Minimal Dissection Research Articles

Retroperitoneal laparoscopic non-dismembered pyeloplasty for uretero-pelvic junction obstruction due to crossing vessels: A matched-paired analysis and review of literature

ObjectiveTo compare laparoscopic Anderson-Hynes pyeloplasty (LAHP) and retroperitoneal laparoscopic YV-pyeloplasty (LRYVP) in ureteropelvic junction obstruction (UPJ) in presence of a crossing vessels (CV). MethodsOur database showed 380 UPJO-cases,who underwent laparoscopic retroperitoneal surgery during the last 2 decades including 206 non-dismembered LRYVP, 157 dismembered pyeloplasties LAHP, and 17 cases of laparoscopic ureterolysis. Among them 198 cases were suitable for a matched-pair (2:1) analysis comparing laparoscopic retroperitoneal non-dismembered LRYVP (Group 1, n = 131) and dismembered LAHP (Group 2, n = 67) in presence of a crossing vessel. Patients were matched according to age, gender, kidney functions, and obstruction grade. Complications were graded according to modified Clavien-classification. ResultsComparative data were similar between both groups (LRYVP vs. LAHP) including mean operating time (112 min vs. 114 min), complication rates (4.2% vs. 7.3%) mainly Grade 1–2 according to Clavien classification, and success rates (90% vs. 89%). These results reflected in the reviewed literature indicate that LRYVP provides the advantage of minimal dissection in case of CV with similar outcome. However, redundant pelvis and anteriorly crossing vessels still require a dismembered pyeloplasty LAHP. ConclusionLRYVP has achieved similar results compared with the previous golden standard of open surgery, especially in case of crossing vessels apart from presence of a redundant pelvis or anteriorly crossing vessel. This can be further improved when using the small access retroperitoneoscopic technique respectively mini-laparoscopy.

Pure laparoscopic anatomical segment VI resection using the Glissonian approach, Rouviere's sulcus as a landmark, and a modified liver hanging maneuver (with video).

Pure laparoscopic anatomical segmental resection has rarely been reported because this technique frequently presents technical difficulties. We describe the laparoscopic resection of anatomical segment VI using the Glissonian approach and a modified liver hanging maneuver. Rouviere's sulcus is identified after retracting superiorly the gallbladder. The Glissonian approach for anatomical resection of segment VI can be performed with minimal dissection of the liver parenchyma around the sulcus. After clamping the Glissonian pedicle in the sulcus, the ischemic area fed by the portal pedicle was confirmed. The right triangular ligament was divided to create a small opening for placement of the hanging tape along the ischemic line. The liver parenchymal transection was performed along the hanging tape. Four patients underwent pure laparoscopic anatomical segment VI resection using the Glissonian approach and a modified liver hanging maneuver. The median operation time was 205min (range, 110-250min), and median estimated blood loss was 110mL (range, 100-350mL). The median postoperative hospital stay was 5days (range, 4-8days). There was no postoperative morbidity or mortality. The Glissonian approach at Rouviere's sulcus as a landmark combined with the modified liver hanging maneuver may be safe and useful for laparoscopic anatomical segment VI resection.

Incidence of inferior alveolar nerve affection with and without nerve exposure during bilateral sagittal split osteotomy

Objective: The aim of this study was to determine the presence and severity of inferior alveolar nerve (IAN) affection during bilateral sagittal split osteotomy (BSSO) in two groups of patients with and without direct exposure and visualization of the nerve during surgical procedure.Patients and Methods: In this prospective randomized clinical study, 14 patients (28 sides) indicated for BSSO were included. The sides were randomly divided into two groups with equal number of sides (14 sides). Group I with wide soft tissue dissection of the medial side of the ramus and exposure of IAN above the ligula and group II with minimal soft tissue dissection of the medial side of the ramus without exposure of IAN. For evaluation of neurosensory function of IAN, two methods were used including subjective evaluation and two-point discrimination test.Results: According to the subjective evaluation, there was a statistically significant difference between both groups in favor of group II in all follow-up recalls except in the final one at 12 months postoperatively. Considering the results of two-point discrimination test, the improvement obviously continued during the successive follow-up periods in both groups, with a statistically significant difference in favor of group II until the ninth month, and then in the last follow-up at the 12th month, the records were almost equal.Conclusion: To markedly reduce the postoperative neurosensory disturbances of IAV and to accelerate the full recovery of sensation of the lower lip and chin regions following BSSO, limited exposure and dissection of the medial soft tissues of the ramus should be practiced with avoidance of direct exposure and manipulation of IAN.

