Anterolateral Incision Research Articles

Management of Hip Dislocations in Children with Arthrogryposis

From a review of 131 children with arthrogryposis, we studied 18 patients with hip dislocations. Fourteen patients (10 unilateral, four bilateral) were treated by open reduction. Mean age at surgery was 9.7 months, and follow-up ranged from 9 to 245 months. Range of motion of patients treated by open reduction following the medial approach was greater than in those treated by anterolateral incision and greater than in bilateral cases treated by closed reduction. Acetabular development was satisfactory following the medial approach and there were no re-dislocations, but one hip developed avascular necrosis.

Osteochondritis Dissecans of the Talus (Transchondral Fractures of the Talus): Review of the Literature and New Surgical Approach for Medial Dome Lesions

A retrospective study of 22 ankles in 22 patients with osteochondral talar dome lesions between 1975 and 1983 has indicated that surgical treatment yields superior results to conservative therapy. Thirteen male and 9 female patients, ages 9 to 72 years, average age 28 years, showed 10 medical lesions (Berndt and Harty classification (stage I (one); stage II/III (nine)) and 12 lateral lesions (stage II/III (5), stage IV (7)). Examination follow-up on 19 patients (86%) has averaged 24 months. The initial diagnosis seen retrospectively on x-rays was missed 43% of the time by emergency room physicians. A history of trauma was verified in 100% of the lateral lesions and 80% of the medial talar dome lesions. Of the 22 ankles, 14 lesions were isolated injuries, while 8 had concomitant fractures, lateral ligament, or peroneal tendon damage. Surgical treatment consisted of removal of the osteochondral fragment, curettage, and drilling of its bed. Two distinct surgical approaches were utilized. Lateral dome lesions were approached through the standard anterolateral incision, while medial dome lesions were approached through the anterior tibial tendon sheath with grooving of the anteromedial distal tibia articular surface. The medial approach allowed the somewhat posteriorly placed medial lesions to be reached, negating the need for a medial malleolar osteotomy and postoperative immobilization. On follow-up, no untoward ankle arthrosis was noted as a result of the grooving of the anteromedial distal tibia. Nineteen of the 22 patients had surgical therapy with 79% excellent or good, 21% fair, and no poor results. Five of the eight patients who elected prolonged conservative therapy finally had surgery. Of the three remaining patients conservatively treated, there were two fair results and one poor result.

Compression arthrodesis of the ankle. Evaluation of a cosmetic modification.

Between 1955 and 1979, a modification of the compression arthrodesis of the ankle was performed in twenty-eight patients at The Campbell Clinic. The ages of the patients ranged from twenty-one to seventy-seven years, with an average of 48.4 years. The modification narrows both the medial and lateral sides of the ankle, resulting in a much better cosmetic appearance as the fused ankle is essentially the same width as the normal ankle. The distal end of the tibia and the talus are easily approached through anteromedial and anterolateral incisions, and all articular cartilage can be removed without difficulty. A solid arthrodesis was achieved in 92.8 per cent of the ankles, a higher percentage than in most reported series. Not only is the final appearance of the ankle more pleasing to the patient, but the modification also eliminates the complication of irritation and abrasion of the soft tissue beneath the malleoli by the top of the shoe.

Treatment of Pathologic Fractures or Impending Fractures of the Humerus with Rush Rods and Methylmethacrylate

A retrospective study of 54 patients with established or impending pathologic humeral fractures was done to evaluate the technique of intramedullary fixation with a Rush rod, during the period from 1968 to 1977. Breast carcinoma, multiple myeloma, and hypernephroma were the most common metastatic tumors. Primary tumors included Ewing's sarcoma and a low-grade chondrosarcoma, in which case the patient refused any other form of treatment. An anterolateral incision was used to expose the fracture site and a deltoid-splitting incision to introduce the Rush rod. Thirty-eight of the 55 procedures utilized methylmethacrylate to help stabilize the fracture. All patients had relief of their preoperative pain after the procedure. Seven patients subsequently experienced pain: four had proximal migration of the Rush rod with impingement, three of which required removal of the Rush rod; three other patients had discomfort two years postoperatively. All patients except one had good functional motion. Six patients had complications: three with proximal migration of the Rush rod, two with transient subluxation of the humeral head, and one with limited glenohumeral motion secondary to a technical error. This procedure provides significant pain relief and maintains function.

