Iatrogenic posterior tibial nerve division during ankle arthroscopy

AIM: To evaluate the validity of cumulative rim/disc area (RA/DA) curve analysis as a clinical tool for the identification of glaucoma induced optic disc pathology. METHODS: 71 normal and 83 glaucomatous eyes were evaluated from a series of 154 subjects recruited for this study. For each eye, the cumulative distribution of RA/DA was calculated from 36 equally spaced rim sectors of each optic disc obtained by the automatic evaluation of simultaneous videographics (Image-net X Rev.3/51b). To increase the sensitivity of this analysis in early glaucoma and in normal eyes, these cumulative curves were subsequently divided into two equal segments and the slopes of their respective regression lines compared. RESULTS: The median RA/DA value obtained from the 36 sectors was significantly different in glaucomatous eyes compared with normals (p < 0.001). Nevertheless, the curves (5th-95th percentile of the cumulative curves distribution) of early glaucomatous eyes fell within the normal range. When the cumulative curve of these marginal cases was then divided into two equal segments, the comparison of the slopes of the regression lines showed a significant difference (p < 0.05) in 100% of early glaucomatous eyes. Furthermore, normal eyes were shown to be true negatives in 93% of the cases in which no significant difference between the two slopes was observed. CONCLUSION: Analysis of the RA/DA cumulative curve from 36 sectors of the optic disc was a valid method for the identification of glaucomatous disc pathology; however, a further calculation of the slopes of the two RA/DA regression lines was needed to identify early glaucomatous damage.     

Recurrent dislocation of tibialis posterior tendon. A report of two cases

We successfully treated two patients with recurrent dislocation of the tibialis posterior tendon by creating a bone block. Sudden resistive contraction of the tibialis posterior muscle is considered to be the mechanical cause of the initial traumatic injury, and a shallow tibialis posterior tendon sulcus may be the predisposing factor. Once the flexor retinaculum is torn during the initial trauma, recurrent dislocation is inevitable, and surgical treatment is mandatory. When treating patients with a complaint of long-standing pain around the medial malleolus, we must bear in mind the possible diagnosis of recurrent dislocation of the tibialis posterior tendon. If the patient can voluntarily dislocate the tendon by active plantar flexion and inversion of the ankle, the diagnosis is definitive.     

Open medial subtalar dislocation associated with fracture of the posterior process of the talus

A case of medial subtalar dislocation associated with fracture of the posterior process of the talus is described. Although this injury pattern is uncommon, it is important to recognize the associated fracture, as it involves a weightbearing articular surface. In this case, the flexor hallucis longus also prevented anatomic closed reduction necessitating open reduction and internal fixation.     

Deformity of the foot following anterior transfer of the posterior tibial tendon and lengthening of the Achilles tendon for spastic equinovarus

Twenty-four children with spastic equinovarus deformity due to cerebral palsy were treated by anterior transfer of the posterior tibial tendon and Achilles tendon lengthening. In five patients, the operation was performed on both sides, making a total of 29 feet available for evaluation after an average follow-up of five years. Only 38 per cent of the results were graded "good" or "satisfactory." Sixty-two per cent were rated as "poor" because of valgus, calcaneus or equinus deformity severe enough to require re-operation. The post-operative deformity was generally evident one or more years after surgery, often progressive, and more disabling as well as more difficult to correct than the original condition. Although the percentage of acceptable results was considerably higher for hemiplegic patients than for others in the study, we conclude that in this group and in all other categories of spastic patients anterior transfer of the posterior tibial tendon should not be performed.     

Torsion of the tendon of tibialis posterior

The authors present a previously undescribed torsion located within the tendon of tibialis posterior. The musculotendinous unit of tibialis posterior was isolated from 17 lower extremities of cadavers. A small goniometer was constructed and used to quantify the degree of torsion located within each tibialis posterior tendon. Torsion was present in all 17 cadaver specimens, with a mean of 47.5 degrees and a range from 21 degrees to 62 degrees. The regional anatomy and biomechanical functions of tibialis posterior are discussed, and proposed bases for the embryologic origins and functional significance of the torsion are presented.     

The posterior tibial tendon and the tarsal sinus in rheumatoid flat foot: magnetic resonance imaging of 40 feet

OBJECTIVE: To investigate the role of the posterior tibial tendon in the flat foot deformity of rheumatoid arthritis (RA). METHODS: Eleven patients with hyperpronated feet and 9 without hyperpronation underwent magnetic resonance imaging (MRI) of the feet and ankles. Radial oblique double echo images provided cross sectional views of the posterior tibial tendon as it coursed behind and under the medial malleolus and inserted beneath the midfoot. RESULTS: Complete tears (Type III) of the posterior tibial tendon were seen in one patient with hyperpronation and in one without hyperpronation. However, partial tears (Types I and II) of the posterior tibial tendon were common, and when Type I-III posterior tibial tendon tears were grouped together, they were seen in 68% of flat feet and in 43% of feet that were not flat. Abnormalities of the tarsal sinus, including cortical erosions and replacement of the normal fat signal with intermediate signal soft tissue, were seen in 74% of flat feet and in 5% of feet that were not flat. CONCLUSION: Posterior tibial tendon tears are common in RA flat feet, but are usually incomplete and are not solely responsible for the flat foot deformity.     

