Dorsal Approach Research Articles

Surgical approaches and applied anatomy of the wrist

A familiarity with common approaches to the wrist and their associated anatomy is essential for any surgeon operating in this area. Such knowledge reduces the likelihood of iatrogenic injury to adjacent structures; enabling the surgeon to progress purposefully and with confidence through an operation, to reveal underlying pathology. Furthermore, it is a favourite topic for the fellowship examiner. This article provides a description of the common dorsal, volar, radial and ulnar approaches to the carpus and distal radius. Safe corridors for external fixation are also considered. Additionally, clinical pearls are included for each approach, to enable the surgeon to avoid common pitfalls.

Computed tomography evaluation of proposed implant corridors in canine thoracic vertebrae.

Identify acceptable implant corridors in the normal canine thoracic vertebrae (T) from T1 to T9. Retrospective study. Computed tomographic (CT) studies of normal canine thoracic spines (n=39). CT imaging studies of normal T1-T9 canine spines were evaluated by five independent observers. Each identified a proposed corridor, measured the width, length, and angle off mid-sagittal that the corridor occupied. CT studies were from 39 dogs weighing 3.19-60 kg (mean 10.72, SD 9.9 kg). Vertebral corridors ranged in average width from 3.8 to 5.2 mm, the widest being located at T1. They ranged in average length from 13.3 to 17.5 mm, shortest being T1 and longest being T6. The angle of corridors varied the most between individual vertebrae at T1-T3. The average corridor angles were: T1=38°, T2=32°, T3=27°, T4=26°. T5-T9 angle ranged from 23° to 24°. The average dimensions of corridors measured in dogs weighing 3.1-60 kg were consistent with those of commercially available cortical screws and pins. Corridor trajectories identified in this population can be achieved from a dorsal approach between T5 and T9. A dorsal approach for implant placement would be challenging for T1-T4 due to the variability found in these vertebrae as well as regional anatomical constraints.

Comparative analysis of the quality of life of children with congenital scoliosis after surgical treatment: Extirpation of the hemivertebra from dorsal and combined access

BACKGROUND: Congenital scoliosis with disorders of the formation of the vertebrae is the most common cause of pronounced deformities of the spine in early childhood. This pathology can be treated surgically using various techniques that differ in invasiveness, severity of the condition in the postoperative period, achieved result of deformity correction, and nature of the long-term prognosis. Numerous studies have assessed the quality of life of patients who underwent surgery for acquired deformities, trauma, and degenerative and neoplastic diseases of the spine in adults. However, features of the childs quality of life following surgical technique for congenital scoliosis have not been sufficiently studied.
 AIM: This study aimed to compare the quality of life of children with congenital scoliosis of the thoracolumbar localization after extirpation of the hemivertebra from the dorsal and combined approaches.
 MATERIALS AND METHODS: An intergroup prospective analysis of the results of a survey of 60 patients with congenital deformity of the spine against the background of an isolated violation of the formation of the thoracic or lumbar vertebra was carried out. Patients underwent standard surgical treatment. Patients were divided into two groups according to the surgical approach to the abnormal vertebral body: dorsal group (n = 28) and combined group (n = 32). The average age of the patients was 75 (minmax, 26196) months. The follow-up period was 18 months after surgery. To assess the quality of life, a specialized Russian version of the PedsQL v4.0 questionnaire and a modified visual analog scale were used.
 RESULTS: After surgical treatment of congenital spinal deformity, quality of life indicators decreased more than two times than the results of a preoperative survey. At 18 months postoperatively, the physical activity and psychoemotional state were restored to the preoperative level, while patients of the combined group had a higher satisfaction score on the quality of life (p 0.05).
 CONCLUSIONS: The combined approach provides the best correction of congenital deformity of the spine and allows maintaining of the achieved result throughout the observation period. In the early postoperative period, the combined group demonstrated a significant decrease in the level of satisfaction with the quality of life, while the pain syndrome was higher than that in the dorsal group. Dynamic observation revealed the leveling of these differences and a subsequent increase in the level of satisfaction with the quality of life of these patients.

Laparoscopic major hepatectomy using dorsal approach to the major hepatic veins

Dorsal approach of right and middle hepatic veins lets their exposure from root to periphery, minimizing venous bleeding. Usefulness of this approach is shown to tradiitional major hepatectomies (right and left hemihepatectomies) as well as tecchnicaly major hepatectomies (anterior and posterior sectionectomies).

