 1 year were included to the study. On the medial side, the tibial nerve, and the posterior tibial artery lied more than 5 mm away from the tendon at all levels in all patient. On the lateral side, the first 4 cm were relatively safe for the middle lateral cut, while increased risk of SN damage was detected in more proximal levels. Overall, 6 of 30 ankles had radiographically detectable SN injury.
CONCLUSIONS
CONCLUSIONS
The first 4 cm of the AT on the lateral side was detected to be safe for the middle lateral directed cut, while whole tendon length were found to be safe for the first and the third cuts of the percutaneous Achilles lengthening surgery using 3 hemisections in children with cerebral palsy.
LEVEL OF EVIDENCE
METHODS
Level III.
Identifiants
pubmed: 34995262
doi: 10.1097/BPO.0000000000002020
pii: 01241398-202202000-00024
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
e201-e205Informations de copyright
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Déclaration de conflit d'intérêts
The authors declare no conflicts of interest.
Références
Lee W-C, Ko H-S. Achilles tendon lengthening by triple hemisection in adult. Foot Ankle Int. 2005;26:1017–1020.
Volpon JB, Natale LL. Critical evaluation of the surgical techniques to correct the equinus deformity. Rev Col Bras Cir. 2019;46:e2054–e2064.
Hoffman B, Nunley J. Achilles tendon torsion has no effect on percutaneous triple-cut tenotomy results. Foot Ankle Int. 2006;27:960–964.
Katz K, Arbel N, Apter N, et al. Early mobilization after sliding Achilles tendon lengthening in children with spastic cerebral palsy. Foot Ankle Int. 2000;21:1011–1014.
Salamon ML, Pinney SJ, Van Bergeyk A, et al. Surgical anatomy and accuracy of percutaneous Achilles tendon lengthening. Foot Ankle Int. 2006;27:411–413.
Kammar H, Carmont MR, Kots E, et al. Anatomy of the sural nerve and its relation to the Achilles tendon by ultrasound examination. Orthopedics. 2014;37:298–301.
Webb J, Moorjani N, Radford M. Anatomy of the sural nerve and its relation to the Achilles Tendon. Foot Ankle Int. 2000;21:475–477.
Lawrence SJ, Botte MJ. The sural nerve in the foot and ankle: an anatomic study with clinical and surgical implications. Foot Ankle Int. 1994;15:490–494.
Krans AVD, Louwerens JWK, Anderson P. Adult acquired flexible flatfoot, treated by calcaneo-cuboid distraction arthrodesis, posterior tibial tendon augmentation, and percutaneous Achilles tendon lengthening: a prospective outcome study of 20 patients. Acta Orthop. 2006;77:156–163.
Hatt RN, Lamphier TA. Triple hemisection: a simplified procedure for lengthening the Achilles tendon. N Engl J Med. 1947;236:166–169.
Waters Rl, Perry J, Garland D. Surgical correction of gait abnormalities following stroke. Clin Orthop Relat Res. 1978;131:54–63.
Brandão RA, So E, Steriovski J, et al. Outcomes and incidence of complications following endoscopic gastrocnemius recession: a systematic review. Foot Ankle Spec. 2021;14:55–63.
Hoefnagels EM, Waites MD, Belkoff SM, et al. Percutaneous Achilles tendon lengthening: a cadaver-based study of failure of the triple hemisection technique. Acta Orthop. 2007;78:808–812.
Mulier T, Molenaers G, Fabry G. A false aneurysm complicating a subcutaneous Achilles tendon lengthening. J Pediatr Orthop B. 1995;4:114–115.
Dobbs MB, Gordon JE, Walton T, et al. Bleeding complications following percutaneous tendoachilles tenotomy in the treatment of clubfoot deformity. J Pediatr Orthop. 2004;24:353–357.
Tashjian RZ, Appel AJ, Banerjee R, et al. Anatomic study of the gastrocnemius-soleus junction and its relationship to the sural nerve. Foot Ankle Int. 2003;24:473–476.
Ortigiiela ME, Wood MB, Cahill DR. Anatomy of the sural nerve complex. J Hand Surg Am. 1987;12:1119–1123.
Blackmon JA, Atsas S, Clarkson MJ, et al. Locating the sural nerve during calcaneal (Achilles) tendon repair with confidence: a cadaveric study with clinical applications. J Foot Ankle Surg. 2013;52:42–47.
Gatz M, Driessen A, Eschweiler J, et al. Open versus minimally-invasive surgery for Achilles tendon rupture: a meta-analysis study. Arch Orthop Trauma Surg. 2021;141:383–401.
McGee R, Watson T, Eudy A, et al. Anatomic relationship of the sural nerve when performing Achilles tendon repair using the percutaneous Achilles repair system, a cadaveric study. Foot Ankle Surg. 2021;27:427–401.
Rossi F, Zaottini F, Picasso R, et al. Ankle and foot ultrasound: reliability of side-to-side comparison of small anatomic structures. J Ultrasound Med. 2019;38:2143–2153.
Chavez J, Hattori S, Kato Y, et al. The use of ultrasonography during minimally invasive Achilles tendon repair to avoid sural nerve injury. J Med Ultrason. 2019;46:513–514.