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Introduction Improving the approaches to treating patients with hammer toe deformity is a relevant task. The problems of its management are a lack of uniform approaches to treatment, a significant number of complications and low patient satisfaction with the results of treatment. A frequent complication of its surgical treatment is a residual abduction deformity of the second toe. However, the available literature does not adequately cover the treatment of this pathology, and the methods of surgical correction have serious shortcomings. In this regard, the aim of the study was to evaluate the efficiency of the original method for correcting the abduction deformity of the second toe. The proposed approach is based on strengthening the medial capsulo-ligamentous structures of the metatarsophalangeal joint with the tendon of the brevis extensor digitorum muscle. Material and methods Treatment of 26 (100 %) patients operated for abduction deformity of the second toe at the Novosibirsk Research Institute of Traumatology and Orthopedics in 2016 and 2017 was analyzed. The index group included 15 (58 %) patients in whom the residual deformity was corrected according to the method proposed. In the comparison group of 11 (42 %) patients, the capsulotomy method of the second metatarsophalangeal joint with transarticular Kirschner wire fixation was used. The study utilised clinical, radiological, surgical, functional and statistical methods. Final treatment results were evaluated one year after the operations. Results The use of the traditional method of abduction deformity correction in the comparison group demonstrated its extremely low efficiency. On the other hand, in the index group there were 13 (86.6 %) good results, one (6.7 %) was fair and one (6.7 %) was poor. Discussion Many authors state the importance of restoring the capsulo-ligamentous complex of the metatarsophalangeal joint while correcting the toe deformity in the plantar plane. The method proposed by us enables to avoid residual deformities due to a number of technical merits with good clinical and functional results.

Background: The aim of this study was to demonstrate an increase in muscle action potentials and an enhancement of the efficacy of botulinum toxin (BoNT) after mechanical leg vibration. Methods: A 53-year-old healthy male volunteer underwent vibration ergometry training (VET) every morning and every evening for 10 min for 14 days. Compound muscle action potential (CMAP) of the right (R) and left (L) extensor digitorum brevis (EDB) muscle was analyzed by supramaximal peroneal nerve stimulation before and after VET 12 times during the 14 days. Thereafter, VET was stopped and 20 U incobotulinumtoxin (incoBoNT/A) were injected into the right EDB. During the following 10 days, CMAP of both EDBs was tested 12 times. Results: Under VET, the CMAP of both EDBs significantly increased (L: p < 0.01; R: p < 0.01). During the first 14 days, CMAP of the left EDB before VET was significantly (

Delayed wound healing of dorsal foot skin necrosis can be problematic for patients.1 The aim of wound treatment is to cover the bone and joint, ensuring that the necrosis is fully covered. The tendon should be covered as fully as possible and treated with free tissue transfer.2, 3 We performed an extensor digitorum brevis (EDB) flap for the skin necrosis in which the primary skin defect was covered, but the patient had a new skin necrosis at the donor site of the local flap.4 The patient was subsequently treated for donor site skin necrosis via negative‐pressure wound therapy (NPWT). Through several therapeutic failures, we sought to determine the appropriate treatment for dorsal foot skin necrosis with exposed tendon.

Supplemental Digital Content is available in the text., Summary: Presented is the case of an obese, 72 year-old diabetic man with a dorsal foot de-gloving injury. Whilst the tendons of extensor hallucis longus, extensor digitorum longus to all digits, and extensor digitorum brevis to hallux and second toe were intact after surgical debridement, none had any covering paratenon. The joint between the medial cuneiform and first metatarsal was open. Reconstructive options were limited by his age and co-morbidities. A novel, completely synthetic dermal matrix (NovoSorb BTM) was applied, after which the patient was discharged home to attend for dressings and review of integration progress as an outpatient. He was allowed to mobilise without limitation. Because of the poor quality of the wound bed (and patient), the material integrated slowly over 9 weeks. Delamination of the matrix, and definitive closure by application of sheet split skin autograft, produced a robust, soft, mobile and excellent aesthetic result, over which he could wear footwear immediately. Clinically, the paratenon-denuded tendons glided under the neo-dermis without tethering to the overlying integrated matrix, allowing a full range of digital movement. This was confirmed on ultrasound examination, which also demonstrated no inflammation or oedema. Already proven in extensive burns, necrotising fasciitis and complex surgical wounds, BTM represents a useful addition to the reconstructive surgeon’s toolbox.

Background: The muscle patterns involved in the "split-leg" syndrome of amyotrophic lateral sclerosis (ALS) remains controversial. We sought to evaluate and reassess the pattern of the extensor digitorum brevis (EDB) and the abductor hallucis (AH) muscles' involvement in split-leg syndrome in ALS. Methods: We recruited 60 consecutive patients with ALS and 25 healthy controls (HCs). Compound muscle action potentials (CMAPs) and F-waves were recorded over the EDB and AH muscles in all subjects. For comparison, we classified patients into two categories based on the presence or absence of lower limbs symptoms. Results: The EDB/AH CMAP amplitude ratio was significantly reduced in patients with affected legs (0.33 ± 0.21, P = 0.007), whereas patients with unaffected legs had a ratio similar to that of the HCs. The EDB/AH ratios for the F-wave latencies, mean F-wave amplitude, mean F/M amplitude ratio, and the persistence of the total repeater F-wave shapes (index Freps) of the EDB-AH, were significantly increased in the affected leg group, whereas the EDB/AH ratio for F-wave persistence was significantly reduced. These findings indicated a greater loss of lower motor neurons (LMNs) innervating the EDB and dysfunction of spinal motoneurons innervating the EDB. In the unaffected leg group, the EDB, but not the AH, F-wave latencies, mean and maximal F/M amplitude ratios, and index Freps were significantly altered. Receiver operating characteristic curve analysis suggested that the EDB F-wave latencies, mean F/M amplitude ratios, and index Freqs (area under the curve [AUC] > 0.8) more strongly differentiated patients with ALS from the HCs compared to the EDB/AH CMAP amplitude ratio (AUC = 0.61). Notably, the EDB maximal F-wave latency and index Freqs reliably differentiated patients with unaffected legs (HCs), with AUCs of 0.83 (95% CI 0.76-0.91) and 0.81 (95% CI 0.72-0.89), sensitivities of 76 and 78%, and specificities of 76 and 78%, respectively. Conclusions: These results suggest preferential EDB compared to AH involvement in the split-leg syndrome of ALS. The EDB maximal F-wave latency and index Freqs robustly differentiated patients with ALS from HCs, which might facilitate an earlier identification of ALS.

