The dorsomedial cutaneous nerve and bunion surgery

NewsBot · Nov 19, 2016

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BUNIONS, FEET AND BATTLING NERVE DAMAGE: IS THE SENTINEL VEIN A RELIABLE LANDMARK TO LOCATE THE DORSOMEDIAL CUTANEOUS NERVE OF THE HALLUX?
J. Lindsay
Manchester Medical Journal Voll 1, No 1 (2016)

Background Hallux valgus is a common condition in which the phalanges of the hallux deviate laterally and the first metatarsal deviates medially. The deformity is attributed to the long-term wear of tightly fitting footwear; however, a genetic predisposition may contribute to developing the condition. Surgical treatment of hallux valgus includes an osteotomy and rebalancing of the soft tissues. The sensory branch of the dorsomedial cutaneous nerve (DMCN) lies close to the surgical incision site and is at risk of iatrogenic damage. Sensory nerve damage following the procedure has been reported in up to 45% of patients.

Objectives A previous study described a transverse vessel, named the sentinel vein, located immediately superficial to the DMCN. It was therefore suggested that the sentinel vein could act as a landmark for the DMCN. The objective of the current study was to recreate the work from this previous study as far as possible, and determine if the sentinel vein is a reliable landmark for the DMCN.

Methods Cadaveric specimens were carefully dissected to observe both the appearance and position of the sentinel vein. Non-dimensional measurements were then taken to report the anatomical location of the vein.

Results A preserved sentinel vein was observed in 18 out of 31 specimens. In all cases the DMCN was found to either lie immediately deep to the overlying sentinel vein or just distal at the point where the vein joined the plantar venous network. Subjectively, the appearance and position of the vein was seen to vary greatly between different specimens. Non-dimensional measurements placed the sentinel vein at a mean of 30.17% of the total metatarsal length. However intra- and inter-observer repeatability analysis of the results suggested that the measurements may not be reliable in accurately describing the location of the vein.

Conclusion The variation in appearance of the sentinel vein between the specimens, along with the inability to reliably measure the position of the vein, indicates that the sentinel vein may not be a reliable landmark for the dorsomedial cutaneous nerve, and therefore the use of this structure as an anatomical landmark should be cautioned.
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Admin2 · Nov 19, 2016

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Other threads on HAV surgery

NewsBot · Nov 22, 2016

Increasing the safety of minimally invasive hallux surgery—An anatomical study introducing the clock method
Francesc Malagelad et al
Foot and Ankle Surgery; 17 November 2016

Highlights
•At the sites of hallux MIS skin incision, the DMDN and the DLDN of the first toe were found between the 10 oclock and 2 oclock positions regardless of foot laterality.
•The plantar medial branch of the DMDN is a constant structure and branches off at a distance of 2.18 cm proximal to the first MTPJ.
•Distance from the EHL to the DLDN was found to be an average of 0.39 cm.
Background
The purpose of this study is to describe a simple and reproducible method to localize the neurological structures at risk and to describe a safe zone for hallux minimally invasive surgery (MIS) procedures.

Methods
Ten fresh-frozen cadaveric feet were dissected to identify the dorsomedial digital nerve (DMDN) and the dorsolateral digital nerve (DLDN) of the first toe. Axial sections were performed at the sites of metatarsal osteotomies. We documented the position of the nerves with respect to the extensor hallucis longus (EHL) tendon using a clock method superimposed on the axial section

Results
The DMDN was found at an average of 26.2 degrees medial to the medial border of the EHL tendon. (SD 11.26, range 14.5–45.5), whereas the average distance of the DLDN was 32.3 degrees lateral to the medial border of the EHL tendon. (SD 6.29, range 13.5–40).

Conclusions
Using the clock method the DMDN and DLDN were found consistently between 10 o’clock and 2 o’clock in either right and left feet. The clock method may facilitate avoiding the area where these nerves are located serving as a valuable tool in minimally invasive foot surgery.
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NewsBot · Mar 21, 2018

An Anatomical Study of Nerves at Risk During Minimally Invasive Hallux Valgus Surgery.
Dalmau-Pastor M et al
J Vis Exp. 2018 Feb 17;(132). doi: 10.3791/56232.

The growing popularity of minimally invasive surgical (MIS) procedures makes it necessary that new anatomical references arise, to aid in tridimensional orientation and localization of structures that are not directly visible to the surgeon. This is especially critical for structures at risk like nerves or blood vessels. Optimization of the handling of cadaveric material and the combination of multiple techniques compensate for the limited availability of adequate specimens. The described protocol combines anatomical plane-by-plane dissection and sectional anatomy of fresh-frozen specimens to help localize relevant structures, such as nerves, arteries, veins and to correctly position the portals during MIS procedures. Depiction of these structures in anatomy textbooks can differ from what is encountered in the surgical field; and for this reason, new anatomical studies with a surgical orientation are needed. However, this is a complex, time-consuming technique requiring specific training. The anatomical references described with the so-called 'clock method' provide the surgeon with an easy and reproducible system to locate the path of the nerves at risk in Hallux Valgus MIS procedures. This model can be extrapolated to many other minimally invasive surgical procedures.
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NewsBot · Apr 18, 2021

Anatomy of the Dorsomedial Cutaneous Nerve to Hallux and Surgical Implications According to the Severity of Hallux Valgus Deformity: A Cadaveric Study.
Sérgio Soares, MD et al
JFAS: April 13, 2021