Surgical Approaches to Large Peripheral Nerve Sheets Tumors

Peripheral nerve sheath tumors (PNSTs) are not rare tumors. Its sound management is complete surgical excision. The aim of this study was to describe clinical presentation, accuracy of different investigations and ideal surgical approaches in relation to outcomes. The study is a prospective and included 26 surgically treated large PNSTs in 22 patients operated through different surgical approaches according to the site of the tumors. The fellow up period was 6 - 60 months. The mean age was 41.8 years, 9 were males and 13 were females. The common presentations were pain in 12 lesions, swelling in 8 lesions, neural deficits in 4 lesions and positive Tinel’s test in 2 lesions. These lesions were excised through 6 surgical approaches. Histopathological examination showed 20 benign and 6 malignant lesions. Five cases of malignant peripheral nerve sheet tumors (MPNSTs) had local recurrent, 4 cases had distant metastasis, 4 cases received chemotherapy and radiotherapy, and 4 cases were died in the postoperative fellow up period. It was concluded that surgical approaches to the PNSTs, depends on their locations. Adequate exposure with minimal dissection minimized the neurological deficit and decreased rate of local recurrence.

Internal Capsule Elevation (ICE Procedure)

The internal capsule elevation (ICE) procedure is a new operation designed to reposition an inferiorly or laterally displaced or misplaced breast implant. The distinct advantage of this procedure is the ease of the operation because it is essentially a suture-free capsulorrhaphy. The premise of this procedure was derived from the simple observation that replacing a deflated saline implant after a significant delay (1 month) required a fairly vigorous dissection to reopen the periphery of the original pocket. This is due to the fact that the peripheral pocket that is no longer kept open by the inflated implant adheres to itself through the body’s normal healing processes. This natural phenomenon may be enhanced by lightly cauterizing in a fractionated pattern, the area of desired closure inferiorly or laterally in an arc like fashion. By opening the opposite superior and/or medial pocket with an electrocautery capsulotomy and minimal blunt dissection, this allows the repositioned implant to be more easily relocated in the more desirable position. Suture capsulorrhaphy is a procedure that requires extreme accuracy in placement of the sutures to avoid dimpling or irregular contours of the inferior and lateral breast. In experienced hands, it can be a very reliable procedure.1-3 In my experience, many patients have presented with misshapen breasts after suture capsulorrhaphy in inexperienced hands. Many of the patients have expressed regret and are displeased with their outcomes. The ICE procedure offers a technically easier alternative for repositioning the minimally inferiorly and or laterally displaced implant as compared with more traditional suture capsulorrhaphy.

Distal transsylvian keyhole approach for unruptured anterior circulation small aneurysms

BackgroundTo reduce complications associated with conventional pterional craniotomy, a transsylvian keyhole approach for unruptured small anterior circulation aneurysms is proposed.MethodsA 7-cm linear scalp incision is made along the hairline, beginning at the zygoma, followed by minimal temporal muscle dissection. Two burr holes are drilled out at McCarty’s point and the temporal bone, and a 3-cm equilateral triangle bone flap is made, whose apex is located above the sylvian point. After the sphenoid ridge is drilled off, aneurysms are exposed and clipped with conventional microsurgical instruments.ConclusionsThis approach permits access to aneurysms via the transsylvian corridor with a smaller area of potential injury of superficial structures.

