An anatomical study of a new portal for ankle arthroscopy

We describe a medial midline portal between the tendons of extensor hallucis longus and tibialis anterior for arthroscopy of the ankle. We dissected 20 cadaver specimens to compare the risk of neurovascular injury using this approach with that of using standard arthroscopic portals. Compared with the anterocentral portal, the medial midline was a mean of 11.2 mm further from the nearest branch of the superficial peroneal nerve and 10.3 mm further from the dorsalis pedis artery. This portal allows good access to the joint surface and intra-articular structures and has a lower risk of injury to the dorsalis pedis artery, deep peroneal nerve or the medial branch of the superficial peroneal nerve.     

Screening of a library of phage-displayed peptides identifies human bcl-2 as a taxol-binding protein

The study was conducted in two parts. First, evoked responses to common peroneal nerve stimulation at four electrode positions were tested in 25 awake volunteers. The initial threshold stimulus current (ITS) (minimal current producing dorsiflexion or eversion of the ankle joint and great toe) and the supramaximal stimulus current (SMS) (the point at which further increases in current did not produce increases in twitch tension) were defined. SMS was not reliably achieved using electrodes at each side of the fibular head. However, an exploratory electrode accurately located the nerve and enabled SMS in all volunteers (SMS/ITS = 3.4). Second, 16 anesthetized, paralyzed patients were studied. The common peroneal and ulnar nerves were stimulated simultaneously. Evoked tension was recorded at the adductor pollicis using a force transducer and at the great toe by a blinded observer. Reversal was given when the train-of-four count at the great toe reached four. Onset times were longer, and median posttetanic counts were greater, at the great toe compared with the adductor pollicis. Time from reversal to train-of-four ratio = 0.7 at the adductor pollicis was 207+/-160 s. We conclude that neuromuscular monitoring at the common peroneal nerve was not equivalent to monitoring at the ulnar nerve. IMPLICATIONS: Accurate neuromuscular monitoring is important for patient safety. We studied the accuracy of monitoring at the common peroneal nerve in volunteers and patients. An exploratory electrode accurately located the common peroneal nerve. Monitoring at the common peroneal nerve was not equivalent to monitoring at the ulnar nerve in patients.     

Nucleus basalis magnocellularis and hippocampus are the major sites of FMR-1 expression in the human fetal brain

Functional assessment of rat sciatic, tibial, and peroneal nerve injuries was performed using walking track analysis. Individual walking print length (PL), toe spread (TS), and intermediate toe spread (ITS) values were measured up to 24 weeks after specific nerve transection, with or without repair. Sciatic and tibial nerve manipulation initially affected all footprint measurements, consistent with loss of intrinsic and extrinsic motor function. After sciatic repair, TS demonstrated partial recovery without any substantial recovery in PL or ITS, compared with sciatic transection values. By contrast, after tibial repair, PL values recovered dramatically, between 16 and 24 weeks, to levels not significantly different from control subjects. This was not observed after tibial transection without repair. TS recovered partially, whereas ITS recovered to control levels by 20 weeks after tibial repair. Peroneal transection resulted in multiple contractures, rendering this group unmeasurable at 4 weeks. After peroneal repair, only the PL reflected significant loss of function at 2 weeks, recovering to control values by 8 weeks. Manual TS measurements in nonwalking rats did not reflect functional nerve regeneration. Thus, individual PL measurements alone can be used to characterize functional recovery after tibial and peroneal nerve injury, whereas TS reflected recovery after sciatic nerve injury.     

