Anterolateral Incision Research Articles

Adult Tillaux-Chaput tubercle fracture of the ankle with rupture of the peroneus tertius muscle: a case report

BackgroundTillaux-Chaput tubercle fractures occur in adolescents, which are often associated with the separation of the distal tibial growth plate. These types of fractures are rare in adults and even rarer when accompanied by a rupture of the peroneus tertius muscle. Given the limited number of reported cases, there is limited clinical awareness, resulting in missed diagnoses and delayed treatment, ultimately affecting ankle function.Case presentationWe report a case of an adult patient who experienced a right ankle injury resulting in swelling and pain after a traffic accident. Initial examination failed to identify the rupture of the peroneus tertius muscle, but the patient was observed to have restricted dorsiflexion and eversion of the foot. Surgical exploration through an anterolateral incision confirmed the rupture and the muscle was then repaired. The patient received four weeks of cast immobilization and then engaged in progressive rehabilitation exercises.Discussion and conclusionThis report shares the diagnostic and therapeutic experiences of an adult with a Tillaux-Chaput tubercle fracture associated with peroneus tertius muscle rupture to improve clinical recognition of such injuries, thus preventing misdiagnosis and treatment delays.

Continuous serratus anterior plane block for postoperative analgesia following lung transplantation via anterolateral incision: a pilot study.

Unilateral or bilateral anterolateral thoracotomy May lead to severe acute pain in lung transplantation (LTx). Although serratus anterior plane block (SAPB) is apparently effective for pain control after open thoracic surgery, there remains a lack of evidence for the application of SAPB for postoperative analgesia after LTx. In this case series pilot study, we describe the feasibility of continuous SAPB after lung transplantation and provide a preliminary investigation of its safety and efficacy. After chest incisions closure was complete, all patients underwent ultrasound-guided SAPB with catheter insertion. Numerical rating scale (NRS), additional opioid consumption, time to endotracheal tube removal, ICU length of stay, and catheter-related adverse events were followed up and recorded for each patient within 1 week after the procedure. A total of 14 patients who received LTx at this center from August 2023 to November 2023 were included. All patients received anterolateral approaches, and 10 (71.4%) of them underwent bilateral LTx. The duration of catheter placement was 2 (2-3) days, and the Resting NRS during catheter placement was equal to or less than 4. A total of 11 patients (78.6%) were supported by extracorporeal membrane oxygenation (ECMO) in LTx, whereas 8 patients (57.1%) removed the tracheal tube on the first day after LTx. Intensive care unit (ICU) stay was 5 (3-6) days, with tracheal intubation retained for 1 (1-2) days, and only one patient was reintubated. The morphine equivalent dose (MED) in the first week after LTx was 11.95 mg, and no catheter-related adverse events were detected. We did not assess the sensory loss plane due to the retrospective design. In addition, differences in catheter placement time May lead to bias in pain assessment. Although continuous SAPB May be a safe and effective fascial block technique for relieving acute pain after LTx, it should be confirmed by high-quality clinical studies.

Single Versus 3-incision Triple Pelvic Osteotomy: Comparison of Clinical and Radiologic Results.

Triple pelvic osteotomy (TPO) is indicated when the anatomic and functional realignment of the hip joint is needed. Although the traditional approach for TPO involves a separate incision for ischial cut, there has been a trend for single-incision TPO in recent years. This study aims to compare the clinical and radiologic results of 2 different approaches. Forty-two hips of 39 patients treated using TPO with a minimum of 24 months of follow-up were included in our cohort. Demographics, perioperative, and radiologic parameters were evaluated. Harris Hip Score and International Hip Outcome Tool were used for clinical evaluation. A single anterolateral incision approach was used in 18 hips (17 patients), whereas a 3-incision approach was used in 24 hips (22 patients). The mean follow-up was 4.7 years in the 3-incision group and 3.8 years in the single-incision group ( P =0.43), with mean surgery age at 8.7 years (range, 5.4 to 12) for single-incision and 9.7 years (range, 7.7 to 11.7) for 3e-incision ( P =0.22). There were no significant differences observed between the 2 groups concerning radiographic measurements, complications, and functional scores. The mean surgical time was 118.6 minutes in the single-incision group and 97.9 minutes in 3-incision group ( P =0.036). Mean intraoperative blood loss was 181.7ml in the single-incision group and 243.4ml in 3-incision group ( P =0.028). Three-incision group demonstrated significantly higher intraoperative blood loss, leading to lower hemoglobin values ( P =0.042). The single-incision TPO demonstrated similar outcomes compared with the traditional 3-incision approach in terms of radiologic correction and functional improvement. The single-incision technique exhibited advantages such as reduced intraoperative blood loss and potential benefit of decreased pain due to fewer scars. However, it required a longer surgical time compared with the 3-incision approach. Surgeons should consider patient-specific factors and their expertise when selecting the most appropriate approach for each case. Level III-retrospective comparative series.

