Lateral Cutaneous Nerve Research Articles

Partial Tears of the Distal Biceps Brachii Tendon: A Systematic Review of Surgical Outcomes

To systematically review the literature regarding surgical outcomes for treatment of partial tears of the distal biceps brachii tendon. This study was conducted in accordance with the Preferred Reporting Items for SystematicReview and Meta-Analysis guidelines. A systematic review of the literature regarding treatment of partial tears of the distal biceps tendon was conducted using PubMed, Embase, and Cochrane. Inclusion criteria consisted of studies in the English language on the treatment of partial distal biceps tendon tears. Exclusion criteria consisted of (1) studies without outcome data, (2) studies that did not specify the degree of distal biceps tendon tear (ie, complete rupture vs partial tear), and (3) studies without partial tear subgroup data. Two investigators independently reviewed the abstracts from all identified articles. Only 5 patients who underwent successful nonsurgical treatment were identified; all were treated with different algorithms, and because of the small number, outcomes for nonsurgical treatment are not included in this review. Therefore, 19 studies involving 86 partial tears that underwent surgical treatment are reported; at least 65 of these received a trial of nonsurgical treatment before surgery. Surgery resulted in 94% satisfactory clinical outcomes. Of the 16 studies (n= 83) that specified the presence or absence of surgical complications, lateral antebrachial cutaneous nerve paresthesia (17%), posterior interosseous nerve palsy (6%), elbow discomfort (2%), surgical revision (2%), and asymptomatic heterotopic ossification (1%) were reported. Surgical treatment including tendon tear completion and anatomic repair to the radial tuberosity can yield satisfactory results and appears to provide predictable outcomes. Further research is necessary to better define the optimal regimen and duration of nonsurgical treatment, as well as the indications for surgery. Therapeutic IV.

Technical feasibility of robot-assisted minimally-invasive neurolysis of the lateral cutaneous nerve of thigh: About a case

To limit the risk of iatrogenic neuroma and recurrence after surgical treatment of meralgia paresthetica, some authors have recently developed a technique of endoscopic neurolysis of the lateral cutaneous nerve of thigh (LCNT) below the level of the inguinal ligament. We report the case of a robot-assisted endoscopic technique underneath the inguinal ligament. A 62-year-old patient suffering of idiopathic meralgia paresthetica for the past 18 months received a Da Vinci robot-assisted minimally-invasive 10cm long neurolysis, of which 1/3 was situated above the level of the inguinal ligament and 2/3 below it. The patient was discharged the following day without complications. At 6-months follow-up the pain was rated 0/10 compared to 5/10 pre-operatively. Robot-assisted endoscopic neurolysis of the LCNT retains the advantages of conventional endoscopy and enables to approach the nerve in the most frequently compressed zone underneath the inguinal ligament. The three-dimensional view offered by robotic surgery facilitates the dissection. The superiority of this technique remains to be demonstrated by comparing it to conventional techniques.

Clinical and neurophysiological evaluation of persistent sensory disturbances in breast cancer women after mastectomy with or without radiotherapy.

Breast cancer surgery or radiotherapy (RT) are potential causes of persistent pain syndrome. It remains to be clarified whether numbness or pain reported by patients after mastectomy and RT are conditioned by changes in nerve transmission. The aim of this study was to examine the potential relationship between subjective sensory complications and neurophysiological examinations in breast cancer survivors with post-mastectomy pain syndrome. Sixty breast cancer survivors (30 patients only after mastectomy - group A; and 30 after mastectomy with RT - group B) complaining of pain and sensory disturbances in the brachial plexus area and 20 healthy women (group C) were studied with regard to sensory perception and pain intensity using the Visual Analogue Scale and electroneurography (ENG). There was a statistically significant decrease in the amplitudes in SCV recordings following stimulation of the ulnar (p=0.04) and lateral cutaneous antebrachii nerves (p=0.02) in group B in comparison to group C. Additionally, a significant decrease in the amplitude and conduction velocity parameters was detected in the sensory fibers of the median and medial cutaneous antebrachii nerves in group A (p=0.00 and p=0.02, respectively) in comparison to group C. The results of this pilot study suggest persistent post-mastectomy pain syndrome sometimes appears as a result of nerve injury in course of breast cancer surgery and RT. Therefore studies in nerve conduction may be added to the comprehensive patient assessment used in planning breast cancer patients' rehabilitation after oncological treatment has finished.

