1
|
Boluda-Mengod J, Olías-López B, Forcada-Calvet P, Martín-Herrero A, Herrera-Pérez M, Álvarez-De-La-Cruz J, Herrera-Rodríguez A, Pais-Brito JL. Modified Oblique Lobenhoffer (MOL) approach for posterolateral and posteromedial column access in tibial plateau fractures: a detailed cadaveric anatomical study. J Orthop Traumatol 2024; 25:27. [PMID: 38769283 PMCID: PMC11106229 DOI: 10.1186/s10195-024-00769-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 05/08/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Tibial plateau fractures involving posteromedial (PM) and posterolateral (PL) columns are complex injuries that require an appropriate approach. The management of the PL column in these cases can be controversial, and limitations using deep posteromedial interval approaches have been referenced. In this paper, a modification of the Lobenhoffer approach, designed to optimize the access to the PL column, is described in detail. The aim of this study was to assess the feasibility of this approach in a cadaveric anatomical study. MATERIALS AND METHODS In total, five fresh-frozen cadaveric specimens were used for detailed anatomical study surrounding the approach. Relationships with cutaneous and deep neurovascular structures were evaluated. The exposure area of the PL and PM columns using this approach was assessed. RESULTS The cadaveric study showed safe and adequate exposure. Oblique skin and fascia incision just medial to the posterior midline was safe to protect the medial sural cutaneous nerve and the small saphenous vein. Elevation of the popliteus and tibialis posterior muscles offered safe protection of the anterior tibial artery and popliteal neurovascular bundle during retractor placement. Adequate full proximal exposure of the PM and PL columns, including the posterolateral lateral (PLL) and posterolateral central (PLC) segments, was obtained in all specimens. CONCLUSIONS The Modified Oblique Lobenhoffer (MOL) approach can be a feasible option to access PL and PM columns in tibial plateau fractures. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Juan Boluda-Mengod
- Orthopaedic Trauma Unit, Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain.
- Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain.
- Faculty of Medicine, Universidad de La Laguna (ULL), Campus de Ofra, S/N, 38071, La Laguna, Tenerife, Spain.
| | - Beatriz Olías-López
- Orthopaedic Trauma Unit, Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
- Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
| | - Pau Forcada-Calvet
- Department of Anatomy, Faculty of Medicine, Universitat de Lleida (UdL), Avinguda de L'Alcalde Rovira Roure, 80, 25198, Lleida, Spain
| | - Azucena Martín-Herrero
- Orthopaedic Trauma Unit, Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
- Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
| | - Mario Herrera-Pérez
- Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
- Faculty of Medicine, Universidad de La Laguna (ULL), Campus de Ofra, S/N, 38071, La Laguna, Tenerife, Spain
| | - Javier Álvarez-De-La-Cruz
- Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
| | - Alejandro Herrera-Rodríguez
- Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
| | - José Luis Pais-Brito
- Department of Orthopaedics, Hospital Universitario Canarias (HUC), Carretera Ofra S/N, 38320, La Laguna, Tenerife, Spain
- Faculty of Medicine, Universidad de La Laguna (ULL), Campus de Ofra, S/N, 38071, La Laguna, Tenerife, Spain
| |
Collapse
|
2
|
Förch S, Reuter J, von der Helm F, Lisitano L, Hartwig C, Sandriesser S, Nuber S, Mayr E. A minimally invasive cerclage of the tibia in a modified Goetze technique: operative technique and first clinical results. Eur J Trauma Emerg Surg 2021; 48:3115-3122. [PMID: 34951655 PMCID: PMC9360161 DOI: 10.1007/s00068-021-01857-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 12/04/2021] [Indexed: 12/02/2022]
Abstract
Introduction In spiral fractures of the tibia, the stability of an osteosynthesis may be significantly increased by additive cerclages and, according to biomechanical studies, be brought into a state that allows immediate full weight bearing. As early as 1933, Goetze described a minimally invasive technique for classic steel cerclages. This technique was modified, so that it can be used for modern cable cerclages in a soft part saving way. Method After closed reduction, an 8 Fr redon drain is first inserted in a minimally invasive manner, strictly along the bone and placed around the tibia via 1 cm incisions on the anterolateral and dorsomedial tibial edges using a curette and a tissue protection sleeve. Via this drain, a 1.7 mm cable cerclage can be inserted. The fracture is then anatomically reduced while simultaneously tightening the cerclage. Subsequently, a nail or a minimally invasive plate osteosynthesis is executed using the standard technique. Using the hospital documentation system, data of patients that were treated with additional cerclages for tibial fractures between 01/01/2014 and 06/30/2020 were subjected to a retrospective analysis for postoperative complications (wound-healing problems, infections and neurovascular injury). Inclusion criteria were: operatively treated tibial fractures, at least one minimally invasive additive cerclage, and age of 18 years or older. Exclusion criteria were: periprosthetic or pathological fractures and the primary need of reconstructive plastic surgery. SPSS was used for statistical analysis. Results 96 tibial shaft spiral fractures were treated with a total of 113 additive cerclages. The foregoing resulted in 10 (10.4%) postoperative wound infections, 7 of which did not involve the cerclage. One lesion of the profundal peroneal nerve was detected, which largely declined after cerclage removal. In 3 cases, local irritation from the cerclage occurred and required removal of material. Conclusion In the described technique, cerclages may be inserted additively at the tibia in a minimally invasive manner and with a few complications, thus significantly increasing the stability of an osteosynthesis. How this ultimately affects fracture healing is the subject of an ongoing study.
