Joseph Blackmon

Locating the Sural Nerve during Calcaneal (Achilles) Tendon Repair with Confidence: A Cadaveric Study with Clinical Applications

The sural nerve is at risk of iatrogenic injury even during minimally invasive operative procedures to repair the calcaneal (Achilles) tendon. Through 107 cadaveric leg dissections, the data derived from the present study was used to develop a regression equation that will enable surgeons to estimate the intersection point at which the sural nerve crosses the lateral border of the Achilles tendon, an important surgical landmark. In most cases, the sural nerve crossed the lateral border of the Achilles tendon 8 to 10 cm proximal to the superior border of the calcaneal tuberosity. By simply measuring the leg length of the patient (from the base of the heel to the flexor crease of the popliteal fossa), surgeons can approximate the location of this intersection point with an interval length of 0.68 to 1.80 cm, with 90% confidence, or 0.82 to 2.15 cm, with 95% confidence. For example, for a patient with a lower leg length of 47.0 cm, the mean measurement in the present study, a surgeon can be 90% confident that the sural nerve will cross the lateral border of the Achilles tendon 8.28 to 8.96 cm (interval width of 0.68 cm) proximal to the calcaneal tuberosity. Currently, ultrasound and clinical techniques have been implemented to approximate the location of the sural nerve. The results of the present study offer surgeons another method, that is less intensive, to locate reliably and subsequently avoid damage to the sural nerve during calcaneal (Achilles) tendon repair and other procedures of the posterolateral leg and ankle.

Kindler Syndrome: A Rare Genodermatosis Presenting in 2 Brothers

We report a case of two Asian brothers, aged 21 and 29, born to consanguineous parents, who presented with cutaneous hyperand hypopigmentation, skin atrophy, and skin fragility of the face, neck, and distal parts of the extremities. They were the first and second, full-term pregnancies in a family without any history of skin disease. Both patients had a history of recurrent minor trauma-induced blistering over the extensor aspects of the forearms, lower legs, dorsal hands, and feet since infancy. The blisters contained either serous or hemorrhagic fluid and typically ruptured within 4 to 5 days producing erosions that healed with dyspigmentation and atrophy, but no scarring. The tendency for blister formation after minor trauma gradually subsided by the ages of 13 and 15, respectively. Additionally, the brothers had severe skin fragility affecting the face, neck, distal limbs, and gums. They reported increased photosensitivity with sunburn after minimal sun exposure and exacerbation of their disease during the summer months. Dysphagia started at the ages of 17 and 19 and has been persistent with variable severity. The evolution of the disease led to the subsequent development of reticular pigmentation, progressive skin atrophy, gingival fragility with bleeding, webbing of the fingers and toes, nail dystrophy, dysuria and eye soreness. On physical examination, both patients had normal physical and mental development. Skin examination revealed poikiloderma, patchy hyperpigmentation and hypopigmentation, and telangiectasias (Figures 1 and 2). Also, skin fragility was noted mainly on the face, neck, upper chest, and over the dorsal hands and feet.

UVA and UVB Therapy: Practical Applications and Implications for the Immunosuppressed Patient and Skin Disease

Phototherapy is an effective treatment option for a variety of skin disorders including psoriasis, photodermatoses, cutaneous T cell lymphoma, atopic dermatitis, vitiligo, and a number of sclerosing skin disorders. A variety of light sources can be used, either as a sole modality or in combination with sensitizing drugs, and treatments can be designed to address localized or diffuse skin conditions. Various types of light produce unique responses based on light energy/intensity and depth of penetration. The mechanisms by which various phototherapies impact target tissues are complex and it is clear that host immune responses play a key role in these processes.