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A cadaver with anomalous origin of the sural nerve
Foot and Ankle Surgery 2001
7: 257±260
Case report
A cadaver with anomalous origin of the sural nerve Ï _ , M. C _ E N A N D I. _ O TA G H . E R D IL Ë IM Department of Anatomy, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey
Summary
In this study, sural nerve (SN) variations were observed during the dissection of a 45-year-old male cadaver. The origins were different in each legs. In particular, a variation that we observed in the right leg has rarely been described in the literature. Because of its clinical importance and the fact that the exact anatomical branching is still not precise and uniform, these variations are compared and discussed with those described in other related articles to determine the exact anatomy of the SN. Keywords: cadaver, sural nerve, variation
Introduction It has been stated that several large sensory cutaneous nerves are accessible and suitable for using as a nerve graft [1]. Because of the greater sensitivity of small nerve ®bres, the preferred nerve for nerve repair in the upper extremity when large grafts are needed is the sural nerve (SN) [2]. This nerve is the most frequent donor nerve used for peripheral nerve grafting, and it is particularly advantageous as it provides a generous length of expendable nerve and has an ideal calibre for revascularization and graft placement [3]. The SN is readily accessible, has several large fascicles and results in minimal sensory de®cit of the donor area [1,4]. Although the SN is considered purely sensory, motor ®bres in the nerve have been reported by Amoiridis et al. [5]. In that study, the motor ®bres were found to occur in 331 SN from 207 individuals investigated (4.5%). Furthermore, this nerve has been used routinely clinically in the evaluation of suspected peripheral neuropathy [6,7]. Correspondence: Asst Prof. Dr H. Erdil, Faculty of Medicine, Department of Anatomy, Cumhuriyet University, 58140 Sivas, Turkey (e-mail: [email protected]). Ó 2001 Blackwell Science Ltd
Not only has the SN been used as a graft in nerve reconstruction but biopsies obtained from it have also been used for diagnosis in some situations, including nerve ®bre loss, atrophy and injury of diabetic peripheral polyneuropathy and their responses to metabolic intervention [6±8]. It has been demonstrated that the identi®cation of motor ®bres in the SN should be made clear before biopsy because of important implications for the interpretation of pathological ®ndings [5]. In addition, this nerve has been used in morphometric and nerve conducting velocity studies [6,9]. Besides the above-mentioned clinical situations, it has also been reported that description of the SN course is important because this nerve injury is a complication of Achilles tendon (AT) rupture [10], which exhibits signs of SN dysfunction [11]. In study carried out by Huelke (1958) [12], the description of the presence of the SN was made by joining the lateral and medial sural cutaneous nerves. Although these descriptions appeared in previous studies and textbooks, the exact anatomical occurrence pattern of the SN is not uniform, and there is controversy between the literature and anatomical textbooks about the branching, origination and course of the SN [12±16]. In order to make an 257
2 58
_ ET AL . H . E R D IL
accurate description of the origin and course of the SN, 30 cadavers were dissected by Webb et al. [10]. In that study, signi®cant individual variations in the position of this nerve were demonstrated in relation to the AT. That study also emphasized that the variations in the SN should not be overlooked when placing sutures in the proximal part of the AT but percutaneous sutures should not be placed in the lateral half of the AT [10]. As anatomical variations in the SN between individual patients are very frequent and the exact anatomy of this nerve is not uniform, awareness of the SN course still remains necessary in many clinical situations. As a result of the demonstrated anatomical and clinical importance of the SN course, the purpose of our study was to clarify the exact anatomy of the SN and to compare this variation with other related articles.