The dorsomedial cutaneous nerve to hallux provides sensation to the dorsomedial aspect of the first metatarsophalangeal joint and hallux. Postoperative damage to the dorsomedial cutaneous nerve to hallux have been reported with the dorsomedial approach and symptoms can be very debilitating. The present study aims to understand how the distance between this nerve and the extensor hallucis longus tendon are affected by the severity of the hallux valgus deformity, at the level of the first metatarsophalangeal joint. We performed a cadaveric study using 35 cadaveric lower extremities (N=35). Each specimen was classified according to the hallux valgus severity through a 30 Kg partial weight-bearing antero-posterior radiograph. Before dissection, the lower extremities’ greater saphenous vein was injected with black latex to simplify the distinction between anatomical structures. We concluded that as the hallux valgus angle and the first intermetatarsal angle increase, the distance between the dorsomedial cutaneous nerve to hallux and the extensor hallucis longus tendon also increases, ranging from 12mm in normal feet to 19mm in severely deformed feet.
Hallux valgus is a three-dimensional deformity that changes traditional surgical landmarks. To avoid harming this nerve, we established a danger zone ranging from 12mm to 19mm medial from the extensor hallucis longus tendon, at the level of the first metatarsophalangeal joint. The mid-medial approach to MTP should be preferred as it is out of the danger zone.
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NewsBot · Jan 31, 2022

An Anatomic Study of the Lateral Dorsal Cutaneous Nerve Using 3-Tesla MRI: A Comparison to Cadaveric Data With Surgical Applications
Claudio B. Ghetti, BA, Brendon C. Mitchell, MD, Vrajesh J. Shah, BS, ...
January 24, 2022

Background:
The lateral dorsal cutaneous nerve (LDCN) and the anastomotic branch of the sural nerve (AB) are cutaneous sensory nerves at risk of iatrogenic injury during lateral foot surgery. This study is the first to use a large cohort of high-resolution magnetic resonance images (MRIs) of the ankle to better describe the course of these nerves in vivo in order to aid surgeons intraoperatively. Our study intends to build on the “high and inside” approach to the proximal 5MT by accounting for variations in course of the LDCN and AB.

Methods:
One hundred twenty-five 3-tesla (T) MRI studies of the ankle were analyzed. Three reviewers measured the distance from the LDCN and AB to landmarks including the most proximal aspect of the fifth metatarsal tuberosity (5MT) and the peroneus brevis tendon (PBT).

Results:
Mean vertical distance from the LDCN to the 5MT was 0.8 ± 0.2 cm. Presence of an AB was visualized in 59 of 125 studies (47.2%) and was found 2.2 ± 0.5 cm dorsal to the 5MT. The AB was found to become superior to PBT at a horizontal distance 1.9 ± 0.5 cm proximal to the 5MT. The LDCN was found superior to the PBT at its insertion onto the 5MT in approximately 10% (n = 12) of our studies. During these instances, the LDCN was located an average of 0.3 cm dorsal to the PBT.

Conclusion:
Our proposed “safe zone” for the approach to the proximal 5MT remains superior to the LDCN and inferior to the AB and avoids crossing directly over either nerve in >95% of analyzed MRI studies. This incision begins 1.5 cm dorsal to the most proximal aspect of the 5MT and extends no more than 1 cm posteriorly. Careful dissection and identification of the LDCN and possible AB is necessary prior to further extension of incision.
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NewsBot · May 15, 2022

Supernumerary Branches of the Dorsomedial Cutaneous Nerve of the Hallux Crossing the Extensor Hallucis Longus Tendon
Alexander J Pocwierz et al
FASEB J. 2022 May

The dorsomedial cutaneous nerve of the hallux (DMCN) provides sensation to the skin of the dorsomedial hallux (big toe) and the first metatarsophalangeal joint. This cutaneous nerve, a terminal branch of the superficial fibular (peroneal) nerve, is located in the dorsum of the foot and crosses the extensor hallucis longus (EHL) tendon during its course. At this intersection point, the DMCN is at risk for injury during operations of the hallux and metatarsophalangeal joint including EHL tendon transfer, hallux valgus or hallux rigidus corrections, bunionectomy, cheilectomy, or injection procedures. Iatrogenic injuries often result in sensory loss, debilitating causalgia, or neuroma formation. The aim of this study was to identify anatomical variations at the intersection of the DMCN and the EHL tendon. Twenty-three feet (12 left-sided, 11 right-sided) from 12 cadavers were dissected to follow the course of the DMCN and look at its intersection with the EHL tendon. Dissection resulted in damage to three DMCNs; however, 20 feet (11 left-sided and 9 right-sided feet) dissections resulted in excellent visualization of both the DMCN and the EHL tendon. Supernumerary branches of the DMCN were identified crossing the EHL tendon in multiple locations in fourteen of twenty feet (70.0%), including nine left feet (9/11, 81.8%) and five right feet (5:9, 55.6%). Of the fourteen feet with supernumerary branches, seven feet (50.0%) had two branches, four feet (28.6%) had three branches, and three feet (21.4%) had four-to-six branches of the DMCN crossing over the EHL tendon in multiple locations. The results of this study identify the complex branching patterns of the DMCN. Surgeons should be aware of that supernumerary branches of the DMCN exist, crossing the EHL tendon in multiple locations, and use ultrasonography to lower the risk of iatrogenic injury to the DMCN during surgical procedures.
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