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Anesthesiology and Pain Medicine Feb 2023Minimally invasive therapies can alleviate pain and improve walking in individuals with persistent foot and ankle pain.
BACKGROUND
Minimally invasive therapies can alleviate pain and improve walking in individuals with persistent foot and ankle pain.
OBJECTIVES
The current study aimed to define the protracted consequences of tibial nerve blocks with steroids for individuals with persistent foot pain and to investigate the link between the thermography of the plantar foot and the beneficial effect of a tibial nerve block with steroids.
METHODS
All patients with chronic foot pain (n = 45) in this cohort underwent a block of the tibial nerve in the Department of Pain Therapy of Pain Clinic De Bilt, Utrecht, Netherlands, within November 2019 to April 2020. The thermographic images of patients were taken before and after injection. Results were retrospectively evaluated after 18 months.
RESULTS
In this study, 53% of the patients had pain relief at 7 weeks of follow-up with a unilateral or bilateral block of the tibial nerve. An improvement in walking distance was reported by 22% of the patients. Side effects of the tibial nerve block reported at 7 weeks of follow-up increased pain (5%) and the occurrence of leg cramps (5%) among the treated patients. At 18 months, 45% of the successfully treated feet still had benefits. A difference between the big toe's temperature and the foot's average temperature of less than -0.9°C on thermography before and after the tibial nerve block can predict a beneficial result of therapy.
CONCLUSIONS
Tibial nerve block provides a safe, minimally invasive treatment option for almost half of the patients with painful feet in this cohort, and when successful, it can last a long term. Thermographic imaging of the plantar foot can predict only to a small extent the beneficial effect of the tibial nerve block with steroids on foot pain. Tibial nerve block should be considered when custom foot orthoses have been inadequate for pain relief or restricted walking distance.
PubMed: 37489169
DOI: 10.5812/aapm-131180 -
Foot & Ankle Specialist Feb 2022Despite multiple surgical modalities available for the management of Morton's neuroma, complications remain common. Targeted muscle reinnervation (TMR) has yet to be...
BACKGROUND
Despite multiple surgical modalities available for the management of Morton's neuroma, complications remain common. Targeted muscle reinnervation (TMR) has yet to be explored as an option for the prevention of recurrence of Morton's neuroma. The purpose of the present investigation was to determine the consistency of the relevant foot neurovascular and muscle anatomy and to demonstrate the feasibility of TMR as an option for Morton's neuroma.
METHODS
The anatomy of 5 fresh-tissue donor cadaver feet was studied, including the course and location of the medial and lateral plantar nerves (MPNs and LPNs), motor branches to abductor hallucis (AH) and flexor digitorum brevis (FDB), as well as the course of sensory plantar digital nerves. Measurements for the locations of the muscular and sensory branches were taken relative to landmarks including the navicular tuberosity (NT), AH, FDB, and the third metatarsophalangeal joint (third MTPJ).
RESULTS
The mean number of nerve branches to FDB identified was 2. These branch points occurred at an average of 8.6 cm down the MPN or LPN, 9.0 cm from the third MTPJ, 3.0 cm distal to AH distal edge, and 4.8 cm from the NT. The mean number of nerves to AH was 2.2. These branch points occurred at an average of 6.3 cm down the MPN, 11.9 cm from the third MTPJ, 0.8 cm from the AH distal edge, and 3.8 cm from the NT.
CONCLUSIONS
Recurrent interdigital neuroma, painful scar, and neuropathic pain are common complications of operative management for Morton's neuroma. Targeted muscle reinnervation is a technique that has demonstrated efficacy for the prevention and treatment of neuroma, neuropathic pain, and phantom limb pain in amputees. Herein, we have described the neuromuscular anatomy for the application of TMR for the management of Morton's neuroma. Target muscles, including the AH and FDB, have consistent innervation patterns in the foot, and consequently, TMR represents a viable option to consider for the management of recalcitrant Morton's neuroma.
LEVELS OF EVIDENCE
V.
Topics: Feasibility Studies; Foot; Foot Diseases; Humans; Morton Neuroma; Muscles; Neuroma
PubMed: 34854338
DOI: 10.1177/19386400211002702 -
Stem Cells International 2022To investigate the effect of placenta-derived mesenchymal stem cells (PMSCs) on diabetic peripheral neuropathy and explore the role of Wnt signaling pathway.
OBJECTIVES
To investigate the effect of placenta-derived mesenchymal stem cells (PMSCs) on diabetic peripheral neuropathy and explore the role of Wnt signaling pathway.
