2-incision Approach Research Articles

Safety and Efficacy of One vs Two Incision Broström Gould with Calcaneal Osteotomy and Peroneal Tendon Debridement Surgery

Surgical intervention, such as the Broström-Gould procedure, is typically indicated for patients with chronic lateral ankle instability. In this study, we are comparing the safety and efficacy of the Broström-Gould procedure with peroneal tendon debridement, a sliding lateralizing calcaneal osteotomy, and adjuvant procedures performed with a single- versus double-incision approach. Our retrospective analysis included patients who underwent the procedure of interest between 2011 and 2020. Patients were divided into 2 groups: undergoing either a 1-incision (n = 53) or a 2-incision approach (n = 47), both with a lateralizing calcaneal osteotomy. A significant difference in skin bridge breakdown was observed between the 2-incision (n = 6 [13%]) and 1-incision groups (n = 0 [0%]). There were no significant differences in infection, deep wound dehiscence, nerve palsy, or neuroma between patients in the 2 groups. Furthermore, no statistically significant differences in mean PROMIS scores existed between the cohorts. The described Broström-Gould procedure shows promise for treating chronic ankle instability. While patients in both single- and double-incision groups had similar rates of postoperative complications, the decreased incidence of skin bridge breakdown in the 1incision group highlights the approach's safety and potential benefits in reducing wound-related complications.

Comparison of Two Surgical Approaches for Trimalleolar Ankle Fracture Fixation

Ankle fractures account for 10% of all presenting fractures, with research quoting the involvement of the posterior malleolus in around 7% of cases. Trimalleolar fractures are estimated to have greater long-term complications due to the significant disruption to the articular surface of the joint and the reduced weight-bearing potential associated with this. Despite the well-documented role of the posterior malleolus in ankle fractures, its fixation is often a matter of debate. One barrier to this is the potential need for an additional surgical incision. Our study compared two surgical approaches to trimalleolar ankle fracture fixation: One through an extended posterolateral and medial approach (2-incision approach) and one through a combined posterolateral, direct lateral, and medial approach (3-incision approach). Thirty-eight open reduction and internal fixation of trimalleolar ankle fractures were performed by the senior author in a single institution between January 2017 and January 2020. Fifteen underwent a 2-incision approach and 3 separate incisions were used in 23 cases. Outcomes of the two different surgical methods included a postoperative functional score (Ankle-Hindfoot American Orthopedic Foot and Ankle Society), postoperative complications, and evaluation of postoperative radiographs. Twenty-three patients were recruited to the 3-incision group and 15 to the 2-incision group. The utilization of 3 separate incisions for the fixation of trimalleolar fractures showed fewer complications than a 2-incision approach. Further, smoking was positively correlated with reported complications. All other perioperative variables did not reach statistical significance. In our study, a 3-incision approach showed a tendency for lower complication rates in the surgical treatment of trimalleolar ankle fractures compared with a 2-incision approach. In our opinion, a direct approach to the 3 malleoli through individual incisions allows better visualization of the fracture site, including intercalary and incisura fragments, enabling better reduction and avoiding unnecessary destructive tissue handling. Level of Evidence: Diagnostic Level 2. See Instructions for Authors for a complete description of levels of evidence.

Single Medial vs 2-Incision Approach for Double Hindfoot Arthrodesis: Is There a Difference in Joint Preparation?