INTRODUCTION This study was performed to evaluate the effect of prior voluntary activation of a muscle on the subsequently-recorded compound muscle action potential (CMAP). METHODS The CMAPs from the hypothenar, thenar, and extensor digitorum brevis muscles were recorded in 6 healthy volunteers at rest and for up to 30 min following 5 separate epochs of up to 20 s of voluntary muscle activation. RESULTS There was consistent, significant (P

Synergic and antagonist actions of intrinsic and extrinsic foot muscles are acknowledged during walking of adult people. Conversely, reciprocal role of these muscles in children walking has not been adequately deepened yet. Purpose of the study was the surface-EMG-based evaluation of mutual recruitment of intrinsic and extrinsic foot muscles during healthy-children walking. Extensor digitorum brevis (EDB) is one of the main intrinsic foot muscles, controlling foot movement and stability. In this study, EDB and tibialis anterior (TA) were considered as representative of intrinsic and extrinsic foot muscles, respectively. Surface-EMG signals during 4-minute walking trial were acquired in eight healthy school-age children (mean±SD: age 8.3±1.7 years; height 136±8 cm; mass 30.9±6.2 kg) to fulfill the goal of the study. Then, Statistical gait analysis, a recent methodology performing a statistical characterization of gait, was applied to process EMG data. Data from an exceptional number of strides were acquired and analyzed to consider the expected variability (mean±SD = 265±30 strides for each child, nearly 2500 in total). Results showed that: 1) the most frequent recruitment of EDB muscle occurred between 25% and 55% of gait cycle, i.e., in Flat foot contact and Push off phases; 2) the most frequent recruitment of TA occurred from 55% to following 10% of gait cycle, i.e., during Swing and Heel strike phases. This indicated that the most significant EDB activity overlapped the region of no activity (or infrequent activity) for TA and vice versa. In conclusion, present study suggests that TA and EDB muscles acted mainly as antagonist muscles for foot/ankle-joint movement during children walking. These findings highlighted the need of measuring the mutual activity of extrinsic vs. intrinsic foot muscles as tool for a deeper understanding of mechanisms regulating ankle-foot stability and as a possible marker of pathology of neuro-muscular system.

A relationship between intrinsic and extrinsic foot muscles is acknowledged during walking. Literature on foot-muscle recruitment in children is not very extensive. Purpose of the study was the surface-EMG-based evaluation of possible concomitant recruitment of intrinsic and extrinsic foot muscles during healthy-children walking. Gastrocnemius lateralis (GL) was analyzed as representative for extrinsic foot muscles (ankle plantar flexor). Extensor digitorum brevis (EDB) is one of the main intrinsic foot muscles, controlling foot movement and stability. In this study, EDB was considered as representative of foot muscles. Surface-EMG signals during 4-min walking trial were acquired in eight healthy school-age children (mean ± SD: age 8.3 ± 1.7 years; height 136 ± 8 cm; mass 30.9 ± 6.2 kg) to fulfill the goal of the study. Then, Statistical gait analysis, a recent methodology performing a statistical characterization of gait, was applied to process EMG data. An exceptional number of strides were analyzed to consider the expected variability (mean ± SD = 265 ± 30 strides for each child, nearly 2500 in total). The research was undertaken in compliance with ethical principles of Helsinki Declaration and approved by institutional expert committee. Results showed that EDB activity is localized in two separate regions of gait cycle: mid-stance (from 8.2 ± 7.0 to 50.3 ± 15.0% of gait cycle) and swing phase, from 73.8 ± 13.8 to 95.1 ± 4.7%. Main GL activity occurred in the same regions: mid-stance (from 5.7 ± 2.5 to 49.7 ± 4.6% of gait cycle) and swing phase, from 69.2 ± 18.7 to 95.4 ± 5.4%. These findings showed that regions of activity of EDB and GL were practically overlapped, suggesting that EDB and GL worked synergistically for foot and ankle-joint control in children walking, in a large percentage of strides. Present study produced novel data on the variability of the reciprocal role of EDB and GL during children walking, providing a deeper insight in mechanisms regulating ankle-foot stability.

Lower motoneuron degeneration are not among the characteristic features of Parkinson’s disease(PD), although there are single studies considering the peripheral neuron involvement in PD as a continuum of degenerative process. The aim of our study was to find out if possible lower motor neuron involvement in PD is reflected with the MUNE method (motor unit number estimation). Material and methods 41 patients with PD (mean age 62.6 yrs; 51%M) were included. The control group consisted of 45 healthy volunteers. MUNE with multipoint incremental method was calculated in the abductor pollicis brevis (APB), the abductor digiti minimi (ADM) and the extensor digitorum brevis (EDB). Results Significant difference in the number of motor units estimating by MUNE was found between groups aged 60 years or older in ADM comparing with control group (p Conclusions The loss of motor units in sporadic Parkinson’s disease revealed by the multipoint incremental MUNE method may be considered as a sign of lower motor neuron involvement and a feature of generalized neurodegeneration.