Emergency Transfemoral Amputation in a Severely Sick and Hemodynamically Unstable Patient through Eco-Guided Peripheral Nerve Block: Case Report

Critically ill and/or anticoagulated patients remain a great challenge for anesthesiologists regarding the anesthetic procedure. Its perioperative management should focus on organ preservation and avoid further damage. In this context, ultrasound-guided regional blocks are essential tools, as they avoid neuraxial invasion and deterioration in borderline hemodynamics, conferred by spinal anesthesia and general anesthesia, respectively. In this report, we present a case of a patient with septic shock, anticoagulated, and in need of an emergency surgical approach in the right lower limb in which ultrasound-guided peripheral nerve block was essential for a favorable outcome for the patient. Case Report: Patient in septic shock in need of amputation of the right lower limb at the level of the thigh, with unstable hemodynamics and severe respiratory conditions, undergoing ultrasound-guided peripheral nerve block, of the right femoral, sciatic and lateral cutaneous nerves of the thigh, as a single anesthetic technique. Conclusion: Regional anesthesia of the peripheral nerve guided by ultrasound as a unique anesthetic technique, performed by experienced professionals or under supervision, is effective and safe for lower limb surgical procedures. We suggest this approach, especially in hemodynamically borderline patients or seriously ill with or without anticoagulation.

A Rare Variation of the Human Median Nerve Direction

Introduction: The brachial plexus, a complex network of nerves, innervates to the upper limbs. Variation in the course of the nerves in the upper limb is common. CasePresentation: This paper describes two cases of upper limb variations in a cadaver dissected at Lorestan University of Medical Sciences. In the first variation, the median nerve in the arm has a dierent route, so that the median moves deep into the brachialis muscle. In the latter case, after piercing the coracobrachialis muscle a musculocutaneous nerve exists between the brachialis and biceps and goes to the lateral region of the forearm. This is known as the lateral cutaneous nerve of the forearm nerve, and innervates the skin of the lateral part of the forearm and the dorsal part of the hand. Conclusions: Because of the possibility of damage to the brachial plexus branches is high in upper limb injuries and surgeries, full knowledge of normal anatomy and variations of these branches is essential for orthopedic specialists, neurosurgeons, radiologists, and anatomists.

Distal biceps reconstruction using an Achilles tendon allograft, transosseous EndoButton, and Pulvertaft weave with tendon wrap technique for retracted, irreparable distal biceps ruptures

Distal biceps ruptures can result in ongoing pain and weakness when treated nonoperatively. If retraction of the tendon renders primary repair impossible, reconstruction using a graft is recommended. The current literature includes a variety of techniques with studies reporting small patient numbers. The aim of this study was to report the results of a larger cohort of patients using a technique modified from those previously described in the literature. Twenty-one consecutive male patients underwent distal biceps reconstruction through 2 small anterior incisions using an Achilles tendon allograft that was fixed distally using a transosseous EndoButton and secured proximally using a Pulvertaft weave and tendon wrap. The mean age was 44 years, and the mean time to surgery was 25 months (range, 2-96 months). Functional outcomes were collected prospectively. The mean preoperative Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score (11 patients) was 1.9 (range, 0-4.5). The mean postoperative Oxford Elbow Score, QuickDASH score, and Mayo Elbow Performance Score were 44.7 (range, 35-48), 4 (range, 0-20.5), and 92.9 (range, 70-100), respectively, at a mean follow up of 15 months (range, 6-35 months). The mean postoperative QuickDASH score was significantly improved compared with preoperatively (P < .001). All patients were satisfied and all returned to their previous level of activity. There were 2 transient lateral antebrachial cutaneous nerve paresthesias, and 2 patients had a 5° extension lag. There were no other complications. Achilles allograft reconstruction of retracted irreparable distal biceps ruptures provides consistently good results with few complications using this technique.

Relation of Lateral Antebrachial Cutaneous Nerve to the Volar Approach to Distal Radius.

The anatomy of the lateral antebrachial cutaneous nerve (LABCN) in relation to volar approaches to the distal radius is not well visited. With the increasing popularity of distal radius fracture fixation with volar locking plates, it is prudent to study the innervation pattern of the LABCN to minimize the risk of nerve injury. Ten cadaveric distal radial forearms were dissected to study the relationship between the LABCN, flexor carpi radialis (FCR), superficial branch of radial nerve (SBRN), and scaphoid tubercle (ST). The LABCN coursed closer to the FCR than the SBRN, with branches traversing the tendon in two specimens. The LABCN was also noted to be intimately related to the radial artery, with an average distance of the LABCN from the lateral border of FCR was 6.4mm distally and 9.6mm proximally. There is a sparsely innervated corridor between the radial border of the FCR and terminal branches of the LABCN that provides safe access for volar approach to the distal radius.

