Lateral Parapatellar Approach Research Articles

Long‐term outcome of a canine longitudinal patellar fracture treated with lag screw and pin

AbstractWe report a rare case of a 4‐year‐old, female, mixed‐breed dog with a longitudinal patellar fracture of the left hindlimb. Orthopaedic examination revealed pain, swelling and crepitus in the patella. Stifle radiography and computed tomography confirmed a longitudinal patellar fracture with lateral displacement of the fragment. A lateral parapatellar approach was chosen to assess the stifle joint. Intraoperative findings were consistent with the diagnostic imaging findings, with an additional partial tear of the quadriceps tendon at the fracture location. The fracture was treated using a 2 mm lag screw combined with a 1.25 mm K‐wire, and the partial quadriceps tendon tear was repaired with a locking‐loop suture. Despite a soft tissue injury due to temporary external coaptation treated conservatively, recovery was uneventful, and lameness gradually decreased, remaining lameness‐free from postoperative Week 7. The dog finally returned to full activity without recurrence of lameness during long‐term follow‐up (422 days).

The Lateral Para-Patellar Approach for Intramedullary Tibia Nailing in Distal Tibia Extra-articular Fractures: A Prospective Cohort Study.

The treatment of extra-articular distal tibiafractures is still a subject of debate and frequently necessitates surgical treatment, and intramedullary nailing (IMN) offers a minimally invasive approach with excellent results. Important factors in these procedures are positioning, operative duration, and radiation exposure. This study details the semi-extended lateral para-patellar approach for IMN of distal tibia extra-articular fractures and documents our findings regarding operative time, intra-operative radiation exposure, residual anterior knee pain, knee functional and radiological outcomes at six months follow-up. We reviewed the cases of 60 patients who underwent IMNfor distal tibia extra-articular fractures from May 2022 to March 2024, employing an extra-articular lateral para-patellar approach in the semi-extended position. Patients were evaluated clinically and radio-graphically for a minimum follow-up period of six months. Data collected included duration of surgery, intraoperative radiation exposure, and knee functional scorefor all patients. Assessment of fracture healing, residual deformities, residual anterior knee pain, and range of motion of the treated knee compared to the contralateral knee was done at a six-monthfollow-up. The average surgery duration was 54 ± 5 minutes, with intraoperative imaging averaging 48 exposures. The average time to union was 16 ± 3 weeks. Six months post-surgery, the mean Knee Society Score was 86.4 ± 3.5 (out of 100). At the six months follow-up, all patients exhibited clinical and radiographic healing, with only two cases showing mal-alignment (angular deformity <10 degrees).All patients regained a comparable range of motion in their knees. The semi-extended lateral para-patellar approachfor nailing of distal tibiaextra-articular fracturesenhances reduction, simplifies nail insertion,reduces both fluoroscopy and operative time, minimizes anterior knee pain and improves knee functional outcomes at six months follow-up.

Clinical Outcomes and Survivorship of Lateral Unicompartmental Knee Arthroplasty: A Large Single Surgeon Cohort