Vascular injuries associated with dislocation of the knee

Two hundred and forty-five knee dislocations were analyzed including forty-one new cases. The high incidence of injuries to the popliteal artery that accompanies this lesion (32 per cent) was confirmed, and it was re-emphasized that vascular repair must be completed within six or at the most eight hours from the time of injury to avoid amputation. Of the patients not treated within that time period, 86 per cent had an amputation and two-thirds of the remaining 14 per cent had ischemic changes.     

Avulsion fracture of the coracoid associated with acromioclavicular dislocation

A 5-year-old girl was bitten in her left eye by a lance-headed viper identified as Bothrops moojeni, measuring 115 cm of length. There was severe facial swelling and left exophthalmus, and enucleation of the eye was necessary. The patient apparently had mild systemic envenoming, but local inflammatory signs and histological evidence of necrosis suggest that both the mechanical trauma and the local action of the venom had a role in the genesis of the eye lesion. It is arguable if the loss of the eye could be prevented even if the antivenom was administered earlier.     

Radiologic findings in lymphangioma of the posterior tibial nerve

This article describes the conceptual framework upon which the Bachelor's Degree program in Dental Laboratory Sciences at the University of Texas Health Science Center was constructed. Development of specific program objectives rested on the following four guiding principles: 1) combine professional laboratory training with management education; 2) focus on a problem-based pedagogy; 3) provide flexibility to accommodate today's "nontraditional" student population; and 4) utilize the close relationship with the University of Texas Dental School at San Antonio.     

Closed rupture of the anterior tibial tendon. A case report

Closed subcutaneous rupture of the anterior tibial tendon is a relatively uncommon injury that requires a thorough clinical examination to diagnose correctly. The authors report a case of this disorder and provide a review of the relevant literature. A method of surgical repair not previously described in the literature is also presented.     

Median-nerve neuropathy associated with chronic anterior dislocation of the lunate

Ten patients who had median-nerve neuropathy in association with chronic anterior dislocation of the lunate were managed operatively and were followed for an average of five years (range, three to eight years). The average time from the injury to the initial evaluation was twenty-one months (range, six to sixty-five months). All ten patients had pain as well as sensory and motor dysfunction in the distribution on the median nerve. Nerve-conduction-velocity studies revealed a delay in distal motor and sensory latencies in all patients; the distal motor latency averaged 12.5 milliseconds (range 5.6 to 18.6 milliseconds), and the distal sensory latency averaged 12.4 milliseconds (range, 4.8 to 16.8 milliseconds). Three patients had had a failed carpal tunnel release and needed excision of the lunate for decompression of the median nerve. In the other seven patients, three distinctive sites of nerve compression were identified: the volar and dorsal edges of the lunate and the proximal edge of the transverse carpal ligament. Excision of the osseous protuberance (excision of the lunate in three patients and a proximal-row carpectomy in four), combined with a release of the transverse carpal ligament, resulted in relief of the symptoms, functional improvement, and sensory and motor recovery in the distribution of the median nerve.     

Early posterior ankle release in the treatment of congenital clubfoot

Eighty-one patients (116 clubfeet) underwent posterior ankle release before the age of two years, following unsatisfactory responses to serial corrective casts applied according to the technique of Kite. Seventy-three per cent of these feet showed no or only mild talar flattening at an average follow-up of 7.5 years. Four years, following posterior ankle release there was a none-mild talar flattening rate of 69 per cent in this group compared to a 40 per cent none-mild rate in ankle release reduces the incidence of recurrent equinus deformity and the necessity for subsequent surgery in comparison to the results obtained with serial plaster casts or with tendo Achillis lengthening alone. Recent trends in clubfoot management have favored increasingly early operative intervention. Denham stated that "In the infant hard tissues (bone and cartilage) should be regarded as soft, and the soft tissues (tendon and ligament) as hard." Our operative experience with posterior ankle release supports this philosophy and indicates that early aggressive surgical management is the treatment of choice for the resistant clubfoot.     

In-situ forces in the human posterior cruciate ligament in response to posterior tibial loading

The presence of human cytomegalovirus (HCMV) DNA in liver, spleen, and kidney samples of HCMV-seropositive trauma victims during latency was demonstrated by polymerase chain reaction (PCR), using primers reactive with the major immediate early gene exon 4 and the structural gene pp150. Sequence analysis of the PCR amplificates showed more than 95% homology with the reference HCMV strain AD169. The few mutations observed were mostly distributed randomly. In one subject two types of the MIE-4 gene were detected, and in another subject two types of the pp150 gene were found, suggesting that different strains of HCMV can be found in organs of the same patient during latency.     

Tibial tuberosity avulsion associated with patellar tendon avulsion

We report an adolescent boy with avulsion of the tibial tuberosity associated with avulsion of the patellar tendon. He underwent open reduction and internal fixation of his bone injury and the patellar tendon was successfully reattached. The boy experienced a full recovery.     

Focal myoclonus associated with posterior thalamic hematoma

PURPOSE: We report a new incision for repair of penile fracture. MATERIALS AND METHODS: We describe 2 cases in which the inguinal scrotal incision was used for repair of penile fracture. The preoperative evaluation as well as the technical case and rationale for use of this incision are discussed. RESULTS: Preoperative cavernosogram delineated the site of the fracture. Immediate repair of the fracture using the inguinal scrotal incision was successful. CONCLUSIONS: The inguinal scrotal incision should be entertained for cases of penile fracture. It avoids incision into markedly edematous penile skin and allows for excellent visualization of the fracture site.