A Clinical Anatomical Study Of Ultrasound-guided Acupotomy In The Treatment Of Tarsal Tunnel Syndrome

BACKGROUNDThe clinical treatment of tarsal tunnel syndrome(TTS)generally involves the four-point acupuncture method invented by Professor Zhu Hanzhang.However,because acupotomy is a closed operation with indirect visualization,there are certain risks and difficulties.Therefore,this treatment operation should be assessed.On the other hand,ultrasound visualization technology has developed rapidly in recent years.There have been clinical reports on the use of both ultrasound and acupotomy for the treatment of tarsal tunnel syndrome,but the number of cases reported is small,and ultrasound-guided acupotomy guidelines for the treatment of tarsal tunnel syndrome do not exist.This study was carried out for clarify the anatomical basis of ultrasound-guided percutaneous release of flexor retinaculum,and make it a scientific,accurate,safe and reliable clinical treatment technology for TTS.OBJECTIVETo simulate the operation of percutaneous flexor retinaculum by acupotomy in the treatment of tarsal tunnel syndrome on human specimens by clinical anatomy,and compare the safety and accuracy with ultrasound-guide,and non-ultrasound-guide acupotomy treatment.Observe the puncture path of percutaneous flexor retinaculum release and its adjacent nerve and blood vessel tissues,and provide anatomic basis for the treatment of tarsal tunnel syndrome with ultrasound-guided percutaneous flexor retinaculum release by acupotomy.METHODS26 adult specimens(14 males and 12 females)fixed with 10%formalin,aged 47-98 years old with an average age of(80.84±11.60)years,including 51 sides(26 on the right side and 25 on the left,as one side was damaged and could not be tested),were selected.Fifty-one ankle and foot specimens were tested in three groups:Group U(ultrasonic-guided group),with 20 ankle and foot specimens;Group N(nonultrasound guided group),31 foot and ankle specimens(the specimens with clear foot and ankle imaging were included in group U after scanning with high-frequency probe,and the specimens with indistinct foot and ankle imaging were included in group N).Taking the center of the medial malleolus as the a point and the medial distance of the foot from the distal calcaneus of the medial malleolus tip as the b point,two straight lines are drawn at the proximal and distal cm of the ab line,and the range between the two lines is defined as the range of flexor support band.(1)Regarding safety,?whether the tendon was damaged and whether there was tendon damage were assessed visually(none;minor damage:minor surface damage or damaged tendon thickness<10%;severe damage:tendon rupture or damaged tendon thickness?10%).?Whether the nerves and blood vessels were damaged and whether there were cut marks on these nerves were assessed visually.? The damage rate was calculated,and the nerve and blood vessel damage rates were calculated separately.Injury rate=number of cases of nerves or blood vessels injury/total number of cases×100%.Total injury rate=number of tarsal tunnel injury cases/total number of cases×100%.(2)Effectiveness of release,the released depth and length were assessed,and whether the incision from the acupotomy were within the range of the flexor retinaculum and whether the flexor retinaculum was cut completely were observed visually;an electronic Vernier caliper was used to measure the length of the incision of the acupotomy.The effective release was defined when the release length L?W/2(W is the width of the flexor retinaculum,defined as 20 mm)Total release efficiency=effective release number/total number X 100%.At the same time,the flexor retinaculum after release was dissected,and the anatomical structure under it could be seen clearly by naked eye.(3)For the anatomical measurements,the L means the length of the ankle flexor retinaculum and the T means the thickness of the middle section were measured;the shortest linear distance(DTn-a)from the tibial nerve(Tn)to the center of the medial malleolus(a);the shortest straight line distance(DO-a)from the medial malleolus center(a)at the tibial nerve bifurcation(O),the shortest linear distance(DV1-a)from the posterior tibial vein(V1)to the medial malleolus center(a),the shortest linear distance(DV2-a)from the posterior tibial vein(V2)to the medial malleolus center(a),and the shortest linear distance(DA-a)between the posterior tibial artery(A)and the medial malleolus center(a)were measured.The angle(?S-Z)between the acupotomy and the horizontal line(i.e.,the skin of the flexor retinaculum)was measured when the needle was inserted at the needle insertion point on the ultrasound image,and the distance between the needle insertion point U and a"b"(DU-a"b")was measured upon needle insertion.The shortest distance(Da-u)between point U and the medial malleolar center(a),the length of the needle body Lu,and the angle formed by the acupotomy and the ab line(?ab-Z)were measured.The order of ankle tube contents and the position of tibial nerve bifurcation were observed,the data were processed and analyzed,and the injury rate of ankle tube contents was compared between ultrasonic and non-ultrasound needle knife.And the accuracy and effectiveness of loosening the flexor support band of ankle tube by needle knife between the two surgical methods.RESULTSThe high-frequency ultrasound probe can better display the anatomy of the flexor retinaculum,and it is easier to operate by placing the probe long in a longitudinal position over the tarsal tunnel and inserting the needle-knife in the plane.