Lesser digital deformities may present a surgical challenge to even the most skilled foot and ankle surgeon. Multiplanar toe deformities, including the crossover toe, are especially difficult to correct with reproducible results. Undercorrection, pain, stiffness, and recurrent deformity are well reported throughout foot and ankle literature. The goal of this article is to describe a method of correcting digital deformity utilizing the extensor digitorum brevis tendon transfer and a biotenodesis screw. The controlled tension established with the extensor tendon provides the necessary stability for multiplanar correction of multiplanar digital deformities. This technical tip article should serve as pilot study for future evaluation of this method of correction. Levels of Evidence: Level IV: Case series

Idiopathic adult hallux varus is a rare deformity. In this report, I present a technique for correction of this condition by extensor hallucis longus tenodesis and extensor digitorum brevis transfer.

Background: The dilemma in managing patients with low back ache lies in differentiating radiculopathy from lumbar canal stenosis. This has a huge bearing in patients being planned for surgical intervention as underperforming leads to failed back syndrome whereas over‑doing leads to instability. There still remains a loophole in clinically diagnosing lumbar canal stenosis.Aim: We opt to utilize a simple bedside clinical examination in routinely assessing patients presenting with low back ache in ruling out underlying canal stenosis.Subjects and Methods: We performed a prospective study on 120 consecutive patients presenting with low back ache in the spine clinic. Each of them was neurologically examined and thoroughly assessed for wasting of extensor digitorum brevis (EDB) muscles. These were then correlated with the radio‑imaging and the intraoperative findings.Results: Lumbar canal stenosis was mostly observed in the age group of 50–60 years. Diagnosis for L3/4 canal stenosis was made in 44/120 (36.6%), L5‑S1 in 52/120 (43.3%), and L3/L4/L5 level in 48/120 (40%) of patients. EDB wasting was seen unilaterally in 72/120 (60%) and bilaterally in 36/120 (30%) of the study group.Conclusion: This study appraises the clinical implication of observing for the wasting of EDB muscle so as to aid in the diagnosis of lumbar canal stenosis. This simple bedside clinical pearl can help us in predicting the need of further imaging studies and also in taking right therapeutic decision.Keywords: Extensor digitorum brevis, Lumbar canal, Stenosis

An accessory muscle adjacent to the extensor digitorum brevis muscle was encountered between the extensor digitorum brevis muscle and the tendon of the peroneus brevis on the right foot of a 75-year-old male cadaver. This accessory muscle and its tendon is of clinical significance for clinicians performing tendon transfers and other surgical procedures in the region, or when they use EDB as pedicles or free flaps at the ankle area or in other body parts. Keywords: accessory muscle; extensor digitorum brevis; variation

Congenital hypertrophy of a single intrinsic muscle of the foot is rare, and as far as we know, only six cases have been reported. We describe a case of congenital anomaly that showed hypertrophy of multiple intrinsic muscles of the foot; the affected muscles were all the intrinsic muscles of the foot except the extensor digitorum brevis or extensor hallucis. Other tissues such as adipose tissue, nervous tissue, or osseous tissue showed no abnormalities. To reduce the volume of the foot we removed parts of the enlarged muscles.

The authors report their experience about more than 50 patients with soft tissue defects in the area of the lower leg, of the ankle and of the dorsal aspect of the foot and toes, managed with the Extensor digitorum brevis flap. We have most often performed it with a proximal pedicle. Healing was obtained for all case. Infections of malleola have been treated thank to the better delivery of antibiotics. The donor site shows often delayed healing, but in one case, the harvestment area has presented a complete necrosis, which healed with immobilisation of the ankle with external fixator and dressings. At last, we insist on the fast learning of the procedure and the aim to use it in humanitary mission.

Rehabilitation of the paralyzed face requires consideration of the functional, esthetic, and psychological concerns of the afflicted patient. Lack of spontaneous facial animation significantly impairs the capacity to interact socially and convey emotion. With the advent of microneurovascular free tissue transfer, a new era of dynamic reconstruction was introduced, and symmetry with movement became a clinical reality. Although the gracilis is highly touted as the workhorse flap in facial reanimation surgery, a better understanding of flap physiology and neurovascular anatomy has contributed to the increased versatility in flap design while minimizing donor site morbidity. The purpose of this manuscript is to explore alternative donor muscle groups used in the surgical management of chronic facial paralysis and describe their operative technique, namely, the extensor digitorum brevis, serratus anterior, and anterolateral thigh flaps.

Objective To assess the duration of the distal compound muscle action potential (dCMAP) recording from the tibialis anterior (TA) as a supportive electrodiagnostic feature in chronic inflammatory demyelinating polyneuropathy (CIDP). Methods We performed peroneal motor conduction studies with recording from the TA in 35 CIDP patients, 30 normal controls, and 21 disease controls. The normal cut-off for the TA dCMAP duration was determined to be 14 ms. Results Prolonged TA dCMAP durations were detected in 34% of CIDP patients (12/35) and in 33% (2/6) of patients in whom only one demyelinating lesion was identified by conventional motor conduction studies. Prolonged TA dCMAP durations were present in 28% (5/18) of patients with normal duration dCMAPs recorded from the abductor hallucis (AH) and in 42% (5/12) of patients with normal duration dCMAPs recorded from the extensor digitorum brevis (EDB). In patients with AH or EDB dCMAP amplitudes Conclusions Determination of TA dCMAP duration appears to be useful for detecting demyelination in CIDP, especially when there is significant coexisting axon loss. Significance In patients with potential CIDP and limited electrodiagnostic abnormalities by routine studies, the finding of additional demyelinating findings, such as increased TA dCMAP duration, could allow for improved diagnostic sensitivity.