The Comparison of Latero-Medial versus Dorso-Palmar/Plantar Drilling for Cartilage Removal in the Proximal Interphalangeal Joint.

Simple SummaryArthrodesis of the proximal interphalangeal joint consists of the assisted fusion of the proximal and middle phalanges. The main indications for performing arthrodesis in equine patients are chronic osteoarthritis unresponsive to medical treatment, articular fractures, luxation and subluxation. This procedure can allow a return to athletic career in selected cases, or free the animal from chronic pain in others. Arthrodesis is performed through two basic steps: articular cartilage removal and bone immobilization. Whereas several methods have been studied to achieve the second one, little has been investigated for cartilage removal. The most utilized technique consists of disarticulating the joint to remove the cartilage. Other techniques have been investigated to remove enough cartilage to allow bone fusion and reduce the invasiveness of the procedure. The aims of this work were to assess the capability of a lateral drilling approach to the joint to remove a sufficient amount of cartilage, and compare it to the previously proposed dorsal drilling approach. The lateral drilling approach, especially when performed under digital fluoroscopy, turned out to be more efficient in articular cartilage removal in the proximal interphalangeal joint.The aims of the present study were to compare the percentages of articular cartilage removed using a lateral drilling approach of the proximal interphalangeal joint (PIPJ) and a dorsal drilling approach, and to assess the usefulness of digital fluoroscopy when performing a lateral drilling approach. Sixty cadaveric PIPJs were drilled using a surgical drill bit to remove the articular cartilage. The limbs were divided into three groups containing 10 forelimbs and 10 hindlimbs each. One group received the dorsal drilling approach, the second one received the lateral drilling approach and the last one received the lateral drilling approach under digital fluoroscopy guidance. The percentage of articular cartilage removed from each articular surface was assessed using Adobe Photoshop ® software. The percentages of removed cartilage turned out to be significantly higher with lateral approach, especially under fluoroscopic guidance, both in the forelimbs (p = 0.00712) and hindlimbs (p = 0.00962). In conclusion, the lateral drilling approach seems to be a minimally invasive technique with which to perform PIPJ arthrodesis, even more efficient than the previously reported dorsal approach.

Perilunate Dislocations and Fracture-Dislocations: A Retrospective Study of 11 Cases

Perilunate dislocations (PD) and perilunate fracture-dislocations (PFD) of the carpus are rare but important entity in so far as it presents a high risk of after-effects and post-traumatic osteoarthritis. We report a retrospective, monocentric and multioperator series of 11 patients with a mean follow-up of 24 months over a -year period from 2016 to 2020. The objective of our study was to establish an epidemiological profile and to study the clinical, functional and radiological results of PD and PFD of the carpus while underlining the interest of early management. There were 3 pure PDs and 8 trans-scaphoid PFDs with 10 dorsally displaced forms and only one ventrally displaced form. Clinical and functional evaluation was based on mobilities, strength, pain, Cooney Score, Quick-DASH, and PRWE. Radiological abnormalities were analyzed with the Herzberg classification. All patients were treated surgically after closed reduction, with a dorsal approach in 3 cases, and a palmar approach in 8 patients. Early diagnosis and anatomical reduction provide a satisfactory functional result to avoid complications. This implies an emergency open surgical treatment, a close follow-up and a postoperative rehabilitation in the shortest possible time.

Finger abduction as a novel function of the extensor digitorum brevis manus muscle

A 25-year-old female presented with a chronic scapho-lunate ligament injury with development of carpal instability requiring reconstruction. During a standard dorsal longitudinal mid-line approach to the carpus, an extensor digitorum brevis manus (EDBM) muscle was found taking its origin from the dorsal wrist capsule overlying the lunate with innervation from the posterior interosseous nerve (PIN). Electrical stimulation of the muscle belly demonstrated abduction of the middle finger. The EDBM is a rare anatomical variant of the extensor compartment of the wrist and may be encountered during surgical approaches. Where possible these variant muscles should be carefully dissected off underlying structures, preserved and repaired at the conclusion of a procedure to ensure no perceived functional deficit to the patient. We present a case of a previously undescribed EDBM muscle function of pure finger abduction with no extension and a surgical technique of preserving its origin. We propose that the middle finger variant of the EDBM should be re-named the extensor digitorum brevis medius to reflect our findings.