To analyze the functional outcome of proximal tibial fractures treated with minimally invasive percutaneous plate osteosynthesis technique

<p class="abstract"><strong>Background:</strong> Tibial plateau fractures constitute about 1% of all fractures and complex bicondylar fractures constitute 30% of all Tibial plateau fractures. Minimally Invasive Percutaneous Plate Osteosynthesis [MIPPO] is a method of biological fixation in which a plate is percutaneously inserted and fixed at a distance proximally and distally from the fracture site. By minimal exposure, this helps in the preservation of the essential fracture hematoma, minimal soft tissue dissection, avoidance of periosteal stripping and providing an adequate fixation. The objective of the study was to analyze the functional outcome of proximal Tibial fractures treated with MIPPO technique. The method of fixation shall be evaluated for the time period required for the patients to return to active work following surgery.</p><p class="abstract"><strong>Methods:</strong> In our study, all 18 patients with proximal Tibial fractures underwent definitive fixation by MIPPO technique. All our cases underwent initial stabilization as per the ATLS guidelines. Patients with closed Tibial plateau fractures associated with a tense haemarthrosis underwent aspiration of the joint under aseptic precautions. The limb was immobilized either in an above knee slab or through skeletal traction using a distal Tibial or calcaneal pin traction on a Bohler Braun splint until definitive fixation was carried out. In cases complicated with excessive swelling and blistering, definitive fixation was delayed until the swelling/ blistering subsided.<strong></strong></p><p class="abstract"><strong>Results:</strong> The post-operative results were designated as excellent, good, fair and poor according to pain, walking capacity, the range of motion and stability of the knee using Rasmussen’s grading system. In our study, the average functional knee score was 22.89. Rasmussen’s score does not consider articular congruity while assessing the functional outcome of the knee.</p><p class="abstract"><strong>Conclusions:</strong> MIPPO technique gives good to excellent results even in high energy Tibial condyle fractures [72.22% cases in our study]. Our patients were able to achieve a good functional range of movement, averaging 120 degrees. [Krettek et al – 124 degrees]. Those who were treated with early fixation and early mobilization were found to have a better functional outcome irrespective of the fracture type. No secondary bone grafting was required. </p>

Are esophagocrural sutures needed during laparoscopic fundoplication: A prospective randomized trial

PurposeHistorically, fundoplication has been performed with extensive dissection of the esophageal attachments to the diaphragm. Previously, we conducted a randomized trial demonstrating that minimal esophageal dissection and mobilization reduce the rate of wrap herniation and the need for reoperation. In that study, four esophagocrural (EC) sutures were placed in both groups to help obliterate the space between the esophagus and diaphragmatic crura. In this current study, we evaluate the need for these EC sutures. MethodsChildren less than age 7 undergoing laparoscopic fundoplication were randomized to receive four EC sutures or none. Exclusion criteria included an existing hiatal hernia. The primary outcome was transmigration of the fundoplication wrap through the esophageal hiatus into the mediastinum. A contrast study was performed around 1year postoperatively. Telephone follow-up was performed at a minimum of 1.5years. Results120 patients were enrolled from 2/2010 to 2/2014, and 13 did not survive. One patient was excluded because a hiatal hernia was found at laparoscopy, leaving 52 patients with EC sutures (S) and 54 without EC sutures (NS). Operative time was 20min longer in the S group (P<0.01). Contrast studies were obtained in 62% of S and 68% of NS patients, and there were no wrap herniations in either group. There was one reoperation for wrap loosening in the NS group, none in the S group. Final telephone and clinic follow up was at a median of 4years (IQR 3–4.7). Reflux symptoms and medications were not different at one month, one year, and final follow-up. ConclusionWhen minimal phrenoesophageal dissection is performed, EC sutures offer no advantages and increase operating time. Level of evidenceLevel II.

Une nouvelle voie d’abord antérieure pour la synthèse des fractures de l’apophyse coronoïde au coude

