Risk of Radial Nerve Injury in Anterolateral Humeral Shaft Plating.

PURPOSE: The purpose of this study was to evaluate and compare the risk of iatrogenic radial nerve injury between arm positionings of 45° and 60° abduction in anterolateral humeral plating using a 4.5-mm narrow dynamic compression plate. METHODS: Fifty-six humeri of cadavers in the supine position with 45° of arm abduction were exposed through the anterolateral approach. A hypothetical fracture line was marked at the middle of the humerus, and a precontoured ten-hole 4.5-mm narrow dynamic compression plate was applied and fixed to the anterolateral surface. After the fixation, the radial nerve was exposed through a triceps-splitting approach. Screws in contact with or which had penetrated the radial nerve were deemed to be injuries. Then, the screws and plate were removed, the arm changed to the 60° arm abduction position, and the steps of applying the plate and inserting the screws were followed as in the 45° arm abduction step. RESULTS: The screws which could potentially injure the radial nerve were those of the second to sixth screw holes in both the 45° and 60° of arm abduction positions. The incidences of iatrogenic radial nerve injury of the second to sixth screw holes in the 45° position were 5.36%, 39.29%, 80.36%, 60.71%, and 10.71%, respectively, and at the 60° position were 5.36%, 53.57%, 83.93%, 60.71%, and 7.14%, respectively. There were no statistically significant differences in risk of injury between the two positions in all screw holes (all P-values > 0.05). DISCUSSION: In anterolateral humeral shaft fixation, arm abduction position did not affect the risk of iatrogenic radial nerve injury, with the main risk from certain screw holes. The surgeon should be careful in screw insertion, especially at the fourth and fifth screw holes. LEVEL OF EVIDENCE: IV; cadaveric study.

The risk of iatrogenic radial nerve and/or profunda brachii artery injury in anterolateral humeral plating using a 4.5 mm narrow DCP: A cadaveric study.

INTRODUCTION: Fixation of humeral shaft fractures with a plate and screws can endanger the neurovascular structure if proper care is not taken. No studies to our knowledge have studied the risk of iatrogenic radial nerve and/or profunda brachii artery (RNPBA) injury from each screw hole of a 4.5 mm narrow dynamic compression plate (narrow DCP). The purpose of this study is to evaluate the risk of RNPBA injury in anterolateral humeral plating with a 4.5 mm narrow DCP. MATERIAL AND METHODS: 18 humeri of 9 fresh-frozen cadavers in the supine position were exposed via the anterolateral approach with 45 degrees of arm abduction. A hypothetical fracture line was marked at the midpoint of each humerus. A precontoured ten-hole 4.5mm narrow DCP was applied to the anterolateral surface of the humerus using the fracture line to position the center of the plate. All screw holes were drilled and screws inserted. The cadaver was then turned over to the prone position with 45 degrees of arm abduction, and the RNPBA exposed. The holes through in which 100% of the screw had contact with or penetrated the RNPBA were identified as dangerous screw holes, while lesser percentages of contact were defined as risky. RESULTS: The relative distance ratios of the entire humeral length from the lateral epicondyle of the humerus to the 4th, 3rd, 2nd and 1st proximal holes were 0.64, 0.60, 0.56 and 0.52, respectively. The most dangerous screw hole was the 2nd proximal, in which all 18 screws had contacted or penetrated the nerve, followed by the risky 1st (12/18), 3rd (8/18) and 4th (2/18) holes. CONCLUSION: In humeral shaft plating with the 4.5mm narrow DCP using the anterolateral approach, the 2nd proximal screw hole carries the highest risk of iatrogenic radial nerve and/or profunda brachii artery injury.

The Danger Zone for Iatrogenic Neurovascular Injury in All-Inside Lateral Meniscal Repair in Relation to the Popliteal Tendon: An MRI Study.