BackgroundLateral unicompartmental knee arthroplasty (UKA) is an effective treatment for isolated lateral compartment osteoarthritis. However, due to the rarity of the procedure, long-term outcomes and survivorship are poorly understood. We report the clinical and radiographic outcomes after lateral UKA. MethodsWe retrospectively reviewed a consecutive series of patients who underwent lateral UKA by a single fellowship-trained arthroplasty surgeon from 2001 to 2021 with a minimum 2 year follow up. There were 161 knees in 153 patients (average age 69 years) that met inclusion criteria, with a mean follow up of 10.0 years (range 0.05 to 22.2). All patients underwent the procedure via a minimally invasive lateral parapatellar approach with a fixed-bearing implant. Patient demographics, complications, radiographic findings, patient-reported outcomes, and the need for revision surgery were evaluated. Survivorship was defined with the end point as revision of components. ResultsThere were 8 patients (5.0%) who underwent conversion to total knee arthroplasty for lateral UKA implant failure or progression of arthritis. There were 3 patients (1.9%) who underwent ipsilateral medial UKA due to medial compartment arthritis progression with preserved mechanical alignment and patellofemoral joint. There were 8 additional procedures that did not require implant changes, including 5 irrigation and debridements for acute periprosthetic joint infection (3.1%), 2 wound closures for dehiscence (1.3%), and one loose body removal (0.6%). ConclusionsLateral UKA showed a survivorship rate of 98.0% at 5 years, 96.0% at 10 years, and 94.5% at 15 years. When including patients who underwent additional surgery for the progression of arthritis, survivorship was 97.4% at 5 years, 95.4% at 10 years, and 91.3% at 15 years. Lateral UKA should be seen as a durable treatment option for isolated lateral compartment osteoarthritis.

A retrospective investigation on clinical and radiographic outcomes of distal tibial fractures after intramedullary nailing using the lateral parapatellar extra-articular approach.

According to reports, the modified extra-articular parapatellar approach allows the performance of tibial nailing in the semi-extended position without the concern of joint violation. However, there remains no special study that has provided a detailed assessment of the benefits and risks of this approach for treating distal tibial fractures (DTFs). The aim of this retrospective study was to investigate the clinical and radiological outcomes of patients with DTFs after intramedullary nailing using a lateral parapatellar extra-articular (LPE) approach in comparison to using the suprapatellar (SP) and transpatellar (TP) approaches. Data were collected from 99 patients with a minimum follow-up period of 12 months. Comparisons were conducted between the groups regarding the number of intraoperative fluoroscopies, complications, knee pain, knee range of motion (ROM), the Lysholm Knee Scale (LKS), the Olerud-Molander Ankle Score (OMAS) and radiological findings. The demographic characteristics were comparable between the groups. Fewer intraoperative fluoroscopies were performed in the LPE (27.47 ± 4.98) and SP (26.03 ± 5.12) groups than in the TP group (30.20 ± 7.42; P<0.001). When compared with the other two approaches, the LPE approach was associated with less knee pain (P<0.001) and better knee ROM (P<0.001) at one week postoperative. No significant intergroup differences were detected in the incidence of complications, LKS scores (P = 0.687) and OMAS (P = 0.926). Radiological findings demonstrated that postoperative tibial alignment (P = 0.853), the time of bony union and rate of non-union were similar between the groups. The LPE approach can serve as a safe and effective option for tibial nailing, as it offers favourable outcomes in knee pain relief and knee ROM in the early postoperative period and is equivalent to the other two approaches in terms of the incidence of complications, fracture healing, functional recovery and postoperative alignment for patients with DTFs.

Lateral Parapatellar Approach with Preservation Infrapatellar Fat Pad in TKA for Severe Valgus Deformity with Flexion Contracture and Patella Subluxation: A Case Report

Lateral Parapatellar Approach with Preservation Infrapatellar Fat Pad in TKA for Severe Valgus Deformity with Flexion Contracture and Patella Subluxation: A Case Report

Exposure of Hoffa Fractures Is Improved by Posterolateral and Posteromedial Extensile Approaches: A Qualitative and Quantitative Anatomical Study.