Scaphotrapezoid Assessment during Thumb Carpometacarpal Arthroplasty: A Cadaveric Study.

Background Due to limited sensitivity of radiographs for scaphotrapeziotrapezoid (STT) arthritis and the high rate of concurrence between thumb carpometacarpal (CMC) and STT arthritis, intraoperative visualization of the STT joint is recommended during CMC arthroplasty. Purpose We quantified the percentage of trapezoid facet of the scaphotrapezoid (ST) joint that could be visualized during this approach, and compared it to the degree of preoperative radiographic STT arthritis. Methods We performed dorsal surgical approach to the thumb CMC joint after obtaining fluoroscopic anteroposterior, lateral, and oblique wrist radiographs of 11 cadaver wrists. After trapeziectomy, the ST joint was inspected and the visualized portion of the trapezoid articulation marked with an electrocautery. The trapezoid was removed, photographed, and the marked articular surface area and total surface area were independently measured by two authors using an image analysis software. The radiographs were analyzed for the presence of STT arthritis. Results The mean visualized trapezoid surface area during standard approach for CMC arthroplasty was 60.3% (standard deviation: 24.6%). The visualized percentage ranged widely from 16.7 to 96.5%. There was no significant correlation between degree of radiographic arthritis and visualized percentage of the joint ( p = 0.77). Conclusions: On average, 60% of the trapezoid joint surface was visualized during routine approach to the thumb CMC joint, but with very large variability. Direct visualization of the joint did not correlate with the degree of radiographic STT arthritis. Clinical Relevance A combination of clinical examination, pre- and intraoperative radiographs, and intraoperative visualization should be utilized to assess for STT osteoarthritis and determine the need for surgical treatment. Level of Evidence This is a Cadaveric Research Article.

Techniques for Injection of the Scaphotrapezium-Trapezoid Joint Without Image Guidance

PurposeScaphotrapezium-trapezoid (STT) joint arthritis is one of the most common forms of wrist arthritis. Conservative management often involves corticosteroid injection. Despite this, there is a scarcity of literature on palpation-guided injection techniques for the STT joint. We aimed to determine a standardized palpation-guided injection method that is easily reproducible and poses minimal risk to local anatomic structures.MethodsSix fresh-frozen cadaveric upper extremity specimens were tested. Access to the STT joint was attempted with dorsal, volar, and radial approaches. Fluoroscopy was used to confirm accurate placement within the joint. Needle placement was documented in relation to the surrounding soft tissue and bony landmarks were measured with a ruler, and the angle of the needle entry was recorded using a goniometer. The cadavers were carefully dissected to identify the surrounding neurovascular structures at risk of injury.ResultsTo access the STT joint with the dorsal approach, the needle was angled at 90º and inserted one-third of the distance from the prominence of the base of the second metacarpal to Lister tubercle. No neurovascular structures were found in the immediate vicinity of the needle. For the volar approach, the needle was angled at 65º and inserted at the distal wrist crease, 1 cm ulnar to the radial border of the wrist, in line with the second metacarpal. The volar branch of the radial artery was at risk with this approach. For the radial approach, the needle was angled at 60º and inserted immediately dorsal to the extensor pollicis brevis tendon, midway between the radial styloid and the prominence of the thumb metacarpal base. The dorsal branch of the radial artery was at risk with this approach.ConclusionsIn a clinical setting where fluoroscopy or ultrasound is not readily available, the dorsal approach may allow for safe and accurate placement of the injectate into the STT joint.Type of study/level of evidenceTherapeutic IV.

Silicone and Pyrocarbon Artificial Finger Joints.

