Risk of injury to the sural nerve during posterolateral approach to the distal tibia: An ultrasound simulation study

Abstract

When surgeons operate on the foot and ankle, the most common complication that may arise is injury of the cutaneous nerves. The sural nerve (SN) is potentially at risk of being injured when treating fractures involving the distal tibia using the posterolateral approach. The aim of this study was to evaluate how differences in length and position of the surgical treatment of fractures involving the distal tibia can affect the risk of SN injury. The study involved 40 healthy volunteers (n = 80 lower limbs). Ultrasound simulation of each potential surgical incision site was used to locate the SN and to assess the risk of injury. The study showed that the SN predominantly travels more posteriorly at levels more proximal from the tip of the lateral malleolus. At these more proximal points of the SN's course, it was proven that there was an overall increased incidence of iatrogenic injury to the SN in incisions made closer to the Achilles tendon. Based on these results, a quasi 3 dimensional figure was created showing the anatomical structures of this region to identify areas at high risk for SN injury. By revealing how length and position of the surgical incision can influence the risk of SN injury, we hope to provide information to surgeons on the optimal technique to avoid iatrogenic SN injury while operating on the distal tibia via a posterolateral approach. Clin. Anat. 31:870-877, 2018. © 2018 Wiley Periodicals, Inc.

The anatomical landmarks effective in the localisation of the median nerve during orthopaedic procedures

“…Ultimately, proper anatomical knowledge provided by the safe zone may help surgeons avoid iatrogenic injury to the MN while decompressing the carpal tunnel [18]. Other examples of safe zones established with USG includes the posterolateral approach to the sural nerve [14] and the infrapatellar branch of the saphenous nerve during tendon graft harvesting for knee ligament reconstruction [21].…”

Distribution patterns of the cutaneous nerves on the dorsum of the foot and their clinical significance

“…The superficial fibular, deep fibular, and sural nerves on the dorsum of the foot may be at risk of iatrogenic injury during surgical procedures such as removing painful neuromas in the foot (Canovas et al, ; Lans et al, ), neurovascular free flap from the dorsum of the foot (Daniel et al, ), ankle arthroscopy (Malagelada et al, ), and treating fractures involving the tarsal bone or distal fibula (Li, ; Mizia et al, ). These nerves can also be compressed in various conditions such as acute trauma, repetitive microtrauma, varicosities, hematoma, soft‐tissue edema, and bone, joint, or muscle abnormalities (Delfaut et al, ).…”

“…There is a risk of iatrogenic injury to the cutaneous nerves of the dorsum of the foot during various surgical procedures performed at the distal part of the fibula, the ankle, and the dorsum of the foot (Daniel et al, ; Canovas et al, ; Li, ; Mizia et al, ; Lans et al, ; Malagelada et al, ). Entrapment neuropathy secondary to trauma or excessive repetitive movement can also affect the cutaneous nerves on the dorsum of the foot (Styf, ; Schon, ).…”

The anatomical relationship between the sural nerve and small saphenous vein: An ultrasound study of healthy participants

“…Due to its close relationship to the SSV, the SN is at risk during sapheno‐popliteal junction dissection, stripping, thermal ablation, and phlebectomy of the SSV (Ricci et al, ; Schweighofer et al, ; Kerver et al, ). Injury to the SN has also been reported following Achilles tendoscopy and surgical repair (Kammar et al, ), in the treatment of distal tibial fractures (Mizia et al, ), and ankle arthroscopy (Appy‐Fedida et al, ).…”

“…There is no consensus regarding the surgical and surface landmarks for a safe approach to the SSV harvest or treating fractures involving the distal tibia and ankle (Jowett et al, ; Kerver et al, ; Mizia et al, ). The SN and the SSV are in closest proximity to each other in the distal two‐thirds of the leg and are furthest in the upper one‐third of the leg (Kerver et al, ).…”