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Concept: Small saphenous vein


BackgroundLess invasive percutaneous acute Achilles tendon rupture repair techniques gain popularity because of lower risk of surgical wound complications. But these approaches have an increased risk of sural nerve iatrogenic injury as this sensory nerve is usually not visualized during minimally invasive operative procedures. We compared standard percutaneous Bunnell type and our proposed modified-medialized percutaneous technique in a cadaver study to evaluate potential advantages. Methods10 pairs of fresh frozen specimens were divided into two groups for comparative anatomical study. Tenotomies of Achilles tendons were made and wounds sutured. 10 standard and 10 modified-medialized repairs were applied for artificially performed ruptures. All sutured tendons were dissected meticulously. We carefully looked at repaired Achilles tendon end-to-end contact and adaptation, distance from Achilles insertion in calcaneal tubercle to place where sural nerve crosses lateral border of the Achilles tendon and possible sural nerve and vein entrapment. Groups were compared using Fisher’s exact and Student-T tests.ResultsAll ends of sharply dissected tendons in both groups were in sufficient contact. No measurable diastasis between tendon ends was found in all cases. No entrapment of sural nerve or vein was found in modified percutaneous Bunnell suture technique group. Whereas 7 of 10 sural nerves and 9 small saphenous veins were entrapped when using standard percutaneous Bunnell type technique. Average distance from Achilles tendon insertion in tuber calcanei to sural nerve crossing the lateral border of Achilles was 93 mm.ConclusionMedialization of percutaneous suture in acute Achilles tendon rupture repair show clear advantages compared to standard non medialized technique ensuring a possible lower incidence of sural nerve entrapment injury. Our modified percutaneous Bunnell type technique allows sufficient adaptation of ruptured Achilles tendon.

Concepts: Muscle, Wound, Tendon, Achilles tendon, Tendons, Small saphenous vein, Sural nerve, Achilles tendon rupture


INTRODUCTION:: No randomized clinical trial comparing treatment options for small saphenous vein (SSV) incompetence exists, and there is no clear evidence that this axis behaves the same as the great saphenous vein after treatment. This means that the existing literature base, centered on the treatment of great saphenous vein incompetence cannot simply be extrapolated to inform the management of SSV insufficiency. This trial compares the gold standard of conventional surgery and endovenous laser ablation (EVLA) in the management of SSV incompetence. METHODS:: Patients with unilateral, primary saphenopopliteal junction incompetence and SSV reflux were randomized equally into parallel groups receiving either surgery or EVLA. Patients were assessed at baseline and weeks 1, 6, 12, and 52. Outcomes included successful abolition of axial reflux on duplex, visual analog pain scores, recovery time, complication rates, Venous Clinical Severity Score, and quality of life profiling. RESULTS:: A total of 106 patients were recruited and randomized to surgery (n = 53) or EVLA (n = 53). Abolition of SSV reflux was significantly higher after EVLA (96.2%) than surgery (71.7%) (P < 0.001). Postoperative pain was significantly lower after EVLA (P < 0.05), allowing an earlier return to work and normal function (P < 0.001). Minor sensory disturbance was significantly lower in the EVLA group (7.5%) than in surgery (26.4%) (P = 0.009). Both groups demonstrated similar improvements in Venous Clinical Severity Score and quality of life. CONCLUSION:: EVLA produced the same clinical benefits as conventional surgery but was more effective in addressing the underlying pathophysiology and was associated with less periprocedural morbidity allowing a faster recovery. (Registration number: NCT00841178.).

Concepts: Clinical trial, Vein, Great saphenous vein, Varicose veins, Sclerotherapy, Superficial vein, Dorsal venous arch of the foot, Small saphenous vein


Cyanoacrylate closure of the great saphenous vein with the VenaSeal™ Closure System is a relatively new modality. Studies have been limited to moderate-sized great saphenous veins and some have mandated postoperative compression stockings. We report the results of a prospective study of cyanoacrylate closure for the treatment of great saphenous vein, small saphenous veins, and/or accessory saphenous veins up to 20 mm in diameter.

Concepts: Great saphenous vein, Varicose veins, Saphenous nerve, Superficial vein, Dorsal venous arch of the foot, Small saphenous vein, Veins of the lower limb


We investigated the effectiveness of shear wave elastography (SWE) in patients with lower extremity superficial venous insufficiency (VI). A total of 138 symptomatic patients, 51 asymptomatic volunteers, and a total of 359 lower extremities (257 symptomatic, 102 asymptomatic) were examined. All participants underwent Doppler ultrasound (US) evaluation to determine VI and SWE measurements performed by manually drawing vein wall and perivenous tissue with free region of interest at the great saphenous vein (GSV) and small saphenous vein (SSV). The GSV, SSV diameter, VI, and volume flow of reflux were compared with the SWE values. The SWE values of the symptomatic group for GSV and SSV were significantly higher than those of the asymptomatic control group regardless of whether VI was detected by Doppler US (P < 0.001). There was a statistically significant increase in SWE values for the symptomatic group who were diagnosed as having reflux in GSV and SSV (P < 0.001). A significant positive correlation between increased GSV, SSV diameter, and SWE values was seen (P < 0.001). Venous insufficiency can be diagnosed with a 84.7% sensitivity and 84.2% specificity when 2655 m/s was designated as cutoff value, and with a 85.4% sensitivity and 84.2% specificity when 22,350 kPa was designated as the cutoff value in GSV. Venous insufficiency can be diagnosed with a 84.3% sensitivity and 82.4% specificity when 2845 m/s was designated as cutoff value, and with a 85.7% sensitivity and 84.4% specificity when 27,100 kPa was designated as the cutoff value in SSV. Shear wave elastography may be used effectively in addition to conventional Doppler US examination in diagnosing and following VI.