Purpose This study explores the vascular and morphologic anatomy of extensor digitorum brevis (EDB), which can be alternatives to donor muscles used in functional muscle transfer in long-standing facial paralysis reanimation. Methods A total of 14 EDB muscles from 7 embalmed cadavers were dissected and examined. Diameters and lengths of major and minor arteries supplying the muscle, venous pedicle diameter, neural pedicle diameter and length, their entrances into the muscle, the extendibility of neurovascular pedicles, when necessary, and the morphology of muscles were evaluated. Results Mean results obtained for EDB muscle in the study were as follows: the longest distance between the starting point and the area where the tendon started was a mean of 5.1 ± 0.1 cm (range, 4.8-5.4 cm), the distance between the widest points was 4.2 ± 0.3 cm (range, 3.7-4.9 cm), the thickest area was 1.4 ± 0.8 cm (range, 1-1.9 cm), and surface area was a mean of 32.1 ± 1.2 cm (range, 29.8-35.7 cm). The mean length of the major artery is type 2 according to Mahtnes-Nahai classification and was found to be 2.1 ± 0.03 cm (range, 1.6-3.2 cm), and its diameter was found to be 1.95 ± 0.15 mm (range, 1.7-2.1 mm). Mean length and diameter of the nerve providing motor innervation to the muscle were found to be 2.3 ± 0.03 cm (range, 2.1-2.6 cm) and 2.4 ± 0.08 mm (range, 2-2.9 mm), respectively. Conclusion As a result of this preliminary study, we think that the morphologic and neurovascular structures of this muscle are suitable for use in long-standing facial paralysis reanimation.

Objective To compare the effect of electrical stimulation applied before and after botulinum toxin injection. Subjects Eight healthy subjects. Methods Both extensor digitorum brevis muscles were injected with low fixed doses of botulinum toxin. Subjects received a 20-min session of electrical stimulation before botulinum toxin injection for the right foot and after the injection for the left foot. Percentage changes in compound muscle action potential amplitude were calculated at different intervals over a 60-day period. Results A reduction in compound muscle action potential percentage was measured at every time-point, both for the muscles stimulated before injection of botulinum toxin and for those stimulated after injection. The compound muscle action potential percentage was always lower on the side stimulated after injection of botulinum toxin. A reduction in compound muscle action potential percentage was measured on the 7th and 15th days in all extensor digitorum brevis muscles examined. On the 15th day the compound muscle action potential percentage was 38.8 (right foot) vs 24.1 (left foot) (p=0.0117). A slow recovery was observed after this period. Conclusion Electrical nerve stimulation enhances the effect of botulinum toxin to a greater extent if applied after injection rather than before. The short stimulation time used in our study gave similar results to those seen in previous research using longer application times.

A single incision is generally used to dissect the extensor digitorum brevis (EDB) muscle flap. However, in addition to exposure difficulties, this single incision may cause problems at donor sites, since both the dorsalis pedis vascular bundle and the sinus tarsi branch of the lateral tarsal artery require careful dissection. Thus, we modified the approach by using two parallel longitudinal incisions to expose the dorsalis pedis vascular bundle and the sinus tarsi branch of the lateral tarsal artery separately. Using this modified parallel-incision EDB muscle flap, we were able to reduce the operation times and donor site skin complications.

Objective: Although it is important to have strong predictors of outcome in peripheral mononeuropathies so that appropriate management can be instituted early, little is known about the prognostic value of electrodiagnostic results for these lesions. Our objective in this study was to evaluate the prognostic value of electrodiagnostic studies in fibular neuropathy. Design: In this retrospective study, 39 of 138 subjects with fibular neuropathy met the inclusion criteria. Electrodiagnostic results at the time of testing were evaluated for their value in predicting outcome. Good outcome was defined as grade 4 or higher strength on the Medical Research Council Scale in ankle dorsiflexion. Results: Compound muscle action potential responses from extensor digitorum brevis and tibialis anterior predicted prognosis: 81 % of subjects with any tibialis anterior response and 94% with any extensor digitorum brevis response had a good outcome vs. those with absent responses (46% and 52%, respectively). Importantly, there was still a high likelihood of good outcome with absent compound muscle action potential responses. Tibialis anterior compound muscle action potential gave additional prognostic information when extensor digitorum brevis response was absent. Recruitment in tibialis anterior was predictive in traumatic cases. All patients with nontraumatic compression had a good outcome. Conclusions: We conclude that electrodiagnostic studies produce useful prognostic information in fibular neuropathy, particularly in traumatic cases.