Low anterolateral incision for single-port extraperitoneal robot-assisted pyeloplasty: description of technique and initial experience

PurposeThis study aims to describe the surgical steps for the single-port low anterolateral extraperitoneal approach to pyeloplasty, report its feasibility, and share the initial outcomes of our experience.MethodsWe analyzed all consecutive patients who underwent single-port low anterolateral extraperitoneal pyeloplasty due to ureteropelvic junction obstruction (UPJO). The surgical steps included a pure single-port approach through a 3.5 cm low anterolateral incision two fingerbreadths above the superior pubic ramus. The ureter was localized and followed cranially, a dismembered pyeloplasty was performed, and a running ureteropelvic anastomosis was completed. No drains were placed. The urinary catheter was removed upon discharge, and the ureteral stent after 3–5 weeks.ResultsA total of eight cases (two adults and six children) were completed successfully, without complications or conversions. Median operative time, console time, and estimated blood loss were 208.5 min, 114.5 min, and 10.0 ml, respectively. All patients were discharged within 24 h, except for one that required urinary output observation due to retention. There were no major postoperative complications. The median pain score at discharge was 0/10. Only one patient was prescribed PRN opioids at discharge. The readmission rate was 0.0%. All patients were asymptomatic on their last follow-up with no definitive obstruction on imaging, and no requirement for additional procedures or stents.ConclusionSingle-port low anterolateral extraperitoneal pyeloplasty is a feasible alternative for surgical treatment of UPJO in adult and pediatric patients with improved recovery outcomes.

Dual Approach to Talar Body Fractures Increases Talar Dome Access for Fracture Care without Osteotomy

Category: Trauma; Ankle; Hindfoot Introduction/Purpose: No consensus surgical treatment algorithm exists for talar body fractures, with authors recommending both soft-tissue and osteotomy-based approaches. This study evaluated the utility of dual approaches to the talar dome through anterolateral transligamentous (ATL) and modified posteromedial (mPM) approaches, both with and without distraction. Methods: Ten cadaveric legs (5 matched pairs) were included. A mPM approach, between FHL and Achilles tendon, and an ATL approach, utilizing an anterolateral incision with transection of the ATFL and CFL fibular insertions, were performed on each specimen. Order of approach was alternated within each pair. Accessible dome surface area (DSA) was outlined by drilling with a 1.6-mm Kirschner wire at the visualized talar dome margin both with and without 4mm of tibiotalar distraction. Specimens were analyzed by micro-computed tomography. Primary outcome was total accessible DSA. Student's t-tests compared DSA accessed by different exposure methods. Results: An initial mPM approach allowed access to 25.6% and 33.6% of DSA without and with distraction (p=0.002). An initial ATL approach provided access to 47.0% and 58.1% of DSA without and with distraction, respectively (p=0.003). No significant difference in DSA accessibility were observed for either approach when they were performed second. Accessibility via dual approaches was 71.7% and 93% of DSA without and with distraction with an initial ATL approach and 71.3% and 87.5% of DSA without and with distraction with an initial mPM approach (p=0.96 and 0.37, respectively). (Figure 1) Conclusion: Dual approaches provided access to greater than 70% and 85% of DSA without and with distraction. Order of approach did not change access. These results may promote soft-tissue only treatment strategies in talar body fracture care.

Chronic Exertional Compartment Syndrome of the Lower Extremity: Diagnosis and Surgical Treatment.