Case report In the present study, the case was a 45-year-old male cadaver in the Department of Anatomy at Cumhuriyet University. SN variation was observed during routine dissection. The origin of the SN differed in each leg. In the right leg, it originated directly from the common peroneal nerve (CPN) (Figure 1). The CPN began at the superior angle of the popliteal fossa. In the left leg, the SN was found to be formed by combination of the medial sural cutaneous nerve, a branch of the tibial nerve (TN), and the lateral sural cutaneous nerve (branch of the CPN) (Figure 2). The medial sural cutaneous nerve arose from the TN in the popliteal fossa and descended between the two heads of gastrocnemius muscle to the middle of the
leg. At this level, it joined with the lateral sural cutaneous nerve to form the SN. Within the popliteal fossa, the CPN gave off the lateral sural cutaneous nerve. The anatomical courses of both SNs were normal in situation. Small saphenous veins were ascending medial to them.
Discussion The SN has been chosen by clinicians for nerve grafting and diagnostic biopsies because of its easy access and minimal sequelae after its withdrawal. Although it has clinical importance, the studies carried out to quantify the course of the SN and its origin are controversial [17]. Because of its clinical importance, it is necessary to describe skin incision of the SN. An endoscopic technique of harvesting the SN graft was investigated by Olivera et al. [18] on six cadaveric legs. In that study, a 2-cm longitudinal incision was made posterior to the lateral malleolus and followed to the popliteal space, and nerve dissection was performed proximal to distal [18]. Rindell and Teleranta [19] developed an atraumatic method for its harvesting. The SN was identi®ed in the popliteal region by stretching it slightly behind the lateral malleolus. They performed only two short incisions for centrifugal liberation of the SN [19]. The endoscopic SN grafting approach offers advantages such as less injury to soft tissues, decreased pain and good aesthetic results, shorter operation time, a superior cosmetic result and a fairly long nerve for grafting [18,19]. The anatomical description of the SN has been de®ned as when the medial sural cutaneous nerve, arising from the TN, is joined by the peroneal
Figure 1 About the level of the popliteal fossa, the sural nerve originated directly from the common peroneal nerve. Common peroneal nerve (cpn), tibial nerve (tn), sural nerve (arrow), small saphenous vein (ssv). Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 257±260
CADAVER WITH ANOMALOUS SURAL NERVE ORIGIN
259
Figure 2 About the level of the popliteal fossa, the sural nerve was formed by combination of the medial and lateral cutaneous sural nerves. Common peroneal nerve (cpn), tibial nerve (tn), lateral cutaneous sural nerve (arrowhead), medial cutaneous sural nerve (double arrowhead), sural nerve (arrow), small saphenous vein (ssv).
communicating branch, which originates from the CPN; the combined nerve is termed the SN [14,15,20]. On the other hand, the SN has also been described as originating directly from the TN [13], or there may be no union at all [12]. As early as 1907, Bardeen noted that the SN originated from both TN and CPN [12]. Later, in anatomical studies, Kosinski found this occurrence of the SN as 40.2% of 118 limbs [21]. According to Huelke (1958), the frequency of presence of the SN formed by union with the lateral and medial sural cutaneous nerves was 80.5% of 550 lower limbs [12]. Huelke (1958) used his ®ndings and others to document exact anatomical variations in the SN complex and gave a table for comparison. According to this, the presence and occurrence of the SN formed by union with the lateral and medial sural cutaneous nerves were reported to be 81.5% by P'an (1939), 63.9% by Andreassi (1931) and 65.0% by Catania (1924) [12]. Similar to Huelke's ®ndings, the occurrence of the SN formed by communication with the lateral and medial sural cutaneous nerves was observed in 83.7% of 257 cases by Williams (1954) [22]. OrtiguÈela et al. [3] reported that, in 80% of 20 cadavers, the SN was formed by the union of the medial sural cutaneous nerve with the peroneal communicating branch. Hill et al. [1] reported that the SN was formed by the union of the medial sural cutaneous nerve and most often a single communicating fascicle of the lateral sural cutaneous branch of the peroneal nerve. However, the larger contribution comes from the tibial nerve in the popliteal fossa between the heads of the gastrocnemius muscle. Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 257±260