Double hindfoot arthrodesis is a reliable treatment option in lower extremity deformity and arthritis. Single (medial) and 2-incision techniques have been described. The purpose of this study was to evaluate the extent of cartilage debrided in each approach and to evaluate the competency of the deltoid ligament. Eight matched pairs of cadaveric specimens were acquired. One limb from each pair was randomly assigned to the single medial incision and the other to the 2-incision technique. Stress radiographs were obtained prior to dissection to evaluate for valgus tibiotalar tilt. The talonavicular and subtalar articular surfaces were denuded of cartilage and the joints disarticulated. The percentage of cartilage debrided was determined using ImageJ software. Postoperative tibiotalar tilt was measured with a technique and threshold previously described by our group. The intraclass correlation coefficient was calculated to determine inter- and intraobserver reliability. The single medial incision demonstrated significantly less cartilage denuded than the 2-incision technique at the talar head (61.1% ± 20.4% vs 88.1% ± 6.1%, P < .001), and the posterior facets of the talus (53.5% ± 7.6% vs 73.6% ± 7.0%, P < .001) and calcaneus (55.3% ± 16.5% vs 81.0% ± 7.4%, P = .001). Overall, 75% of specimens that underwent a single medial incision approach demonstrated increased valgus tibiotalar tilt postdissection, whereas none that underwent the 2-incision technique developed increased tibiotalar tilt (P < .01). The average tibiotalar tilt among these specimens was 4.6 ± 1.3 degrees (range 2.5-5.7 degrees). For all measurements, the intraclass correlation coefficient was greater than 0.8. The posterior facet of the subtalar joint and talar head are at risk of subtotal debridement, as well as increased tibiotalar tilt with the single medial incision technique. Adequate debridement may require greater soft tissue dissection, possibly at the expense of medial ankle stability. Level III, retrospective cohort study.

Radiographic and clinical results of modified 2-incision sinus tarsi approach for treatment of calcaneus fracture

BackgroundSinus tarsi approach (STA) is the most commonly used minimally invasive surgery (MIS) in the treatment of displaced intra-articular calcaneal fracture (DIACF). However, there are some limitations related to its limited access. The goal of the present study is to describe a modified 2-incision STA and to evaluate the radiographic and clinical outcomes in the treatment of DIACF. Materials and methodsPatients had a Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification 82-C, Sanders type II, III calcaneal fracture, and underwent modified 2-incision STA and internal fixation were included in this retrospective study. Serial radiographic measurements and clinical assessment were taken to evaluate the effectiveness of this technique. ResultsThirty-four feet of 33 patients treated between 2014 and 2019 were included with an average follow-up of 28.5 (range, 12-65) months. Mean preoperative Böhler's angle was 1.5 ± 10.0 (range, -26.0-16.9) degrees and mean final Böhler's angle was 29.8 ± 4.9 (range, 19.3-39.3) degrees with significant difference (P < .001). The average American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue scale (VAS) pain score at last follow-up were 86.2 ± 5.0 (range, 76-97) and 1.6 ± 1.1 (range, 0-4), respectively. Major complications included 2 (5.9%) wound infections and 1 (2.9%) incomplete separation of the lateral wall prior to plate insertion. Discussion and conclusionsThis modified 2-incision STA is a safe and effective procedure. It allows access to the posterior facet and posterior calcaneal tuberosity, appropriate restoration of blowout lateral wall, and easy placement of a standard calcaneal plate.

Two-incision Approach for the Open Reduction Internal Fixation of Intra-articular Hamate Body Fractures Using a Cannulated Headless Compression Screw.

Fractures of the hamate are relatively rare and there is a paucity of literature describing their natural history, indications for operative fixation, surgical techniques, and outcomes. Most authors recommend operative fixation of displaced intra-articular coronal hamate body fractures, and a dorsal approach with Kirschner wires has most commonly been recommended to achieve this. In this report, a 2-incision approach to the hamate is presented that facilitates rigid internal fixation of coronal hamate body fractures with a cannulated headless compression screw and minimizes the possibility of iatrogenic injury to critical branches of the ulnar nerve. The authors summarize a series of 2 patients with displaced, intra-articular coronal hamate body fractures of differing severity treated successfully with the proposed approach.