BackgroundThere is no universally accepted approach to the elbow for the fixation of coronoid process fractures. This study aims to introduce a novel anterior surgical approach for the fixation of the ulnar coronoid fracture, with minimal surgical dissection damage and excellent visualization for reduction and internal fixation. HypothesisThe anterior approach can facilitate satisfactory outcomes for coronoid process fractures. Material and methodsFrom February 2010 to July 2014, 12 patients (8 males and 4 females; range: 14–62 years; mean age: 31 years) with a closed fracture of the coronoid process of the ulna were included in this study. According to Adams classification, we included 5 type II, 3 type III, 3 type IVAM, and 1 type IVAL. The fractures were treated operatively via an anterior approach between nerves and blood vessels. The anatomical reduction and fixation with cannulated screws or a mini plate was easily performed. One elbow showed significant joint instability, necessitating, another incision to repair the lateral collateral ligament, and a subsequent operation with a hinged external fixator was required. The remaining patients received a splint for 2 weeks followed by functional exercises. ResultsMean follow-up was 21 months (13–36). Fracture union was achieved in each patient. The arc of elbow flexion and extension were (135±15)°, and forearm pronation/supination were restored to (165±15)°. When compared with the normal side, there was no significant difference in the functional outcome (P>0.05). According to Morrey's scale, the functional recovery of the injured arms was assessed as excellent in eleven patients and good in one. Mild heterotopic ossification was found in one case, which had not impaired the elbow function. No other complications were noted. ConclusionsThe anterior approach has the benefits of simplicity, safety, minimal invasion, excellent exposure, and satisfactory prognosis for coronoid process fractures. Level of evidenceProspective study, level IV.

Safe Zone for the Plantar Portal

Category: Arthroscopy Introduction/Purpose: Open surgery of the sole of the foot requires an extensive amount of soft tissue to be dissected. In recent years, various types of endoscopic surgery for the sole of the foot have been reported, making it possible to dynamically evaluate and treat plantar lesions with a small skin incision and minimal dissection. However, there have also been reports of complications involving plantar nerve injury. A good knowledge of the plantar nerve anatomy is crucial for safe endoscopic surgery of the sole. We aimed to anatomically dissect the soles of cadaveric feet to investigate the safe zones for plantar portals. Methods: We studied 36 feet of 24 cadavers. The soft tissue of the sole was dissected, and the relationships between the plantar nerve and flexor digitorum longus tendon, flexor hallucis longus tendon and peroneus longus tendon were studied. The plantar nerve course was digitally imaged and uploaded into Image J software to determine the nerve position. The back of the calcaneus, the medial side of the base of M (Metatarsal) 1, the medial side of the head of M1, the lateral side of the head of M5, and the proximal tip of M5 were plotted and defined as A, B, C, D, and E respectively on Image J. The nerve courses were plotted on AB, BE, and CD, and the percentage at which they were positioned on the line segment was calculated. Next, the bifurcation positions of each nerve were plotted and measured to the defined line segments. Results: No major differences were noted in the course of the medial plantar nerve and lateral plantar nerve. The medial plantar nerve and lateral plantar nerve ran between B and E, at 32.4% ± 4% and 61.2%± 5.1% respectively from B. No plantar arteries were found to run between the medial plantar nerve and lateral plantar nerve on BE. Taking mean and standard deviation values into account, no neurovascular structure existed from 36.4% to 56.1% along a line between the medial aspect of the base of M1 to the proximal tip of M5. The flexor digitorum longus tendon and peroneus longus tendon passed through the deep layer of this region. Conclusion: We believe this region to be a safe zone for creating plantar endoscopic portal. The plantar central portal can be created at the center of the sole. An approach from the plantar central portal to the flexor digitorum longus tendon, flexor hallucis longus tendon, and peroneus longus tendon with the plantar lateral portal, posteromedial portal, and toe portal allows for a greater range of vision and treatment options and may further advance endoscopic surgery of the sole.

Laparoscopic Paraesophageal Hernia Reduction with Two Point Fixation via Ponsky PEG Tube in a Patient in their early 90s

Paraesphageal hernia (PEH) repairs have been historically controversial due to widely variable clinician opinions. However, there is little research regarding the use of PEH reduction and gastropexy via a percutaneous endoscopic gastrostomy (PEG) tube. Guidelines by the Society of American Gastrointestinal and Endoscopic Surgeons do advise that the use of gastropexy alone is a valid option in patients with high risk of morbidity and mortality, but is associated with high hernia recurrence rates. A male in his early 90s presented with a six-week history of dysphagia, regurgitation and a 30- pound weight loss. Imaging revealed a large PEH and the entire stomach within the thoracic cavity. Despite the patient’s age and significant risk factors, it was determined that he required surgical intervention due to the severity of his symptoms. The safest course of action was reduction of PEH with two-point gastric fixation, rather than a prolonged repair of the hiatus or mesh implant. Due to the patient’s significant surgical risks, it was determined that the safest surgical approach would be laparoscopic reduction with dual gastropexy via PEG tube gastropexy. This approach was quick, without encroachment into the mediastinum and avoided any complications that mesh implantation could have posed. Gastropexy is a relatively simple technique with minimal tissue dissection that is tolerated well in elderly patients or those with decreased cardiac and pulmonary status. Regardless of the surgical PEH approach, there are inherent hernia recurrence rates

Minimally Invasive Plate Osteosynthesis Using Locking Plates for AO 43-Type Fractures: Lessons Learnt From a Prospective Study.