In another investigation related to this nerve variation, it has been found that the lateral and medial branches unite to form the SN in 96% of 25 cadavers [16]. Benjamin et al. [23] found that the SN arose from the junction between the medial sural cutaneous nerve and the lateral sural cutaneous nerve with a frequency of 21% in 19 cadavers. In our study, we also observed that the SN was formed by a combination of the medial sural cutaneous nerve, a branch of the TN, and the lateral cutaneous sural nerves, branches of the CPN, in the left leg (Figure 2). These ®ndings were compatible with the results of Kosinski (40.2%), Huelke (80.5%), P'an (81.5%), Andreassi (63.9%), Catania (65.0%), Henk (96%) and Benjamin (21%) [12,16,21]. During intraoperative nerve conduction studies, Phillips and Morgan [24] observed that the SN arose directly from the CPN. Also, it was recognized by Kosinki [21] that the SN could originate completely from the CPN (6.0%) and, from Huelke's table, the frequency of SN originating directly from the CPN is 0.5%, 5.2%, 1.4% and 6.0% according to Huelke, P'an, Andreassi and Catania respectively [12]. Similarly, it was found that the SN originated directly from the CPN in 5.2% of 19 cadavers' lower limbs [23]. In other investigations, the absence of the lateral SN was found in 0.4% of 550 and 4% of 25 cadavers [12,16]. In this study, we observed that the SN originated directly from the CPN in the right leg (Figure 1). As noted above, the variation in the SN observed in the right leg is the most infrequent one in comparison with other type of variations in the SN (0.4%±4%±5.2%) [12,16,23,24].
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_ ET AL . H . E R D IL
As many different occurrence patterns of the SN have been observed, this nerve has been subjected to wide variations in interpretation. If this variation is different in each leg from the same subject, it becomes more important for the surgeon to identify the SN before surgical intervention. The documentation of SN variations has been reported in earlier studies. Still, there have been controversies among the investigations regarding the normal variations in frequency branching and distribution of the SN. We can conclude that, as a result of its clinical and diagnostic importance, the precise anatomy of this nerve is critical and needs to be investigated in terms of its variations and occurrence patterns.
References 1 Hill HL, Vascones LO, Jurkiewicz MJ. Method for obtaining a sural nerve graft. Plastic Reconst Surgery 1978; 61: 177±179. 2 Denislic M, Meh D. Quantitative determination of the function of thin nerve ®bers. Nervenarzt 1997; 68: 509±514. 3 OrtiguÈela ME, Wood MB, Cahill DR. Anatomy of the sural nerve complex. J Hand Surg 1997; 12A: 1119±1123. 4 Berger A, Millesi H. Nerve grafting. Clin Orthop Rel Res 1978; 133: 49±55. 5 Amoiridis G, SchoÈls L, Ameridis N et al. Motor ®bers in the sural nerve of humans. Neurology 1997; 49: 1725±1728. 6 Izzo KL, Sobel E, Berney S et al. Distal sensory nerves of lower extremity in peripheral neuropathy: comparison of medial dorsal cutaneous and sural nerve abnormalities. Arch Phys Med Rehabil 1985; 66: 7±10. 7 Sima AAF, Brown MB, Prashar A et al. The reproducibility and sensitivity of sural nerve morphometry in the assessment of diabetic peripheral polyneuropathy. Diabetologia 1992; 35: 560±569. 8 Ohnishi A, Yamato T, Ikeuchi M et al. Two siblings with congenital adrenocortical unresponsiveness to ACTH showing
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