METHOD
Twenty-seven male db/db mice were randomly categorized into the control group, PMSC group, and PMSC treatment with Wnt inhibitor treatment group. Intervention was initiated in week 22. Thermal stimulation response was determined with a plantar analgesia tester. The mice were sacrificed on 7, 14, and 28 days. The morphology of sciatic nerves was observed by electron microscopy, and the expression of protein gene product (PGP) 9.5, S100, and Ku80 was detected by immunofluorescence. Bax, -catenin, and dishevelled1 (DVL1) were detected by western blot.
RESULTS
Thermal stimulation response was improved in the PMSC group on 14 and 28 days. Compared with the control group, PGP9.5 was increased in the PMSC group, accompanied by a significant increase in the expression of S100. On the contrary, LGK974 inhibited the effect of PMSCs on thermal stimulation response and the expression of PGP9.5 and S100. Both PGP9.5 and S100 were correlated with Ku80 in fluorescence colocalization. The myelin sheath of sciatic nerves in the PMSC group was uniform and dense compared with that in the control group. The effects of PMSCs promoting myelin repair were significantly inhibited in the PMSC+LGK974 group. Bax in the PMSC group expressed less than the control group. In contrast, the expressions of -catenin and DVL1 were higher compared with that in the control group on the 14th and 28th days. The expression of DVL1 and -catenin was lower in the PMSC+LGK974 group than in the PMSC group.
CONCLUSIONS
PMSCs improved the symptoms of diabetic peripheral neuropathy, along with the improvement of nerve myelin lesions, promotion of nerve regeneration, and activation of Schwann cells, which might be related to the regulation of Wnt signaling pathway and inhibition of apoptosis.
PubMed: 36440182
DOI: 10.1155/2022/6897056 -
Plastic and Reconstructive Surgery Jan 2023Symptomatic postresection interdigital neuroma is a frustrating problem that causes debilitating foot pain. Implementing the concepts of targeted muscle innervation,...
BACKGROUND
Symptomatic postresection interdigital neuroma is a frustrating problem that causes debilitating foot pain. Implementing the concepts of targeted muscle innervation, this study offers a novel nerve transfer involving the resected third common plantar digital nerve (CPDN) to the motor nerve branch of the third dorsal interosseous muscle (DIMB) to improve postresection pain.
METHODS
Ten fresh feet from seven cadaveric donors were used for this study. CPDN and DIMB lengths and diameters were measured, along with nerve overlap after the transfer with ankle in neutral position and in maximal dorsiflexion. Motor entry point to the calcaneal tuberosity and to the fifth metatarsal tuberosity were measured and used to evaluate the ratio relative to foot length. Means, standard deviations, and P values were calculated for each measure and between sexes and feet (right and left).
RESULTS
In all specimens, the nerve transfer was technically feasible, without notable size mismatch between the donor and recipient nerves. CPDN, DIMB, and important anatomical reference points were identifiable in all specimens. Average CPDN length was 30.1 ± 8.2 mm. The average DIMB length was 14.4 ± 3.9 mm. The overlap between the donor and recipient in neutral ankle position at the transfer site was 6.4 ± 1.8 mm.
CONCLUSIONS
Given their anatomical locations, a nerve transfer between the third CPDN and third DIMB is surgically feasible. This novel technique is a viable option that can be used instead of the conventional technique of muscle implantation or more proximal re-resection for symptomatic postresection interdigital neuroma.
Topics: Humans; Feasibility Studies; Neuroma; Pain; Muscles; Cadaver
PubMed: 36219864
DOI: 10.1097/PRS.0000000000009785 -
Acta Orthopaedica Et Traumatologica... May 2023This study aimed to describe the course, branches, and variances of the posterior tibial artery, which provides the arterial supply of the plantar surface of the foot,...
OBJECTIVE
This study aimed to describe the course, branches, and variances of the posterior tibial artery, which provides the arterial supply of the plantar surface of the foot, starting from the tarsal tunnel level to provide descriptive information for all surgical interventions, diagnostic radiological procedures, and promising endovascular therapies in the tarsal region.
METHODS
In this study, a dissection of 48 feet was performed on 25 formalin-fixed cadavers (19 males and 6 females). Surgical instruments and a digital caliper were used for dissection and measurements, and the critical structures were recorded by a Canon 250D camera to be illustrated later.
RESULTS
All parameters were significantly longer in male cadavers compared to females. According to the correlation analysis, while there was a significant and robust correlation between the axial line and pternion-deep plantar arch (R=.830, P .05), a moderate correlation was found between the axial line and sphyrion-bifurcation (R=.575; P < .05), axial line and deep plantar arch-2nd interdigital commissure (R=.457; P < .05), and sphyrion-bifurcation and pternion-deep plantar arch (R=.480; P < .05). Variation in any branch of the posterior tibial artery was observed in 27 of the 48 studied sides.