Managing fractures of distal tibia is still a subject of debate for orthopaedic surgeons in terms of both, reduction and fixation. Subcutaneous location and soft tissue anatomy predisposes it to angular and rotational instability as well as other bony and soft tissue complexities. Minimally invasive plating offers many advantages over conventional open techniques. It causes minimal soft tissue dissection and surgical trauma to the bone. Minimally invasive plate osteosynthesis(MIPO) maintains biological configuration of distal tibia and fracture hematoma and also provides a construct, which is biomechanically more stable. Evaluation of results of MIPO in management of distal tibia fractures considering radiological union, ankle function restoration, and complications. In our study, 25 closed distal one-third tibia fracture with/without articular extension were taken, fulfilling the inclusion criteria (AO classification: 10, 43A1; 3, 43A2; 2, 43B1; 4, 43B2; and 6, 43C1). MIPO with locking plates was the treatment undertaken. Patients were followed up for 18 months prospectively. Average injury-hospital interval was 11.16 hours and average injury-operation interval was 2.44 days. All fractures showed radiological union at an average duration of 20.5 weeks (14-28 weeks). Olerud and Molander score was used for evaluation at 3, 6, and 18 months. One patient had union with valgus angulation >5° but there was no nonunion. There was 1 superficial postoperative wound infection. Our study shows that plating with MIPO is an effective treatment for closed distal one-third tibia fractures, considering union time and complications rate. Younger age promotes early union and functional recovery. Therapeutic, Level II: Prospective.

Endoscopic Thyroid Surgery Through Trans-oral Vestibular Approach (TOVA): A Case Series and Review of Literature

Endoscopic surgery is now standard of care for different Endocrine Disorders; the endoscopic thyroid surgery is becoming more popular and different approaches has been practice by many thyroid surgeon worldwide. Trans-orovestibular approach, based on the principle of natural orifice transluminal surgery is truly scar free thyroid surgery and has minimal dissection. We are presenting here three cases of benign solitary thyroid nodule operated endoscopically through trans-oro-vestibular approach in one male and two female patients. Describedabout the approach, challenges during surgery and outcome. These surgeries documented very few in literatures in live human patients. Transoral endoscopic thyroid surgery through vestibular approach is shortest and direct remote access approach. The need of limited dissection in this approach provides less complication and excellent cosmetic outcome in strictly selected patients.

Tubular microdiscectomy: techniques, complication avoidance, and review of the literature.

OBJECTIVE Microendoscopic discectomy is a minimally invasive surgery technique that was initially described in 1997. It allows surgeons to work with 2 hands through a small-diameter, operating table-mounted tubular retractor, and to apply standard microsurgical techniques in which a small skin incision and minimal muscle dissection are used. Whether the surgeon chooses to use an endoscope or a microscope for visualization, the technique uses the same type of retractor and is thus called tubular microdiscectomy. The goal in this study was to review the current literature, examine the level of evidence supporting tubular microdiscectomy, and describe surgical techniques for complication avoidance. METHODS The authors performed a systematic PubMed review using the terms "microdiscectomy trial," "tubular and open microdiscectomy," "microendoscopic open discectomy," and "minimally invasive open microdiscectomy OR microdiskectomy." Of 317 references, 10 manuscripts were included for analysis based on study design, relevance, and appropriate comparison of open to tubular discectomy. RESULTS Similar and very favorable clinical outcomes can be expected from tubular and standard microdiscectomy. Studies have demonstrated equivalent operating times for both procedures, with lower blood loss and shorter hospital stays associated with tubular microdiscectomy. Furthermore, postoperative analgesic usage has been shown to be significantly lower after tubular microdiscectomy. Overall rates of complications are no different for tubular and standard microdiscectomy. CONCLUSIONS Prospective randomized trials have been used to evaluate outcomes of common minimally invasive lumbar spine procedures. For lumbar discectomy, Level I evidence supports equivalently good outcomes for tubular microdiscectomy compared with standard microdiscectomy. Likewise, Level I data indicate similar safety profiles and may indicate lower blood loss for tubular microdiscectomy. Future studies should examine the comparative value of these procedures.