The current literature lacks recommendations regarding surgical approaches to best visualize and reduce Hoffa fractures. The aims of this study were to (1) define surgical corridors to the posterior portions of the lateral and medial femoral condyles and (2) compare the articular surface areas visible with different approaches. Eight fresh-frozen human cadaveric knees (6 male and 2 female donors; mean age, 68.2 ± 10.2 years) underwent dissection simulating 6 surgical approaches to the distal femur. The visible articular surface areas for each approach were marked using an electrocautery device and subsequently analyzed using image-processing software. The labeled areas of each femoral condyle were statistically compared. At 30° of flexion, visualization of the posterior portions of the lateral and medial femoral condyles was not possible by lateral and medial parapatellar approaches, as only the anterior 29.4% ± 2.1% of the lateral femoral condyle and 25.6% ± 2.8% of the medial condyle were exposed. Visualization of the lateral femoral condyle was limited by the posterolateral ligamentous structures, hence a posterolateral approach only exposed its central (13.1% ± 1.3%) and posterior (12.4% ± 1.1%) portions. Posterolateral extension by an osteotomy of the lateral femoral epicondyle significantly improved the exposure to 53.4% ± 2.7% and, when combined with a Gerdy's tubercle osteotomy, to 70.9% ± 4.1% (p < 0.001). For the posteromedial approach, an arthrotomy between the anteromedial retinaculum and the superficial medial collateral ligament, and one between the posterior oblique ligament and the medial gastrocnemius tendon, allowed visualization of the central (13.5% ± 2.2%) and the posterior (14.6% ± 2.3%) portions of the medial femoral condyle, while a medial femoral epicondyle osteotomy significantly improved visualization to 66.1% ± 5.5% (p < 0.001). Visualization of the posterior portions of the femoral condyles is limited by the specific anatomy of each surgical corridor. Extension by osteotomy of the femoral epicondyles and Gerdy's tubercle significantly improved articular surface exposure of the femoral condyles. Knowledge of the surgical approach-specific visualization of the articular surface of the femoral condyles might be helpful to properly reduce small Hoffa fragments.

Lateral UKA can be a safe solution in a young patients' population: a 10-year follow-up report.

This study aimed to assess the long-term survivorship and functional outcomes of fixed-bearing lateral unicompartmental knee arthroplasty (UKA) in a young patients' population with osteoarthritis limited to the lateral compartment. The study included a cohort of consecutive patients who underwent lateral UKA between January 2008 and December 2014 at a single high-volume surgical center. The surgical procedures were performed by experienced surgeons using a lateral parapatellar approach and fixed-bearing implants. Patient follow-up included a retrospective re-evaluation, clinical assessments, patient-reported outcome measures (PROMs), and X-ray analysis. A total of 40 lateral UKAs were analyzed, with 19 performed on the left and 21 on the right knee. The mean age of the patients at the time of surgery was 57.6 years, and the mean BMI was 24.8. At the final follow-up, 80% of patients achieved excellent outcomes (OKS > 41), and 20% had good outcomes (OKS: 34-41). No patients exhibited fair or poor outcomes. The mean FJS at the final follow-up was 82.8. The mean WOMAC was 10.5. Kaplan-Meier survival analysis revealed a survivorship rate of 93.1% at 10 years, considering revision for any reason as endpoint. Lateral UKA proved to be an effective treatment option for osteoarthritis affecting the lateral compartment of the knee. The study demonstrated a high survivorship rate and favorable functional outcomes at a mean follow-up of 132.7 months. These findings highlight the potential benefits of fixed-bearing lateral UKA in selected patients with lateral compartment knee pathology.

Reduction of Operative Time, Intraoperative Radiographs, and Anterior Knee Pain With the Lateral Parapatellar Approach for Tibial Shaft Fracture Nailing: A Case Series.

Background Tibia fracture is a common indication for operative intervention in orthopedics. Usage of Intramedullary nailing provides a minimally invasive technique with good results. Positioning, operative time, and radiation exposure are major points in such cases. This study described the semi-extended lateral parapatellar intramedullary technique as a technique that helps achieve and maintain reduction, simplifies nail insertion, and decreases fluoroscopy and operative time. Methodology This prospective case series study included nine patients with tibial shaft fractures operated at Royal Rehabilitation Center from April to October 2023 by intramedullary nailing and extra-articular lateral parapatellar insertion technique using the semi-extended knee position. Duration of surgery, intraoperative radiation exposure, and anterior knee pain score were assessed for all patients. Results The average duration of surgery was 63.78 ± 5.3 minutes, and the average intraoperative imaging was 94 (85-103). The average union time was 18 ±2 weeks. The mean Kujala score was 90.9% ± 2.3% six months after the surgery. All patients regained a comparable range of motion in their knees and ankles. One patient reported minimal pain at the pin site but did not require any analgesia. Conclusion The lateral parapatellar approach for tibial shaft fracture nailing has the advantage of reducing operative time, the number of intraoperative radiographs, and lower postoperative anterior knee pain. Additionally, this approach did not cause patellar instability.