peripheral neuropathy morphometric evaluation of the sural nerve. Rinsho-Shinkeigaku 1994; 34: 493±496. Van-Veen BK, Schellens RL, Stegeman DF et al. Conduction velocity distributions compared to ®ber size distributions in normal human sural nerve. Muscle Nerve 1995; 18: 1121±1127. Webb J, Moorjani N, Radford M. Anatomy of the sural nerve and its relation to the achilles tendon. Foot Ankle Int 2001; 21: 475±477. Fletcher MD, Warren PJ. Sural nerve injury associated with neglected tendon Achilles ruptures. Br J Sports Med 2001; 35: 131±132. Huelke DF. The origin of the peroneal communicating, nerve in adult man. Anat Rec 1958; 132: 81±92. Carpenter MB. Human Neuroanatomy. Baltimore: Williams & Wilkins, 1976. Snell R. Clinical Anatomy, 2nd edn. Boston: Little, Brown & Co.; 1981. Moore KL. Clinical Oriented Anatomy, 2nd edn. Baltimore: Williams & Wilkins, 1985. Henk JC, Dellon AL. Clinical implication of the surgical anatomy of the sural nerve. Plast Reconstr Surg 1994; 94: 850±855. Lawrence SJ, Botte MJ. The sural nerve in the foot and ankle: an anatomic study with clinical and surgical implications. Foot Ankle Int 1994; 15: 490±494. Olivera MT, Marttos JR, Fallopa F. Endoscopic harvesting of the sural nerve graft: a cadaveric investigation. Orthopedics 2000; 23: 1189±1191. Rindell K, Teleranta T. A new atraumatic and simple method of taking sural nerve grafts. Ann Chir Gynaecol 1984; 73: 40±41. Williams PL, Warwick R, Dyson M et al. Gray's Anatomy, 37th edn. New York: Williams & Wilkins, Churchill Livingstone, 1989. Kosinski C. The course, mutual relations and distribution of the cutaneous nerves of the metazonal region of leg and foot. J Anat 1926; 60: 274±297. Williams DD. A study of human ®bular communicating nerve. Anat Rec 1954; 120: 533. Benjamin AC, Tuma JP, Grillo MA et al. Surgical anatomy of the sural nerve. Rev Hosp Clin Med Sao Paulo 1995; 50: 25±29. Phillips LH, Morgan RF. Anomalous origin of the sural nerve in a patient with tibial-common peroneal nerve anastamosis. Muscle Nerve 1993; 16: 414±417.
Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 257±260
7: 257±260
Case report
A cadaver with anomalous origin of the sural nerve Ï _ , M. C _ E N A N D I. _ O TA G H . E R D IL Ë IM Department of Anatomy, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey
Summary
In this study, sural nerve (SN) variations were observed during the dissection of a 45-year-old male cadaver. The origins were different in each legs. In particular, a variation that we observed in the right leg has rarely been described in the literature. Because of its clinical importance and the fact that the exact anatomical branching is still not precise and uniform, these variations are compared and discussed with those described in other related articles to determine the exact anatomy of the SN. Keywords: cadaver, sural nerve, variation
Introduction It has been stated that several large sensory cutaneous nerves are accessible and suitable for using as a nerve graft [1]. Because of the greater sensitivity of small nerve ®bres, the preferred nerve for nerve repair in the upper extremity when large grafts are needed is the sural nerve (SN) [2]. This nerve is the most frequent donor nerve used for peripheral nerve grafting, and it is particularly advantageous as it provides a generous length of expendable nerve and has an ideal calibre for revascularization and graft placement [3]. The SN is readily accessible, has several large fascicles and results in minimal sensory de®cit of the donor area [1,4]. Although the SN is considered purely sensory, motor ®bres in the nerve have been reported by Amoiridis et al. [5]. In that study, the motor ®bres were found to occur in 331 SN from 207 individuals investigated (4.5%). Furthermore, this nerve has been used routinely clinically in the evaluation of suspected peripheral neuropathy [6,7]. Correspondence: Asst Prof. Dr H. Erdil, Faculty of Medicine, Department of Anatomy, Cumhuriyet University, 58140 Sivas, Turkey (e-mail: [email protected]). Ó 2001 Blackwell Science Ltd
Not only has the SN been used as a graft in nerve reconstruction but biopsies obtained from it have also been used for diagnosis in some situations, including nerve ®bre loss, atrophy and injury of diabetic peripheral polyneuropathy and their responses to metabolic intervention [6±8]. It has been demonstrated that the identi®cation of motor ®bres in the SN should be made clear before biopsy because of important implications for the interpretation of pathological ®ndings [5]. In addition, this nerve has been used in morphometric and nerve conducting velocity studies [6,9]. Besides the above-mentioned clinical situations, it has also been reported that description of the SN course is important because this nerve injury is a complication of Achilles tendon (AT) rupture [10], which exhibits signs of SN dysfunction [11]. In study carried out by Huelke (1958) [12], the description of the presence of the SN was made by joining the lateral and medial sural cutaneous nerves. Although these descriptions appeared in previous studies and textbooks, the exact anatomical occurrence pattern of the SN is not uniform, and there is controversy between the literature and anatomical textbooks about the branching, origination and course of the SN [12±16]. In order to make an 257