Buck's fascia repair with glanuloplasty in hypospadias surgery: A simple approach with excellent outcome

Hypospadias is a common problem encountered in surgical practice and its repair is challenging because of various complications. Urethro-cutaneous fistula is the most common postoperative complication (incidence of 0-33%). Different types of intermediate protective layers have been used in attempts to decrease UCF formation; however, no single surgical technique is ideal. The aim of this study was to compare use of dartos fascia and Buck's fascia as intermediate layers in prevention of the formation of UCF. This was a prospective, comparative study conducted over a period of 2 years from January 2014 to December 2015. Patients with primary hypospadias without or with mild ventral penile curvature were included in the study. Patients were categorised into two groups, A and B, with alternate patients assigned to each group. Patients in group A underwent Snodgrass repair with urethroplasty by two-layer subepithelial closure and dartos tissue as an intermediate layer. Patients in group B underwent a urethral repair followed by Buck's fascia repair as intermediate layer and glanuloplasty after excision of a triangular skin strip on either side of the urethral plate. Patients were followed at regular intervals for a minimum of 6 months and complications were noted. Over a period of 2 years, 160 patients were included in the study: 80 patients in group A and 80 patients in group B. The age of patients ranged from 1 year to 4.6 years, with a mean age of 1.8 years. Postoperative complications are listed in the summary table. A protective intermediate layer between the neourethra and the skin can be used to reduce fistula formation. We describe a technique of urethroplasty using Buck's fascia as intermediate layer and glanuloplasty, with excellent results. Buck's fascia over the corpora spongiosum which is deficient ventrally in hypospadias is not completely absent, and can be easily used to cover the neourethra, needs minimal dissection and hence vascularity of tissues is preserved (summary Fig.). We used this Buck's fascia as a second protective layer over the neourethra in an attempt to decrease UCF formation, and compared it with use of dartos fascia. In our study, UCF occurred in 2.5% of patients in the Buck's fascia group and 12.5% of patients in the dartos group, a statistically significant difference. We believe that the native Buck's fascia lateral to spongiosum is a more appropriate, natural, and strong layer to cover the neourethra. Use of Buck's fascia as an intermediate layer along with glanuloplasty is simple and very effective in preventing UCF formation and glanular dehiscence. We recommend the use of Buck's fascia as an intermediate layer to cover the neourethra to reduce incidence of postoperative complications and improve results.

Motor cortex arteriovenous malformation.

Supratentorial arteriovenous malformations in eloquent territories can be difficult to resect. This video presents the treatment of a patient with a symptomatic 3-cm arteriovenous malformation in the left motor strip. At the authors' institution, per the surgeon's discretion, preoperative angiography is performed to evaluate the need for preoperative embolization. Multimodality treatment reduced the microsurgical risk by allowing early occlusion of a draining vein, by decreasing overall intraoperative hemorrhage, and by allowing minimal pial dissection in the deep aspect of the arteriovenous malformation that abutted the corticospinal tract. The choice of embolysate was an additional nuance of the embolization. The video can be found here: https://youtu.be/HWZ0RjgPEXg .

Comparison of Minimally Invasive Strabismus Surgery (MISS) and Conventional Strabismus Surgery Using the Limbal Approach.

To compare minimally invasive strabismus surgery (MISS) with conventional strabismus surgery for horizontal recti in terms of functional outcome and complications. A total of 40 patients requiring surgery for horizontal recti were divided into two groups: those undergoing MISS and those operated on using the conventional limbal technique. In the MISS group, two small keyhole radial cuts were made superior and inferior to the insertion of the muscle margin. Keyhole cut size was almost 1 mm less than the amount of muscle recessed or resected. There were significant differences in conjunctival redness and swelling in both groups on postoperative days 1 and 7 and week 3. However, after the third week, both groups had a similar appearance. Visual acuity was decreased at postoperative day 1 in both groups, but the difference was not significant. No significant differences were found for final alignment, binocular single vision, other visual acuities, refractive changes, or complications. This study shows that this new, small incision, minimal dissection technique is feasible. The MISS technique seems to be superior in the immediate postoperative period because there were fewer conjunctival and eyelid swelling complications. Long-term results did not differ between the two groups. [J Pediatr Ophthalmol Strabismus. 2017;54(4):208-215.].

