To provide an anatomical basis for diagnosis and treatment of the tarsal tunnel syndrome, the relationship of the tibial nerve to the tarsal tunnel was investigated in 31 feet of 20 cadavers. The bifurcation into medial and lateral plantar nerves occurred within 1 cm of the malleolar-calcaneal axis in 90% of the feet. Seven of 11 bilateral specimens were bilaterally symmetrical in the bifurcation location; three varied within 1 cm between sides; and in the fourth cadaver, one side bifurcated at 3 cm and the other at 5 cm proximal to the axis. The calcaneal nerve showed great variability; in seven cadavers, it arose within, in eight cadavers proximal to, and in five cadavers there were multiple branches arising both proximal to and within the tarsal tunnel.
"ns of the tibial nerve in 82% of our cases (Fig. 3).This is similar to the studies by Andreason Struijk et al. (2010), Bilge et al. (2003), Davis et al. (1995), who illustrated that in the majority of their cases, 80%, 96% and 90% respectively, the tibial nerve bifurcated into the medial and lateral plantar nerves within 2cm of the MMCA. Dellon et al. (1984) found a similar majority (90%) but noted that they bifurcated within 1cm of this axis."
[Show abstract][Hide abstract] ABSTRACT: In this anatomical, cadaveric study we describe a
novel method of determining the point of origin of
the plantar and calcaneal divisions of the tibial
nerve around the tarsal tunnel, in the clinical setting,
without requiring the exact path of the nerve
to be known.
To this end, we describe an area that arises from
the midpoint of the navicular-calcaneal line (MPNCL),
which contains both nerve divisions in the
majority of cases. We called this area the danger
zone. We identified the size and location of this
danger zone by dissecting a total of 50 cadaveric
feet. We measured the distance from the origin of
each nerve division to both the navicular tuberosity
and the calcaneal insertion of the Achilles tendon.
From these measurements we were able to calculate
the distance of each division from the MP-NCL
along two axes, the navicular-calcaneal line (NCL)
and a line perpendicular to this crossing at the
The danger zone of the tibial nerve, around the
tarsal tunnel is a 16.5 cm² (5.9 x 2.8 cm) quadrilateral
area that passes posterior and proximal from
the MP-NCL. This area in our study contained both
the plantar and calcaneal divisions of the posterior
tibial nerve in 82% of cases. Those divisions that
arose outside this area (18%) occurred up to 0.5
cm anterior to the MP-NCL and 1.4 cm distal to the
"(Table 1) Horwitz16 only reported the existence of one or more branches, not specifying
numbers. Dellon et al.17
found one or two branches, while the former was the most common (75%). Davis et
al.21 observed from one to
three branches, with two to three occurring most often (60%). "
[Show abstract][Hide abstract] ABSTRACT: Determine, through dissection in fresh cadavers, the topographic anatomy of the tibial nerve and its branches at the ankle, in relation to the tarsal tunnel.
Bilateral dissections were performed on 26 fresh cadavers and the locations of the tibial nerve bifurcation and its branches were measured in millimeters. For the calcaneal branches, the amount and their respective nerves of origin were also analyzed.
The tibial nerve bifurcation occurred under the tunnel in 88% of the cases and proximally in 12%. As for the calcaneal branches, the medial presented with one (58%), two (34%) and three (8%) branches, with the most common source occurring in the tibial nerve (90%) and the lower with a single branch per leg and lateral plantar nerve as the most common origin (70%). Level of Evidence, V Expert opinion .
[Show abstract][Hide abstract] ABSTRACT: Neuropathy associated with Diabetes is increasing at epidemic rates throughout the world. Traditionally, this neuropathy causes loss of protective sensation leading to ulceration, infection , and amputation. Even with good glycemic control, this neuropathy is still considered progressive and irreversible. In many patients with diabetic neuropathy there is also associated pain and loss of balance, requiring expensive neuropathic pain medication and treatment of hip and wrist fractures. In 1988, Dellon observed that therecould be a new optimism for this problem, because the metabolic neuropathy made the peripheral nerve susceptible to compression, which might be responsible for these clinical symptoms and sequelae. In 1992, Dellon published the first clinical research documenting that decompression of peripheral nerves at known sites of anatomic narrowing could relieve the symptoms of neuropathy and prevent ulcers and amputations. In this Thesis, the primary hypothesis tested is that the metabolic neuropathy of diabetes makes the peripheral nerve susceptible to nerve compression at known sites of anatomic compression, and that decompression of these superimposed compressions can relieve the symptoms and thereby alter the natural history of diabetic neuropathy. The basic animal science research models and anatomic investigations that form the basis for this clinical approach are described and their results documented. New clinical outcome studies are described and their results documented. The summary of this research is that: I) The ideal patient for surgical decompression of peripheral nerves who has diabetes is one who can have the degree of neuropathy documented and staged by neurosensory testing with the Pressure-Specified Sensory Device and one who has clinical evidence of nerve compression with a positive Tinel sign at known anatomic sites of narrowing; the common peroneal nerve at the fibular head, the deep peroneal nerve over the foot dorsum, and the branches of the tibial nerve in the four medial ankle tunnels. Furthermore, the patient should have sufficient blood supply to the foot and be without edema in the foot to permit satisfactory wound healing. II) Given the above inclusion criteria for surgery, it can be expected that there will be an 80% chance of relief of pain from an 8.5 to a 2.0 on a Visual Analog Scale within 3 months of surgery, and an 80% chance to improve sensibility significantly within one year after surgery. III). In the group of patients for whom sensibility is restored, the natural history of diabetic neuropathy will be changed such that there will be no ulcerations and no amputations. IV) In patients who have bilateral Dellon Triple Nerve Decompression surgery, balance will be improved minimizing the risk of fractures due to falls. It is concluded that patients with diabetes who have superimposed nerve compressions in the lower extremities can achieve relief of symptoms and prevention of ulceration and amputation by decompression of these multiple sites of nerve compression using the operative approaches described in this Thesis.
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