2 58
_ ET AL . H . E R D IL
accurate description of the origin and course of the SN, 30 cadavers were dissected by Webb et al. [10]. In that study, signi®cant individual variations in the position of this nerve were demonstrated in relation to the AT. That study also emphasized that the variations in the SN should not be overlooked when placing sutures in the proximal part of the AT but percutaneous sutures should not be placed in the lateral half of the AT [10]. As anatomical variations in the SN between individual patients are very frequent and the exact anatomy of this nerve is not uniform, awareness of the SN course still remains necessary in many clinical situations. As a result of the demonstrated anatomical and clinical importance of the SN course, the purpose of our study was to clarify the exact anatomy of the SN and to compare this variation with other related articles.
Case report In the present study, the case was a 45-year-old male cadaver in the Department of Anatomy at Cumhuriyet University. SN variation was observed during routine dissection. The origin of the SN differed in each leg. In the right leg, it originated directly from the common peroneal nerve (CPN) (Figure 1). The CPN began at the superior angle of the popliteal fossa. In the left leg, the SN was found to be formed by combination of the medial sural cutaneous nerve, a branch of the tibial nerve (TN), and the lateral sural cutaneous nerve (branch of the CPN) (Figure 2). The medial sural cutaneous nerve arose from the TN in the popliteal fossa and descended between the two heads of gastrocnemius muscle to the middle of the
leg. At this level, it joined with the lateral sural cutaneous nerve to form the SN. Within the popliteal fossa, the CPN gave off the lateral sural cutaneous nerve. The anatomical courses of both SNs were normal in situation. Small saphenous veins were ascending medial to them.
Discussion The SN has been chosen by clinicians for nerve grafting and diagnostic biopsies because of its easy access and minimal sequelae after its withdrawal. Although it has clinical importance, the studies carried out to quantify the course of the SN and its origin are controversial [17]. Because of its clinical importance, it is necessary to describe skin incision of the SN. An endoscopic technique of harvesting the SN graft was investigated by Olivera et al. [18] on six cadaveric legs. In that study, a 2-cm longitudinal incision was made posterior to the lateral malleolus and followed to the popliteal space, and nerve dissection was performed proximal to distal [18]. Rindell and Teleranta [19] developed an atraumatic method for its harvesting. The SN was identi®ed in the popliteal region by stretching it slightly behind the lateral malleolus. They performed only two short incisions for centrifugal liberation of the SN [19]. The endoscopic SN grafting approach offers advantages such as less injury to soft tissues, decreased pain and good aesthetic results, shorter operation time, a superior cosmetic result and a fairly long nerve for grafting [18,19]. The anatomical description of the SN has been de®ned as when the medial sural cutaneous nerve, arising from the TN, is joined by the peroneal
Figure 1 About the level of the popliteal fossa, the sural nerve originated directly from the common peroneal nerve. Common peroneal nerve (cpn), tibial nerve (tn), sural nerve (arrow), small saphenous vein (ssv). Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 257±260
CADAVER WITH ANOMALOUS SURAL NERVE ORIGIN
259
Figure 2 About the level of the popliteal fossa, the sural nerve was formed by combination of the medial and lateral cutaneous sural nerves. Common peroneal nerve (cpn), tibial nerve (tn), lateral cutaneous sural nerve (arrowhead), medial cutaneous sural nerve (double arrowhead), sural nerve (arrow), small saphenous vein (ssv).
