经皮跟腱延长术治疗脑瘫患儿跟腱时腓肠神经和内侧神经血管束与跟腱的关系。

Relation of the Sural Nerve and Medial Neurovascular Bundle With the Achilles Tendon in Children With Cerebral Palsy Treated by Percutaneous Achilles Tendon Lengthening.

机构信息

Ortopediatri Istanbul, Academy of Pediatric Orthopaedics.

Nisantasi Orthopaedics Center.

出版信息

J Pediatr Orthop. 2022 Feb 1;42(2):e201-e205. doi: 10.1097/BPO.0000000000002020.

DOI:10.1097/BPO.0000000000002020

PMID:34995262

Abstract

BACKGROUND

One of the most common treatment options for a short Achilles tendon (AT) in cerebral palsy is percutaneous AT lengthening using 3 hemisections. Because of proximity of neurovascular structures around the tendon, iatrogenic injury to them have been a concern about this technique. The sural nerve (SN) is under risk of injury at the site of the lateral incomplete cut, especially if it is done proximally. The medial neurovascular bundle is under injury risk at medial cuts. The aim of the article was to study the anatomical relations of the SN and medial neurovascular bundle to the AT, and define dangerous levels for injury with the help of magnetic resonance imaging (MRI).

METHODS

Patients operated for percutaneous Achilles lengthening were called for MRI investigation of the SN and medial neruvascular bundle integrity and their anatomical relation with the AT. The distance of 5 mm was taken as the threshold for increased risk of injury. Measurements were done on MRI at each cm from the insertion of the tendon on both medial and lateral sides, and at the level of the middle cut.

RESULTS

Thirty ankles operated and followed at least 1 year were included to the study. On the medial side, the tibial nerve, and the posterior tibial artery lied more than 5 mm away from the tendon at all levels in all patient. On the lateral side, the first 4 cm were relatively safe for the middle lateral cut, while increased risk of SN damage was detected in more proximal levels. Overall, 6 of 30 ankles had radiographically detectable SN injury.

CONCLUSIONS

The first 4 cm of the AT on the lateral side was detected to be safe for the middle lateral directed cut, while whole tendon length were found to be safe for the first and the third cuts of the percutaneous Achilles lengthening surgery using 3 hemisections in children with cerebral palsy.

LEVEL OF EVIDENCE

Level III.

摘要

背景

脑瘫患者短跟腱的一种常见治疗选择是采用 3 次半切开经皮跟腱延长术。由于跟腱周围神经血管结构的位置接近，因此人们一直担心这种技术会造成医源性损伤。在外侧不完全切开处，跟腱外侧神经（SN）有受伤的风险，尤其是在靠近近端处进行操作时。在进行内侧切开时，内侧神经血管束有受伤的风险。本文的目的是通过磁共振成像（MRI）研究 SN 和内侧神经血管束与跟腱的解剖关系，并确定在该技术中受伤的危险水平。

方法

对接受经皮跟腱延长术的患者进行 MRI 检查，以评估 SN 和内侧神经血管束的完整性及其与跟腱的解剖关系。以 5mm 的距离作为增加损伤风险的阈值。在每条腿的跟腱附着处的近端和远端各 1cm 处，以及中间切开处，测量每条腿的跟腱内外侧各 1cm 处的距离。

结果

本研究共纳入 30 例至少随访 1 年的踝关节手术患者。在内侧，在所有患者的所有水平，胫神经和胫后动脉均距离肌腱超过 5mm。在外侧，前 4cm 对于中间外侧切开相对安全，而在更靠近近端的水平则检测到 SN 损伤的风险增加。总的来说，在 30 例踝关节中，有 6 例出现了可在影像学上检测到的 SN 损伤。