Chronic exertional compartment syndrome of the lower extremity is a condition that characteristically presents as recurrent anterior, posterior, and/or lateral lower-extremity pain on repetitive activity and physical exertion1. This condition is commonly seen in athletes, runners, and military personnel2. Open fasciotomy has been demonstrated to be a highly effective surgical treatment for patients with this condition who do not experience symptomatic relief after a thorough trial of nonoperative treatment3. Diagnostic compartment pressure management is achieved through direct insertion of a compartment-pressure-measuring device into the anterior, lateral, and posterior compartments of the lower extremity4. Surgical treatment of the anterior and lateral compartments with use of open fasciotomy employs longitudinal proximal and distal incisions that are made on the lateral surface of the leg approximately 3 finger-breadths distal and proximal to the fibular flare, respectively, and 3 finger-breadths lateral to the tibial crest. Surgical treatment of the posterior compartments with use of open fasciotomy employs a single, mid-shaft incision made approximately 2.5 cm medial to the tibial ridge. Dissection is carried down to the deep fascia at both sites, beginning at the distal operative site. Care is taken to avoid transection of the superficial peroneal nerve at the distal anterolateral incision and saphenous vein and nerve at the medial incision. Once down to the deep fascia, a scalpel is utilized to incise the fascia. Metzenbaum scissors are then employed under the incision, spreading the scissors while sliding them over the muscles proximally and distally to release the muscular attachments from the fascia as well as to release the fascia itself3. This process is repeated in the anterior, lateral, and superficial posterior compartments through the proximal and distal incisions. In the deep posterior compartment, the fascia is released from the tibial ridge with a large Cobb elevator. Closure is achieved with deep dermal and superficial sutures. Nonoperative alternatives have been reported to include nonpharmacological modalities such as walking modification and shoe inserts, pharmacological therapy with nonsteroidal anti-inflammatory drugs, and physical therapy targeted at conditioning the lower extremity5. Nonoperative intervention has been demonstrated to increase endurance in select patients; however, most patients must either stop the activity associated with the compartment syndrome altogether or proceed to surgery for complete resolution of symptoms5. There are a few surgical alternatives that differ in their utilization of minimally invasive approaches versus a direct open approach6; however, all existing surgical treatments of this condition involve physical release of the fascial compartment. Diagnostic compartment-pressure measurement is useful in confirming or ruling out the presence of this condition in patients with unclear symptoms4. Furthermore, diagnostic compartment-pressure management ensures accuracy in diagnosis and validates invasive treatment when patients desire surgical intervention. Surgical management of exertional compartment syndrome of the lower extremity is indicated in patients when nonoperative treatment has failed despite clinically notable symptoms and objectively elevated lower-extremity compartment pressures. Open fasciotomy has been postulated to prevent compression of local vasculature and effectively prevent ischemia; however, the definitive mechanism is unclear1. Surgical treatment of chronic exertional compartment syndrome with use of open fasciotomy is highly successful in the civilian population. One study showed excellent return to activity/sport in 15 of 16 patients (25 of 26 limbs; 96%), with patients often reporting no symptoms postoperatively3. Military personnel have been reported to experience satisfactory results, with another study showing positive subjective feedback in 35 (76%) of 46 patients on long-term follow-up; however, only 19 patients (41%) were able to return to full active duty postoperatively7. Balloting the fascial compartment with ∼1 cc of saline solution can be helpful in determining successful placement of the pressure-measuring device at the time of needle entry.Identifying the course of the superficial peroneal nerve via physical examination can help avoid iatrogenic injury to this important superficial structure during the dissection leading to the distal fasciotomy.Deep posterior compartment release with use of open fasciotomy may not provide symptomatic relief; patients who demonstrate elevation of pressures in this specific compartment should be counseled accordingly. ROM = range of motionSPN = superficial peroneal nerve.

Clinical Comparison of the “Windowing” Technique and the “Open Book” Technique in Schatzker Type II Tibial Plateau Fracture

ObjectiveSurgical treatment for Schatzker type II tibial plateau fractures remains challenging and requires high‐quality research. The aim of the study is to compare the “windowing” and “open book” techniques for the treatment of Schatzker type II tibial plateau fractures.MethodsIn this prospective study, all patients with Schatzker type II tibial plateau fractures between January 2014 and December 2017 were managed by open reduction and internal fixation using an anterolateral incision approach. “Windowing” group included 78 patients (53 men and 25 women), with an average age of 57.7 ± 13.5 years, who underwent the “windowing” technique, in which the procedure was performed through a small cortical window against the depressed zone of the lateral plateau. The “open book” group included 80 patients (56 men and 24 women), with an average age of 54.8 ± 12.4 years, who underwent the technique. The clinical outcomes included the Rasmussen classification of knee function and grading of post‐traumatic arthritis. The radiographic outcome (x‐ray and computed tomography [CT]) was the reduction quality of the lateral plateau based on the modified Rasmussen radiological assessment. The patient‐reported outcome was visual analogue scale (VAS) scores.ResultsThe mean follow‐up time for the158 patients was 32 months (range, 24–42 months). The time elapsed from injury to surgery in “windowing” group and “open book” group were 3.7 ± 1.2 (range, 1–10 days) and 3.5 ± 1.4 days (range, 1–11 days), respectively, with no significant difference between the groups (P > 0.05). The operation times did not differ significantly between the “windowing” group (61.0 ± 8.3 min, range, 45–120 min) and the “open book” group (61.2 ± 10.4 min, range, 40–123 min) (P > 0.05). After surgery, CT revealed five (6.4%) and 15 (18.8%) cases of articular depression in the “windowing” and “open book” groups, respectively. Significant differences were observed in the articular depression of tibial plateau fractures between the groups (P < 0.05). However, condylar widening or valgus/varus did not differ significantly between the groups. Furthermore, no significant differences in knee function were observed during follow‐up (P > 0.05). VAS scores were similar between the groups at 24 months after surgery (P > 0.05). There were significant differences in the number of severe post‐traumatic arthritis (grades 2 and 3) cases between the groups (P < 0.05).ConclusionsThe “windowing” and “open book” techniques are both effective for the treatment of Schatzker type II tibial plateau fractures. However, the “windowing” technique provides better reduction quality, leading to a satisfactory prognosis.

