Anatomy and Neuroscience - Theses
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ItemComplex spatial 3D anatomy of the tarsal tunnel and the plantar compartments of the foot( 2021)Anatomical understanding of the foot, to a level appropriate to inform precise clinical management, is lacking. Whilst much of the foot is in need of a clear evidence-base, the tarsal tunnel and plantar compartmentalisation of the foot are areas of particular concern for two reasons. First, the anatomy of these areas is readily visualised in a lab setting, so should be well- investigated, yet it is not. Secondly, conditions that affect these areas, such as tarsal tunnel syndrome and plantar compartment syndromes, are common and can be debilitating or even life-threatening. The clinical identification and management of these disorders is varied, has high rates of failure and high rates of patient dissatisfaction from procedures that the clinical team deem successful. Something is amiss, and the confusion and inconsistency in the reviewed literature suggests that imprecise anatomical knowledge may be a prominent contributing factor. The studies presented in this thesis aimed to explore, in sequence, the tarsal tunnel, followed by the medial and lateral columns of the foot. This sequence follows the structures coursing into the plantar aspect of the foot via the tarsal tunnel. These studies aimed to present a detailed anatomical account of these areas by using clear protocols, which involved a variety of dissection, 3D modelling, sectional anatomy and medical imaging techniques. Dissection involved following individual fascicles of soft tissue structures, identifying their orientation and attachments. Each structure was modelled during dissection, as to revaluate the spatial relationships of structures in 3D space post-dissection. Sectional anatomy and medical imaging were used to correlate the dissection findings for what is more readily applied in a clinical setting. The tarsal tunnel roof was described variably in the reviewed literature. The current data demonstrated that the roof is not formed by a singular structure, but through the combination of the passive flexor retinaculum and the dynamic abductor hallucis muscle. The boundaries of the tunnel were defined by the roof, making the description of these tissues of greater importance clinically. The tunnel was also subdivided by fibrous tissues, suggesting that the neurovasculature could be compressed by various surrounding structures. This contrasts much of the reviewed literature and provides anatomical evidence for some failures of surgical release. These data may inform tarsal tunnel surgical care and could increase the effectiveness of these procedures. The plantar aspect of foot was described in the reviewed literature as having anything from zero to ten compartments. Differences in terminology, investigative medium and methodology may have contributed to the variability. The data presented here clearly and consistently demonstrated four distinct compartments of the mid- to hind-foot region: medial, lateral and two central plantar compartments. They had well-defined anatomical boundaries formed by fibrous and muscular intermuscular septae. The relationship of the bounding structures to the muscular and tendinous structures, and the course of the plantar neurovascular bundles was demonstrated digitally in three dimensions. These models may help inform the diagnosis of causative relations for nerve impaction or vascular blockage which lead to compartment syndromes, or simply increase the likelihood of rapid decline in health, such as with foot ulceration in a patient with advanced diabetes. Lower limb amputation and death are common acute sequelae of inadequate treatment of patients in such situations, so improved anatomical understanding may hasten the diagnosis. The studies presented in the form of this thesis provide a technical foundation for future anatomical studies in the foot and other regions of the body. These data provide accurate and reproducible accounts of the complex anatomy of the tarsal tunnel and plantar foot compartments and may have a positive impact on the future care of common foot disorders.