Intramedullary Fibular Strut Allograft and a Small Fragment Nonlocking T-plate for Periprosthetic Lateral Femoral Condyle Fracture: A Case Report

Intramedullary Fibular Strut Allograft and a Small Fragment Nonlocking T-plate for Periprosthetic Lateral Femoral Condyle Fracture: A Case Report

Total Knee Replacement in Valgus Knee

Total knee replacement (TKR) in valgus knee patients presents unique challenges and requires careful consideration of various factors to ensure optimal outcomes. Valgus knee deformity can be associated with various underlying conditions, including autoimmune diseases like rheumatoid arthritis. Nearly 10% of patients undergoing total knee replacement have valgus knee deformity, which is associated with poorer functional outcomes than varus knees. When planning TKR procedures for patients with valgus knee deformity, it is crucial to identify the underlying reason, as the surgical strategy and implant selection may vary according to the individual etiology and patient factor. Proper alignment and stability of the knee joint need precise bone cuts, soft tissue balance, and implant design. Soft tissue balance ensures optimal joint function and range of motion. A comprehensive pre-operative planning process that takes into account these factors is essential for achieving the best possible outcomes and patient satisfaction in TKR for valgus knee patients. Different surgical approaches, such as the medial parapatellar and lateral parapatellar approaches, offer distinct advantages and disadvantages in treating valgus knee patients, and the choice of approach should be based on the surgeon's expertise and the patient's specific anatomy and deformity. For a successful output, the coronal, sagittal, and rotational alignment must be in proper proportion. Therefore, before performing a total knee replacement on a valgus knee, it is necessary to have a thorough understanding of the problem and the treatment options available.

Robotic-Arm-Assisted Lateral Unicompartmental Knee Arthroplasty with a Fixed-Bearing Implant.