A fresh "slant" on modified Mitchell bladder neck reconstruction: A contemporary single-institution experience.

IntroductionPatients with neurogenic urinary incontinence due to an incompetent outlet may be offered bladder neck reconstruction, but the quest for the perfect surgical-outlet procedure continues. Our aim was to characterize continence and complications after modified Mitchell urethral lengthening/bladder neck reconstruction (MMBNR) with sling and to introduce a modification of exposure that facilitates subsequent steps of MMBNR.MethodsA single-institution, retrospective cohort study of patients who underwent primary MMBNR between May 2011 and July 2019 was performed. Data on demographics, urodynamic testing, operative details, unanticipated events, continence, bladder changes, and additional procedures were collected. A 2013 modification that permits identification of the incompetent bladder neck prior to urethral unroofing was applied to the last 17 patients. The trigone and bladder neck are exposed via an oblique low anterolateral incision on the bladder. Ureteral reimplantation is not routinely performed. Focal incision of the endopelvic fascia after posterior plate creation limits breadth of blunt dissection for sling placement. Descriptive statistics were utilized.ResultsA total of 25 patients (13 females) had MMBNR with sling at a median age of 10 years [interquartile range (IQR) 8–11]. Bladder augmentation was performed concurrently in 14/25 (56%) patients. At a median of 5.0 (IQR 3.9–7.5) years follow-up after MMBNR, 9/11 (82%) without bladder augmentation and 13/14 (93%) with bladder augmentation had no leakage per urethra during the day without further continence procedures. Of the three patients with persistent incontinence, two achieved continence with bladder wall Botox injection (overall continence 24/25, 96%). New and recurrent vesicoureteral reflux was noted in five patients and one patient, respectively. Two patients required subsequent bladder augmentation for pressures and one other will likely require it. None have required bladder neck closure or revision.ConclusionMMBNR with sling provides promising continence per urethra in neurogenic bladder with low need for secondary continence procedures. Ongoing modifications may achieve elusive total continence.

Posteromedial plate application using medial midline incision for complex tibia plateau fractures: a retrospective study

BackgroundApplication of a posterior plate for tibia plateau fractures associated with posterior column involvement is becoming a widespread standard practice as previous studies have shown that additional fixation of the posterior column with a posteromedial buttress plate creates strongest fixation in terms of fracture stabilization This study evaluated the clinical and radiological results of patients undergoing surgery for complex tibial plateau fractures involving the posterior column with a posteromedial plate applied via a medial midline incision.MethodsMedical records of patients undergoing surgery for Schatzker type IV, V, and VI tibia plateau fractures involving the posterior column in our institution were reviewed retrospectively. Patients with a follow-up of less than 1 year, pathological fractures, posterolateral column fractures requiring separate fixation, and open fractures were excluded from the study. Three-dimensional computed tomography (3D CT) was performed in all patients before surgery. The study population consisted of 25 patients (21 males and 4 females) with a mean age of 41.5 (19–66) years. The etiologies of the fractures were traffic accidents in seven cases, pedestrian falls in five cases, falls from a height in seven cases, and motor vehicle accidents in six cases.ResultsThe mean follow-up period was 15.9 months (12–25), mean time to union was 14.32 (9–20) weeks, mean Knee Society score (KSS) was 88 (81–95), and range of movement (ROM) was 123° (95°–140°). Loss of reduction was detected in only one patient (4%). A superficial incisional infection occurred in an anterolateral incision in only one patient (4%), and it recovered after oral antibiotic therapy. None of the patients required early implant removal and none had vascular or nerve complications in the postoperative period. Postoperatively, 23 (92%) patients had anatomical reduction and 2 (8%) had acceptable reduction in the sagittal plane CT sections. Acceptable reduction was achieved in 6(24%) patients and anatomical reduction was achieved in 19 (76%) in the coronal plane CT sections (Table 2).ConclusionsClinical results of posteromedial plate application using a single medial midline incision is promising as complication rates were very low and knee scores were high.