P1157Defibrillation threshold with subcutaneous implantable-cardioverter defibrillator implanted using an intermuscular 2-incision approach

Abstract Funding Acknowledgements NO FUNDING OnBehalf Rhythm Detect Registry Background Current subcutaneous implantable cardioverter–defibrillators (S-ICD) deliver 80J, and the conversion test is usually conducted by delivering shock energy of 65 J to ensure a safety defibrillation margin of at least 15 J. However, little is known about the real safety margin in real life clinical practice. Purpose To determine the defibrillation threshold (DFT) with S-ICD and to investigate its association with clinical characteristics. Methods De novo S-ICD patients were consecutively enrolled and DFT was evaluated using a pre-specified step-up protocol at implantation. Results 35 patients, BMI 25 ± 4 kg/m2, left ventricular ejection fraction (LVEF) 48 ± 19%, underwent S-ICD implantation. The generator was positioned in an intermuscular pocket and a 2-incision technique was applied in all patients. The mean DFT was 30 ± 10J and the DFT was &amp;gt;30J in 7 (20%) patients. A single patient had a &amp;gt;40J DFT. The time to shock was 11 ± 3 seconds and the shock impedance was 67 ±21 Ohm at the lowest effective energy. The DFT was comparable in patients with LVEF ≤35% (33 ± 15J) versus &amp;gt;35% (29 ± 5J, p = 0.278), and in patients with BMI ≤25 kg/m2 (30 ± 5J) versus &amp;gt;25kg/m2 (31 ± 14J, p = 0.864). Conclusions We observed low DFT and low shock impedance in patients who received S-ICD with an intermuscular 2-incision approach. The S-ICD defibrillation success rate at ≤30J was 80%, while 97% of patients were defibrillated at ≤ 40J. We found no difference in DFT according to the LVEF or the BMI.

Single-Incision 4-Compartment Fasciotomy of the Lower Leg: Safe, Effective, and Advantageous.

The optimal surgical approach for acute compartment syndrome (ACS) of the lower leg remains debatable. Although a majority of surgeons tend to use a 2-incision approach to 4-compartment fasciotomies, the authors have used a single-incision technique followed by protocolized, staged skin closure. The purpose of this study was to determine the safety, efficacy, and complication rate of this strategy. This retrospective study included all patients treated for ACS by a single surgeon during a 3-year period. A protocol was used including a single-incision technique followed by vacuum-assisted wound-closure dressing, periodic return to the operating room at 48- to 72-hour intervals, and sequential wound closure with vertical mattress sutures. Complications associated with this protocol were analyzed. Eleven patients were included in the study. Average length of follow-up was 12 months (range, 2-35 months). There were no instances of malunion, deep or superficial infection, intraoperative neurovascular injury, or progressive neurologic deficits-indicating adequate release of all 4 compartments through a single incision. All patients were closed primarily without need for skin grafting. Average time to primary closure was 4.5 days. One patient had a tibial fracture nonunion and 1 had distal wound breakdown, which healed by secondary intention. A single-incision approach to 4-compartment fasciotomies followed by protocolized skin closure is safe and effective and may reduce the need for skin grafting. [Orthopedics. 2020;43(4):e225-e230.].

Complications and outcome after periacetabular osteotomy - influence of surgical approach.

Bernese periacetabular osteotomy (PAO) was introduced by Ganz as a novel surgical technique for hip dysplasia with a congruent hip to reorient the acetabulum in skeletally mature patients. The PAO through a modified Smith-Petersen (Iliofemoral) approach, has been subject to many modifications in order to avoid complications and to minimise risks for failure. The aim of this review was to report on the complication rates, functional and radiological outcomes in relation to surgical approaches. A search of NICE healthcare database advanced search, was conducted from the year of inception to May 2018. We included studies that reported complications of PAO. Data extracted from case series was analysed to detect the incidence of complications, relation to surgical approach and temporal trend of complications. 40 studies including 4070 hips with a mean age of 29 years and a mean follow-up of 52.8 month, were analysed. Outcome measures demonstrated good to excellent outcome in 82%. Higher rates of LFCN and sciatic nerve injuries were found to be associated with the ilioinguinal and the 2-incision approach. Minimally invasive (MIS) modified Smith-Petersen (MSP), minimally invasive trans-sartorial and trans-trochanteric approaches were not reported to be associated with any major wound complications. Radiological correction achieved with a mean improvement in acetabular inclination of 17.90 (range 4.5-40), anterior centre-edge correction 25.40 (range 10-51), lateral centre-edge correction 23.30 (range 15-44.6) and medial translation of 6 mm (range 3.2-10). The complication rates seem to be lower in this current review (7%) as compared to the previous review performed by Clohisy et al. (6-37%). The MIS trans-sartorial/MIS MSP and intertrochanteric approaches are associated with an even reduced complications rates. This review enables favouring the minimally invasive approaches with regard to reducing nerve injury and wound complications.