Approximately 5% to 10% of patients with knee arthritis have isolated lateral compartment arthritis; however, lateral unicompartmental knee arthroplasty (UKA) comprises just 1% of all knee arthroplasties1. This low proportion is partly because of the perceived complexity of lateral UKA and concerns over implant longevity and survivorship compared with total knee arthroplasty (TKA)2,3. With an improved understanding of knee kinematics alongside advances in implant design and tools to aid in appropriate restoration of limb alignment, lateral UKA can be an appealing surgical alternative to TKA for certain patients with lateral knee arthritis4,5. In appropriately selected patients, lateral UKA has been associated with reduced osseous and soft-tissue resection, more natural knee kinematics, less pain, shorter hospitalization, decreased blood loss and infection rates, and excellent survivorship and patient-reported outcomes6-9. This surgical approach and technique described for lateral UKA utilizes robotic-arm assistance and modern fixed-bearing implants10. The specific steps involve appropriate patient evaluation and selection, extensive radiographic and computed-tomography-based preoperative templating, a lateral parapatellar approach, intraoperative confirmation of component position and alignment, and robotic-arm assistance to perform osseous resections to achieve limb alignment and kinematic targets10. Final implants are cemented in place, and patients typically are discharged home on the day of surgery10. Nonoperative treatment for end-stage knee arthritis includes weight loss, activity modification, assistive devices, bracing, nonsteroidal anti-inflammatory medications, and various injections11. Alternative surgical treatments include TKA4 and, in certain patients, an offloading periarticular osteotomy12. Lateral UKA is an appealing surgical option for nonobese patients who have disabling knee pain isolated to the lateral compartment, good preoperative range of motion, and a passively correctable valgus limb deformity10,13. Patients are typically discharged home on the day of surgery, or occasionally on postoperative day 1 if medical comorbidities dictate hospital monitoring overnight10. Patients return to light activities, including walking, immediately postoperatively. By 3 months postoperatively, patients will generally have returned to all desired activities9. The mid-term outcomes of this procedure, as performed by the corresponding author, have been published recently14,15. The 5-year survivorship of 171 lateral UKAs was 97.7%, with 72.8% of patients reporting that they were very satisfied with their procedure and 19.8%, that they were satisfied14. Only 3.8% of patients reported dissatisfaction with their lateral UKA14. The mean Knee Injury and Osteoarthritis Outcome Score (KOOS) and standard deviation were 85.6 ± 14.314. These outcomes did not differ from those observed in 802 medial UKAs, which showed a survivorship of 97.8% and KOOS of 84.3 ± 15.914. These findings are generally in line with previously published studies, which have demonstrated excellent survivorship and patient-reported outcomes with fixed-bearing lateral UKA16-19. Component position and alignment are critical to achieve target knee kinematics.Target postoperative alignment is 1° to 4° of valgus.A meticulous cementation technique is required for optimal fixation and avoidance of excess residual cement in the posterior knee. ACL = anterior cruciate ligamentAP = anteroposteriorBMI = body mass indexCT = computed tomographyCAT = computed axial tomographyIT = iliotibialKOOS JR = Knee Injury and Osteoarthritis Outcome Score for Joint ReplacementMCL = medial collateral ligamentMRI = magnetic resonance imagingOR = operating roomPFJ = patellofemoral jointpoly = polyethyleneROM = range of motionTKA = total knee arthroplastyUKA = unicompartmental knee arthroplasty.

Assessment of Patellar Vascularity after Patellar Cartilage Restoration via Lateral Parapatellar Approach: Analysis Using Dynamic Contrast-Enhanced Magnetic Resonance Imaging.

Patellofemoral cartilage restoration procedures, including osteochondral allograft, particulated juvenile cartilage, and matrix-induced autologous chondrocyte implantation, have been shown to be effective treatments for patellofemoral cartilage lesions. However, concerns exist regarding disruption of the patellar vascular supply and secondary stabilizers of the patellofemoral joint during medial parapatellar approaches, especially when combined with a lateral release. A lateral parapatellar approach affords the possibility of avoiding disruption of the medial blood supply to the patella, while also allowing laterally-based soft tissue stabilization procedures. The purpose of this study was to investigate in vivo changes in patellar vascularity following patellofemoral cartilage restoration procedures performed via a lateral parapatellar approach via use of dynamic contrast-enhanced magnetic resonance (MR) imaging. This study is a prospective case series of 5 adult patients undergoing patellofemoral cartilage restoration procedures via a lateral parapatellar approach with pre-operative and post-operative dynamic contrast-enhanced MR imaging to assess changes in patellar vascularity. Secondary outcomes included knee range of motion, need for revision surgery, and complications. There was no significant post-operative difference in patellar vascularity in patients undergoing patellofemoral cartilage restoration procedures via a lateral parapatellar approach, as evaluated by qualitative MR imaging. Our results suggest that a lateral parapatellar approach for cartilage restoration procedures may preserve patellar vascularity, while also allowing for lateral release to be performed through the same incision.

Mid-vastus total knee arthroplasty for medial osteoarthritis recovers gait balance control better than lateral parapatellar approach three months post-surgery.