Despite extensive clinical experience and published data regarding botulinum toxin, questions remain about the clinical substitution of one botulinum toxin formulation for another. In the case of Dysport® and Botox®, doseequivalence ratios ranging from 1:1 to 6:1 (Dysport:Botox) have been advocated. This dose-ranging, electroneurographic study investigated the dose equivalence, diffusion characteristics (spread) and safety of these two type-A toxins in 79 volunteers. Dysport and Botox caused significant and similar reductions in compound muscle action potential (CMAP) amplitude in the target muscle (extensor digitorum brevis, EDB) 2 weeks after injection, with effects persisting to the 12-week timepoint. For both products, the reduction in amplitude was increased with increasing doses and with increasing concentration. The effects of toxin on neighbouring muscles were much smaller and of a shorter duration than those on the target muscle, implying a modest spread of toxin. Unlike the target muscle, the effects were greater with the higher volume, suggesting this volume led to greater diffusion from the EDB. No adverse events were reported. Statistical modelling with CMAP amplitude data from the target muscle gave a bioequivalence of 1.57 units of Dysport:1 unit of Botox (95 % CI: 0.77–3.20 units). The data indicate that a dose-equivalence ratio of 3:1 was within the statistical error limits, but ratios over 3:1 are too high.

reconstruction of the distal foot, especially of the toe has always been a challenging problem. various methods have been tried with variable success rates and limitations. presented here is a series of four cases, where distally based flaps were used. two of them were extensor digitorum brevis (edb) muscle flaps and the other two were first dorsal metatarsal artery (fdma) based skin flaps. one in each of the two was augmented with a plantar v-y advancement flap. all flaps survived completely without any flap- or donor site-related complications. the patients were ambulated two weeks following the reconstruction and were symptom-free after an average follow-up of thirteen months. distal flaps based on the dorsalis pedis system provide a reliable cover for distal foot defects.

The effects of various heel elevations on postural adjustment and lower-extremity muscle activity during the squat-to-stand (SQ-ST) movement were investigated. Eight healthy male subjects participated in the experiment, which involved rising from a deep squat with three different heel elevations: a full squat (FS), in which the plantar aspects of the feet were in full contact with the floor (0 degree), slope squat (SS), in which a 15-degree wedge was applied underneath the foot, and tiptoe squat (TS), in which subjects lifted their heels to their preferred height by extending the metatarsophalangeal joint. Electromyograms were taken of the extensor digitorum brevis (EDB), tibialis anterior (TA), rectus femoris (RF), and gastrocnemius (G) muscles. The results showed that heel elevation significantly affected the postural adjustment: TS caused significantly smaller anterior displacement in the knee and the hip during ankle dorsiflexion and minimized the duration of the forward movement required to stand. On the other hand, EDB activity strongly increased in TS. However, use of foot slope appeared to decrease activities of RF, TA, and EDB. These findings suggest that the use of a foot slope to achieve a squat-to-stand movement may be appropriate to assist patients with weak lower-extremity muscles.

MT10107 is botulinum neurotoxin type A derived drug which utilizes the 150 kDa portion without complexing proteins and human serum albumin contents. To evaluate the efficacy and the safety of MT10107, it was compared with onabotulinumtoxinA in this double-blind, randomized controlled trial. Twenty-five healthy males received a randomly selected dose of MT10107 into the extensor digitorum brevis (EDB) muscle of one foot, and an equivalent dose of onabotulinumtoxinA (BOTOX) was injected into the contralateral EDB muscle. While efficacy of the administered substance was determined by measuring paretic effects on the EDB, the local spread of toxin effects was evaluated by the paretic effects on the nearby abductor hallucis (AH) and abductor digiti quinti (ADQ) muscles. Paretic effects were defined as the percentage of reduction of the compound muscle action potential (CMAP) amplitudes, measured at 14, 30, 90 days after the injection, compared to the baseline value. Intergroup (MT10107 and onabotulinumtoxinA) differences were not significant in the percentage reduction of the amplitudes in the EDB muscles. In this study, there was no significant difference in efficacy and safety between the two test drugs. MT10107 may be effective and safe as much as onabotulinumtoxinA to produce the desired paretic effect.

Objectives (1) To evaluate the relationship between the thickness and compound muscle action potential (CMAP) of the extensor digitorum brevis (EDB) muscle; (2) to obtain reference values for distal lower extremity muscle thickness as a possible measure of peripheral neuropathy; and (3) to evaluate various factors associated with unexplained EDB atrophy. Methods We measured the thickness of EDB, abductor hallucis brevis (AHB) and tibialis anterior (TA) muscles in 80 healthy volunteers with ultrasound and assessed EDB CMAP with fibular nerve stimulation. Two foot muscle-associated lifestyle factors were assessed and sociodemographic information was collected. Results A significant correlation was observed between the amplitude of the fibular nerve CMAP and EDB thickness. The thickness of each of the three muscles was greater in men compared to women. EDB thickness decreased significantly with age although the thicknesses of the AHB and TA muscles were not correlated with age. Conclusions EDB thickness was closely associated with fibular nerve CMAP but with less variation and differed among groups by age and sex; it was not associated with lifestyle factors. Significance The ability to obtain this measure painlessly with ultrasound and its low variation recommend it as a potentially useful complementary measure of distal neuromuscular function.

Different nerve fibers may have disparate conduction parameters even though they are in the same peripheral nerve. Hyperglycemia can have differential effects on nerve fibers, depending on diameter. In diabetes, conventional nerve conduction studies have allowed us to classify a peripheral nerve as normal or not. But, there may be differential involvement in disparate nerve fibers of the same peripheral nerve. This study evaluated the effects of hyperglycemia on nerve fibers of peroneal nerve by diameter. Thirty-five diabetic patients with normal nerve conduction studies and thirty-two healthy controls were included to the study. The peroneal nerve was stimulated from two points (upper and below the fibula head) and recorded from the tibialis anterior (TA) and extensor digitorum brevis (EDB) muscles. Then the ratios of conduction velocity parameters recorded in these sides were compared between the diabetic and control groups. The conduction velocity recorded from EDB seemed to be faster in both groups. But there were no significant differences among the ratios between the groups. Our study has demonstrated the conduction parameters of two nerve fibers with different diameters in the peroneal nerve. The ratios of conduction parameters were similar in both groups, suggesting that fibers in the peroneal nerve are similarly affected by hyperglycemia. © 2015, Research Society for Study of Diabetes in India.