Collapse
Affiliation(s)
- Stefan Förch
- Department of Trauma, Orthopaedics, Plastic and Hand Surgery, University Hospital Augsburg, Augsburg, Germany.
| | - Jan Reuter
- Department of Trauma, Orthopaedics, Plastic and Hand Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Franziska von der Helm
- Department of Trauma, Orthopaedics, Plastic and Hand Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Leonard Lisitano
- Department of Trauma, Orthopaedics, Plastic and Hand Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Christopher Hartwig
- Department of Trauma, Orthopaedics, Plastic and Hand Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Sabrina Sandriesser
- Institute for Biomechanics, Berufsgenossenschaftliche Unfallklinik Murnau, Murnau, Germany.,Institute for Biomechanics, Paracelsus Medizinische Privatuniversität Salzburg, Salzburg, Austria
| | - Stefan Nuber
- Department of Trauma, Orthopaedics, Plastic and Hand Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Edgar Mayr
- Department of Trauma, Orthopaedics, Plastic and Hand Surgery, University Hospital Augsburg, Augsburg, Germany
| |
Collapse
|
3
|
Beaton Comulada D, Hernández-Rodríguez S, Rivera L, Zierenberg C, Lojo-Sojo L. Anterior tibialis artery pseudoaneurysm after minimally invasive plate osteosynthesis in the proximal tibia: a case report. J Surg Case Rep 2020; 2020:rjaa168. [PMID: 32864092 DOI: 10.1093/jscr/rjaa168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/05/2020] [Accepted: 05/08/2020] [Indexed: 11/14/2022] Open
Abstract
Tibial plateau fractures are common fractures associated with high-energy trauma. The treatment of these fractures remains a challenge today. Recent management of fractures has moved from open surgery toward minimally invasive surgery to reduce complications and improve functional outcomes. Nevertheless, such a minimalistic approach makes visualization of neurovascular structures difficult, placing them at risk. We report the case of a 39-year-old male who developed a pseudoaneurysm of the anterior tibial artery following minimally invasive plate osteosynthesis of the right proximal tibia. Diagnosis was made through noninvasive duplex ultrasound and was referred to endovascular service. Understanding of the anatomy of the surgical site is vital to minimize complications. In addition, proper postsurgical patient evaluation is important to monitor the insurgence of such complications.
Collapse
Affiliation(s)
- David Beaton Comulada
- Orthopaedic Surgery Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA
| | - Saul Hernández-Rodríguez
- Orthopaedic Surgery Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA
| | - Lenny Rivera
- Orthopaedic Surgery Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA
| | - Charles Zierenberg
- Orthopaedic Surgery Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA
| | - Luis Lojo-Sojo
- Orthopaedic Surgery Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA
| |
Collapse
|
4
|
Lewallen L, Theissen A, Sucato DJ. Partial Tibial Nonunion due to Entrapment of Anterior Tibial Artery: A Case Report. J Orthop Case Rep 2019; 9:51-54. [PMID: 32548004 PMCID: PMC7276617 DOI: 10.13107/jocr.2250-0685.1530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Arterial injury/entrapment is an uncommon sequelae of long bone fractures, particularly in closed injuries. The proximity of the anterior tibial artery to the distal tibia poses a risk of entrapment with a fracture at this level. To the best of our knowledge, this is the first case report of a partial nonunion due to entrapment of the anterior tibial artery in a healed tibia fracture in a pediatric patient. Case Report: We describe a case of a 16-year-old male who presented with leg pain 2 years after a left distal third oblique tibia fracture. The fracture was initially treated non-operatively with excellent alignment. He did well for many months and returned to playing football with some vague persistent discomfort in his leg. Two years after the original injury, he was hit while playing football and started experiencing increasing left leg pain. The subsequent evaluation and findings are outlined here. Conclusion: This is an original case report of an adolescent patient with a partial tibial nonunion requiring surgical intervention. Possible entrapment of neurovascular structures should be considered when managing these patients following injury.