CONCLUSION
In our study, the branching and variability of posterior tibial artery on the plantar surface of the foot were described in detail with the determined parameters. In conditions that cause tissue and function loss and require reconstruction, such as diabetes mellitus and atherosclerosis, the most critical factor in increasing treatment success is a better understanding of the region's anatomy.
Topics: Female; Humans; Male; Tibial Arteries; Foot; Dissection; Cadaver; Tibial Nerve
PubMed: 37395357
DOI: 10.5152/j.aott.2023.22158 -
Foot & Ankle International Nov 2019We describe a thick fascial band arising from the medial aspect of the lateral plantar aponeurosis diving deep into the forefoot crossing over a branch of the lateral...
BACKGROUND
We describe a thick fascial band arising from the medial aspect of the lateral plantar aponeurosis diving deep into the forefoot crossing over a branch of the lateral plantar nerve. Because a review of current literature resulted in limited and outdated sources, we sought to first determine the frequency of this fascial band and the location where it crosses the lateral plantar nerve and, second, discuss the clinical applications these anatomical findings could have.
METHODS
50 pairs of cadaveric feet (n = 100) were dissected to investigate for presence of the fascial band and its interaction with the lateral plantar nerve. Images were taken of each foot with the fascial band. ImageJ was used to take 2 measurements assessing the relationship of the tuberosity of the base of the fifth metatarsal to where the nerve crossed deep to the fascial band.
RESULTS
Overall, 38% of the feet possessed the fascial band. It was found unilaterally in 10 pairs and bilaterally in 14 pairs. On average, the point at which the lateral plantar nerve passed deep to the fascial band was 2.0 cm medial and 1.7 cm anterior to the tuberosity of the base of the fifth metatarsal.
CONCLUSION
When present, the deep band of the lateral plantar aponeurosis (PA) was consistently found to be crossing the lateral plantar nerve. The discovery of the location where this most commonly occurs has not been previously reported and adds an interesting dimension that elevates an anatomical study to one that has clinical potential.
CLINICAL RELEVANCE
The established target zone gives a precise location for where the relationship between the deep band of the lateral PA and the lateral plantar nerve exists when evaluating the foot. The target zone provides a potential springboard for future investigations concerning said relationship clinically.
Topics: Aponeurosis; Cadaver; Fascia; Female; Foot; Humans; Male; Tibial Nerve
PubMed: 31387386
DOI: 10.1177/1071100719864352 -
Journal of Pain Research 2021Quercetin (que) is one abundant flavonol with a variety of biological activities. Previous studies have shown quercetin can reduce neuropathic pain in rats with chronic...
CONTEXT
Quercetin (que) is one abundant flavonol with a variety of biological activities. Previous studies have shown quercetin can reduce neuropathic pain in rats with chronic constriction injury (CCI).
OBJECTIVE
To evaluate the effects of quercetin on neuropathic pain in CCI model and explore its underlying mechanism in vivo.
MATERIALS AND METHODS
CCI model was established by ligating the sciatic nerve of right leg on the SD rats. They were divided into ten groups: sham group, CCI model, sham+ que, CCI+ que group (30, 60, 120 mg/kg), CCI+ AICAR, CCI+ que+ compound C, CCI+etoricoxib, and the control group. They were administered for 28 days, and were performed the mechanical withdrawal threshold (MWT) and thermal withdrawal latency (TWL) during the experiment. At the end of the experiment, sciatic nerves and spinal cord segments of rats were collected, ELISA detected the expression of inflammatory factors, detected the microglia and astrocytes with fluorescence, and Western blot detected AMPK/MAPK pathway.
RESULTS
Que could increase the MWT of CCI rats, improve the TWL of plantar, and reduce the inflammatory cells at the ligation site of the sciatic nerve. Also, que could reduce the levels of TNF-α, IL-6, and IL-1β. Western blotting results showed that p-38 MAPK, p-ERK, and p-JNK were activated in the spinal dorsal horn of CCI model group. After treatment with que and AMPK agonists, the phosphorylation levels of related proteins were inhibited. In addition, the analgesic effect of que was abolished when the AMPK inhibitor was added.
DISCUSSION AND CONCLUSION
Quercetin alleviated the inflammatory response of sciatic nerve and spinal dorsal horn in rats induced by CCI. Quercetin alleviates neuralgia in CCI rats by activating AMPK pathway and inhibiting MAPK pathway and its downstream targets, p-38, p-ERK, and p-JNK.