Posterior Interosseous Nerve Proximity to Cortical Button Implant for Distal Biceps Repair With Single and 2-Incision Approaches

Fixation with a cortical button is the biomechanically strongest surgical approach for distal biceps repair, and utilization of the 2-incision approach may provide a more anatomical repair and improved terminal supination strength. The risk of injury to the posterior interosseous nerve (PIN) associated with this approach requires further investigation. A distal biceps repair with a cortical button was performed on 10 cadavers, 5 utilizing the single-incision approach and 5 utilizing the 2-incision approach. Contrast was injected into the radial nerve and computed tomography scans were obtained. The distance between the drilled cortical perforation and the PIN was measured. The mean distance from the cortical perforation to the PIN was not significantly different between approaches (9.4 mm and 8.8 mm). A PIN entrapment was seen in 0 out of 5 for the single-incision approach and 1 out of 5 for the 2-incision approach. Distal biceps repair with cortical button fixation places the PIN at risk of injury regardless of the approach used. Methods of fixation that require bicortical drilling should be especially avoided when using the 2-incision approach. Distal biceps repair utilizing bicortical drilling for fixation through a 2-incision approach poses high risk of injury to the PIN and should be avoided.

Operative Treatment of Talar Head Fractures: Surgical Technique.

Talar head fractures represent a rare subtype of injury to the talus. Clinical series of talar head fractures are nonexistent in the current literature, and treatment of these injuries is based on expert opinion. Many authors recommend a single-incision approach to open reduction and internal fixation of talar head fractures; however, we have found that a 2-incision approach allows for optimal visualization while facilitating proper implant placement. We present a description of our technique and our clinical experience treating 8 of these rare injuries.

Modified Two-Incision Approach for Repair of Distal Biceps Tendon Rupture

Rupture of the distal biceps tendon is an uncommon injury that usually results from an excessive eccentric load across the biceps tendon. Various operative techniques have been described but anatomical repair is preferred to restore near native function in patients for whom such deficits would be debilitating. Boyd and Anderson originally described a 2-incision technique that minimizes the incidence of surgical complications while restoring anatomical function. This technique was further modified by Morrey to reduce the rate of ectopic bone formation that has been observed in the original Boyd-Anderson approach. With Morrey’s modification, the 2-incision approach is a safe and effective method for repair of a distal biceps tendon rupture. We describe the modified procedure in full and report on recovery, complications, and comparative outcomes.

Single-Incision Anatomic Repair Technique for Distal Biceps Tendon Rupture Using Tunneling Device

Distal biceps tendon ruptures are uncommon and generally occur in men aged 30 to 50 years in their dominant arm as a result of a strong eccentric load. Numerous surgical exposures and methods of fixation exist for repair of a ruptured distal biceps tendon. The goal of surgical management is to restore the anatomic footprint of the biceps tendon on the radial tuberosity to maximize flexion strength, supination strength, and muscle endurance. When compared with 2-incision repair techniques, single-incision repairs historically may not have restored the anatomic footprint of the distal biceps. Single-incision repair with the ArthroTunneler is a safe and effective technique that provides the anatomic restoration of a 2-incision approach with the decreased complication profile of a single-incision approach and does not require suture anchors, buttons, screws, or other implants.