Artificial finger joint design has been developed through different stages through the past. PIP (proximal interphalangeal) and MCP (metacarpophalangeal) artificial finger joints have come to replace the amputation and arthrodesis options; although, these artificial joints are still facing challenges related to reactive tissues, reduced range of motion, and flexion and extension deficits. Swanson silicone artificial finger joints are still common due to the physician's preferability of silicone with the dorsal approach during operation. Nevertheless, other artificial finger joints such as the pyrocarbon implant arthroplasty have also drawn the interests of practitioners. Artificial finger joint has been classified under three major categories which are constrained, unconstrained, and linked design. There are also challenges such as concerns of infections and articular cartilage necrosis associated with attempted retention of vascularity. In addition, one of the main challenges facing the silicone artificial finger joints is the fracture occurring at the distal stem with the hinge. The aim of this paper is to review the different artificial finger joints in one paper as there are few old review papers about them. Further studies need to be done to develop the design and materials of the pyrocarbon and silicone implants to increase the range of motion associated with them and the fatigue life of the silicone implants.

MO504LOW BIRTH WEIGHT ASSOCIATES WITH SMALLER KIDNEY SIZE IN MIDDLE-AGED WOMEN

Abstract Background and Aims Low birth weight is associated with increased risk of kidney disease due to lower nephron endowment leading to hyperfiltration and subsequent nephron loss. Nephron number is thought to associate with kidney size. We compared kidney size measured by magnetic resonance imaging (MRI) with ultrasonography and measured glomerular filtration rate (mGFR) in adults with normal versus low birth weight. Method Healthy individuals aged 42-52 years with Low birth weight (LBW – 1100-2300g) and normal birth weight (NBW - 3500-4000g) were invited. GFR was measured using plasma clearance of iohexol. Kidney volume was measured on MRI images using axial T2 images and coronal T1 images with fat saturation without contrast enhancement, calculations were performed according to the ellipsoid formula - π/6 x Length x Width x Depth. Ultrasonographic imaging was done using a dorsal approach. In the maximal longitudinal view the parenchymal area was calculated subtracting the area of a manual tracing around the renal pelvis from the area of a manual tracing of the whole kidney. Volume and area from the two kidneys were added and total value was used for analyses. Kidney size measurements were compared between the two groups of LBW vs NBW, and analysis using Pearson’s correlation coefficient R between kidney volume and measured GFR and parenchymal area was performed. Results We included 102 individuals (54 LBW, 48 NBW). Total kidney volume was 302 ± 51 ml for female NBW vs 258 ± 48 ml for female LBW (p=0.002). For men, total kidney volume was 347 ± 51 ml vs 340 ± 65 ml (p=0.7). Measured GFR was significantly associated with kidney volume with R=0.52 (p<0.001) for women and R=0.39 (p=0.007) for men. Kidney parenchymal area measurements using ultrasonography showed similar results with an R=0.77 between the MRI and the ultrasonography measurement and similar differences for sex and birth weight were seen. Conclusion Healthy middle-aged females born with LBW have smaller kidneys than healthy middle-aged females born with NBW, no difference were seen for males. Kidney volume associate with measured GFR.

Volar rerouting of the 1,2 intercompartmental supraretinacular artery vascularized bone graft for middle and distal scaphoid nonunions

BackgroundThe bone graft vascularized by the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) placed on the scaphoid by a dorsal approach is a technique used to treat scaphoid nonunions with avascular necrosis of the proximal pole and without significant bone loss or carpus collapse. We present the results of patients treated with a volar rerouting of the 1,2 ICSRA graft under the tendons of the first extensor compartment to treat more distal scaphoid nonunions than the proximal pole. The aim of this study was to assess the clinical and radiological outcomes of patients operated with this technique with the hypothesis that it would allow to treat more distal nonunions than those of the proximal pole. Patients and methodsThis retrospective study involved patients treated by a volar rerouting of the 1,2 ICSRA graft for nonunions of the middle and distal thirds of the scaphoid. Assessments included clinical outcomes and radiological bone consolidation. QuickDASH and Mayo Wrist scores were computed. Range of motion and grip strength were evaluated for both the operated and the contralateral sides. ResultsNineteen patients were followed-up for 33 months (range: 6-75). Mean postoperative QuickDASH score was 10 (range: 0-45), and mean Mayo wrist score was 85 (range: 50-100). Flexion and extension, ulnar and radial deviations were statistically different between the affected and healthy sides (p<0,05). Consolidation was achieved in 17 patients (89%). DiscussionThis technical modification allowed good functional outcomes and scaphoid consolidation. It expands the classic indications of the vascularized 1,2 ICSRA bone graft to more distal nonunions than the proximal pole. Level of evidenceIV.