Collapse
Affiliation(s)
- Laura Lewallen
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, 2222 Welborn Street Dallas, TX 75219, USA
| | - Adam Theissen
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, 2222 Welborn Street Dallas, TX 75219, USA
| | - Daniel J Sucato
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, 2222 Welborn Street Dallas, TX 75219, USA
| |
Collapse
|
5
|
Proximity and Risks of the Anterior Neurovascular and Tendinous Anatomy of the Distal Leg Relative to Anteriorly Applied Distal Locking Screws for Tibia Nailing: A Plea for Open Insertion. J Orthop Trauma 2017; 31:375-379. [PMID: 28198793 DOI: 10.1097/bot.0000000000000818] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the proximity and potential risks to distal leg anatomy from anterior to posterior (A-P) applied distal tibia locking screws for tibial nailing. DESIGN Retrospective. SETTING ACS level I trauma center. PATIENTS/PARTICIPANTS Twenty consecutive adult patients undergoing computed tomograms with intravenous contrast (computed tomography angiograms) on uninjured legs. MAIN OUTCOME MEASUREMENTS Simulated 5-mm distal interlocking screws placed in the A-P axis of an ideally placed tibial nail at 10-mm increments from the tibial plafond (10-40 mm) were studied in relation to the distal leg's anterior anatomy. RESULTS All A-P screws (80/80, 100%) impacted the tibialis anterior tendon, extensor hallucis longus tendon, and/or anterior tibial neurovascular (NV) bundle between 10 and 40 mm cranial to the plafond. The NV bundle was impacted in 53% of cases. The medial extent of the tibialis anterior tendon was greatest 10 mm cranial to the plafond and averaged 27 degrees (95% confidence interval, 22-33 degrees) medial to the A-P line. The maximum lateral border of the foot's common extensors, found 40 mm cranial to the plafond, averaged 71 degrees (95% confidence interval, 62-80 degrees) lateral to the A-P line. DISCUSSION The anterior tibial NV bundle and foot and ankle extensor tendons are at high risk from A-P-directed distal locking screws. The tendinous anatomy of the distal leg is at risk between 33 degrees medial and 80 degrees lateral to the A-P axis of a tibial nail. Distal locking screws placed from the A-P direction should be thoughtfully applied and an open approach should be strongly considered.
Collapse
|
6
|
Katsuura Y, Gardner WE. Transection of the anterior tibial artery during minimally invasive plate osteosynthesis of the proximal tibia. Trauma Case Rep 2017; 8:32-35. [PMID: 29644311 PMCID: PMC5883215 DOI: 10.1016/j.tcr.2017.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 01/02/2017] [Indexed: 11/22/2022] Open
Abstract
Minimally invasive plate osteosynthesis (MIPO) techniques have been developed to protect the blood flow to tissues surrounding fractures and reduce the risk of non-union. Typically, MIPO involves the insertion of a plate through a small incision and fixation with percutaneously applied screws targeted fluoroscopically. Here we present a case of a transected anterior tibial artery during routine minimally invasive plate osteosynthesis of a tibial plateau fracture to highlight a rare complication of this type of surgery and discuss relevant anatomical considerations. Level of evidence According to the OCEBM Levels of Evidence Working Group, this study is graded as a Level of Evidence IV.
Collapse
|
7
|
Fanter NJ, Inouye SE, Beiser CW. The risk of iatrogenic injury to anterior tibial artery variations during tibial nail distal interlocking. J Orthop Surg (Hong Kong) 2017; 25:2309499016684471. [PMID: 28176597 DOI: 10.1177/2309499016684471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Tibial intramedullary nailing remains a common tibial fracture fixation method. Tibial nailing indications continue to expand. Neurovascular complications from tibial nailing have been described; however, the proximity of distal tibial locking bolts to the anterior tibial artery (ATA) variants has not. MATERIALS AND METHODS 52 cadaveric legs were dissected identifying three common ATA variants. Each ATA variant received an intraluminal wire to facilitate fluoroscopic identification. Three different intramedullary tibial nails were inserted in each of the three ATA variant specimens. With fluoroscopy, the proximity of the distal locking holes of each tibial nail to the intraluminal wire representing the ATA variant course was measured. RESULTS Of the 40 measurements, the intraluminal wire was directly in the bolt insertional path in 8 of 40 (20%) and within 5 mm in 16 of 40 (40%). All specimens had the wire cross the locking bolt insertional path at least once in each of the nails. The ATA variant taking a more lateral course deep to the extensor digitorum longus and peroneus tertius to overlay the lateral malleolus had the highest occurrence of measurements less than 5 mm. CONCLUSIONS The close proximity of tibial nail distal locking bolt holes to ATA variants presents a risk for iatrogenic vascular injury during insertion. The coronal locking bolts pose the greatest iatrogenic risk to the most laterally positioned ATA variant.