communicating branch, which originates from the CPN; the combined nerve is termed the SN [14,15,20]. On the other hand, the SN has also been described as originating directly from the TN [13], or there may be no union at all [12]. As early as 1907, Bardeen noted that the SN originated from both TN and CPN [12]. Later, in anatomical studies, Kosinski found this occurrence of the SN as 40.2% of 118 limbs [21]. According to Huelke (1958), the frequency of presence of the SN formed by union with the lateral and medial sural cutaneous nerves was 80.5% of 550 lower limbs [12]. Huelke (1958) used his ®ndings and others to document exact anatomical variations in the SN complex and gave a table for comparison. According to this, the presence and occurrence of the SN formed by union with the lateral and medial sural cutaneous nerves were reported to be 81.5% by P'an (1939), 63.9% by Andreassi (1931) and 65.0% by Catania (1924) [12]. Similar to Huelke's ®ndings, the occurrence of the SN formed by communication with the lateral and medial sural cutaneous nerves was observed in 83.7% of 257 cases by Williams (1954) [22]. OrtiguÈela et al. [3] reported that, in 80% of 20 cadavers, the SN was formed by the union of the medial sural cutaneous nerve with the peroneal communicating branch. Hill et al. [1] reported that the SN was formed by the union of the medial sural cutaneous nerve and most often a single communicating fascicle of the lateral sural cutaneous branch of the peroneal nerve. However, the larger contribution comes from the tibial nerve in the popliteal fossa between the heads of the gastrocnemius muscle. Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 257±260
In another investigation related to this nerve variation, it has been found that the lateral and medial branches unite to form the SN in 96% of 25 cadavers [16]. Benjamin et al. [23] found that the SN arose from the junction between the medial sural cutaneous nerve and the lateral sural cutaneous nerve with a frequency of 21% in 19 cadavers. In our study, we also observed that the SN was formed by a combination of the medial sural cutaneous nerve, a branch of the TN, and the lateral cutaneous sural nerves, branches of the CPN, in the left leg (Figure 2). These ®ndings were compatible with the results of Kosinski (40.2%), Huelke (80.5%), P'an (81.5%), Andreassi (63.9%), Catania (65.0%), Henk (96%) and Benjamin (21%) [12,16,21]. During intraoperative nerve conduction studies, Phillips and Morgan [24] observed that the SN arose directly from the CPN. Also, it was recognized by Kosinki [21] that the SN could originate completely from the CPN (6.0%) and, from Huelke's table, the frequency of SN originating directly from the CPN is 0.5%, 5.2%, 1.4% and 6.0% according to Huelke, P'an, Andreassi and Catania respectively [12]. Similarly, it was found that the SN originated directly from the CPN in 5.2% of 19 cadavers' lower limbs [23]. In other investigations, the absence of the lateral SN was found in 0.4% of 550 and 4% of 25 cadavers [12,16]. In this study, we observed that the SN originated directly from the CPN in the right leg (Figure 1). As noted above, the variation in the SN observed in the right leg is the most infrequent one in comparison with other type of variations in the SN (0.4%±4%±5.2%) [12,16,23,24].
2 60
_ ET AL . H . E R D IL
As many different occurrence patterns of the SN have been observed, this nerve has been subjected to wide variations in interpretation. If this variation is different in each leg from the same subject, it becomes more important for the surgeon to identify the SN before surgical intervention. The documentation of SN variations has been reported in earlier studies. Still, there have been controversies among the investigations regarding the normal variations in frequency branching and distribution of the SN. We can conclude that, as a result of its clinical and diagnostic importance, the precise anatomy of this nerve is critical and needs to be investigated in terms of its variations and occurrence patterns.