(1)regarding safety,of the 20 cases in the ultrasound-guided group,acupotomy did not damage the ankle,namely,the nerves,arteries or veins,and the injury rate was 0.00%.And among the specimens of the nonultrasound guided group,there were no acupotomy injuries to nerves or tendons and 4 cases of blood vessel damage.In one of the cases with damage,the blood vessel was pierced and the damage was severe;in 3 cases,there was injury to the posterior tibial vein;and in 1 case,there was injury to the posterior tibial artery,the injury rate was 12.90%.The total injury rate of the two groups was compared:N group>U group,chi-square test was used to compare the group,the P=0.094>0.05,the difference of the total injury rate between the two groups was not statistically significan.(2)Regarding accuracy,In the U specimens,the incisions of the acupotomy exceeded 10.00 mm,the average length of the acupotomy releasing marks was(18.29±1.18)mm,and the length among 31 cases ranged from(15.43-20.00)mm.In the 4 cases that failed to release,the surface of the flexor retinaculum was cut,and in 16 cases,the flexor retinaculum was completely cut.The overall success rate of release was 80.00%.And in the N group of specimens,the incisions of the acupotomy exceeded 10.00 mm,the average length of the acupotomy releasing marks was(16.67±2.25)mm,and the length among 31 cases ranged from 12.46 to 20.00 mm.In the 12 cases in which the flexor retinaculum failed to be released,and the overall success rate of flexor retinaculum release among 20 cases was 61.29%.The release length of the two groups:Lu>Ln,using independent sample t test to compare the two groups,with statistical significance(P=0.002<0.05),indicating that the use of ultrasound between the two groups has statistical significance for the release length of flexor support band.The length of flexor support band under non-ultrasound guidance was significantly larger than that under non-ultrasound guidance.The effective rate of release between the two groups:using chi-square test to compare the two groups,P=0.497>0.05,the difference is not statistically significant.(3)Anatomical data measurements:length of flexor support band(49.45±5.90)mm,Compared with men and women,it was found that the length and thickness of flexor support band in men were significantly larger than that in women(P<0.001);There was no significant difference in left and right contrast analysis.The thickness of the middle section of the flexor support band is(1.00±0.14)mm;and There was no significant difference between men and women.The mean value of the shortest straight line distance(DTn-a)from the tibial nerve(Tn)to the center(a)of the medial malleolus was(27.46±5.93)mm,The mean value of the shortest straight line distance(DO-a)at the bifurcation(O)of the tibial nerve from the center(a)of the medial malleolus is(32.37±6.79)mm,the The mean value of the shortest straight line distance(DV1-a)from the posterior tibial vein(V1)to the center(a)of the medial malleolus was(25.82±5.26)mm;and The mean of the shortest straight line distance(DV2-a)from the posterior tibial vein(V2)to the center(a)of the medial malleolus is(31.51±5.56)mm;and The mean shortest straight line distance(DA-a)of posterior tibial artery(A)from the center of medial malleolus was(28.13±5.50)mm,the There was no significant difference between men and women.An average angle(?S-Z)between the needle knife and the horizontal line(i.e.flexor support skin)is 6,The mean value of U and a"b" distance(DU-a"b")was(5.38±2.41)and The mean minimum distance(Da-u)a the center of the medial malleolus was(32.69±7.78)mm,the point of injection The average Lu length of needle body is(30.42±4.11)mm,The average angle(?ab-Z)between the needle knife and the ab line(flexor support band)is 70.The relationship between tibial nerve and posterior tibial arteriovenous was divided into five cases:the nerve was located below the outer vessel,outside the vessel,directly below the vessel,inside the vessel and below the vessel.The relationship between the position of the tibial nerve bifurcation and the ankle canal is divided into five situations:the internal bifurcation of the ankle canal,the anterior bifurcation of the ankle canal,the posterior bifurcation of the ankle canal,the upper bifurcation a"b" the proximal boundary of the ankle canal and the upper bifurcation a'b' the distal boundary of the ankle canal.CONCLUSIONThe comparison of safety and accuracy between the two groups was not significant.In the actual experimental data,it can be found that the safety and release efficiency of the new operation under ultrasound guidance is higher than that of non-ultrasound guided needle knife therapy,which may be related to the small sample size of this experiment.The shortest distance between the tibial nerve and blood vessel from the center of the medial malleolus was approximately half of the length of the flexor retinaculum;that is,the neurovascular course was basically located in the middle of the flexor retinaculum.In addition,we did not find the tibial nerve under the blood vessel.The flexor retinaculum was released above the nerves and blood vessels(that is,the middle of the flexor retinaculum).When the needle tip does not touch the blood vessel under ultrasound guidance,the possibility of damaging the nerve is almost zero,so the procedure is relatively safe.The tibial nerve is the most compressed component,so the release effect is the most obvious in the tibial nerve.The cure rate and effective rate of the two surgical methods still need to be determined by future clinical trials.