title: Nerve structures at risk in the plantar side of the foot during anterior tibial tendon transfer: a cadaver study.
abstract: BACKGROUND
  Anterior tibial tendon transfer is a common procedure for treatment of clubfoot recurrence. Fixation of the tendon usually includes passing the tendon through the lateral cuneiform. Drilling the bone and passing sutures through the plantar aspect of the foot may cause neurovascular damage.
  
  
  METHODS
  Anterior tibial tendon transfer was performed through the lateral cuneiform in twelve cadaveric limbs. Drill holes were made perpendicular to the lateral cuneiform surface (group A), made perpendicular to the weight-bearing surface (group B), inclined 15° in the frontal and sagittal planes (group C), or aimed at the middle of the plantar aspect of the foot (group D). Two unmodified Keith needles and two blunted Keith needles were each passed ten times per foot. A dissection was performed. The average distance from the drill hole to the nerve structures and the number of punctures of nerve structures were reported.
  
  
  RESULTS
  In group A, the drill hole was 1.7 mm from a medial plantar nerve branch and 5 mm from the nerve bifurcation. In group B, the hole was 0.3 mm from a branch of the lateral plantar nerve and 25.3 mm from the lateral plantar nerve bifurcation. The drill hole in group C was 1.7 mm from the lateral plantar nerve bifurcation. In group D, the drill direction resulted in an inclination of 22° in the frontal plane and 4° in the sagittal plane. The drill exited 7.7 mm from a medial plantar nerve branch and 4.3 mm from a lateral plantar nerve branch. The medial and lateral plantar nerve bifurcations were at a distance of 13 mm and 14.7 mm, respectively, from the drill hole in group D. Unmodified Keith needles punctured nerve structures twelve times in group A, twenty times in group B, six times in group C, and once in group D. Use of blunted Keith needles resulted in no nerve punctures.
  
  
  CONCLUSIONS
  When anchoring the transferred anterior tibial tendon in the lateral cuneiform for the treatment of clubfoot recurrence, the drill should be aimed at the middle of the plantar surface of the foot to minimize the risk of nerve damage. Passing the sutures with a blunt needle might prevent damage to nerves or vessels when anterior tibial tendon transfer to the lateral cuneiform is performed for the treatment of clubfoot recurrence.
authors.affiliation: International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21211, USA. christof.radler@chello.at
authors.forename: Christof
authors.initials: C
authors.lastname: Radler
authors.forename: Monique C
authors.initials: MC
authors.lastname: Gourdine-Shaw
authors.forename: John E
authors.initials: JE
authors.lastname: Herzenberg
mesh_terms: D002102:Cadaver; D003025:Clubfoot / Q000601:surgery; D005260:Female; D005528:Foot / Q000294:innervation*; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control*; D008297:Male; D059348:Peripheral Nerve Injuries / Q000517:prevention & control*; D012306:Risk; D013709:Tendon Transfer / Q000379:methods*