Collapse
Affiliation(s)
- Nathan J Fanter
- 1 Department of Orthopaedic Surgery, Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - Sandra E Inouye
- 2 Department of Anatomy, Midwestern University, Downers Grove, IL, USA
| | - Christopher W Beiser
- 3 Department of Orthopaedic Surgery, St Vincent Mercy Medical Center, Toledo, OH, USA
| |
Collapse
|
8
|
Surface Projection of Interosseous Foramen of the Leg: Cadaver Study. ANATOMY RESEARCH INTERNATIONAL 2016; 2016:6312027. [PMID: 27957341 PMCID: PMC5124443 DOI: 10.1155/2016/6312027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 09/07/2016] [Accepted: 11/01/2016] [Indexed: 11/17/2022]
Abstract
Purpose. This study was conducted to identify the surface projection of the interosseous foramen and associated structures of the proximal leg using the average clinician's thumb width as a quick measurement to assist in differential diagnosis and treatment. Methods. Twelve cadavers (5 males and 7 females, age range = 51-91 years, and mean age = 76.9) were dissected for analysis. Location and size of interosseous foramen, location of anterior tibial artery, location of deep fibular nerve, and corresponding arterial branches were measured and converted into thumb widths. Results. Mean thumb width measured among the cadavers was 17.94 ± 3.9 mm. The interosseous foramen measured was approximately 1 thumb width vertically (18.47 ± 3.0 mm) and 1/2 thumb width horizontally (7.32 ± 2.1 mm) and was located approximately 1 thumb width distally to the tibial tuberosity (20.81 ± 6.8 mm) and 2 thumb widths (37.47 ± 4.7 mm) lateral to the tibial ridge. The anterior tibial artery and deep fibular nerve converged approximately 4 thumb widths (74.31 ± 14.8 mm) inferior to the tibial tuberosity and 2 thumb widths (33.46 ± 4.9 mm) lateral to the tibial ridge. Conclusion. Clinicians may identify anatomical structures of the proximal leg with palpation using the thumb width for measurement.
Collapse
|
9
|
Entrapment of the deep peroneal nerve and anterior tibial vessels by a spiral tibial fracture causing partial non-union: a case report. Skeletal Radiol 2016; 45:551-4. [PMID: 26408316 DOI: 10.1007/s00256-015-2259-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 09/07/2015] [Accepted: 09/14/2015] [Indexed: 02/02/2023]
Abstract
We report a case of entrapment of the deep peroneal nerve as well as the anterior tibial artery and vein by a spiral distal tibial shaft fracture, causing partial non-union. The authors describe the utility of MRI in making the diagnosis of this post-traumatic complication, which may potentially result in a permanent neurovascular deficit and adverse functional outcome if left undetected. The importance of recognizing the distinct possibility of entrapment and injury to the deep peroneal nerve as well as the anterior tibial vessels, when managing a fracture involving the distal third of the tibial shaft is emphasized. Absence of clinical symptoms or signs of neurovascular entrapment should not deter one from performing the relevant investigations to exclude this complication, in particular when surgical fixation is being contemplated, or in the presence of a non-healing fracture.