Bilateral talus neck fracture in an 11-year-old patient resulting from a fall from height: A case report

We here present an 11-year-old patient with bilateral Hawkins type 3 talus neck fractures resulting from a fall from height. When the patient was brought to the Emergency Department, the ankles were edematous and there were bilateral talus neck fractures with subtalar dislocation. The taluses on both sides were entered with anteromedial and anterolateral incisions, and after an open reduction, the fractures were fixed with one cannulated screw from the anterior and one from the posterior side. No additional edema developed. The patient was followed up for 2 days in the ward, then discharged with outpatient follow up recommendations. Pediatric bilateral talus neck fractures are rare and must be treated immediately.

Serratus anterior plane block for cardiothoracic surgeries: a meta-analysis of randomized trials

BackgroundComparison of serratus anterior plane block to different analgesic methods for anterolateral thoracic wall incisions. Meta-analysis was used to address this concern. Authors systemically searched the MEDLINE, EMBASE, PubMed, and Cochrane databases to identify all published randomized and prospective clinical trials, comparing the SAPB with other methods that used for analgesia in different thoracic surgical procedures and trauma.ResultsTen studies were identified for inclusion in this study, involving a total of 735 patients. Meta-analysis showed that, compared with thoracic wall analgesia and PCA methods, the SAPB group resulted in a significant decrease in pain scores, significant decrease in consumption of analgesic drugs, and a significant decrease in the incidence of nausea and vomiting with no difference in the rate of hypotension.ConclusionsThe use of SAPB in cardiothoracic surgery and trauma is a safe and effective option for thoracic analgesia.

Suture Hemostasis - Conservative Management of Ectopic Pregnancy

<h3>Study Objective</h3> The conservation of fertility in spite of recurrent ectopic pregnancy in women who want to continue to have children. This procedure will allow for the regeneration of the tubal structure which will make future pregnancies possible and affordable when compared to other methods such as in vitro fertilization. <h3>Design</h3> Case Study, early first trimester diagnosis of ectopic pregnancy which includes ultrasound and serial serum B-hCG levels will lead to medical or surgical management of the ectopic pregnancy. <h3>Setting</h3> Hospital, operating room. <h3>Patients or Participants</h3> Case Study 28-yo Gravida 4 Para 2 with a previous salpingectomy for and ectopic gestation presents with a recurrent ectopic in her remaining fallopian tube and had failed medical management with methotrexate. She was offered conservative surgical management with suture hemostasis. <h3>Interventions</h3> At laparotomy (in this case) or laparoscopy the ectopic site was identified in the fallopian tube. Overlapping vicryl rapide sutures were placed proximal to the ectopic site and distal to it. An anterolateral incision was made in the ectopic site with removal of the products of conception. The site remained blood less, hemostasis of the surgical site was noted, peritoneal lavage performed and the abdomen closed in layers. <h3>Measurements and Main Results</h3> 1. Hemostatic suture placement. 2. Removal of the products of conception and confirmation of same on histopathology. 3. Hemostasis of the surgical site. 4. Confirmation of a tubal patency by a successful intrauterine pregnancy. <h3>Conclusion</h3> Suture hemostasis must be an option in ectopic pregnancy whether primary or recurrent since the method is cost effective and tubal patency can be confirmed in the post operative recovery phase. It allows for an additional conservative surgical option when hemostasis may be difficult using linear salpingostomy for larger ectopics leading to an unfortunate salpingectomy. A more extensive case series is recommended to further advance the technique and to note its potential benefits and drawbacks.

Midline versus anterolateral incisions for total knee arthroplasty-a systematic review and analysis of the angiosomes of the knee.

The most common incision for total knee arthroplasty is the anterior midline incision; however, it is commonly associated with lateral knee numbness, kneeling difficulties and restricted flexion range. We sought to review the literature regarding the neurovascular supply and angiosomes over the anterior knee, and evaluate the anterolateral incision as a viable alternative for knee arthroplasty. A systematic review of the literature was performed searching PUBMED, MEDLINE and EMBASE to evaluate the incisions available for total knee arthroplasty with respect to neurological function, kneeling ability and complications. Ten studies were identified evaluating midline or anterolateral incisions for total knee arthroplasty, with a total of 664 knees for analysis. Mean patient age was 68 years (45-88), and average length of followup was 1year. A total of 586 had an anterior midline incision and 78 had an anterolateral incision. A total of 62% of anterior midline incisions sustained altered sensation compared to 15% (12/78) of anterolateral incisions (p < 0.0001). Incision length was similar in both groups (19.8cm midline vs. 20.8 cm anterolateral). Wound dehiscence was not significantly different between the two groups being 8.3% for midline incisions, and 2.5% for anterolateral incisions (p=0.153). Kneeling ability was reported in two studies which reported an improved ability to kneel with an anterolateral incision. The lateral parapatellar incision respects the neurovascular anatomy of the knee and offers a significant reduction in sensory changes, better kneeling ability and similar rates of wound problems to a standard midline incision and should be considered as a viable alternative for knee arthroplasty.