Clinical experience of functional electrical stimulation in complete paraplegia

In the Riordan (bridle) transfer, the posterior tibialis muscle as motor is routed through the interosseous membrane and anastomosed into a "bridle" formed by the distal tibialis anterior and peroneus longus muscles. In theory, the bridle provides inversion/eversion balance even if the transfer effects only tenodesis. However, the procedure has been criticized because its insertion is not into bone. This review analyzes the use of bridle transfer in flaccid paresis involving musculature innervated by the peroneal nerve. Surgery was performed 1 to 3 years after injury for patients with traumatic etiology. Ten patients are reviewed at 61 months' mean follow-up. Eight patients had traumatic peroneal nerve loss. Two had neuromuscular etiology. Evaluation included review of records, telephone interviews, and physical examinations. Data on functional status included walking barefoot running, need for bracing, return to duty, and patient satisfaction. Physical examination recorded ankle position and motions, gait findings, and results of static electromyograms. All patients were able to walk barefoot, but 6 of 10 had a mild to moderate limp. Five patients returned to running initially; only two were able to keep running. Nine patients were brace-free initially (polio sequela required bracing initially), and four others returned to bracing. Of these, two experienced an acute "tearing" and dorsiflexion loss, one sustained a prolonged gradual loss of dorsiflexion, and one sustained a contralateral cerebrovascular accident. Only three of seven patients returned to active duty, and one is on jump status. All patients were satisfied with their initial result. Only two patients had no detectable swing phase problems (both returned to active duty). Five patients had peroneal nerve exploration with repair or neurolysis; two of them sustained complete transections. Postoperative electromyograms showed insignificant, if any, nerve return. The Riordan transfer works well for neuromuscular flaccid paresis and in patients with peroneal nerve injuries with low demands. It may stretch out over time to the point of acute failure in patients with high demands. Concurrent peroneal nerve exploration and repair did not seem to be beneficial in this small study.     

Traumatic common peroneal nerve palsy: a retrospective study

A retrospective analysis of 26 consecutive cases of traumatic common peroneal nerve palsy seen during a four-year period in the Department of Rehabilitation Medicine at New York Medical College was carried out. Fifteen were complete lesions, nine were incomplete lesions, and there were two cases of neurapraxia. Among the factors studied were etiology, age, sex, associated injuries, electrodiagnostic findings, and prognosis for recovery. The ultimate functional status of the patients was evaluated up to three years following injury. Of the patients, 19.2% recovered fully, and 26.9% showed partial recovery. The maximum time of recovery was achieved in 15.5 months in complete lesions and 9.5 months in incomplete lesions. The relationship of peronneal nerve injury to fractures of the femur is emphasized. The indications for medical, surgical and rehabilitative management are discussed.     

Classical conditioning of a flexor nerve response in spinal cats: Effects of tibial nerve CS and a differential conditioning paradigm.

Examined, in 4 experiments using 59 cats, the effects of a differential conditioning paradigm on the deep peroneal motor nerve response. Results show that flexor nerve response increases were produced when the conditioned stimulus/stimuli (CS) was delivered to the whole tibial nerve or to the medial plantar branch. The responses to CS/unconditioned stimuli presentations on the superficial peroneal nerve increased, whereas responses to CS presentations on the tibial nerve remained unchanged. However, lack of extinction effects in the superficial peroneal data suggests that stimulation of the tibial nerve potentiated superficial peroneal evoked responses. Furthermore, responses evoked by stimulation of either nerve increased when paired trials were given on the tibial nerve. These data demonstrate that stimulation of the tibial nerve potentiates responses to superficial peroneal nerve stimulation but that superficial peroneal nerve stimulation has no effect on responses to CS presentations to the tibial nerve. (7 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dynamic control of location-specific information in tactile cutaneous reflexes from the foot during human walking

The purpose of the present study was to determine whether tactile cutaneous reflexes from the skin of the foot contain location-specific information during human walking. Muscular responses to non-nociceptive electrical stimulation of the sural, posterior tibial, and superficial peroneal nerves, each supplying a different skin area of the foot, were studied in both legs during walking on a treadmill. For all three nerves the major responses in all muscles were observed at a similar latency of approximately 80-85 msec. In the ipsilateral leg these reflex responses and their phase-dependent modulation were highly nerve-specific. During most of the stance phase, for example, the peroneal and tibial nerves generally evoked small responses in the biceps femoris muscle. In contrast, during late swing large facilitations generally occurred for the peroneal nerve, whereas suppressions were observed for the tibial nerve. In the contralateral leg the reflex responses for the three nerves were less distinct, although some nerve specificity was observed for individual subjects. It is concluded that non-nociceptive stimulation of the sural, posterior tibial, and superficial peroneal nerves each evokes distinct reflex responses, indicating the presence of location-specific information from the skin of the foot in cutaneous reflexes during human walking. It will be argued that differentially controlled reflex pathways can account for the differences in the phase-dependent reflex modulation patterns of the three nerves, which points to the dynamic control of this information during the course of a step cycle.     