Collapse
|
10
|
van der Woude JAD, van Heerwaarden RJ, Bleys RLAW. Periosteal vascularization of the distal femur in relation to distal femoral osteotomies: a cadaveric study. J Exp Orthop 2016; 3:6. [PMID: 26915006 PMCID: PMC4735087 DOI: 10.1186/s40634-016-0042-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/26/2016] [Indexed: 11/23/2022] Open
Abstract
Background The purpose of this study was to investigate periosteal vessels location as intra-operative landmarks in distal femoral osteotomies and focused on the branching pattern of the vascular supply of the medial and lateral femoral condyle, its constancy, and the relationship to the height of distal femoral osteotomies. Anastomoses of relevant vessels were studied to analyze the risk of vascular insufficiency after transection of landmark vessels. Methods A human cadaver dissection study on the vascular supply of the medial and lateral side of the distal femur was conducted. Surgical dissection was performed in eight knees in total. Distances between the vascular supply and bony landmarks were calculated. Relation of the vascular structures to the transverse bone cuts of distal femoral osteotomies was described, as well as anastomoses of relevant vessels. Results On the medial side of the distal femur the periosteum was primarily supplied by the descending genicular artery (DGA) in 87.5 % of the specimens. In the absence of the DGA, the superior medial genicular artery was the supplier. Vascularization took place through two constant branches, the upper transverse artery (UTA) and the central longitudinal artery. The UTA originated at a mean distance of 6.9 cm (range 5.9–7.9 cm) above the knee joint line. On the lateral side of the distal femur the superior lateral genicular artery was the main vessel. In all dissected knees it gave off the lateral transverse artery (LTA). The LTA originated at a mean distance of 6.9 cm (range 5.8–7.6 cm) above the knee joint line. Anastomoses between the UTA, LTA and the longitudinal arch of the femoral shaft were found that could prevent vascular insufficiencies after transection of the UTA and LTA. Conclusions The vascular supply of the medial and lateral aspects of the femoral condyle is highly constant. Both the UTA, on the medial side, and the LTA, on the lateral side, can serve as a landmark for orthopedic surgeons in determining the height of the osteotomy cuts in distal femoral osteotomies. Transection of these landmark vessels during the osteotomy will not result in vascular insufficiency because of a collateral supply.
Collapse
Affiliation(s)
- J A D van der Woude
- Department of Orthopedic Surgery, Limb Reconstruction Center, Maartenskliniek Woerden, Polanerbaan 2, 3447, GN, Woerden, The Netherlands
| | - R J van Heerwaarden
- Department of Orthopedic Surgery, Limb Reconstruction Center, Maartenskliniek Woerden, Polanerbaan 2, 3447, GN, Woerden, The Netherlands.
| | - R L A W Bleys
- Department of Anatomy, University Medical Center, Utrecht, The Netherlands
| |
Collapse
|
11
|
Liu GY, Xiao BP, Luo CF, Zhuang YQ, Xu RM, Ma WH. Results of a modified posterolateral approach for the isolated posterolateral tibial plateau fracture. Indian J Orthop 2016; 50:117-22. [PMID: 27053799 PMCID: PMC4800952 DOI: 10.4103/0019-5413.177578] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND There are few posterolateral approaches that do not require the common peroneal nerve (CPN) dissection. With the nerve exposure, it would pose a great challenge and sometimes iatrogenic damage over the surgical course. The purpose was to present a case series of patients with posterolateral tibial plateau fractures treated by direct exposure and plate fixation through a modified posterolateral approach without exposing the common peroneal nerve (CPN). MATERIALS AND METHODS 9 consecutive cases of isolated posterior fractures of the posterolateral tibial plateau were operated by open reduction and plate fixation through the modified posterolateral approach without exposing the CPN between June 2009 and January 2012. Articular reduction quality was assessment according to the immediate postoperative radiographs. At 24 month followup, all patients had radiographs and were asked to complete a validated outcome measure and the modified Hospital for Special Surgery (HSS) Knee Scale. RESULTS All patients were followedup, with a mean period of 29 months (range 25-40 months). Bony union was achieved in all patients. In six cases, the reduction was graded as best and in three cases the reduction was graded as middle according to the immediate postoperative radiographs by the rank order system. The average range of motion arc was 127° (range 110°-134°) and the mean postoperative HSS was 93 (range 85-97) at 24 months followup. None of the patients sustained neurovascular complication. CONCLUSIONS The modified posterolateral approach through a long skin incision without exposing the CPN could help to expand the surgical options for an optimal treatment of this kind of fracture, and plating of posterolateral tibial plateau fractures would result in restoration and maintenance of alignment. This approach demands precise knowledge of the anatomic structures of this region.