Bilateral Lung Transplantation for Patients With Destroyed Lung and Asymmetric Chest Deformity.

Background: Destroyed lung can cause mediastinal displacement and asymmetric chest deformity. Reports on bilateral lung transplantation (LT) to treat destroyed lung and asymmetric chest deformity are rare. This study presents our surgical experience of bilateral LT among patients with destroyed lung and asymmetric chest deformity.Methods: Six patients with destroyed lung and asymmetric chest deformity who underwent bilateral LT at our center from 2005 to 2020 were included in the study. Demographic data, technical data, perioperative details, and short-term follow-up data were reviewed.Results: Three patients underwent bilateral LT via anterolateral incisions in the lateral position without sternal transection, while three patients underwent bilateral LT via clam-shell incisions in the supine position with sternal transection. Only one patient required intraoperative extracorporeal membrane oxygenation. Four patients underwent size-reduced LT. In the other two patients, we restored the mediastinum by releasing mediastinal adhesions to ensure maximal preservation of the donor lung function. Patients in the lateral position group had a higher volume of blood loss, longer operation time, and longer postoperative in-hospital stay than those in the supine position group. However, these differences were not statistically significant. Postoperative computed tomography in the supine position group revealed that the donor lungs were well expanded and the mediastina were in their original positions.Conclusions: Although bilateral LT in patients with destroyed lung and asymmetric chest deformity is high risk, with sufficient preoperative preparation and evaluation, it is safe and feasible to perform bilateral LT for selected patients. For patients without severe chest adhesions, releasing the mediastinal adhesions and restoring the mediastinum through a clam-shell incision in the supine position is a simple and effective method to maximally preserve the donor lung function without pneumonectomy or lobectomy.

Percutaneous Cerclage Wiring Combined with Cephalomedullary Nailing for Irreducible Subtrochanteric Fractures.

ObjectiveTo explore the surgical method, operation essentials and the clinical effect of the treatment of irreducible subtrochanteric femoral fractures by percutaneous cerclage wiring and Cephalomedullary nail.MethodFrom February 2016 to October 2019, 17 cases of irreducible subtrochanteric femoral fractures (SFFs) treated via a minimally invasive wire system and intramedullary nail fixation were reviewed retrospectively. Ten male and seven female patients were involved. The average age was 59.88 ± 16.13 years, ranging from 41 to 94 years. Among the patients, seven were injured in traffic accidents, five fell from a standing height, and five injured themselves from falling. The cases were classified based on the Seinsheimer classification. Specifically, five cases were type IIIA, five cases were type IIIB, one case was type IV, and six cases were type V. According to the AO/OTA classification, 10 cases were 32B3, and seven cases were 32C3. During surgery, the patients were placed on a traction bed andattempted closed reduction. For those patients whose closed reduction failed confirmed by fluoroscopy, we performed a small anterolateral incision through which a self‐made minimally invasive percutaneous wire introducer (passer; patent Z: 2016 2 1002800.8) was employed for temporary fixation with a wire. A double‐stranded steel wire was introduced into a self‐made wire traction and lifting device (patent ZL 2020 2 0205658.7), the wire was pulled vertically and firmly fixed. Then an long InterTan nail was used for the fixation. The following information was recorded: (i) length of the invasive incision, (ii) blood loss on the third day after surgery, (iii) operation time; and (iv) maximum displacement and angulation of the fracture ends of the x‐rayed front and side fractures before and after surgery and the maximum displacement and formation of the three‐dimensional CT‐scanned fracture ends in the coronal plane, sagittal plane, and cross section before and after surgery.ResultA total of 15 of the 17 patients were followed for 12 to 24 months. The 15 patients recovered, but one died from pulmonary infection 1 year after surgery. In the postoperative X‐ray and three‐dimensional CT observation reduction treatment, fracture displacement was less than 5 mm, each plane angle was less than 10 degrees, and postoperative fracture healing time was 3 to 14 months, with an average of 4.19 ± 4.04 months. The postoperative Harris hip function score ranged from 66 to 95 points, with an average of 80.81 ± 9.67 points. In terms of clinical outcomes, 11 cases were excellent, four cases were satisfactory, and one case was fair.ConclusionFor refractory subtrochanteric fractures, percutaneous wiring combined with Cephalomedullary nail fixation is a minimally invasive, rapid, and effective method, which can achieve satisfactory results in clinical practice and is worth promoting.