A novel anterior approach for the fixation of ulnar coronoid process fractures

BackgroundThere is no universally accepted approach to the elbow for the fixation of coronoid process fractures. This study aims to introduce a novel anterior surgical approach for the fixation of the ulnar coronoid fracture, with minimal surgical dissection damage and excellent visualization for reduction and internal fixation. HypothesisThe anterior approach can facilitate satisfactory outcomes for coronoid process fractures. Material and methodsFrom February 2010 to July 2014, 12 patients (8 males and 4 females; range 14–62years; mean age 31years) with a closed fracture of the coronoid process of the ulna were included in this study. According to Adams classification, we included 5 type II, 3 type III, 3 type IV AM, and 1 type IV AL. The fractures were treated operatively via an anterior approach between nerves and blood vessels. The anatomical reduction and fixation with cannulated screws or a mini plate was easily performed. One elbow showed significant joint instability, necessitating, another incision to repair the lateral collateral ligament, and a subsequent operation with a hinged external fixator was required. The remaining patients received a splint for 2 weeks followed by functional exercises. ResultsMean follow-up was 21 months (13–36). Fracture union was achieved in each patient. The arc of elbow flexion and extension were (135±15)°, and forearm pronation/supination were restored to (165±15)°. When compared with the normal side, there was no significant difference in the functional outcome (P>0.05). According to Morrey’ scale, the functional recovery of the injured arms was assessed as excellent in eleven patients and good in one. Mild heterotopic ossification was found in one case, which had not impaired the elbow function. No other complications were noted. ConclusionsThe anterior approach has the benefits of simplicity, safety, minimal invasion, excellent exposure, and satisfactory prognosis for coronoid process fractures. Level of evidenceProspective study, Level IV.

Follow up assessment of patients with humeral bridge plate technique with two year period

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Minimally invasive technique brings together the ease of handling of plates and the relative stability principle of nails. Although there are still only a few studies on this, the initial results have been very satisfactory. The aim of the present study was to report the experience of our shoulder and elbow surgery group relating to treatment of fractures of the humerus, by means of the bridge plate technique, using an anterior route.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; The present study included twenty patients suffering from humerus shaft fracture. The study was done for a total period of two years. The immobilization of the operated shoulder was done till the stitches were removed and average period of the three weeks were kept for immobilization of the shoulder. At the end of the period of immobilization, the patients were asked to perform the active gentle limb range of motion exercises on the basis of their permission of the pain control.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; On the basis of the UCLA score the excellent to good score were found in 16 cases, fair score in rest 4 patients. Less than 5° of valgus angulation intra operatively and on following these patients up, in 4 of the cases the angulation was found to be of acceptable alignment. In the two cases, 5° of varus, angulations was found at the end of one year but it did not affect the functional outcome.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Anterior bridge plating after anterior approach is safe and reproducible option, respects the principles of biological fixation with minimal soft tissue dissection, preserves fracture haematoma and periosteal blood supply, and is more forgiving in comminute fractures of the diaphysis. &lt;/p&gt;

Percutaneous Direct Repair of a Pars Defect Using Intraoperative Computed Tomography Scan

Case report. To describe a young adult with a pars defect undergoing percutaneous direct fixation using intraoperative computed tomography (CT) scan. Direct pars repair has been utilized since the 1960s. There are no reports in the literature describing a percutaneous technique. Using a percutaneous technique under the guide of intraoperative CT scan, a cannulated partially threaded screw was inserted across the pars defect. Surgery was completed without complication and the patient returned to preoperative activity level 3 months post-op. Postoperative CT scan showed a well-healed L4 pars defect. Percutaneous direct pars repair using intraoperative CT scan offers the advantage of minimal soft tissue dissection, thereby reducing blood loss, infection risk, and recovery time. 5.