Total knee arthroplasty (TKA) approaches affect recovery outcomes, with different levels of residual loss of muscle strength and functional deficits. The current study compared the gait balance control in older individuals 3months after TKA via the lateral parapatellar approach (LPPA) and mid-vastus approach (MVA) in terms of the inclination angle (IA) of the center of pressure (COP) to the body's center of mass (COM) vector, and the rate of change of IA (RCIA). In a gait laboratory, 12 patients with severe medial knee osteoarthritis who had undergone bilateral TKA via LPPA and 12 via MVA were evaluated and compared against 12 healthy controls for their balance control during gait 3months after surgery. The participants' kinematic data and ground reaction forces were measured synchronously using an 8-camera motion capture system and three forceplates, respectively, from which the COM, COP, IA and RCIA were calculated using a 13-body-segment model. The LPPA group showed significantly greater sagittal IA during DLS (p < 0.01) but less sagittal and frontal RCIA throughout the gait cycle (p < 0.04) compared to controls. The MVA showed better recovery in the balance control with most IA and RCIA variables similar to those of the healthy controls throughout the gait cycle. The patients with LPPA walked with a compromised balance control throughout the gait cycle while the MVA group showed close-to-normal balance control with a slight decrease in sagittal RCIA during SLS. The current between-approach findings were likely related to the differences in the muscles involved during surgery, suggesting that MVA may be a better choice than LPPA when taking short-term gait balance control into consideration.

Treatment of osteochondral fracture of lateral femoral condyle after patella dislocation with anchor absorbable sutures: A new surgical technique and a case report

Osteochondral fracture (OCF) in weight-bearing area of lateral femoral condyle (LFC) is a rare combined injury caused by patellar dislocation. A 15-year-old female student accidentally sprained her right knee while participating in sports activities. The patient felt pain in his right knee and limited movement. After hospitalization, the patients underwent computed tomography scan and magnetic resonance examination. According to the imaging results, patellar dislocation combined with OCF of LFC was considered in diagnosis. Through the lateral parapatellar approach, we reduced the osteochondral mass and bundled it with absorbable sutures of anchors. The functional and radiographic outcome were satisfactory at 18 months after operation. Anchor absorbable suture bridge fixation for this kind of OCF is not only effective, but also economical.

Treatment of Diaphyseal Tibial Fractures Distal to a Total Knee Arthroplasty by Intramedullary Nailing Is Safe and Effective.

To report the clinical result of a series of patients who underwent intramedullary nailing (IMN) of tibial shaft fractures distal to a total knee arthroplasty (TKA). Retrospective case series. Level-1 trauma center. Patients who sustained a tibial shaft fracture distal to a TKA treated with an IMN. IMN of tibial shaft fractures distal to a TKA. Postoperative weight-bearing status, readmissions, and complications or failure of treatment within 90 days; Knee Injury and Osteoarthritis Outcome Scores at the final follow-up; failure of treatment; and revision surgery. Nine patients were included. The average age was 71.4 years (range 55-87 years). All TKAs were cemented. The average distance between the tibial keel and the cortical density of the tibial tubercle was 24.1 mm (range 19.5-26.7 mm). Six nails were inserted using an infrapatellar portal, 2 were inserted using a suprapatellar portal, and 1 was inserted using a lateral parapatellar approach. The median nail diameter was 10 mm (range 9-12 mm). All fractures were healed at the final follow-up. There were no infections or arthroplasty-related complications. Knee Injury and Osteoarthritis Outcome Scores ranged from 100% to 74% (median 82%). Overall, we report on the largest cohort in the literature undergoing IMN of a tibial shaft fracture distal to a TKA. We demonstrate that IMN of diaphyseal tibial fractures distal to a TKA can be performed safely. We additionally demonstrate that this treatment is highly effective in achieving fracture union with no arthroplasty-related complications. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Isolated Lateral Tibiofemoral Compartment Osteoarthritis: Survivorship and Patient Acceptable Symptom State After Lateral Fixed-Bearing Unicompartmental Knee Arthroplasty at Mean 10-Year Follow-up.