Concepts: Type I and type II errors, Sensitivity and specificity, Great saphenous vein, Saphenous nerve, Superficial vein, Dorsal venous arch of the foot, Small saphenous vein, Veins of the lower limb


Arthroscopy is an important and minimally invasive diagnostic and therapeutic tool. However, the risk of injury to the neurovascular structures around the portals exists during arthroscopy of the ankle. In the present study, we measured the distance between each portal and the adjacent neurovascular structures with the foot in plantarflexion and dorsiflexion in the Japanese population. Standard anterolateral (AL), anteromedial, posterolateral (PL), and posteromedial portal positions were identified in 6 fresh adult cadaveric feet. The skin was dissected from the underlying tissue to visualize the adjacent neurovascular structures as noninvasively as possible. The superficial peroneal nerve was the structure closest to an anterior (i.e., AL) portal (3.2 ± 4.2 and 8.3 ± 3.9 mm in plantarflexion and 5.2 ± 4.3 and 10.8 ± 4.1 mm in dorsiflexion), followed by the saphenous nerve and great saphenous vein (SpV). The distance from the superficial peroneal nerve to the AL portal and from the saphenous nerve and great SpV to the anteromedial portal increased significantly with dorsiflexion and decreased significantly with plantarflexion. The sural nerve was the structure closest to the posterior (i.e., PL) portal (10.4 ± 4.8 mm in plantarflexion and 8.5 ± 3.9 mm in dorsiflexion), followed by the lesser SpV. The distance from the sural nerve, saphenous nerve, and lesser SpV to the PL portal and from flexor hallucis longus, posterior tibial artery, and tibial nerve to the posteromedial portal increased significantly in plantarflexion and decreased significantly in dorsiflexion. These findings could help to prevent damage to the neurovascular structures during ankle arthroscopy.

Concepts: Foot, Tibial nerve, Great saphenous vein, Common fibular nerve, Nerves of the lower limb and lower torso, Saphenous nerve, Small saphenous vein, Intermediate dorsal cutaneous nerve


Vascularized nerve grafting is normally associated with a good outcome, but can be difficult to use for nerve reconstruction in patients with long defects of the sciatic nerve given the graft thickness. We report 3 cases of large defect sciatic nerve reconstruction using the bilateral sural nerves of the lower legs harvested together with the fascia and lesser saphenous vein to form a vascularized flap.

Concepts: Soft tissue sarcoma, Muscle, Tissues, Grafting, Great saphenous vein, Nerves of the lower limb and lower torso, Small saphenous vein, Sural nerve


Endovenous thermal ablation has become the primary modality of treatment for patients with venous insufficiency. Previous literature has provided reviews of radiofrequency ablation (RFA) or endovenous laser ablation (EVLA) that mostly focus on the great saphenous vein (GSV) and small saphenous vein (SSV). Data with an extended review including the anterior accessory saphenous vein (ASV) and perforator veins (PVs) have been limited. This study examines the treatment of venous insufficiency with RFA and EVLA of these multiple veins to identify clinical and demographic predictors of both the early success and thrombotic complications of endovenous thermal ablation.

Concepts: Great saphenous vein, Saphenous nerve, Superficial vein, Dorsal venous arch of the foot, Small saphenous vein, Veins of the lower limb


There is evidence that nerve flaps are superior to nerve grafts for bridging long nerve defects. Moreover, arterialized neurovenous flaps (ANVFs) have multiple potential advantages over traditional nerve flaps in this context. This paper describes a case of reconstruction of a long defect of the ulnar artery and nerve with an arterialized neurovenous free flap and presents a literature review on this subject. A 16-year-old boy sustained a stab wound injury to the medial aspect of the distal third of his right forearm. The patient was initially observed and treated at another institution where the patient was diagnosed with a flexor carpis ulnaris muscle and an ulnar artery section. The artery was ligated and the muscle was sutured. Four months later, the patient was referred to our institution with complaints of ulnar nerve damage, as well as hand pain and cold intolerance. Physical examination and ancillary tests supported the diagnosis of ulnar artery and nerve complete section. Surgery revealed an 8 cm hiatus of the ulnar artery and a 5 cm defect of the ulnar nerve. These gaps were bridged with a flow through ANVF containing the sural nerve and the lesser saphenous vein. The postoperative course was uneventful. Two years postoperatively, the patient had regained normal trophism and M5 strength in all previously paralyzed muscles according to the Medical Research Council Scale. Thermography revealed good perfusion in the right ulnar angiosome. The ANVF may be an expedite, safe and efficient option to reconstruct a long ulnar nerve and artery defect.

Concepts: Muscle, Paralysis, Great saphenous vein, Forearm, Ulnar nerve, Ulnar artery, Small saphenous vein, Sural nerve


Conflicting data exist on outcomes of open vein harvest (OVH) and endoscopic vein harvest (EVH) for infrainguinal bypass. The purpose of this study was to compare outcomes between OVH and EVH in femoral to popliteal artery bypasses.

Concepts: Coronary artery bypass surgery, Femoral artery, Femoral vein, Great saphenous vein, Saphenous nerve, Popliteal artery, Small saphenous vein, Popliteal vein


Endovenous thermal ablation of the small saphenous vein carries a risk for sural nerve injury. Ablation above mid-calf level is recommended to avoid it. However, this strategy could not eradicate this complication. We present our results of consecutive 30 small saphenous vein thermal ablations which are performed after ultrasonographic identification of the sural nerve.

Concepts: Great saphenous vein, Superficial vein, Small saphenous vein, Sural nerve, Ablation, Endometrial ablation