We report a case of deep peroneal neuropathy resulting in foot drop with preserved toe extension. These unexpected findings were the result of the presence of an accessory deep peroneal nerve that provided total innervation of the extensor digitorum brevis. We review the literature on total innervation of the extensor digitorum brevis by the accessory deep peroneal nerve with and without an associated deep peroneal nerve lesion. Muscle Nerve 40: 313-315, 2009.

This study was performed to create a large database of normal peroneal F-wave latencies. A total of 180 subjects were tested bilaterally and had their shortest (Fmin), mean (Fmean), and latency range (Frange) of F-waves recorded. The number of F-waves present out of ten stimuli (Fpersist) was also recorded. Demographic characteristics were noted and an analysis of variance was performed to determine whether any of these characteristics were associated with different results for the F-wave measures. Age and height, and, to a lesser extent, gender correlated with differences in Fmin, and Fmean, but not Frange. Race and body mass index (weight divided by height squared) were not associated with any differences in results. The mean Fmin was 50.2 +/- 5.5 ms. Mean Fmean was 52.0 +/- 5.6 ms and mean Frange was 4.9 +/- 2.3 ms. Median Fpersist was between 5 and 6. Mean side-to-side difference for Fmin was 0.7 +/- 2.4 ms. All other results are provided in the article. This article presents a database for normal values and the upper limits of normal for Fmin, Fmean, Frange, and side-to-side differences. A low Fpersist does not seem particularly clinically useful for the peroneal nerve, although a high Fpersist seems to be a sign of normality.

The compound muscle action potential (CMAP) is a measure of the number of axons in a nerve. Placement of the active recording electrode over the motor point of a muscle is thought to give the maximal response, but there is considerable variation in amplitude among initially negative CMAP wave forms. Ten examiners of varied training backgrounds and experience placed the active electrode as they usually do over the thenar, hypothenar, abductor hallucis, and extensor digitorum brevis muscles in the same normal subject. There was variability of the CMAP amplitude recorded over each muscle; the lowest value recorded from a muscle was 57% of the maximum value, and the lowest median value was 77%. There was no relation between examiner background or level of training and recording the maximal response. Higher amplitude CMAPs were associated with steeper wave form slopes, but the range of correlations between amplitude and slope was 0.42 to 0.92. We conclude that when it is important to record the maximal CMAP response, empirical assessment by moving the active electrode is necessary.

Background Understanding muscle architecture of the foot may assist in the design of surgical procedures such as tendon transfer, biomechanical modeling of the foot, prosthesis design, and analysis of foot function. There is limited published information regarding foot intrinsic muscle architecture. Methods Eleven fresh-frozen cadaveric feet were studied from eight males and three females. Twenty-eight intrinsic muscles were dissected in each foot, and measurements of fiber length, muscle length, and muscle volume obtained using calipers and water displacement technique. The physiologic cross-sectional area, fiber/muscle length ratio, muscle mass fraction, and tension fraction were then calculated. Results Intrinsic muscle length was related to foot size. The mean fiber length ranged from 13.6 mm (first plantar interosseous) to 28.0 mm (second extensor digitorum brevis). The mean muscle length ranged from 24.8 mm (adductor hallucis transverse) to 115.8 mm (abductor hallucis). The mean muscle volume ranged from 0.4 cc (fifth lumbrical) to 15.2 cc (abductor hallucis). The physiologic cross-sectional area ranged from 0.28 cm2 (second and third lumbrical) to 6.68 cm2 (abductor hallucis). The fiber/muscle ratio ranged from 0.20 (abductor hallucis) to 0.82 (adductor hallucis transverse). The mass fraction ranged from 0.33% (fifth lumbrical) to 16.59% (abductor hallucis). The tension fraction ranged from 0.34% (fifth lumbrical) to 15.37% (abductor hallucis). Conclusions The abductor hallucis and adductor hallucis oblique had much greater physiologic cross-sectional areas compared to those of the other intrinsic muscles. The lumbrical muscles had relatively low physiologic cross-sectional areas. These observations illustrate the underlying structural basis for the functional capacities of the intrinsic muscles of the foot. Anat. Rec. 249:143–151, 1997. © 1997 Wiley-Liss, Inc.

The accessory peroneal nerve is a normal anatomical variant, electrophysiologically present in 15–28% of normal individuals. An individual with a rare, complete innervation of extensor digitorum brevis muscle by an accessory peroneal nerve is reported, emphasizing the importance of proximal stimulation during routine electrodiagnostic evaluation despite absent distal responses to avoid misdiagnosing axonal lesions.

Botulinum neurotoxin type A1 (BoNTs/A1) and type B (BoNT/B) have been used for treating hyperactive muscle contractions. In the present study, we compared the effect of botulinum neurotoxin subtype A2 (6.5 mouse LD50 units A2 neurotoxin, A2NTX) and onabotulinumtoxinA (10 mouse LD50 units BoNT/A1 product) by measuring the compound muscle action potentials (CMAPs) before and after administration. In total, 8 healthy subjects were examined in the present study. A2NTX was injected into the extensor digitorum brevis (EDB) muscle, followed by onabotulinumtoxinA injection into the contralateral EDB muscle after 16 weeks. The CMAP amplitudes from the EDB, abductor hallucis (AH), and abductor digiti minimi pedis (ADM) muscles were measured after each BoNT injection on days 1, 3, 7, 14, 28, 56, 84, and 112 to assess the effect of the toxin. On day 14, both A2NTX and onabotulinumtoxinA produced an approximately 70% decline in EDB CMAP amplitude compared to the baseline values; significant reduction of the CMAP continued through day 112. The CMAP amplitudes from neighboring muscles (AH and ADM) remained intact throughout the study period, except for a slight but significant drop at day 28 after onabotulinumtoxinA injection compared to A2NTX. The current findings indicate that small doses (6.5 units and 10 units) of A2NTX and onabotulinumtoxinA have at least comparable onset and duration of action, although similar clinical effects were obtained with lower dose using A2NTX.