Single incision pediatric flexible intramedullary tibial nailing

BackgroundThere has been a trend towards flexible intramedullary nailing for unstable tibial shaft fractures in the pediatric population, traditionally, utilizing a 2-incision technique with passage of one nail medially and one nail laterally. Our study aims to compare a single incision approach for flexible nailing of unstable tibial shaft fractures in pediatric patients to the traditional 2-incision approach. MethodsPatients were selected for operative fixation if they had a length unstable tibial shaft fracture confirmed by fluoroscopy. Exclusion criteria included length stable tibial fractures that could undergo nonoperative treatment. Single incision technique utilized the medial incision only. Patients were monitored in the hospital for one postoperative day and followed up at 4 week, 8 week, and 12 week marks. Radiographic analysis was performed to evaluate for malunion or nonunion. Operative times, infection rates and complications were recorded and analyzed. ResultsAll patients achieved complete fracture healing at the 12-week follow up. There were no delayed unions, nonunions or malunions in either treatment group. ConclusionsSingle medial incision for tibial flexible nails had equivalent outcomes with no difference in primary healing rate, malunion or nonunion rate when compared to the dual incision technique.

A Prospective Randomized Trial of Mini-Incision Posterior and 2-Incision Total Hip Arthroplasty: Minimum 5-Year Follow-Up

BackgroundWe previously described the results of a randomized controlled trial of mini-posterior vs 2-incision total hip arthroplasty and were unable to demonstrate significant differences in early outcomes. As less-invasive anterior approaches remain popular, the purpose of this report was to re-examine the outcomes at a minimum 5-year follow-up. MethodsSeventy-two patients undergoing primary total hip arthroplasty were randomized to a mini-posterior or 2-incision approach. Complications, revisions, and clinical outcome measures were compared. Radiographs were reviewed for implant loosening. A power analysis using a minimal clinically important difference value of 6 points for the Harris hip score revealed 28 patients required per group. ResultsAt a mean of 8.2 years (range, 5-10 years), 6 patients died without revision surgery and 63 of 66 living patients were reviewed. There were 6 total failures, 3 in each group. For unrevised patients, there were no significant differences between groups (posterior vs 2-incision) in the Harris hip score (95.5 ± 3.5 vs 95.7 ± 6.3; P = .88), 12-item Short Form Survey physical composite score (50.5 ± 8.5 vs 49.0 ± 9.1; P = .53), 12-item Short Form Survey mental composite score (57.3 ± 4.1 vs 55.4 ± 8.0; P = .25), or single assessment numeric evaluation score (97.1 ± 3.7 vs 97.8 ± 5.2; P = .55). ConclusionWe found no differences in midterm outcomes between the 2 approaches. Given the increased complexity, operative time, and need for fluoroscopy with the 2-incision approach combined with equivalent early and midterm outcomes, the 2-incision approach has been abandoned in the senior author's practice.

Arthroscopic-Assisted Lower Trapezius Tendon Transfer for Massive Irreparable Posterior-Superior Rotator Cuff Tears: Surgical Technique

Tendon transfer options to reconstruct a massive irreparable posterior-superior rotator cuff tear include latissimus dorsi, teres major, or lower trapezius transfer. We previously described the lower trapezius transfer using a 2-incision approach, which includes a medial incision to harvest the lower trapezius and lateral transacromial incision to expose the rotator cuff and then perform the transfer through a deep tunnel connecting these 2 sites. In this report, we describe an arthroscopic-assisted technique of lower trapezius transfer augmented with an Achilles tendon allograft to reconstruct an irreparable posterior-superior rotator cuff tear.