Increased Articular Exposure of the Lateral Tibial Plateau with a Midline Lateral Parapatellar Arthrotomy Compared to an Anterolateral Submeniscal Arthrotomy: a Cadaveric Study

To quantitatively compare the articular exposure of the proximal tibia with a lateral parapatellar arthrotomy through a straight midline incision (ML) versus a lateral submeniscal arthrotomy through a curvilinear anterolateral incision (AL). Eight surgical approaches (4 ML and 4 AL) were performed on 4 fresh cadavers. Access to key articular landmarks was assessed, including divisions of the lateral meniscus, lateral tibial spine, and anterior cruciate ligament. The boundary of the exposed articular surface of the tibia was marked, and the proximal tibias were then stripped of soft tissues. A calibrated digital image was taken of each proximal tibia, and exposed articular surface area was calculated with ImageJ software (NIH, Bethesda, MD). Statistical analysis was performed using a two-sample t-test. Average articular surface area exposed was 2.2 times greater through the midline approach compared with the anterolateral approach (11.2 vs 5.1 cm2, p = 0.010). All key anatomic landmarks were directly visualized through the midline approach in each specimen. Complete visualization of the lateral meniscus posterior horn, lateral tibial spine, and anterior cruciate ligament was not accomplished through the anterolateral approach in any specimen. The midline approach provides more extensive articular exposure of the lateral tibial plateau compared with the anterolateral approach. This improved exposure may offer an advantage when treating fractures not amenable to arthroscopic or minimally invasive techniques. It may be of most use when treating fractures with extension into the posteromedial quadrant of the lateral plateau, fractures with extensive comminution of the lateral plateau, or fractures with complex lateral meniscus tears and fractures with tibial spine involvement.

Minimally invasive percutaneous plate internal fixation through anterolateral single incision for the treatment of open distal tibiofibula fractures

To investigate therapeutic effect of minimally invasive percutaneous plate internal fixation (MIPPO) through a single incision in treating open distal tibiofibula fractures. From March 2015 to February 2019, 10 patients with open distal tibiofibula fractures were treated with MIPPO technique through single anterolateral incision, including 8 males and 2 females, aged from 31 to 68 years old. According to Gustilo classification, 6 patients were typeⅠ, 3 patients were typeⅡand 1 patient was type ⅢA. Operative time, intraoperative blood loss and fracture healing were observed, Mazur ankle joint scoring was used to evaluate clinical effect. All patients were followed up from 9 to 24 months. Operative time ranged from 85 to 120 min, intraoperative blood loss ranged from 80 to 200 ml, fracture healing time ranged from 18 to 30 weeks. Nine patients with Gustilo typeⅠandⅡachieved satisfactory healing wound, original wound of 1 patient with Gustilo type ⅢA was poor, and healed by skin flap transplantation at stageⅡ. No steel exposed and infection occurred. According to Mazur ankle scoring at the final following-up, total score was from 61 to 97, and 8 patients got excellent result, 1 good and 1 poor. MIPPO technique through anterolateral single incision for the treatment of open distal tibiofibula fractures could protect original medial wound in opertaion, avoid plate exposed through anterolateral extensor tendon to cover internal fixation, and MIPPO technique could protect fracture end blood flow to improve fracture healing rate, and it is a kind of choice.

Surgical approach strategies for open reduction internal fixation of closed complex tibial Pilon fractures based on axial CT scans

BackgroundTo explore the application and clinical efficacy of surgical approach strategies in open reduction internal fixation of closed complex tibial Pilon fractures based on axial CT scans.MethodsThis retrospective cohort study included data of 25 patients with closed complex tibial Pilon fractures treated from October 2011 to March 2014, including 19 males and 6 females aged 18–54 years (average 39.5 years). According to classification criteria of the Association for Osteosynthesis/Orthopedic Trauma Association (AO/OTA), 4 patients were type 43C1, 10 type 43C2, and 11 type 43C3. Surgical approaches were selected based on fracture line distribution and bone displacement revealed by axial CT scans, and an open reduction method was adopted for internal fixation of the bone plates. Postoperatively, Burwell-Charnley radiographic criteria were used to determine fracture reduction quality. Functional evaluation was performed using the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. Complications, fracture union time, and the AOFAS scores at last follow-up were recorded.ResultsThe 25 included patients were followed for 22–60 months postoperatively (average follow-up 33.9 months). Of these, 19 patients achieved anatomical reduction of the articular surface, 5 achieved good reduction, and one achieved fair reduction. Two patients developed superficial infection on the anteromedial incision and delayed union but recovered well after local dressing change and oral administration of antibiotics. Another patient developed deep infection on the anterolateral incision, which was controlled by debridement, catheter irrigation, and intravenous antibiotic injection. All fractures healed well and average union time was 2.8 months (range, 2–3 months). No fracture malunion or internal fixation failures were found at last follow-up. All 25 patients had AOFAS scores ranging from 80 to 100 at last follow-up (average 88.4). Overall, 15 patients were excellent, 10 good, and 0 fair or poor, with excellent and good rates of 100%.ConclusionsSurgical approach strategies for complex tibial Pilon fractures based on axial CT scans accurately reconstruct the articular surface and achieve solid internal fixation of assembled locking plates, while early postoperative functional exercises contribute to the functional recovery of affected limbs and reduce related complications.