PubMed: 34040433
DOI: 10.2147/JPR.S298727 -
Veterinary Surgery : VS Feb 2021To report the outcome of horses used in western performance disciplines after deep branch lateral plantar neurectomy/fasciotomy surgery for hind limb proximal suspensory...
Outcome following neurectomy of the deep branch lateral plantar nerve and plantar fasciotomy for hindlimb proximal suspensory desmopathy in western performance horses: 21 cases.
OBJECTIVE
To report the outcome of horses used in western performance disciplines after deep branch lateral plantar neurectomy/fasciotomy surgery for hind limb proximal suspensory desmopathy (PSD).
STUDY DESIGN
Retrospective analysis.
SAMPLE POPULATION
Twenty-one client-owned horses.
METHODS
Medical records were reviewed (2009-2019) for horses involved in western performance disciplines that had been treated with deep branch lateral plantar neurectomy and plantar fasciotomy for lameness due to hind limb PSD. Follow-up was obtained by reexamination and/or verbal interviews with owners >2 years postoperatively.
RESULTS
Sixteen quarter horses and five paints were used for western pleasure (14/21), barrel racing (2/21), cutting (1/21), steer wrestling (1/21), working cow horse (1/21), team roping (1/21) and reining (1/21). A median duration of 8 months was required before horses were able to resume training or athletic work. Nine horses were able to return to a similar or higher level of athletic use, nine horses returned to a lower level of athletic performance, and three horses could not return to intended function. Owner satisfaction with outcome after the procedure was high (16/21), average (3/21), and low (2/21).
CONCLUSION
Deep branch lateral plantar neurectomy and plantar fasciotomy allowed most horses to resume some athletic function as western performance horses.
CLINICAL SIGNIFICANCE
These results provide evidence of potential outcomes when considering surgical treatment of hind limb PSD in western performance horses.
Topics: Animals; Denervation; Fasciitis, Plantar; Female; Hindlimb; Horse Diseases; Horses; Ligaments; Male; Retrospective Studies; Tibial Nerve; Treatment Outcome
PubMed: 33331004
DOI: 10.1111/vsu.13552 -
Medicine Mar 2022Plantar fasciitis is the most common cause of heel pain. Pain can be persistent in some patients and interrupt daily activities and sportive activities. There are a lot...
Plantar fasciitis is the most common cause of heel pain. Pain can be persistent in some patients and interrupt daily activities and sportive activities. There are a lot of treatment options available for plantar fasciitis. We hypothesized that patients with chronic persistent plantar fasciitis can be successfully treated with radiofrequency nerve ablation (RFNA).Two hundred sixty-one patients with plantar fasciitis (378 feet) treated with RFNA from February 2017 to January 2019 were retrospectively assessed. All the patients had plantar heel pain for at least 6months. Based on their body mass index (BMI), the enrolled patients were divided into obese (BMI ≥ 30kg/m2) and non-obese (BMI < 30kg/m2) groups. The patients were asked to complete a questionnaire just before and after the procedure and during the final follow-up. The BNS Radiofrequency Lesion Generator was used during a single session. The patients' information, including their visual analogue scale (VAS) score and American Orthopaedic Foot and Ankle Society (AOFAS) score, was assessed. During their final follow-up, the patients were asked to rate the success of their treatment by choosing one of the following options: completely successful, very successful, moderately successful, marginally successful, or not successful.The VAS and AOFAS scores of all the patients were evaluated pre-procedure, in the first month after procedure, and during the final follow-up (8-24 months). There was a statistically significant difference between the pre-procedure and postprocedure VAS scores (P < .001), there was no statistically significant difference between the VAS scores in the first month postprocedure and during the final follow-up.There was a statistically significant difference between the pre-procedure and postprocedure AOFAS scores (P < .001), there was no statistically significant difference between the AOFAS scores in the first month postprocedure and during the final follow-up.RFNA can be used as an alternative method to surgical procedures for treating plantar fasciitis because it is safe and effective. The advantages of RFNA are that patients can quickly return to their work and resume weight-bearing activities.
Topics: Catheter Ablation; Fasciitis, Plantar; Humans; Pain; Pain Measurement; Retrospective Studies; Treatment Outcome
PubMed: 35357356
DOI: 10.1097/MD.0000000000029142 -
JBJS Essential Surgical Techniques 2023Total talar replacement is a salvage procedure for end-stage osteonecrosis of the talus. A customized total talar implant is designed with use of computed tomography...