Critical Analysis of Outcome Between Ventral and Dorsal Onlay Urethroplasty In Female Urethral Stricture

To evaluate and compare the 2 surgical approaches of urethral reconstruction for management of refractory female urethral strictures (FUS) in a prospective randomized setting. Early surgical reconstruction is becoming the preferred management strategy for recurrent FUS. Reconstructive techniques have been described as using either dorsal (12-o'clock) or ventral approach (6-o'clock), each with their own advantages. To our best knowledge, a direct comparison between the 2 techniques to prospectively compare outcomes hasn't been made. We performed a prospective randomized study in a single tertiary care center on a total of 24 patients, randomizing them into 2 groups of 12 patients each. One group underwent dorsal onlay and other underwent ventral onlay urethroplasty. Preoperative, intraoperative and postoperative outcomes were evaluated and compared for the 2 approaches. There was high success rate (91%) with significant but comparable improvements in flow rates, post void residue and symptomatic outcomes without any major complication. There was 1 recurrence of stricture each in both groups. Important technical differences were noted with easier meatus preservation, lesser bleeding and wider operative field in the ventral approach, while the dorsal approach proving better in distal urethral strictures requiring meatal reconstruction. Both approaches of urethroplasty present a very promising modality of management of FUS with comparable outcomes but with important technical differences which must be considered to best tailor the approach for each patient.

Endoscopic Endonasal Transclival Approach to Ventral Pontine Cavernous Malformation: Case Report.

Ventral medial pontine cavernous malformations are challenging due to the location in eloquent tissue, surrounding critical anatomy, and potential symptomatic bleeding. Conventional approaches, such as anterolateral, lateral and dorsal approach, are associated with high risk of deleterious consequences due to excessive traction and damage to the surrounding tissues. The authors present an endoscopic endonasal approach for the resection of midline ventral pontine cavernous malformations, which follows principles of optimal access to brainstem cavernous malformations as the “two-point method.” No CSF leak or any other complications are obtained. The successful outcomes indicate that an individualized approach should be chosen before the surgery for brainstem cavernous malformations. With the advance of techniques, endoscopic endonasal approach could provide the most direct route to ventral pontine lesions with safety and efficiency.

Benign or Low-Grade Malignant Masses Occupying the Pelvic Canal Space in 11 Dogs.

Simple SummaryLarge canine pelvic masses, even though benign, can seriously affect dogs’ lives, causing problems regarding defecation and urination, and sometimes complete rectal and/or urethral obstruction. Many of these patients are euthanized owing to their poor clinical condition as a result of chronic compression or because their disease is erroneously considered untreatable. The aim of this study was to evaluate the clinical data of dogs with intra-pelvic benign or well-differentiated malignant masses referred to the Torino Veterinary Teaching Hospital, and treated surgically. Clinical signs, diagnostic approach, surgical procedures and outcome were evaluated. The majority of the dogs recovered uneventfully from surgery in a couple of days, with rapid resolution of the severe preoperative clinical signs. All the dogs experienced long survival with no disease recurrence or progression, even in the well-differentiated malignant tumors. Clinical findings, especially those obtained using digital rectal and vaginal exploration are mandatory for assessing the presence of the tumor and its relationship to the other pelvic structures. Currently, in the authors’ opinion, preoperative computed tomography (CT) is also highly recommended, even if this procedure was not performed in 4 out of the 11 dogs.Dogs with benign intra-pelvic rectal or vaginal masses show symptoms indicating compression on the adjacent organs. Clinical signs usually develop late when the lesion is large enough to interfere functionally. The dogs were referred for severe fecal and/or urinary tenesmus. The data collected included signalment, clinical signs, results of physical examination, pre-surgical diagnostic tests, surgical technique used, surgical complications and histological findings. Digital rectal and vaginal examination allowed the detection of a mass occupying space in the pelvic cavity in all patients. Abdominal ultrasonography and/or total body computed tomography (CT) were used to better characterize the lesion and to exclude a metastatic spread of the tumor in case of malignancy. A dorsal approach to the rectum, a dorsal episiotomy, a midline celiotomy, and a combined perineal and abdominal approach were performed to remove the mass. No postoperative complications were observed. Benign and well-differentiated malignant mesenchymal neoplasms were histologically diagnosed. As a consequence of the chronic urethral compression caused by the mass, urinary incontinence and/or urinary retention were observed for a few postoperative days. Fecal tenesmus resolved in all cases in the immediate postoperative period. The dogs’ quality of life quickly improved after surgery, especially considering the serious and life-threatening pre-surgical clinical conditions. Both the recovery time after surgery and overall survival were also evaluated.