Collapse
Affiliation(s)
- Guan-Yi Liu
- Department of Orthopaedic Surgery, Ningbo 6th Hospital, Ningbo, Zhejiang 315040, China
| | - Bai-Ping Xiao
- Department of Orthopaedic Surgery, Ningbo 6th Hospital, Ningbo, Zhejiang 315040, China
| | - Cong-Feng Luo
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Yun-Qiang Zhuang
- Department of Orthopaedic Surgery, Ningbo 6th Hospital, Ningbo, Zhejiang 315040, China,Address for correspondence: Dr. Yun-qiang Zhuang, 1059, Zhongshan East Road, Department of Orthopaedic Surgery, Ningbo 6th Hospital, Ningbo, Zhejiang 315040, People's Republic of China. E-mail:
| | - Rong-Ming Xu
- Department of Orthopaedic Surgery, Ningbo 6th Hospital, Ningbo, Zhejiang 315040, China
| | - Wei-Hu Ma
- Department of Orthopaedic Surgery, Ningbo 6th Hospital, Ningbo, Zhejiang 315040, China
| |
Collapse
|
12
|
Burkhart TA, Asa B, Payne MWC, Johnson M, Dunning CE, Wilson TD. Anatomy of the proximal tibiofibular joint and interosseous membrane, and their contributions to joint kinematics in below-knee amputations. J Anat 2014; 226:143-9. [PMID: 25469567 DOI: 10.1111/joa.12263] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2014] [Indexed: 11/29/2022] Open
Abstract
A result of below-knee amputations (BKAs) is abnormal motion that occurs about the proximal tibiofibular joint (PTFJ). While it is known that joint morphology may play a role in joint kinematics, this is not well understood with respect to the PTFJ. Therefore, the purposes of this study were: (i) to characterize the anatomy of the PTFJ and statistically analyze the relationships within the joint; and (ii) to determine the relationships between the PTFJ characteristics and the degree of movement of the fibula in BKAs. The PTFJ was characterized in 40 embalmed specimens disarticulated at the knee, and amputated through the mid-tibia and fibula. Four metrics were measured: inclination angle (angle at which the fibula articulates with the tibia); tibial and fibular articular surface areas; articular surface concavity and shape. The specimens were mechanically tested by applying a load through the biceps femoris tendon, and the degree of motion about the tibiofibular joint was measured. Regression analyses were performed to determine the relationships between the different PTFJ characteristics and the magnitude of fibular abduction. Finally, Pearson correlation analyses were performed on inclination angle and surface area vs. fibular kinematics. The inclination angle measured on the fibula was significantly greater than that measured on the tibia. This difference may be attributed to differences in concavity of the tibial and fibular surfaces. Surface area measured on the tibia and fibula was not statistically different. The inclination angle was not statistically correlated to surface area. However, when correlating fibular kinematics in BKAs, inclination angle was positively correlated to the degree of fibular abduction, whereas surface area was negatively correlated. The characteristics of the PTFJ dictate the amount of fibular movement, specifically, fibular abduction in BKAs. Predicting BKA complications based on PTFJ characteristics can lead to recommendations in treatment.
Collapse
Affiliation(s)
- Timothy A Burkhart
- Department of Mechanical and Materials Engineering, Western University, London, ON, Canada
| | | | | | | | | | | |
Collapse
|
13
|
|
14
|
Ferrel JR, Davis RL, Witte ZW, Feibel JB. Anterior Tibial Artery Injury Following Tibiotalocalcaneal Retrograde Intramedullary Nailing: A Case Report. JBJS Case Connect 2014; 4:e104. [PMID: 29252772 DOI: 10.2106/jbjs.cc.m.00281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We report the case of a patient who sustained injury to the anterior tibial artery during tibiotalocalcaneal retrograde nailing and developed an acutely ischemic foot. CONCLUSION Vascular injury during tibiotalocalcaneal arthrodesis with retrograde nailing is a rare but serious complication. While retrograde tibiotalocalcaneal arthrodesis nailing for end-stage ankle and subtalar arthritis has shown encouraging results, a high index of suspicion for postoperative complications is necessary in patients with risk factors for poor posterior collateral circulation.
Collapse
Affiliation(s)
- Jason R Ferrel
- Department of Orthopedic Surgery, Mount Carmel Health System, 793 West State Street, Columbus, OH 43230.
| | - Richard L Davis
- Department of Orthopedic Surgery, Mount Carmel Health System, 793 West State Street, Columbus, OH 43230.
| | - Zackary W Witte
- Department of Orthopedic Surgery, AB Chandler Medical Center, University of Kentucky, 800 Rose Street, Lexington, KY 40536
| | - Jonathan B Feibel
- Department of Orthopedic Surgery, Mount Carmel Health System, 793 West State Street, Columbus, OH 43230.
| |
Collapse
|
15
|
Lowe JA, Rister J, Eastman J, Freind J. Injury to neurovascular structures with insertion of traction pins around the knee. J Orthop 2014; 12:S79-82. [PMID: 26719614 DOI: 10.1016/j.jor.2014.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 04/15/2014] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE Identify risk to neurovascular structures around the knee with placement of skeletal traction pins. METHODS Kirchner wires were inserted into cadaveric limbs followed by layer dissecting of each leg. Correlations between weight, height, BMI, and distance were determined after calculating the average distance with deviation between each anatomic structure and the Kirschner wire. CONCLUSION Insertion of traction pins around the knee did not result in injury to neurovascular structures. Both weight and BMI positively correlated with distance between implants and neurovascular structure. Data collected suggests similar trends for all other anatomic structures.