Rehabilitation of gait in patients after total hip arthroplasty: Comparison of the minimal invasive Yale 2-incision technique and the conventional lateral approach

The minimal invasive anterolateral Yale 2-incision approach for total hip arthroplasty aims minimizing damage to the muscles for faster recovery of function. Therefore the hypothesis was investigated, that during the rehabilitation process the Yale approach shows a faster return to natural gait than a conventional lateral approach.Nineteen patients had the Yale, 16 the conventional Bauer approach. Instrumented gait analysis was performed 3 days, 3 and 12 month post operatively. Velocity, cadence, step length, weight bearing, thorax lean, Trendelenburg limp, hip abduction moments, and hip muscle activation times were evaluated.Three days post-surgery a significantly greater loading of the treated limb and increased hip abduction moment were observed in the Yale group. In addition, the Yale group showed its greatest improvement in walking speed and step length between at 3 days and 3 months, whereas the conventional group showed an additional significant gain between 3 and 12 month to reach a similar walking speed as the Yale group. For all hip muscles investigated, only muscle tensor fasciae latae in the conventional group showed a significant increase in activation time between 3 days and 3 months.This study showed significantly faster return to natural gait in the Yale compared to the conventional approach, which could be biomechanically related to less impairment of abductor muscles in the Yale approach.

Medial Double Arthrodesis With Lateral Column Sparing and Arthrodiastasis: A Radiographic and Medical Record Review

Correction of valgus hindfoot deformity can be successfully achieved with arthrodesis of the subtalar and talonavicular joints through a single medial based incision. The advantages of medial double arthrodesis compared with the standard triple arthrodesis 2-incision approach include the absence of a lateral incision and a few degrees of residual mobility through the unfused calcaneocuboid joint (CCJ). The CCJ has often been noted to distract and decompress with the abduction correction achieved through medial double fusion. The primary goal of the present retrospective study was to identify the frequency of CCJ decompression, measure the radiographic changes at the CCJ, and evaluate the flatfoot correction using this operative approach. A total of 46 patients (47 feet) were identified as possible subjects. Twenty patients (20 feet) with a mean follow-up period of 9.2 ± 4.1 (range 6 to 21) months met our inclusion criteria. Distraction of the CCJ using medial double fusion resulted in increased joint space and improvement of at least 1 grade of arthritis in 50% of the patients. In the patients with severe CCJ arthrosis, the improvement was less predictable, with only 20% showing radiographic improvement. Correction of flatfoot as measured on standard radiographs showed excellent results. Subchondral bone changes as measured by the CCJ arthrosis scale improved in patients with mild to moderate arthritis after distraction arthrodiastasis. However, those with severe preoperative CCJ had less predictable improvement. Medial double arthrodesis for severe flatfoot deformity provides predictable correction of the deformity and improvement in the CCJ arthritis scale when the preoperative arthritis of the CCJ is mild to moderate.

The role of laparoscopy-assisted renal autotransplantation in the treatment of primary ureteral tumor.