External column lengthening with peek cage and modified single approach

Objective: To show the results obtained with the treatment of stage 2B flatfoot according to Myerson classification (reducible and flexible), through external column lengthening with interposition of a peek cage filled with spongious graft taken from the same calcaneus, without osteosynthesis, combined with medial slide calcaneal osteotomy with step plate, both using the a single approach. Medial time was associated with latero-lateral transfer of common flexor tendon of toes to posterior tibial. Methods: Sixteen patients were assessed from 2015 to 2018, of which 11 were women and 5 were men. In all cases, surgery was performed with a first lateral time for osteotomies and a second time for tendon repair. Mean patients’ follow-up was 28 months. Results: All patients achieved consolidation of both osteotomies at nearly 12 postoperative weeks. No patient presented signs of peek cage migration due to lack of stability or dorsal cutaneous nerve branch injuries resulting from this modified single approach. Two patients evolved with wound dehiscence and only one with calcaneocuboid pain so far. No patient required reoperation. Conclusion: The modified single tuberosity approach for the two osteotomies has shown to be a simple procedure that prevents damages to dorsal cutaneous nerve branches described with dorsal approach. Leve lof Evidence IV; Therapeutic Studies; Case Series.

Dorsal approach with tailored partial sacrectomy and gluteal V\u2013Y fasciocutaneous advancement flap for the management of recurrent pelvic sepsis; case report

BackgroundPelvic sepsis after surgery for rectal cancer is a severe complication, mostly originating from anastomotic leakage. Complex salvage surgery, during which an omentoplasty is often used for filling of the pelvic cavity, is seldomly required. If this fails, a symptomatic recurrent presacral abscess with a risk of progressive inflammation can develop. Such patients have often undergone multiple surgeries and have disturbed abdominal wall integrity, adhesion formation, and presence of one or two stoma(s). Subsequent salvage surgery via the conventional anterior abdominal approach is therefore less suitable. We describe three cases with a chronic presacral sinus and failure of first salvage surgery. All three patients underwent a prone only approach with tailored sacrectomy. This novel approach provided direct access to the pelvic abscess with optimal exposure for complete and safe debridement. A unilateral or bilateral gluteal V–Y fasciocutaneous advancement flap was created to completely fill the cavity with well vascularized tissue.Case presentationsThree male patients of 80, 66 and 51 years of age initially underwent low anterior resection with neo-adjuvant radiotherapy for rectal cancer. The first patients underwent intersphincteric resection of the anastomosis with omentoplasty 128 months after index surgery, and second salvage surgery 2 months later. The second patient underwent abdominoperineal resection with omentoplasty for locally recurrent rectal cancer, cystoprostatectomy with revision of the omentoplasty for pelvic sepsis 100 months after index surgery, and second salvage surgery 16 months later. In the third patient, the anastomosis was dismantled with subsequent intersphincteric proctectomy and omentoplasty 20 months after index surgery, and second salvage surgery was performed 93 months later. Second salvage surgery in all three patients was indicated because of symptomatic recurrent pelvic sepsis. Second salvage surgery consisted of sacrectomy, complete debridement of the presacral area, and filling with a gluteal advancement flap. This resulted in favorable postoperative recovery with ultimate healing of the pelvic cavity.ConclusionThe dorsal approach with tailored sacrectomy and gluteal V–Y advancement flap is a valuable option in highly selected patients to treat recurrent pelvic sepsis after multiple prior transabdominal interventions for chronic presacral sinus.

Triquetrum osteotomy to approach an otherwise inaccessible coronal malunion of the hamate

Fractures of the hamate are rare, and a clear treatment algorithm does not exist. Nonetheless, surgical treatment is generally recommended for displaced fractures using a dorsal approach. There is also a lack of data on hamate malunion. We present a case of a 28-year-old female with a coronal malunion of the hamate and hamate hook fracture. Because the triquetrum prevented direct access to the fracture, we planned and undertook a transtriquetral coronal osteotomy based on three-dimensional computed tomography imaging data. After removing the bone callus, reduction was possible with subsequent fixation. We recommend performing a transtriquetral osteotomy to treat an otherwise inaccessible fracture or malunion of select hamate fractures.