Strategy for lipid suppression in lactate imaging using STIR-DQCT: a study of hypoxic-ischemic brain injury

We present MR findings of three cases of surgically proved intraneural ganglion cysts involving the common peroneal nerve (two patients) and ulnar nerve (one patient). The lesions were located along the course of the involved nerve and situated close to a joint. MRI demonstrated the cystic nature and extent of the lesions with clear definition of the anatomic relationship of the lesions to the surrounding structures.     

Effects found in a one-year oral toxicity study in Sprague-Dawley rats of a novel 5-HT1A receptor partial agonist for the treatment of anxiety in humans

Regeneration of motor axons is enhanced if they have sprouted prior to nerve injury. We examined whether sensory axon regeneration and recovery of pain response was affected by previous collateral sprouting. In the experimental group of rats, the right saphenous, tibial, and sural nerves were transected and ligated. The peroneal nerve was left to sprout into the adjacent denervated skin. Two months later, the axons of the peroneal nerve were crushed in the sciatic nerve. In the control group, the right sciatic nerve was crushed at the same time that the saphenous, tibial, and sural nerves were transected. Recovery of pain response in the foot was determined by the skin pinch test. Sensory axon elongation rate was measured by the nerve pinch test. The number of myelinated axons was determined in nerve cross sections stained by Azur blue. Recovery of pain sensitivity in the animals of the experimental group was delayed for 2-3 weeks in comparison to the control group. Moreover, the spatial pattern of pain response in the experimental group was irregular, displaying residual regions of insensitive skin which were not present in controls. The elongation rate of regenerating sensory axons in the experimental group was not decreased, and the number of myelinated axons in the peroneal nerves was even about 10% higher than in the control group. Therefore, we assume that the terminal arborization of the neurilemmal tubes pertaining to the former axon sprouts delayed regrowth of sensory axon terminals in the skin.     

Subacute multifocal painful neuropathy with spontaneous remission

We present the cases of two patients with subacute onset of multifocal painful neuropathy with spontaneous remission and no relapse. The distribution of pain in patient 1 was hands (median > ulnar nerve region) and feet (peroneal and terminal tibial nerve regions), and in patient 2, hands (ulnar nerve region) and feet, left worse than in right. Both patients experienced facial numbness. Deep tendon reflexes were intact except for absent ankle jerks in patient 2. Motor nerve conduction studies demonstrated a marked prolongation of the distal motor latencies with normal proximal segment conduction velocities, suggesting distal demyelination. Cerebrospinal fluid protein concentration was elevated in patient 2, but no definite abnormality was found on sural nerve biopsy. A demyelinating neuropathy with a monophasic self-limited course may be consistent with Guillain-Barre syndrome (GBS). However, the multifocal painful sensory symptoms with facial numbness and the marked distal nerve conduction slowing in our cases are not consistent with GBS.     

Glomerulonephritis associated with basaloid squamous cell carcinoma of the oesophagus. A possible unusual paraneoplastic syndrome

Compressions of the peroneal nerve are rare since only some sixty such cases have been described since 1921. The authors report a new observation of compression extrinsic to the peroneal nerve by a synovial cyst, the source of which was the upper fibulo-tibial joint, in a child of seven years. As far as we know, this is the youngest age found in the relevant literature. Because of a swiftly appearing painful swelling, along with complete paralysis of the peroneal nerve, an electromyogram and a nuclear magnetic resonance were performed, with a view to confirming the diagnosis and to clarifying the topography of the cyst. The removal of the latter led to the child being cured with complete recovery of the peroneal nerve within three months.     

Intraoperative computer-assisted measurement of stimulation threshold of the common peroneal nerve in osteotomy of the head of the tibia

Using a computer-assisted threshold hunting paradigm the motoric threshold of the common peroneal nerve was monitored in 18 patients during a high tibial osteotomy (HTO). The exposed nerve (lateral approach) was stimulated proximal to the osteotomy area and the surface EMG of the M. tibialis anterior was used to guide a threshold hunting device. Motoric threshold as a sensitive indicator of nerve function was found to be almost unaffected by several surgical steps of HTO. Only forceful rotation of a subperiostal Hohmann device during high peroneal osteotomy evoked a slight threshold shift that was fully reversible with device repositioning. The tourniquet, however, affected the threshold significantly. In 10 of the 18 patients the nerve became completely inexcitable after an average time of 59 min. The inexcitability was reversible after opening of the tourniquet. On the other hand, the eight patients maintaining an excitability throughout the entire ischemic period had tourniquet times that did not exceed 60 min. There are several factors that may be responsible for the observed inexcitability after long ischemic periods and we conclude that tourniquet time minimization appears appropriate to avoid neurological deficits during a high tibial osteotomy.     