MT10107 is botulinum neurotoxin type A derived drug which utilizes the 150 kDa portion without complexing proteins and human serum albumin contents. To evaluate the efficacy and the safety of MT10107, it was compared with onabotulinumtoxinA in this double-blind, randomized controlled trial. Twenty-five healthy males received a randomly selected dose of MT10107 into the extensor digitorum brevis (EDB) muscle of one foot, and an equivalent dose of onabotulinumtoxinA (BOTOX) was injected into the contralateral EDB muscle. While efficacy of the administered substance was determined by measuring paretic effects on the EDB, the local spread of toxin effects was evaluated by the paretic effects on the nearby abductor hallucis (AH) and abductor digiti quinti (ADQ) muscles. Paretic effects were defined as the percentage of reduction of the compound muscle action potential (CMAP) amplitudes, measured at 14, 30, 90 days after the injection, compared to the baseline value. Intergroup (MT10107 and onabotulinumtoxinA) differences were not significant in the percentage reduction of the amplitudes in the EDB muscles. In this study, there was no significant difference in efficacy and safety between the two test drugs. MT10107 may be effective and safe as much as onabotulinumtoxinA to produce the desired paretic effect.

Category: Lesser Toes Introduction/Purpose: Instability at the MTPJ of the lessor toes is challenging to treat, particularly when both transverse and sagittal plane deformity coexist. Previous studies have utilized a subligamentous transfer of the EDB for crossover toes. The purpose of this pilot study was to evaluate a transosseous transfer of the EBD to correct multiplanar instability of the lessor toe. Routine exposure of the MTP was performed through a dorsal approach and a Z lengthening of the EDL was performed. The median number of concomitant produres performed was 4 and included hallux valgus repair, neuroma excision, metatarsal osteotomy, hammertoe correction and capsulotomies of other toes as needed. 27 tendon transfers were performed in 25 patients (2nd MTPJ: 20, 3 rd MTPJ: 5, 4th MTPJ: 2) Methods: A capsular release was performed on the concave side (contracted) and the convex side (lax) of the proximal phalanx and metatarsal head were exposed. A tenotomy of the EDB was performed at the musculotendinous junction and its insertion remained intact. The EDB was then transferred through a 2.5 mm drill hole in the base of the proximal phalanx. The drill hole began on the concave side and exited on the convex side with a similar hole from the convex side of the metatarsal neck to the concave side. To correct sagittal deformity the drill hole was oriented from dorsal to plantar. A low profile 1.5 mm polyethylene suture tape augmented the EDB transfer in both the proximal phalanx and metatarsal neck. A 3.0 mm interference screw is placed distally and the tape and EDB were appropriately tensioned and proximal fixation was achieved with another interference screw. Results: Results Median age in years (25-75th interquartile range) Females (N,%) 24, 96% 64(58-85) BMI (25-75th interquartile range) Previous surgery (N,%) Smoking history (N,%) Inflammatory arthritis (N,%) 27.8(21-32) 8, 32% 7, 28% 5, 25% Median number of concomitant procedures (25-75th IQR) Preop AP MTPJangle in degrees (25-75th IQR) Postop AP MTPJ angle in degrees (25-75th IQR) % Transverse Plane Improvement Preoperative to Postoperative 4(3-6) 19(11.5-24.0) 13(4.5-20.5) 31.5% (p < 0.0001) Preop Lateral MTPJ angle in degrees (25-75th IQR) Postop Lateral MTPJ angle in degrees (25-75th IQR) 41(26-58) 29(22.5-36) % Sagittal Plane Improvement Preoperative to Postoperative 29.2%(p < 0.0001) Conclusion: At a median follow up 19 weeks (12-32 weeks), EDB transfer augmented by polyethylene tape resulted in significant improvement in the transverse (31.5%) and sagittal planes (29.2%) without using temporary K wire fixation across the MTPJ. Twenty of 25 patients (80%) were completely satisfied, 4 patients (16%) were partially satisfied and 1 patient (4%) was dissatisfied. One mild infection occurred which was treated with oral antibiotics. No fractures occurred. This study is limited by relatively short follow up and the need to confirm these findings by independent surgeons. A biomechanical study is underway to assess pull out strength of the construct

Summary: Lower limb reconstruction after a traumatic event has always been a challenge for plastic surgeons. The reliability of vessel integrity postinjury often drives us away from a local reconstructive option. With the advancement of computed tomography angiogram, it can not only demonstrate the continuation of major vessels but also helps to map the vascular supply at a perforator level. We hereby report an incidentally identified anatomical variant with dual dominant blood supply to the extensor digitorum brevis muscle from an extra branch of anterior tibial artery originated at midtibial level. This variant was picked up preoperatively by computed tomography angiogram and confirmed intraoperatively to be one of the dominant supply. We took advantage of this unusual anatomy by basing our reconstruction on this branch and hence spared the need to terminalize distal dorsalis pedis artery.