Ultrasound-guided dorsal approach for the brachial plexus block in common kestrels (Falco tinnunculus): a cadaver study

ObjectiveTo develop an ultrasound-guided dorsal approach to the brachial plexus and to investigate the nerve distribution and staining of a dyed injectate in common kestrel (Falco tinnunculus) cadavers. Study designProspective, cadaver study. AnimalsA group of three common kestrel cadavers (six wings). MethodsAll cadavers were fresh-frozen at –20 °C and thawed for 10 hours at room temperature before the study. The cadavers were placed in sternal recumbency and their wings were abducted. A 8–13 MHz linear-array transducer was placed over the scapulohumeral joint, at the centre of a triangle formed by the scapula and the humerus. The brachial plexus was identified between the scapulohumeralis muscle and the pectoralis major muscle, as hypoechoic structures lying just cranially to the axillary vessels. After ultrasound-guided brachial plexus identification, a 22 gauge, 50 mm insulated needle was advanced in-plane using ultrasound visualization. A volume of 0.5 mL kg–1 of a 3:1 (2% lidocaine:methylene blue) solution was injected. Following cadaver dissection, the pattern of the spread was assessed, and the extent of nerve staining was measured with a calliper and deemed adequate if more than 0.6 cm of the nerve staining was achieved. ResultsThe brachial plexus was clearly identified in all wings with the dorsal approach. After dye injection, all the branches of the brachial plexus defined as nerves 1–5 (N1, N2, N3, N4 and N5) were completely stained in five (83%) and partially stained in one (17%) of the six wings. Conclusions and clinical relevanceThe ultrasound-guided dorsal approach allows a clear visualization of the brachial plexus structure. The injection of 0.5 mL kg–1of a lidocaine/dye solution produced complete nerve staining in most cases. Further in vivo studies are mandatory to confirm the clinical efficacy of this locoregional anaesthesia technique in common kestrels (Falco tinnunculus).

Surgical Outcomes of Perilunate Dislocations and Perilunate Fracture-dislocations: A Review of 20 Cases

Background: Perilunate dislocations and perilunate fracture-dislocations (PLD/PLFD) are the second most common wrist injuries. Objectives: Given the limited available case series due to the rarity of these injuries, in this study, we report the functional outcomes of 20 patients who received surgical treatment with a mean follow-up of 28 months (range 24-36). Methods: We retrospectively reviewed the admissions to Imam Khomeini Hospital Sari, Iran, and included patients with (PLD/PLFD) who underwent surgical treatment between January 2014 to December 2019. We included 20 patients (16 males, mean age±SD=33.6±12.4) who had received urgent surgical treatment following the initial closed reduction in the emergency department. All of the patients received surgical treatment from the same surgical team using the dorsal approach. Results: We observed the average Mayo Wrist Score (MWS) of 73.8±8.4 (range 65-100) with excellent or good outcomes in 40% of patients. The MWS was slightly higher in patients with the non-dominant injured side, yet it did not significantly differ with those with a dominant hand injury (75.4±9.6 vs. 71.2±5.8, P=0.29). Furthermore, we did not find a significant difference in MWS between the lesser and greater arc injuries (76.5±10.1 vs. 71.1±5.7, P=0.15). The observed flexion and extension ROM were significantly lower than the contralateral side (p <0.001). Similar patterns of lower grip and pinch strength were observed on the injured side, which was significantly lower than the contralateral hand; 38.4±8.6 (74±14% of the contralateral) and 9.9±2.4 (81±15% of the contralateral), respectively (p <0.001). Conclusion: In line with other cohorts, the present case series demonstrates relatively good functional postoperative outcomes in PLD/PLFD. Our findings are comparable with prior reports concerning reasonably satisfactory MWS, ROM relative to the contralateral side and reported occasional mild pain with activity. Future studies should be directed to investigate long-term complications associated with these injuries, particularly the development of wrist osteoarthritis.