The effect of denervated muscle and Schwann cells on axon collateral sprouting

The effects of denervated muscle and Schwann cells on collateral sprouting from peripheral nerve were studied in the peroneal and tibial nerves of 48 Sprague-Dawley rats. Three groups were prepared. In group MSW (muscle-Schwann cell-window), the peroneal nerves were transected 3 mm below the sciatic bifurcation. The proximal stumps were sealed in a blocked tube to prevent regeneration and the distal stumps were implanted into denervated muscle cells that were wrapped around the ipsilateral tibial nerve, which had a window of perineurium resected. Schwann cells from the ipsilateral sural nerve were implanted into the muscle. Group MS (muscle-Schwann cell) was similar to group MSW, except that the tibial nerve perineurium was kept intact. In group MW (muscle-window), the muscle was prepared without Schwann cells and the tibial nerve perineurium was windowed. S-100 immunostain was used to identify the Schwann cells surviving 1 week after transplantation. After 16 weeks of regeneration, horseradish peroxidase tracer was used to label motor neurons and sensory neurons reinnervating the peroneal nerve. Myelinated axons of the reinnervated peroneal nerves were quantified with the Bioquant OS/2 computer system (R&M Biometrics, Nashville, TN). A mean of 169 motor neurons in group MSW, 64 in group MW, and 26 in group MS reinnervated the peroneal nerve. In the dorsal root ganglion, the mean number of labeled sensory neurons was 1,283 in group MSW, 947 in group MS, and 615 in group MW. The mean number of myelinated axons in the reinnervated peroneal nerve was 1,659 in group MSW, 359 in group MS, and 348 in group MW. Reinnervated anterolateral compartment muscles in group MSW were significantly heavier than those in group MS or MW. This study demonstrates that the transplantation of denervated muscle and Schwann cells promotes motor and sensory nerve collateral sprouting through a perineurial window.     

Evaluation of iatrogenic accessory nerve injury in forensic medical practice

The authors give a survey of the clinical and medical-legal characteristics of the accessory nerve injury. In the past two decades the conception of the successfulness of the surgical treatment of the accessory nerve injury became prevailing. About the medical-legal aspects of the iatrogenic injury of the nerve reported in connection of the reconstructive surgery chiefly also departments of neurosurgery, orthopedics and traumatology. In the case of the authors a 70 year old patient suffered 10 years ago a iatrogenic accessory nerve injury. The mild trapezius palsy recovered spontaneously practically with cosmetic disadvantage. In connection with the development of extreme dorso-lumbal scoliosis associated with torsion the trapezius atrophy worsened. Physical therapy was partly successful. But the patient became unfit for manual work. Their observations sustain the data of authors who established that in the case of accessory nerve injury not only the surgical but also conservative treatment is usually successful. In opposite to certain data of the literature the authors establish that the iatrogenic injuries of the accessory nerve may lead to significant lifelong disability. The diagnosis is not always made in time with consequent delay in repair. This may be regarded as an unfavorable issue during medical-legal discussions. The authors recommend in interest to prevent nerve injury in the posterior triangle of the neck to perform operation in special department.     

Percutaneous repair of a traumatic bile duct laceration in a liver transplant allograft