References 1 Hill HL, Vascones LO, Jurkiewicz MJ. Method for obtaining a sural nerve graft. Plastic Reconst Surgery 1978; 61: 177±179. 2 Denislic M, Meh D. Quantitative determination of the function of thin nerve ®bers. Nervenarzt 1997; 68: 509±514. 3 OrtiguÈela ME, Wood MB, Cahill DR. Anatomy of the sural nerve complex. J Hand Surg 1997; 12A: 1119±1123. 4 Berger A, Millesi H. Nerve grafting. Clin Orthop Rel Res 1978; 133: 49±55. 5 Amoiridis G, SchoÈls L, Ameridis N et al. Motor ®bers in the sural nerve of humans. Neurology 1997; 49: 1725±1728. 6 Izzo KL, Sobel E, Berney S et al. Distal sensory nerves of lower extremity in peripheral neuropathy: comparison of medial dorsal cutaneous and sural nerve abnormalities. Arch Phys Med Rehabil 1985; 66: 7±10. 7 Sima AAF, Brown MB, Prashar A et al. The reproducibility and sensitivity of sural nerve morphometry in the assessment of diabetic peripheral polyneuropathy. Diabetologia 1992; 35: 560±569. 8 Ohnishi A, Yamato T, Ikeuchi M et al. Two siblings with congenital adrenocortical unresponsiveness to ACTH showing
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
peripheral neuropathy morphometric evaluation of the sural nerve. Rinsho-Shinkeigaku 1994; 34: 493±496. Van-Veen BK, Schellens RL, Stegeman DF et al. Conduction velocity distributions compared to ®ber size distributions in normal human sural nerve. Muscle Nerve 1995; 18: 1121±1127. Webb J, Moorjani N, Radford M. Anatomy of the sural nerve and its relation to the achilles tendon. Foot Ankle Int 2001; 21: 475±477. Fletcher MD, Warren PJ. Sural nerve injury associated with neglected tendon Achilles ruptures. Br J Sports Med 2001; 35: 131±132. Huelke DF. The origin of the peroneal communicating, nerve in adult man. Anat Rec 1958; 132: 81±92. Carpenter MB. Human Neuroanatomy. Baltimore: Williams & Wilkins, 1976. Snell R. Clinical Anatomy, 2nd edn. Boston: Little, Brown & Co.; 1981. Moore KL. Clinical Oriented Anatomy, 2nd edn. Baltimore: Williams & Wilkins, 1985. Henk JC, Dellon AL. Clinical implication of the surgical anatomy of the sural nerve. Plast Reconstr Surg 1994; 94: 850±855. Lawrence SJ, Botte MJ. The sural nerve in the foot and ankle: an anatomic study with clinical and surgical implications. Foot Ankle Int 1994; 15: 490±494. Olivera MT, Marttos JR, Fallopa F. Endoscopic harvesting of the sural nerve graft: a cadaveric investigation. Orthopedics 2000; 23: 1189±1191. Rindell K, Teleranta T. A new atraumatic and simple method of taking sural nerve grafts. Ann Chir Gynaecol 1984; 73: 40±41. Williams PL, Warwick R, Dyson M et al. Gray's Anatomy, 37th edn. New York: Williams & Wilkins, Churchill Livingstone, 1989. Kosinski C. The course, mutual relations and distribution of the cutaneous nerves of the metazonal region of leg and foot. J Anat 1926; 60: 274±297. Williams DD. A study of human ®bular communicating nerve. Anat Rec 1954; 120: 533. Benjamin AC, Tuma JP, Grillo MA et al. Surgical anatomy of the sural nerve. Rev Hosp Clin Med Sao Paulo 1995; 50: 25±29. Phillips LH, Morgan RF. Anomalous origin of the sural nerve in a patient with tibial-common peroneal nerve anastamosis. Muscle Nerve 1993; 16: 414±417.
Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 257±260