BACKGROUND: Lateral meniscal repair can endanger the nearby neurovascular structure (peroneal nerve or popliteal artery). To our knowledge, there have been no studies to evaluate the danger zone of all-inside meniscal repair through the anteromedial (AM) and anterolateral (AL) portals in relation to the medial and lateral edges of the popliteal tendon (PT). PURPOSE: To establish the risk of neurovascular injury and the danger zone in repairing the lateral meniscus in relation to the medial and lateral edges of the PT. STUDY DESIGN: Descriptive laboratory study. METHODS: Using axial magnetic resonance imaging (MRI) studies at the level of the lateral meniscus, lines were drawn to simulate a straight, all-inside meniscal repair device, drawn from the AM and AL portals to both the medial and lateral edges of the PT. In cases in which the line passed through the neurovascular structure, a risk of iatrogenic neurovascular injury was deemed, and measurements were made to determine the danger zones of neurovascular injury in relation to the medial or lateral edges of the PT. RESULTS: Axial MRI images of 240 adult patients were reviewed retrospectively. Repairing the body of the lateral meniscus through the AM portal had a greater risk of neurovascular injury than repairs made through the AL portal in relation to the medial edge of the PT (P = .006). The danger zone in repairing the lateral meniscus through the AM portal extended 1.82 ± 1.68 mm laterally from the lateral edge of the PT and 3.13 ± 2.45 mm medially from the medial edge of the PT. Through the AL portal, the danger zone extended 2.81 ± 1.94 mm laterally from the lateral edge of the PT and 1.39 ± 1.53 mm medially from the medial edge of the PT. CONCLUSION: Repairing the lateral meniscus through either the AM or the AL portals in relation to the PT can endanger the peroneal nerve or popliteal artery. CLINICAL RELEVANCE: The surgeon can minimize the risk of iatrogenic neurovascular injury in lateral meniscal repair by avoiding using the all-inside meniscal device in the danger zone area as described in this study.

Danger zone for screw placement in minimally invasive plate osteosynthesis (MIPO) of diaphyseal fractures of forearm: a cadaveric study.

PURPOSES: To identify the anatomical relationship between neurovascular structures and screws and to evaluate the danger zone of screw placement during minimally invasive plate osteosynthesis (MIPO) technique following the volar approach for the radius and the subcutaneous approach for the ulna in diaphyseal forearm fractures. METHODS: Sixteen cadaveric forearms were fixed with a 3.5-mm, 14-hole, locking compression plate (LCP) using the MIPO technique with a volar approach of the radius. Two locking screws were fixed at each end via two separated incisions, and the remaining ten  screws were inserted percutaneously. The same MIPO technique was performed at the ulna with the subcutaneous approach. The forearms were then dissected to identify any damage to or direct contact between the screws and the radial artery (RA), the superficial branch of the radial nerve (SBRN), the posterior interosseous nerve (PIN), and the dorsal cutaneous branch of the ulnar nerve (DCBUN). The distances from the screws to the structures at risk, as well as the radial and ulnar length, were measured. RESULTS: The average lengths of the radius and ulna were 24.74 cm and 25.93 cm, respectively. On the volar aspect of the radius, the danger zones of RA and SRN were between 15.26 and 81.24% of the length of the radius from the radial styloid. The zone of PIN injury at the posterior aspect of the radius was between 41.45 and 81.24% of the length of the radius from the radial styloid. Meanwhile, the danger zone of DCBUN was between 12.21 and 27.23% of the ulnar length from the ulnar styloid. CONCLUSION: Based on our study, the percutaneous screw fixation in MIPO for the treatment of diaphyseal fractures of the forearm is a dangerous procedure, especially for the volar approach of the entire radius and the subcutaneous approach of the distal ulna.

The Transportal Graft Passage in Transtibial Posterior Cruciate Ligament Reconstruction With a Bone-Patellar Tendon-Bone Graft.

Posterior cruciate ligament injury is one of the most common problems in sports medicine. The treatment of choice for this injury is posterior cruciate ligament reconstruction, which improves the biomechanical and clinical stabilities of the knee. There are many graft choices, of which the bone-patellar tendon-bone (BPTB) graft is a popular option. In applying the BPTB graft, most surgeons use the transtibial technique by passing the graft from the tibial tunnel to the femoral tunnel, which is normally performed without problems, but there is a chance of patellar tendon fiber damage because of the sharp turn required from the tibial tunnel to the femoral tunnel. To minimize this risk, herein we propose a transportal graft passage technique with which it is easy to pass the BPTB graft and reduce the risk of graft damage.

Shuttle Suture Technique for Passing Rotator Cuff Suture Through the Plate Eyelet Holes in Proximal Humerus Fixation.

The proximal humerus fracture is common in both adult and elderly patients, with an incidence of approximately 5%, of whom about 1 in 4 is treated operatively. To achieve the healing of the fracture, the operative technique is combined with an internal fixation by a locking plate and tension band rotator cuff sutures by passing the sutures through each eyelet hole of the plate and tightening them. The tension band rotator cuff sutures provide good functional and radiographic outcomes in cases of proximal humerus fracture. The surgeons normally pass a rotator cuff suture through each eyelet hole using a curved needle which can pass only one suture in one eyelet hole. We propose a shuttle suture technique to easily pass the rotator cuff sutures through the eyelet holes of the locking plate.