A strategy to prevent complications of hyperextension type tibial plateau fracture.

Tibial plateau fractures (TPFs) are the most common among periarticular fractures. Mechanism of injuries is most from varus/valgus and flexion injury. Hyperextension type injuries are rare and easily to be overlooked. We reported 12 cases of this fracture type. Complications of early cases were reported, and treatment strategies of late cases were suggested. From 2010 to 2016, we performed a retrospective analysis of 248 cases of TPFs in our institute and 12 cases of hyperextension bicondylar TPFs were diagnosed. Diagnostic method is from both plain films and CT scans. The features of this injury included sagittal plane malalignment with loss of the normal posterior slope of the tibial plateau, tension failure of the posterior cortex, and compression of the anterior cortex. Surgical approach is predominantly via an anterolateral and/or posteromedial double incision at the first. Then anteromedial with adequate grafting to support the bone defect was modified. Postoperative radiographic analysis, physical examination findings, and complications were reported. Patient reported outcome scores from the Knee Injury and Osteoarthritis Outcome Score (KOOS) were recorded. Twelve patients were followed up for a mean period of 16.6months (range 12-26months). The mean time to radiographic bony union was 3.6months (range 3-9months, SD 8.5). About complications, the incidence of popliteal artery occlusion received PTA was 8% (1/12). And 3/12 (25%) patients had either partial or complete peroneal nerve injury. 2/12 (16%) patients developed a leg compartment syndrome. 33% (4/12) demonstrated associated injuries including posterolateral complex injuries mostly and posterior cruciate ligament avulsion fracture in one case. The average range of motion of the affected knees was 3.4-130° postoperatively. Analysis of complication about surgery included inadequate reduction and fixation in two cases, insufficient bone grafting in one case. The mean mPTA was significantly improved after fixation (preoperative 82° postoperative 3months 86°). The mean posterior slope (PTA) was preoperative -3° and postoperative 3months 3°. And mean KOOS was 80. Hyperextension bicondylar tibial plateau fractures show a special characteristic of changes in posterior tibial slope angle and are easy to be overlooked. Complication rate is high after injury and after ineffective fixation. Choosing correct approach with sufficient grafting and stable fixation for treatment of hyperextension bicondylar tibial plateau fractures should be used to improve patients' outcome.

Isolated Triplane Fracture Of Distal Tibia In Adolescent

Introduction:Triplane fracture is a traumatic ankle fracture seen in children 10-17 years of age. Name derives from the fact that the fracture exists in the frontal, lateral, and transverse planes and considered as transitional injuries because occur during the period of distal tibial physeal closure. It results from supinationexternal rotation injury, same as tillaux fracture.Report:We presented a case of 14 years old male with right ankle pain after fall with twisted position while running. Examination revealed tenderness on his right ankle, and radiograph showed Salter-Harris IV of tibial epiphysis. CT scan was performed to determine fracture configurations. Open reduction and internal fixation was done using posterolateral approach using T buttress plate 6 holes to fix the metaphysis fracture. Subsequently anterolateral incision was done to assess epiphysis fracture however fracture site not displaced thus lag screw was abandoned. Postoperatively, the ankle was protected in a backslab for 2week; thereafter, the ankle was mobilized and subjected to progressively increasing motion. Weight bearing was allowed to resume at 6 weeks postoperatively. A normal gait had been achieved by 12 weeks postoperatively. The diagnosis of Triplane fracture poses a diagnostic challenge and often missed in healthcare centres. On standard AP and lateral radiographs, the fractures cannot be easily detected because of superimposition as radiographic sensitivity for Triplane fracture is only 50%. CT scan of the ankle is recommended if clinical findings are suggestive. The treatment of the Tillaux fragment with compression screws in the case of displacement of >2 mm which achieves anatomical reduction, rigid fixation and early mobilization gives good prognosis.Figure 1:CT scan viewFigure 2:CT scan viewFigure 3:Xray post fixationConclusion:Displacement of >2 mm in any plane is an indication for surgery for both triplane and tillaux fracture, to prevent persistent pain and osteoarthritis in the future. CT scan of the ankle is necessary prior to surgery.