Flexor pollicis longus repair in a patient with Linburg-Comstock anomaly: A case report

Background: We present a patient with this anomaly who sustained a saw cut injury to his hand resulting in severance of the FPL and bilateral digital nerves of the thumb. Methods: A 36-year old male laborer who sustained a saw cut injury to his dominant right hand presented to the emergency department. The wound extended from the skin edge of the first web to the base of first metacarpal in the palm at Urbaniak zone 3. The FPL tendon and both digital nerves were cut. In the operating room, the wound was enlarged with Z incisions and a dissection deep into the wound was conducted. The cut end of the FPL tendon was found and secured using a different technique. Bilateral digital nerve repair was performed with interpositional grafting of the lateral antecubital cutaneous nerve bundles. Results: At the end of the rehabilitation program, the thumb recovered full range of motion, and physical examination revealed synchronous flexion movement (synkinesis) of the thumb and index finger. Conclusion: Flexor pollicis longus tendon lacerations are common in the clinical practice of hand surgeons. Making a separate proximal wrist incision is a very useful technique to reach a proximal tendon stump. Otherwise, aggressive maneuvers may cause additional damage to the tendons involved and result in unpredicted outcomes. The attempts to retrieve the tendon at the injury site resulted in failure and gave a tethering sensation to the surgeon who recalled the Linburg-Comstock anomaly.

Radiological analysis of component positioning in total hip arthroplasty using the anterior approach

BACKGROUND: The direct anterior approach for total hip replacement is gaining popularity among surgeons and patients alike, as it is a minimally invasive technique, and a true muscle-sparing operation. Reported advantages of this approach include decreased post-operative pain, faster post-operative mobilisation and a low incidence of hip dislocation. Optimal component positioning is vital for the longevity of total hip replacements. Poor positioning leads to increased dislocation rates, accelerated bearing wear, limited range of motion and higher rates of revision surgery. Minimally invasive surgery strives for smaller incisions, and muscle-sparing dissection. This may result in poor acetabular exposure, and subsequent sub-optimal component positioning. The direct anterior approach is generally done supine on a traction table with/without the use of intra-operative fluoroscopy. This study describes the surgical technique performed with the patient in the lateral decubitus position, without the use of traction, and without intra-operative imaging. We then report on the radiographic outcomes and complications using this approach. METHODS: We retrospectively reviewed 150 patients who had total hip replacements done via the direct anterior approach. Clinical notes were evaluated for patient demographics, body mass index, and post-operative complications. The post-operative radiographs were analysed for acetabular component position inclination and anteversion. RESULTS: The radiographic analysis showed a mean cup inclination of 41.1° (range 27.9-61.1°) and anteversion of 18.33° (range 11.2-25.3°). A total of 95.97% (95% CI) of the components were within the safety zones, as described by Lewinnek, (inclination 40 ± 10°, anteversion 15 ± 10°).23 There were five outliers with regard to cup inclination. Three had excessively abducted cups, which were noted to be in patients with increased BMI >35 kg/ m2. The remaining two were excessively adducted. There were no outliers with regard to cup anteversion There were no dislocations, deep infections or femoral nerve palsies. Two patients required re-operation: one for a periprosthetic fracture and another for a greater trochanter fracture with late displacement. There were six cases of thigh swelling which resolved on discontinuation of oral anti-coagulation, four episodes of soft tissue inflammation responding to physiotherapy, four clinically observed leg length discrepancies, two minor stitch abscesses, and two transient lateral cutaneous nerve palsies. CONCLUSION: The direct anterior approach, done in the familiar lateral decubitus position, as described in this study, is safe and reliable, with an acceptable complication rate. The radiographic results for acetabular component placement are comparable to other surgical approaches, as well as to the direct anterior approach using a fracture table and intraoperative imaging.