Lateral unicompartmental knee arthroplasty (UKA) is an excellent option to alleviate disability and restore function in patients with lateral compartment knee osteoarthritis (OA). The purpose of the present study was to determine the survivorship and long-term outcomes in both younger/middle-aged and older patients with lateral compartment OA following non-robotically-assisted, fixed-bearing lateral UKA and to determine if an acceptable symptom state can be achieved. All patients were managed with fixed-bearing lateral UKA by a single surgeon utilizing a lateral parapatellar approach without robotic assistance. The primary outcome variables were the Knee injury and Osteoarthritis Outcome Score (KOOS) Activities of Daily Living (ADL) and Sport subscale scores. In addition, the other KOOS subscores, the Lysholm score, the achievement of the Patient Acceptable Symptom State (PASS), and the Veterans RAND (VR-12) Physical Component Summary score (PCS) and Mental Component Summary score (MCS) were collected. Failure was defined as conversion to total knee arthroplasty (TKA). Patients were divided into 2 cohorts: younger/middle-aged patients (<60 years of age) and older patients (≥60 years of age). A cohort of 256 patients underwent medial (n = 193) or lateral (n = 63) UKA. Sixty-one patients met the inclusion criteria. At mean of 10 years (range, 4 to 17 years) of follow-up, there were no significant differences between the groups in terms of any patient-reported outcome measures (p > 0.05). The percentage of patients in whom PASS was achieved on the KOOS ADL and Sport subscores was 82% and 88%, respectively, in the younger cohort and 80% and 80%, respectively, in the older cohort. The mean survival estimate of the prothesis was 15.3 years (95% confidence interval [CI], 14.5 to 16.2 years) for the entire cohort. The estimated rate of implant survival in the younger cohort was 100% at 5 and 10 years, and the estimated rate of implant survival in the older cohort was 98% at 5 years and 96% at 10 years. Lateral fixed-bearing, non-robotic UKA for the treatment of isolated lateral compartment OA resulted in >80% of patients reaching an acceptable symptom state in terms of both activities of daily living and sporting activities. UKA provides an excellent option that provides longevity with high PASS rates and return to activities with a low risk of complications and failure. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

A Modified Tension Band Fixation Technique for the Management of Patellar Fractures Using Crossed Pins and a Lateral Parapatellar Approach.

The use of the tension band technique for patellar fracture fixation has been associated with a loss of the rigidity of the construct after cyclic loading. Biomechanical studies have shown the biomechanical superiority of the crossed pin configuration relative to the traditional parallel one. Here, we describe a modified tension band technique that involves the use of crossed pins and a figure-of-eight passed as close to the bone as possible through a lateral parapatellar approach. The basic surgical technique and our case series are reviewed.

A Review of Proximal Tibia Entry Points for Intramedullary Nailing and Validation of The Lateral Parapatellar Approach as Extra-articular.

Tibial shaft fractures are the most common long bone injury and are often treated surgically in an attempt to minimize complications. Although treatment options for tibial shaft fractures vary based on factors including open injury, severity of fracture, and soft tissue status, intramedullary nailing in adults has emerged as the preferred definitive option for stabilization. Therefore, the primary purposes of this review and cadaveric study were to evaluate the entry points for reamed tibial nails and the risks, benefits, and advantages of each approach. Due to concerns of violating the joint capsule and the generalized applicability to everyday practice of the extra-articular lateral parapatellar semi-extended technique, the secondary goal of this manuscript was to evaluate whether an intramedullary tibial nail can be consistently placed extra-articularly using the lateral parapatellar technique described by Kubiak et al.and generalizability to surgeons of varying experience.

The effect of collagenase clostridium histolyticum on adhesion reduction in a rat knee arthrofibrosis model.