Collapse
Affiliation(s)
- Jason A Lowe
- Jason Lowe and Jamie Rister Department of Orthopaedics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jamie Rister
- Jonathan Eastman Department of Orthopaedics, University of California at Davis Medical Center, Sacramento, California, USA
| | - Jonathan Eastman
- Jonathan Friend Department of Anatomy, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jonathan Freind
- Jonathan Eastman Department of Orthopaedics, University of California at Davis Medical Center, Sacramento, California, USA
| |
Collapse
|
16
|
In vitro biomechanical evaluation of fibular movement in below knee amputations. Clin Biomech (Bristol, Avon) 2014; 29:551-5. [PMID: 24726778 DOI: 10.1016/j.clinbiomech.2014.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 03/10/2014] [Accepted: 03/18/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND In below knee amputations, the remaining fibula may be subjected to abnormal forces resulting in problematic tibia-fibular movement. The purpose of the current work was to examine the effect of amputation length and interosseous membrane integrity on fibular movement when subjected to unopposed biceps femoris muscle tension. METHODS Forty embalmed cadaveric specimens were subjected to a below knee amputation with fibular lengths of 5cm and 10cm. A subset of specimens (n=20) was further modified by sectioning the interosseous membrane. The tibias were mounted in a material testing machine and the biceps femoris was sutured to the actuator. Position-controlled tensile cyclic loading was applied (initial displacement of 4mm for 100 cycles at 0.5Hz with increments of 2mm up to 20mm) to the biceps femoris. The kinematics of the fibula with respect to the tibia was analyzed for three degrees of freedom: abduction, flexion and rotation. FINDINGS There was no interaction between below knee amputation length and interosseous membrane integrity on the degree of abduction, flexion, and rotation. However, below knee amputations with a sectioned interosseous membrane are abducted to a significantly greater degree than intact interosseous membrane below knee amputations. Furthermore, although embalmed specimens were tested here, embalming was consistent across specimens and it is unlikely that this confounded the findings. INTERPRETATION Understanding the cause of fibular abduction in below knee amputation will lead to recommendations for preventive surgical and rehabilitative measures.
Collapse
|
17
|
Gary JL, Sciadini MF. Injury to the anterior tibial system during percutaneous plating of a proximal tibial fracture. Orthopedics 2012; 35:e1125-8. [PMID: 22784915 DOI: 10.3928/01477447-20120621-37] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Minimally invasive osteosynthesis of proximal tibial fractures has grown in popularity in recent years. This article describes a patient with a Schatzker type VI proximal tibial fracture (AO/OTA type 41.C3) and previous compartment syndrome treated with definitive fixation 8 weeks after initial injury with a precontoured proximal tibial plate and a distal targeting device. Brisk bleeding occurred during percutaneous insertion of a cortical screw at the midshaft of the tibia. Surgical exploration revealed sidewall tearing of the anterior tibial artery and vein, which were clipped at the screw insertion site. After the bleeding was controlled, the patient had a strong palpable posterior tibial pulse with no palpable dorsalis pedis pulse, and the foot remained well perfused. Function of the deep peroneal nerve was normal postoperatively. Previous concerns regarding the percutaneous treatment of proximal tibial fractures have focused on the risks of damage to the superficial peroneal nerve from distal screws. Based on cadaveric studies, percutaneously and laterally based screw placement in the distal tibial metaphysis threatens injury to the anterior tibial system. However, with alterations to the normal anatomy caused by severe trauma, previously described safe zones may be changed and neurovascular structures may be exposed to risk in locations that were previously thought safe.
Collapse
Affiliation(s)
- Joshua L Gary
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 South Greene St, Room T3R, Baltimore, MD 21201, USA
| | | |
Collapse
|
18
|
Hébert-Blouin MN, Pirola E, Amrami KK, Wang H, Desy NM, Spinner RJ. An anatomically based imaging sign to detect adventitial cyst derived from the superior tibiofibular joint. Clin Anat 2011; 24:893-902. [DOI: 10.1002/ca.21190] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 03/05/2011] [Accepted: 03/07/2011] [Indexed: 11/05/2022]
|
19
|
Cho SH, Kim DH, Jeong ST, Park HB, Hwang SC, Shin TB, Shin HS. Therapeutic Embolization for Pseudoaneurysm of the Anterior Tibial Artery after Tibial Nailing. ACTA ACUST UNITED AC 2010. [DOI: 10.4055/jkoa.2010.45.3.238] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Se-Hyun Cho
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine, Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Dong-Hee Kim
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine, Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Soon-Taek Jeong
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine, Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Hyung-Bin Park
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine, Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sun-Chul Hwang
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine, Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Tae-Beom Shin
- Department of Radiology, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Hyuck-Soo Shin
- Department of Orthopedic Surgery, Research Institute of Clinical Medicine, Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Korea
| |
Collapse
|
20
|
Miki RA, Lawrence JP, Gillon TJ, Lawrence BD, Zell RA. Anterior tibial artery and deep peroneal nerve entrapment in spiral distal third tibia fracture. Orthopedics 2008; 31:orthopedics.32935. [PMID: 19226054 DOI: 10.3928/01477447-20081201-13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The rate of injury to arterial structures following long bone injuries is low. The rate in tibial diaphyseal fractures is similarly low. This rate increases with open fractures, likely reflective of the higher energy nature of open fractures. The possibility of iatrogenic injury to neurovascular structures during fracture fixation is more concerning. Consequently, the clinician must be aware of the location of neurovascular structures and the possible distortion of the normal anatomy when treating fractures. The anterior tibial artery is in proximity to the distal tibia. Typically, the neurovascular bundle lies directly on the anterolateral tibia between the tibialis anterior and the extensor hallucis longus in the distal third of the tibia. After fracture, this normal relationship may be disrupted.