CLINICAL OUTCOMES ASSOCIATED WITH ENDOSCOPIC RADIAL ARTERY HARVEST: A SYSTEMATIC REVIEW AND SELECTIVE META-ANALYSIS

Currently there is no consensus on the safety and efficacy of endoscopic radial artery harvest. We sought to accurately compare selected clinical outcomes associated with radial artery harvesting between open and endoscopic techniques by synthesizing the available evidence and employing more appropriate statistical MethodS: than currently reported. A systematic computer-based search was undertaken using the PubMed and EMBASE databases. Articles were screened for relevance by title, abstract, and full text review using predefined selection criteria. Eleven relevant prospective (or retrospective cohort) studies were selected comparing the outcomes of graft function, harvest site infection, neurologic injury, or patient satisfaction/cosmetics. Seven case series were also evaluated for consistency of results. Using random-effects meta-analysis, the outcomes of graft function (measured by patency) and harvest site infection were synthesized to derive a pooled risk ratio (RR) for the event. Where studies contained instances of non-events, a continuity correction using the inverse of the opposite treatment group was employed. Neurologic injury and patient satisfaction/cosmetics faced extensive methodological heterogeneity, and were deemed inappropriate for meta-analysis. Studies had small populations and outcomes were often secondary in nature. No statistically significant difference was found between open and endoscopic harvest with respect to graft function (RR 0.94, 95% CI: 0.58-1.52). Contrary to previous evidence, no statistical difference was found in incidence of harvest site infection between the two groups (RR 0.38, 95% CI: 0.15-1.00). A differential effect on neurologic injury was observed, where endoscopic harvest eliminated lateral antebrachial cutaneous nerve injury, though was still susceptible superficial radial nerve injury. In both groups, neurologic symptoms tended to resolve by 3-6 months. Patient satisfaction and cosmetics favoured the endoscopic group, though formal statistical analysis was not possible. After systematically reviewing the literature and selectively employing random-effects meta-analytical MethodS:, statistical equivalence for both graft patency and harvest site infection was demonstrated between open and endoscopic radial artery harvest. Neurologic injury tended to be equivalent between groups at 3-6 months post-operatively, though territories were differentially affected. Patient satisfaction/cosmetic results favoured the endoscopic group. This analysis provides evidence more robust than has been recently reported, but it is recognized that a definitive trial on this subject has yet to be published.

Determination and classification of cutaneous innervation of the dorsum of the foot in foetal cadavers.

The aim of this study is to determine cutaneous innervation of the dorsum of the foot on foetal cadavers. In this study. 200 limbs from 100 embalmed foetuses (54 males and 46 females) were studied in Anatomy Laboratory. Contributions of medial, lateral and intermediate dorsal cutaneous nerves (MDCN, LDCN and IDCN) of the foot were identified. Cutaneous innervation of the dorsum of the foot was classified into five types. Type I (75%) where MDCN innervated medial border of the foot and second interdigital cleft; IDCN innervated third, fourth and fifth interdigital clefts; and LDCN innervated the lateral border of the foot. Type II (21%) where MDCN innervated medial border of the foot, second and third interdigital clefts; IDCN innervated fourth and fifth interdigital clefts; and LDCN innervated the lateral border of the foot. Type III (1.5%) where saphenous nerve innervated medial border of the foot; MDCN innervated second and third interdigital clefts; IDCN innervated fourth and fifth interdigital clefts; and LDCN innervated the lateral border of the foot. Type IV (1.5%) was similar to type I, with an extra connection between the MDCN and IDCN on the dorsum of the foot. Type V (1%) where superficial fibular nerve innervated medial border of the foot, and second, third and fourth interdigital clefts; and sural nerve innervated fifth interdigital cleft and lateral border of the foot. The present study provides a new classification for the cutaneous innervation of the dorsum of the foot.

Avoiding Lateral Femoral Cutaneous Nerve Injury During Ilioinguinal Approach

We describe a simple technique of preventing lateral cutaneous femoral nerve injury in acetabular fractures treated by ilioinguinal approach. This nerve has highly variable course, commonly exits within 3 cm medial to anterior superior iliac spine into the thigh beneath inguinal ligament. The injury during ilioinguinal approach should not be underestimated. It usually manifests as meralgia paresthetica, characterized by a painful, burning, tingling sensation or by numbness along the anterolateral aspect of proximal thigh. We leave a 2 to 3 cm muscular cuff of internal oblique, transversalis abdominis and its fascia intact, medial to anterior superior iliac spine to protect lateral cutaneous femoral nerve.