The aim of this study was to investigate whether collagenase clostridium histolyticum (CCH) reduces intra-articular fibrotic adhesion formation in a rat model of arthrofibrosis. A total of 24 male Wistar rats (7 months old, weighing 220 -275 g) were randomly and equally assigned to one of two groups: the collagenase group and the control group (n = 12 each). In each group, a partial capsulotomy, and synovectomy were performed in knee. After a partial capsulotomy and synovectomy were performed in each group, the collagenase group received intra-articular CCH of 0.008 mg in 0.1 mL saline solution while the control group received the equal volume of intra-articular saline solution alone. After 6 weeks of surgery, the rats were sacrificed by decapitation, and the following outcome measures were collected. Knee range of motion (ROM) was measured using with a goniometer under 20 g force. Adhesion formation was rated using the macroscopic visual scoring system after the knee joint was exposed through a lateral parapatellar approach. Histological evaluation was performed on samples including connective tissue and fibrotic adhesions, and fibroblast cell numbers were measured performed per square. Levels of interleukin 1 (IL-1) and fibroblast growth factor (FGF) were assayed by ELISA from the intra-articular fluid. The macroscopic visual scoring system was significantly lower in the collagenasegroup (median = 1, range = 0-2) than in the control group (median = 2, range = 1-3)( < 0.001).ROMwas significantly higher in the collagenase group (102° ± 12.1°) than in the control group (77° ±8.94°) (P <0.001). The number of fibroblasts obtained from the scar tissue were considerably lower in the collagenase group (mean = 16.5 ± 2.74) compared tothe control group (mean = 30.1± 4.89) (P < 0.001). Levels of IL-1 andFGF were significantly lower in the collagenase group (mean = 18.6 ng/l ± 4.39,mean = 36.3 ng/l ± 2.03; respectively) compared to the control group (mean = 31.7ng/l ± 3.75, mean = 38.7 ng/l ± 2.19; respectively) (P < 0.001). Evidence from this study has revealed that CCH injection can inhibit the development ofarthrofibrosis, decreasing the precursor inflammatory cytokines (IL-1 and FGF-1) and histologic fibrosis in a rat knee arthrofibrosis model. Level IV, Therapeutic study.

Tibial alignment following intramedullary nailing via three approaches.

The purpose of this study is to evaluate the incidence of malalignment in patients undergoing IMN for tibial shaft fractures treated with the extra-articular lateral parapatellar, suprapatellar, and infrapatellar approaches. A retrospective review of an institutional trauma database was completed at a single level 1 trauma academic medical centre. Quality of reduction was assessed using the following three parameters: (1) < 10°of angulation in orthogonal radiographic views (2) < 5mm of displacement between the major fracture fragments (3) < 5mm of gap between the major fracture fragments. A good reduction was one that met all 3 criteria, an acceptable reduction met 2 criteria, and a bad reduction met one or none of the criteria. All patients treated consecutively for tibial shaft fractures between June 1, 2019 and June 1, 2020 were identified. The final cohort included 57 tibia fractures in 56 patients. Of the 57 tibia fractures, 8 (14%) were proximal third, 32 (56%) were middle third, and 17 (30%) were distal third fractures. We found no significant difference in angulation, displacement, or gapping with respect to surgical approach utilized or location of fracture (proximal or distal tibia fractures) on one-way ANOVA. Quality of reduction was rated as "good" in 48 (84%) of the cases (19 supra, 13 infra, and 16 lateral). Nine reductions (16%) met only two of the three reduction quality criteria and were considered acceptable reductions. These included 2 suprapatellar (1 > 5mm displacement, 1 > 5mm gapping), 4 infrapatellar (4 > 5mm displacement), and 3 lateral extra-articular parapatellar (2 > 5mm displacement and 1 > 5mm gapping). No reductions were determined to be bad according the Baumgaertner et al. criteria. There was no significant difference in the rate of combined fibula fractures or the rate of fibular fixation between the three cohorts. In conclusion, no significant difference was found in fracture reduction angulation, displacement, and gapping in patients treated with an IMN with respect to approach for diaphyseal or metadiaphyseal tibial shaft fractures.