The repair of interatrial defects through a right anterolateral thoracotomy: A method for controlling a persistent left superior vena cava

A right anterolateral incision has proved to be a most satisfactory operative approach for repair of secundum and ostium primum defects. Its only disadvantage is the unexpected presence of a persistent left superior vena cava which cannot be controlled from a right thoracotomy. However, a technic has been successfully employed in sixty-one cases that adequately deals with the large volume of blood draining into the coronary sinus when a persistent left superior vena cava is encountered at operation. The method consists of cannulating the coronary sinus with a Foley catheter which is then connected to one of the coronary sinus suction lines. This insures a satisfactory perfusion and provides a clear operative field for repair of the defect.

Comminuted fractures and fracture dislocations of the body of the astragalus: Operative treatment

1. 1. The customary treatment for comminuted fractures and fracture dislocations of the body of the astragalus has been astragalectomy or tarsal fusion. Results have, however, not been good. 2. 2. An operation of technical simplicity is suggested for the management of these injuries. Briefly, the principal steps are (1) exposure of the tibio-astragalar joint by means of an anterolateral incision; (2) removal of the fragmented astragalar body; and (3) embedding of a sliding graft from the distal, anterior surface of the tibia into the neck of the astragalus. 3. 3. The considerations of special importance in this operation are that the weight bearing thrust is placed on normal, undisturbed joint tissue and that there is no tendency for subsequent lateral deformity of the foot. 4. 4. Experience indicates that the end result of this procedure should be a painless, normal appearing foot and ankle with good stability and function.

Osteoid-Osteoma of the Astragalus

The so-called osteoid-osteoma, described by Jaffe (1) in 1935 and, more extensively, by Jaffe and Lichtenstein (2) in 1940, is a solitary, benign neoplasm involving spongy or cortical bone. It has been recognized in the extremities, more often the lower, and in the vertebral column, but not yet in the ribs, sacrum, innominate bones, and skull bones. This lesion may be misinterpreted, clinically and roentgenographically, as chronic osteomyelitis or bone abscess. The diagnosis should be considered in an adolescent or young adult with localized pain, with or without localized swelling, of at least several months' duration, unassociated with local heat or bouts of fever, and with normal clinical laboratory findings. The histologic features of osteoid-osteoma are distinctive and unlike those of any other classified lesion of bone. Local excision of the tumor results in immediate and complete recovery. Case Report A 16-year-old colored male complained of increasing pain and swelling of the right ankle of four months' duration. There was no definite history of trauma. Examination of the right foot revealed slight swelling and tenderness on the anterior surface in the ankle region. The temperature, pulse, and respiratory rate were normal, as were repeated blood counts and urinalyses. The blood Wassermann and Kahn tests and an intradermal tuberculin test were also negative. A lateral roentgenogram of the right foot was reported by the radiologist as “negative.” It revealed an oval, sharply defined, radiolucent area near the upper surface of the neck of the astragalus, its superior portion elevating the overlying intact cortical bone like a blister. There was some increase in density of the surrounding cancellous bone, but no periosteal or adjacent soft-tissue reaction (Fig. 1). The lesion was exposed through an anterolateral incision and was excised, together with the overlying cortex and adjacent sclerotic cancellous bone. The wound was closed without drainage and healed per primam. Smears, culture, and guinea-pig inoculation of material taken from the lesion were negative. The patient experienced immediate relief of pain, although some swelling of the right ankle region has persisted. Histopathologic Features: Grossly, the tumor was soft and reddish brown in color. Microscopically, it was composed predominantly of trabeculae and patches of osteoid tissue, lined by osteoblasts and set in a substratum of highly vascular osteogenic connective tissue that was sprinkled with numerous osteoclasts. A few of the osteoid trabeculae were undergoing early calcification and transformation into atypical bone (Figs. 2 and 3). The tumor tissue was sharply delimited from the compact trabeculae of the adjacent bone. Discussion The roentgenographic picture in osteoid-osteoma demonstrates two features—the neoplasm proper and the reaction of the surrounding bone.