Anatomical variations of the formation and course of the sural nerve: A systematic review and meta-analysis

IntroductionThe sural nerve (SN) is a sensory nerve in the lower extremity which branches to supply the skin on the distal posterolateral third of the lower limb. Typically, the medial sural cutaneous nerve (MSCN) and the peroneal communicating nerve (PCN) unite to form the SN. Other variations in the formation, course, and morphometry of the SN have also been described in the literature. ObjectiveTo study anatomical variations in the formation and course of the SN and establish a new classification system for formation patterns of the SN. MethodsA systematic search of all major databases identified articles that studied the prevalence of variations in the formation of the SN. No date or language restrictions were set. Anatomical data was extracted according to our new classification system where the SN is formed by: union of the MSCN and the PCN (Type 1); union of the MSCN and the Lateral Sural Cutaneous Nerve (LSCN) (Type 2); continuation of the MSCN with absent PCN (Type 3); the PCN alone (Type 4); the LSCN (Type 5); or the Sciatic Nerve (SCN) directly (Type 6). Pooled prevalence rates were calculated using MetaXL 2.0. ResultsA total of 39 studies (n=3974 limbs) were included in the meta-analysis. The most common patterns were Type 1, Type 3, and Type 2 with a pooled prevalence of 51.5% (95% CI: 0.293–0.591), 31.2% (95% CI: 0.143–0.410), and 13.8% (95% CI: 0.035–0.234), respectively. The rest of the patterns were rare, with pooled prevalence of Types 4, 5, and 6 calculated to be 1.8% (95% CI: 0–0.063), 1.1% (95% CI: 0–0.050), and 0.7% (95% CI: 0–0.041), respectively. In 83.7% (95% CI: 0.765–0.899) of limbs, the site of union was in the lower half of the lower extremity. The pooled mean length of the SN from the formation to the lateral malleolus was 14.78 (±5.76) cm, while the mean diameter of the SN was 0.28 (±0.03) cm. ConclusionsAnatomical variations in the formation and course of the SN are common in the population. Clinicians, especially surgeons, should be aware of these variations to avoid iatrogenic injury to the nerve during operative procedures.

Adverse effects associated with the direct anterior approach for total hip arthroplasty: a Bayesian meta-analysis.

The direct anterior approach (DAA) is an increasingly popular technique for performing total hip arthroplasty (THA). This muscle-sparing approach may yield functional benefits. However, DAA has been associated with an increased risk incidence (RI) of intra- and postoperative complications. A systematic review of the published literature was conducted to document the cumulative RI of intra- and postoperative complications, as well as the presence of a learning curve in subjects undergoing THA with a DAA. Study selection and data extraction were carried out independently in duplicate. A Bayesian zero-inflated random-effect model was used to calculate pooled estimates for the different endpoints. Thirty-eight studies (6485 patients) were analysed. RIs of 0.8% [95% confidence interval (CI): 0.4-1.6%] and 0.5% (95% CI: 0.3-0.9%) were found for intra-operative trochanter and femoral fractures, respectively, and of 0.9% (95 CI: 0.3-2.6%) for postoperative transient lateral cutaneous femoral nerve (LCFN) impairment. A clear RI for early revisions (2.1%; 95% CI: 1.4-2.8%) and other surgical re-interventions (1.3%; 95% CI: 0.7-1.9%) was present, but these values do not differ from reported RIs for THA overall. The RI for dislocation was low (0.6%; 95% CI: 0.4-0.9%) compared with the reported literature. DAA is a technically demanding procedure, with outcomes possibly indicative of surgeon learning curve. A risk for intra-operative fractures and LCFN is evident, although the risk for other adverse effects is comparable to those with other approaches.

P065. Comparison of radial margins in therapeutic mammoplasty and wide local excisions for invasive breast cancer

P065. Comparison of radial margins in therapeutic mammoplasty and wide local excisions for invasive breast cancer

"Sensory Switching" in Elbow Reconstruction.

In the treatment of the soft tissue defect of the elbow, flap reconstruction is necessitated in many cases because of thinness of soft tissue at this region. In addition, reacquirement of tactile sensation is desirable because of the anatomical and specific functions of the elbow. Of three cases treated for elbow defects, one was reconstructed with a pedicled island forearm flap containing the lateral cutaneous nerve of the forearm, another was reconstructed with a venoneuro-accompanying artery fasciocutaneous flap (VNAF flap) containing the basilic vein, and the third with the VNAF flap containing the cephalic vein. The three cases demonstrated a sudden change of sensory territory 4 to 6 months after surgery, which was confirmed by touching the reconstructed region with patients' eye-closed: from its original territory to the elbow in a "switching"-like action. Here we describe and discuss the concept of "sensory switching."