BACKGROUND: Phrenic nerve palsy in infants and young children usually results from birth injury or iatrogenic damage. The newborn almost invariably presents with severe respiratory distress, diaphragmatic elevation, and paradoxical movement at the affected side. METHODS/RESULTS: In this retrospective analysis a group of 23 patients below the age of 1 year with an obstetric or postoperative phrenic nerve injury was studied and compared with cases in the literature. All patients were admitted between 1986 and 1997 to the Pediatric Surgical Center, Amsterdam. Thirteen of 18 patients with an obstetric phrenic nerve injury underwent plication of the diaphragm after an average observation period of 100 days. In the remaining five children with an obstetric phrenic nerve injury, spontaneous recovery appeared within 1 month. Only one of five patients with a phrenic nerve palsy after a cardiac surgical procedure underwent plication of the diaphragm. Fifteen of the 34 patients described in the literature underwent plication of the diaphragm after an average of 54 days. CONCLUSIONS: If after 1 month no spontaneous recovery of the diaphragmatic paralysis caused by a phrenic nerve injury occurs, plication of the diaphragm is indicated. This operation proved to be successful for relief of symptomatic phrenic nerve injury in all cases. If the condition of the patient clinically deteriorates during this first month of life, the patient should be operated on immediately.     

Schwannoma of the superficial peroneal nerve presenting as web space pain

A 55-year-old male presented complaining of pain at his right fourth toe and dorsal fourth web space. Physical examination findings pointed to a lesion affecting the superficial peroneal nerve. A schwannoma of the superficial peroneal nerve was subsequently excised, relieving the patient's symptoms. In the differential diagnosis of nontraumatic and/or nonarthritic toe and foot pain, benign tumors, including schwannomas of the tibial and peroneal nerves, should be considered.     

Microsurgical replantation of the amputated penis and scrotum in a 29-year-old man

This clinical note describes a 47-year-old man who had a traumatic amputation of the left lower leg. Two months after wearing a Kondylen Bettung Münster (KMB) prosthesis, he developed a compression neuropathy of the common peroneal nerve of this right leg after sitting cross-legged. This troublesome complication can be avoided by giving accurate information to the patient.     

Prevalence of Helicobacter pylori(Hp) infection in the department of gastroenterology staff members in Nanjing

The intraneural ganglion of the peroneal nerve is a rare lesion. The differential diagnosis includes lesions of the knee especially the tendinopathia of the knee flexors. Clinical examination, electrophysiological investigations, ultrasound imaging and magnetic resonance tomography will establish the diagnosis. We report a case in which an artificial puncture of the ganglion caused a temporary peroneal palsy. Surgical procedure led to complete restoration of the nerve function.     

Is transglutaminase the mediator between antimalarial drugs and psoriasis?

The object of this experimental study was to investigate the influence of low-energy He-Ne laser on the motor nerve cells of the spinal cord. The experimental study included as follws: (1) Four rabbits were used in this experiment. The L5-6 spinal cord segment was irradiated by He-Ne laser percutaneously, the nerve velocity of the comon peroneal nerve was measured in order to determine the function of the spinal motor nerve cells when the peripheral nerve was intact. (2) The common peroneal nerve was transected on one side wothout repair, two weeks after laser irradiation, the grey mater of the spinal cord of L5-6 segment was procured for electronic microscopic examination. (3) The common peroneal nerve on the contralateral side was transected and followed by end-to-end anastomosis, and laser irradiation was done on the same spinal cord segment. Two weeks after irradiation, the nerve velocity of the common peroneal nerve and the toe expanding test were investigated. The results were: (1) the He-Ne laser can influence the spinal motor nerve cells function as expressed by latent rate when the peripherial nerve is intact. i.e. the nerve velocity is slower than mormal, and the amplitude is markedly decreared. (2) the change of the microstructure of the spinal motor nerve cells is comparatively slight in the 10 and 15 minutes groups. (3) the recovery of the nerve velocity and the toe expansion are more earlier in the 15 min. group. In short, the low-energy He-Ne laser can influence the function of the spinal motor nerve cells.     

Thrombocytopenia in pregnancy--a case report

Currently used tendon transfers for persistent traumatic paralysis of the common peroneal nerve are based on the transfer of the posterior tibial muscle, an antagonist muscle to the paralytic group of muscles. In order to achieve voluntary active dorsiflexion of the foot and automatic walking we have transposed the lateral head of the gastrocnemius to the anterior side of the lower leg, at the same time suturing the undamaged proximal end of the deep branch of the peroneal nerve to the motor branch of the tibial nerve innervating the lateral head of gastrocnemius muscle. After nerve regeneration and neurotisation the transposed lateral head of gastrocnemius was innervated by the deep branch of the peroneal nerve and thus it took over the function of the paralytic muscles. The indications for the operation, the surgical technique, and the results obtained in 6 cases are presented.