To evaluate the effect and safety of laparoscopy-assisted renal autotransplantation treatment for primary ureteral cancer (PUC). Medical records of patients undergoing hand-assisted retroperitoneoscopic nephroureterectomy–extracorporeal total ureterectomy–renal autotransplantation–pyelocystostomy (Lap AutoTx) were analyzed. Demographic, intraoperative, and postoperative data were assessed. Fifteen patients diagnosed with PUC underwent this novel approach. Three kidneys were abandoned owing to the detection of residual cancer on the renal pelvic junction, surgeon’s judgment on three severe atherosclerotic arteries, and palpable pelvic lymph nodes proven to be evidence of metastatic disease by frozen section analysis. Twelve patients (mean ± SD age 67.5 ± 7.5 years) were treated with Lap AutoTx for PUC successfully. No perioperative mortality occurred. One patient with solitary kidney experienced delayed graft function that required short-term hemodialysis. Three recurrent superficial diseases in three patients were treated with transurethral resection. The mean ± SD follow-up duration was 12.1 ± 6.7 months (range 3–24 months). The renal pelvicaliceal system was easily examined by flexible cystoscopy. Lap AutoTx is less invasive compared with the traditional two-incisional manner and can be performed safely even among elderly patients. Compared with other currently used therapies, this novel treatment can be used to successfully treat PUC with the added advantages of total resection of the ureteral lesion, preservation of the renal function, and simplification of follow-up procedures.Primary ureteral cancer (PUC) is an aggressive disease and has a poor prognosis.1 Studies have shown high prevalence and invasiveness of PUC in Taiwan.2,3 Nephroureterectomy with excision of the bladder cuff is still believed to be the gold standard treatment for PUC.4 Most PUC occurs among individuals aged more than 60 years, and most of these patients are also at high risk of chronic kidney disease (CKD).5,6 Nephroureterectomy not only results in excessive loss of renal function, but also puts the patient at risk of CKD, which contributes to the progression of end-stage renal disease requiring dialysis. In addition, diminished renal function after nephroureterectomy compromises the possible use of adjuvant chemotherapy for advanced disease.Endoscopic surgery (ES) and segmental resection (SR) can be used for renal preservation in PUC cases, but there still are limitations to these approaches, and indefinite invasive ureteroscopy is required during follow-up. Only a few studies have focused on renal autotransplantation (AutoTx) after extracorporeal total ureterectomy (ETU) for PUC. This type of treatment possesses advantages of total resection of malignant ureteral lesions, preservation of renal function, and simplification of follow-up protocols. In two reported case series, all cases involved surgery performed with the traditional 2-incision approach, and only a few cases involved pure PUC.7,8 We have reported that hand-assisted retroperitoneoscopic nephroureterectomy (HARNU) for the treatment of PUC is less invasive and results in better functional outcomes with fewer complications and comparable oncologic control compared with open nephroureterectomy.9 In this study, we report our experience of this treatment combined with ETU and AutoTx for pure PUC.

Effect of Elbow Flexion on the Proximity of the PIN During 2-incision Distal Biceps Repair

The posterior interosseous nerve (PIN) is at risk for injury during surgical dissection for distal biceps repair, yet the optimal position of elbow flexion to avoid a PIN injury has never been established for the 2-incision approach. The purpose of this study was to determine the proximity of the PIN to the radial tuberosity during surgical dissection in different degrees of elbow flexion. Ten cadaveric specimens with an intact elbow and forearm were dissected in full pronation using a modified Boyd-Anderson approach. Half of the dissections were completed in 90° of flexion and the other half were completed in maximal flexion. To simulate the location of the PIN during a single-incision biceps repair, the distance of the PIN to the radial tuberosity was recorded in full extension and supination. Results from these measurements were assessed for differences using paired t tests, with differences deemed significant for P values less than .05. The PIN was not identified in any of the 2-incision surgical dissections. Based on these findings, the proximity of the PIN to the radial tuberosity is not significantly affected by the degree of elbow flexion in the muscle-splitting 2-incision approach. In addition, a safe zone exists for avoiding PIN injury in a single-incision technique for distal biceps repair because a drill bit exiting the radial tuberosity greater than 1 cm in a distal-radial direction would place the PIN at risk.

Single-Incision Medial Approach for Double Arthrodesis of Hindfoot in Posterior Tibialis Tendon Dysfunction

Triple arthrodesis through a 2-incision approach has been the primary salvage procedure for rigid hindfoot malalignment resulting from posterior tibialis dysfunction. However, complications like calcaneocuboid joint nonunion, lateral wound dehiscence, and adjacent joint arthritis have been reported after triple arthrodesis. Hence we adopted single-incision medial approach arthrodesis of subtalar and talonavicular joints, sparing the uninvolved calcaneocuboid joint and lateral skin. We report the results of a series of 18 feet with posterior tibialis dysfunction that had correction of malalignment by this approach. Mean age at surgery was 65 years. The mean follow-up was 24 months. There was statistically significant improvement in all the radiological parameters measured. There were no wound-related complications. The union rate was 89%. There were 2 malunions, and 2 feet developed valgus ankle deformity. The overall satisfaction rate among patients was 78%. We present a case series of treatment of posterior tibialis tendon dysfunction by arthrodesis of the subtalar and talonavicular joints through an isolated medial approach. The results were not encouraging enough to recommend adopting this approach as an alternative to triple arthrodesis. Level IV, retrospective case series.