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The leg was explored to find the proximal extent of injury. area, there have been no deformities [Figure 4]. Patient
The nerve was found to be avulsed from the middle third has regained sensation over the heel and the instep area,
as could be predicted from the length of avulsed segment and the progressive Hoffmann‑Tinnel signs had reached the
[Figure 2b]. In view of the avulsion component and the force forefoot area one and a half year after the surgery. Figure 5
involved (site of rupture was around 8 cm from the site of shows an easy way to monitor the progressive Tinnel signs
a puncture wound), we decided to wait for 3 weeks before in the patient’s record. The patient has been using her limb
going in for definitive reconstruction. The nerve ends were during all her daily activities and was actively participating
tacked for future identification, and the wound was closed. in sports. She has been following the instructions and did
not have any pressure related complication over the plantar
After 3 weeks, the wound was re‑explored. The tibial
nerve was traced proximally into unscarred tissues. After foot. For the past 3 years of follow‑up, she has normal
sectioning the nerve at this level, it was observed under movements of the foot and the toes, no deformities and
microscope for healthy fascicles. The same procedure has recovered good protective plantar sensations.
was followed in the distal leg to secure a healthy distal
end of the nerve. The final defect of around 9.5 cm was DISCUSSION
reconstructed with 3 sural nerve cable grafts of 10 cm
each [Figure 3] harvested from the contra‑lateral lower Well recognized and documented examples of nerve
extremity (the diameter of the tibial nerve at the proximal injuries in the lower limb are the sciatic nerve injury at
and distal end was suitable to accommodate 3 cables of the hip during posterior fracture dislocations, iatrogenic
a sural nerve graft). The patient was instructed regarding injuries during injections and peroneal nerve injury
the care of the insensate foot, to avoid walking bare foot following fracture of the neck of the fibula. [2,3,6] Injury to
and perform regular inspection of the plantar foot. the posterior tibial nerve is, fortunately, very rare. [1,7,8]
She has completed 3 years of follow‑up and the recovery Though the mechanism of injury is not exactly known in
so far is satisfactory. Except mild hallowing of the instep the presented case, some sharp object must have pierced
the Achilles tendon to reach the nerve and due to change
of the direction as the patient fell down it must have got
entangled around the nerve, ultimately avulsing it.
The actual site of nerve injury was much higher than
perceived site of injury, possibly a relatively fixed point
[9]
like a muscular branch and is difficult to predict. This

a b
Figure 2: (a) On exploration, the soft tissue structure was found to be
Figure 1: Patient presenting with a small wound over the posterior the posterior tibial nerve; (b) the nerve was explored in the leg and the
aspect of the heel with soft tissue protruding through tendoachillis nerve was found to have got avulsed from the middle third of the leg

Figure 3: Photograph taken during secondary reconstruction. The nerve Figure 4: Picture taken after 3 weeks. The mark indicated the level of
being reconstructed with sural nerve cable grafts from the same leg tunnels at that time. The wound has healed well

86 Plast Aesthet Res || Vol 2 || Issue 2 || Mar 13, 2015