Reducing the risk of nerve injury during Bernese periacetabular osteotomy: a cadaveric study.

The modified Smith-Petersen and Kocher-Langenbeck approaches were used to expose the lateral cutaneous nerve of the thigh and the femoral, obturator and sciatic nerves in order to study the risk of injury to these structures during the dissection, osteotomy, and acetabular reorientation stages of a Bernese peri-acetabular osteotomy. Injury of the lateral cutaneous nerve of thigh was less likely to occur if an osteotomy of the anterior superior iliac spine had been carried out before exposing the hip. The obturator nerve was likely to be injured during unprotected osteotomy of the pubis if the far cortex was penetrated by > 5 mm. This could be avoided by inclining the osteotome 45° medially and performing the osteotomy at least 2 cm medial to the iliopectineal eminence. The sciatic nerve could be injured during the first and last stages of the osteotomy if the osteotome perforated the lateral cortex of ischium and the ilio-ischial junction by > 10 mm. The femoral nerve could be stretched or entrapped during osteotomy of the pubis if there was significant rotational or linear displacement of the acetabulum. Anterior or medial displacement of < 2 cm and lateral tilt (retroversion) of < 30° were safe margins. The combination of retroversion and anterior displacement could increase tension on the nerve. Strict observation of anatomical details, proper handling of the osteotomes and careful manipulation of the acetabular fragment reduce the neurological complications of Bernese peri-acetabular osteotomy.

Endobutton versus transosseous suture repair of distal biceps rupture using the two-incision technique: a comparison series

The purpose of this study was to report the outcome of a large cohort of patients undergoing distal biceps tendon repair. We compared the endobutton and transosseous suture repair techniques, both performed through a 2-incision approach. At an average of 2.1 years after a distal biceps repair, 46 male patients (19 endobutton and 27 transosseous suture) were reviewed. The mean age of our patients was 50 years. Forty-three patients (93%) were satisfied with the results of their distal biceps tendon repair. The average pain score was 1.3 of 10 at a mean 2.1 years after repair. More than 80% of patients had regained their premorbid function in both recreational and occupational activities. The mean Mayo Elbow Performance Score was 93 of 100. Biodex strength testing demonstrated restoration of 92% of low-velocity supination power, 102% of high-velocity supination power, and 104% endurance compared with the contralateral limb. There was no statistically significant difference in postoperative strength between the transosseous suture and endobutton groups. There were 3 complications in this series, 1 case of heterotopic ossification and 2 cases of injury to the lateral cutaneous nerve of the forearm. In this large cohort of 2-incision distal biceps repairs, we found a high degree of patient satisfaction and a low complication rate. We did not find any difference in clinical outcome with regard to subjective patient rating, pain, range of motion, or supination strength when comparing the 2-incision endobutton and transosseous suture fixation techniques.

Surgical correction of distal radius malunions using an anatomic radial locking plate.

Correction of a distal radius fracture malunion is challenging technically. These malunions most classically deform dorsally, but often the deformity involves three planes. Using an anatomically designed radial plate that takes into consideration the three planes, correction of the deformity can be obtained. In this video we see a patient with a classic dinner fork deformity that is associated with a dorsal malunion involving the distal radius. Correction of a distal radius malunion can be performed using a radial approach and an anatomic radial plate. The authors have used this technique for difficult distal radius fracture malunions and have achieved superb correction, returning patients to early range of motion and an active lifestyle. Careful mobilization of the branches of the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve is required. This technique affords the surgeon excellent access to three sides of the radius to help perform this complex surgery.

Use of anterior cruciate ligament guide in Lisfranc injury fixation.

First, correct the shortening with a traction table. A ballspike reduction tool is introduced under radiographic guidance through a percutaneous anterolateral incision, lateral and inferior to the anterior superior iliacspine (to avoid the lateral cutaneous nerve of the thigh). This is then used to depress the proximal part of the fracture while a crutch placed under the leg at the distal fracture site provides a countering force (Fig 2). This allows the guidewire to be passed across the fracture site and enables the procedure to be completed without need for formal open reduction. Care must be taken not to leave the crutch in place for an extended period of time as this risks compressing the sciatic nerve.