BACKGROUND AND PURPOSE: It is recommended that Botox be used within 5 hours of reconstitution, which results in substantial quantities being discarded. This is not only uneconomic, but also inconvenient for treating patients. The aim of this study was to determine the potencies of Botox used within 2 hours of reconstitution with unpreserved saline, the same Botox refrigerated (at +4℃) 72 hours after reconstitution, and during the next 4 consecutive weeks (weeks 1, 2, 3, and 4). This comparison was used to determine the length of refrigeration time during which reconstituted Botox will maintain the same efficacy as freshly reconstituted toxin. METHODS: Individual paralysis rates in the extensor digitorum brevis (EDB) compound muscle action potential (CMAP) amplitude and area were measured 1 week after injecting fresh reconstituted 2.5 MU of Botox on one side of the foot, and when the same quantity of Botox that had been refrigerated for a designated time (i.e., 72 h, or 1, 2, 3, or 4 weeks) into the other side of the foot. The EDB CMAP amplitude and area at 12 and 16 weeks postinjection were also measured to compare the efficacy durations in all five comparative groups. RESULTS: Ninety-four volunteers were divided into five groups according to the refrigerator storage time of the second Botox injection. The paralysis of the EDBs was significant for each injection of Botox, both fresh and refrigerated, with no statistically significant differences between them, regardless of the refrigeration time. There was a tendency toward increased CMAP amplitude and area at 12 or 16 weeks postinjection (p

Interpretation of neurographic data in follow-up studies of patients with neuromuscular disease is sometimes challenging because of the expected variability in repeated tests. In this study, we explored whether the interexaminer variability of the compound motor action potential (CMAP) amplitude is reduced if the examiner is guided by the previously taken photographs of the position of the recording electrodes. The CMAPs were recorded from 20 subjects by unilateral distal stimulation of the median, ulnar, peroneal, and tibial nerve by 4 different technicians. All the subjects were examined on 2 occasions (similar to 1 week apart). On the first occasion, the technicians recorded the CMAP values according to routine protocols. On the second occasion, the technicians had additional guidance from photographs displaying the recording electrode positions from the first study. The CMAP coefficient of variation (CoV) was calculated for each nerve examined by the four technicians. Differences in CoV between the two types of tests (i.e., with or without photographs) were evaluated. When the examiners were guided by the photographs during electrode application, the CMAP CoV for the tibial innervated abductor hallucis (AH) muscle was reduced (P = 0.02) from 18.5% to 13%. There were, however, no significant reductions in CoV for the abductor pollicis brevis (APB, P = 0.23, median nerve), abductor digiti minimi (P = 0.37, ulnar nerve), or extensor digitorum brevis (EDB, P = 0.15, peroneal nerve) muscles. Photographic documentation of the CMAP recording electrodes seems to have a limited overall effect on interexaminer variability in a subsequent study.

To study the efficacy and safety of the combined plantar plate tenodesis and extensor digitorum brevis transfer in correction of claw toe deformity. Between 2007 and 2008, 11 patients (13 feet) underwent combined plantar plate tenodesis and EDB transfer for the correction of crossover second toe deformity. The clinical and radiological results were studied. There was no more crossover toe deformity in all patients. Two patients had residual mild residual claw toe deformity. The lateral metatarsophalangeal angle in preoperative weight-bearing radiograph averaged 53° ± 5°. The postoperative lateral metatarsophalangeal angle averaged 23° ± 6°. The dorsoplantar metatarsophalangeal angle in preoperative weight-bearing radiograph averaged −9° ± 4°. The postoperative dorsoplantar metatarsophalangeal angle averaged 2° ± 4°. Combined plantar plate tenodesis and extensor digitorum brevis transfer is an effective procedure to correct crossover second toe deformity. This is a relatively simple procedure and can be preformed through small incisions with minimal soft tissue dissection. Level 3 therapeutic study.

Background: Understanding muscle architecture of the foot may assist in the design of surgical procedures such as tendon transfer, biomechanical modeling of the foot, prosthesis design, and analysis of foot function. There is limited published information regard- ing foot intrinsic muscle architecture. Methods: Eleven fresh-frozen cadaveric feet were studied from eight males and three females. Twenty-eight intrinsic muscles were dissected in each foot, and measurements of fiber length, muscle length, and muscle volume obtained using calipers and water displacement technique. The physiologic cross-sectional area, fiber/muscle length ratio, muscle mass fraction, and tension fraction were then calculated. Results: Intrinsic muscle length was related to foot size. The mean fiber length ranged from 13.6 mm (first plantar interosseous) to 28.0 mm (second extensor digitorum brevis). The mean muscle length ranged from 24.8 mm (adductor hallucis transverse) to 115.8 mm (abductor hallucis). The mean muscle volume ranged from 0.4 cc (fifth lumbrical) to 15.2 cc (abductor hallucis). The physiologic cross-sectional area ranged from 0.28 cm 2 (second and third lumbrical) to 6.68 cm 2 (abductor hallucis). The fiber/ muscle ratio ranged from 0.20 (abductor hallucis) to 0.82 (adductor hallucis transverse). The mass fraction ranged from 0.33% (fifth lumbrical) to 16.59% (abductor hallucis). The tension fraction ranged from 0.34% (fifth lumbrical) to 15.37% (abductor hallucis). Conclusions: The abductor hallucis and adductor hallucis oblique had much greater physiologic cross-sectional areas compared to those of the other intrinsic muscles. The lumbrical muscles had relatively low physi- ologic cross-sectional areas. These observations illustrate the underlying structural basis for the functional capacities of the intrinsic muscles of the foot. Anat. Rec. 249:143-151, 1997. r 1997 Wiley-Liss, Inc.