BACKGROUND
Total talar replacement is a salvage procedure for end-stage osteonecrosis of the talus. A customized total talar implant is designed with use of computed tomography scans of the healthy opposite side and made of alumina ceramic. The use of such an implant is potentially recommended, with a guarded prognosis, for the treatment of traumatic, steroidal, alcoholic, systemic lupus erythematous, hemophilic, and idiopathic pathologies. The talus is surrounded by the tibia, fibula, calcaneus, and navicular bones, which account for a large portion of the articular surface area. Yoshinaga reported that alumina ceramic prostheses were superior in terms of congruency and durability of articular cartilage compared with 316L stainless steel in an in vivo test in dogs. Therefore, alumina ceramic is an ideal material for replacement of the talus to preserve postoperative hindfoot mobility.
DESCRIPTION
Total talar replacement is performed with the patient in a supine position. The anterior ankle approach is utilized to exteriorize the talus, facilitating dissection of the ligaments and joint capsule attached to talus. The first osteotomy is performed around the talar neck, perpendicular to the plantar surface of the foot. The talar head fragment is then removed. Subsequent talar osteotomies are performed parallel to the first cutting line, at approximately 2-cm intervals. The attaching articular capsule and ligaments are dissected in each step. The removal of the posterior talar bone fragments is succeeded by careful dissection of the ligament and joint capsule under the periosteum. After dissecting the remaining interosseous talocalcaneal ligament, the foot is distally retracted and a customized talar implant is inserted. After testing and confirming the stability and mobility of the implant, the wound is irrigated with use of normal saline solution. A suction drain is placed anterior to the implant, and the skin is closed after repairing the extensor retinaculum.
ALTERNATIVES
In cases with a limited area of necrosis, symptoms may improve with a patellar tendon-bearing brace. However, in many cases of symptomatic osteonecrosis of the talus, nonoperative treatment is not expected to improve symptoms. Alternative surgical procedures include ankle arthrodesis and hindfoot arthrodesis, but there are risks of nonunion, leg-length discrepancy as a result of extensive bone loss, and functional decline because of loss of hindfoot motion.
RATIONALE
Total talar replacement is a fundamentally unique treatment concept in which the entire talus is replaced with an artificial implant. Compared with ankle or hindfoot arthrodesis, this procedure preserves the range of motion of the foot and allows for earlier functional recovery. Postoperative results were satisfactory in the subjective evaluation, with no failure requiring revision. This procedure reduces the risk of postoperative failure in patients who are elderly and/or have underlying diseases, who often require a long recovery time. As the talus is a small bone with uniquely vulnerable vascularity, treatment of talar pathology is usually difficult; however, total talar replacement is a potential treatment option for patients with end-stage osteonecrosis of the talus without obesity.
EXPECTED OUTCOMES
The greatest advantage of total talar replacement is the preservation of ankle and hindfoot mobility. Second, a customized talar prosthesis based on a mirrored model of the contralateral, unaffected talus will allow the smooth transfer of body weight from the lower leg to the heel and forefoot-a requirement for a stable gait. Third, the artificial talar prosthesis has a potential advantage in that it minimizes leg-length discrepancy, preventing daily inconvenience for the patient. Twenty years after the development of the implant, replacement with a total talar prosthesis resulted in a median score of 97 out of 100 on the Japanese Society for Surgery of the Foot (JSSF) Ankle-Hindfoot Scale as an objective evaluation and yielded a significant improvement in the subjective evaluation of the Ankle Osteoarthritis Scale (AOS) in a follow-up study over 10 years. The median ankle joint range of motion was 45°, and complications requiring implant replacement never occurred.
IMPORTANT TIPS
The skin incision should be placed at the center of the inferior tibial articular surface and curved medially to avoid the medial branch of the superficial peroneal nerve.During the resection of the talus, the attaching ligament and joint capsule are recommended to be debrided prior to osteotomy.Bone fragments should be removed as an entire block in order to avoid leaving small fragments.When inserting the artificial talus, pull the entire foot distally by grasping the heel in order to avoid excessive plantar flexion.During wound closure, the extensor retinaculum should be repaired to avoid skin bowstringing.Although favorable long-term results have been reported, postoperative outcomes in patients with high body mass index have not been adequately investigated. This procedure should be carefully selected on the basis of the physical characteristics of the patient.
ACRONYMS AND ABBREVIATIONS
AVN = avascular necrosis (osteonecrosis)SLE = systemic lupus erythematousCAD = computer-aided designCT = computed tomographyJSSF = Japanese Society for Surgery of the FootIQR = interquartile rangeAOS = Ankle Osteoarthritis ScalePWB = partial weight-bearingW = weeks.
PubMed: 38274145
DOI: 10.2106/JBJS.ST.22.00030