Collapse
Affiliation(s)
- Roberto Augusto Miki
- University of Miami, Miller School of Medicine, Department of Orthopedics, 900 NW 17th St, Miami, FL 33136, USA
| | | | | | | | | |
Collapse
|
21
|
Labler L, Wedler V, Mica L, Trentz O. [Entrapment of the anterior tibial artery in a distal tibial fracture after intramedullary nailing]. Unfallchirurg 2006; 109:156-9. [PMID: 16391935 DOI: 10.1007/s00113-005-1033-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We present a patient with a closed displaced distal tibia fracture with entrapment of the anterior tibial vessels in the fracture after tibial nailing. This complication was initially not recognised. After several debridements of the forefoot on the same side due to open metatarsal fractures and severe soft tissue injury, a free latissimus dorsi flap was used for covering the dorsum pedis. Preoperative angiography showed occlusion of the anterior tibial artery at the fracture line which was interpreted as a secondary occlusion due to an intima lesion of the vessel after injury. The entrapment in the fracture line was recognised intra-operatively during the preparation of the anterior tibial vessel.
Collapse
Affiliation(s)
- L Labler
- Departement Chirurgie, Universitätsspital Zürich, Schweiz.
| | | | | | | |
Collapse
|
22
|
Bono CM, Sirkin M, Sabatino CT, Reilly MC, Tarkin I, Behrens FF. Neurovascular and tendinous damage with placement of anteroposterior distal locking bolts in the tibia. J Orthop Trauma 2003; 17:677-82. [PMID: 14600566 DOI: 10.1097/00005131-200311000-00003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the proximity of anteroposterior locking bolts inserted into the distal metaphyseal tibia to nearby neural, vascular, and tendinous structures. DESIGN A cadaver study. SETTING University trauma center. METHODS Sixteen legs (8 matched pairs) were nailed in either neutral (Group 1) or 10 degrees of internal rotation (Group 2) and locked using one anteroposterior bolt. The anterior tibial and extensor hallucis longus tendons and neurovascular bundle were identified, and their respective locations in relation to the bolt head were measured. Average distances were calculated for each structure in each group and statistically compared. Damage to any structure was noted at final dissection. RESULTS Average distances from the bolt head to the neurovascular bundle, extensor hallucis longus, and anterior tibial tendons were 0.6, 0.5, and 1.6 mm, respectively, for Group 1 and 1.0, 1.5, and 1.8 mm, respectively, for Group 2 legs. Statistical comparison of distances for each anatomic entity for the two groups revealed no detectable significant differences (P = 0.7, 0.4, 0.7, respectively). For all specimens, the rate of nerve, artery, extensor hallucis longus, and anterior tibial tendon injury was 25%, 19%, 0%, and 6%, respectively. However, the incidence of at least one structure damage in Group 1 legs was 63% versus 12% in Group 2 specimens (P = 0.2). CONCLUSION Anteroposterior distal tibial locking bolts lie in close proximity to the neurovascular bundle. With standard percutaneous techniques, these structures can be damaged. Although 10 degrees of internal rotation does not statistically affect the measured distance of the locking bolt to the neurovascular bundle, it appears to decrease the incidence of neurovascular injury. This difference may best be explained by the necessary path the drill bit must take through the soft tissues to reach the underlying bone. Regardless of nail orientation, larger incisions with careful dissection and clear visualization of the anatomy are recommended to help prevent this complication.
Collapse
Affiliation(s)
- Christopher M Bono
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, University, Boston, Massachusetts 02118, USA.
| | | | | | | | | | | |
Collapse
|