A Comparison of Exposure Between the Classic and Modified Judet Approaches to the Scapula.

OBJECTIVES: A debate exists over the optimal approach for addressing fractures of the scapula and glenoid. The purpose of this study is to (1) quantify and compare osseous exposure using modified Judet (MJ) and classic Judet (CJ) approaches and (2) assess the change in scapular exposure after triceps release from the inferior glenoid. METHODS: Ten arms on 5 fresh-frozen torsos underwent MJ and CJ approaches. A triceps release was performed following the CJ approach in all specimens. Visual and/or palpable access to relevant surgical landmarks was recorded. Calibrated digital photographs were taken of each approach and analyzed using Image J (NIH, Bethesda, MD) to calculate the surface area of exposed bone. RESULTS: The MJ and CJ approaches exposed 16.8 (±7.58) cm(2) and 98.6 (±25.39) cm(2) of bone, respectively (P < 0.001). The full medial and lateral borders of the scapula were visualized in all approaches with mobilization of the teres minor. Palpable access to the full scapular spine was possible in all cadavers. Although the MJ and CJ approaches only allowed the inferior gleniod neck to be visualized in 1 and 2 specimens, respectively, performing a triceps release provided access to this structure. It also increased the CJ exposure by 12.6 cm(2) (P < 0.001) and allowed palpation of the anterior glenoid margin in 100% of specimens. CONCLUSIONS: In conclusion, the MJ approach allows similar access to landmarks important for reduction and fixation while exposing only 20% of the surface area typically visualized with the CJ approach.

Limited Added Value of the Posterolateral Approach.

BACKGROUND: Posterolateral tibial plateau fractures (AO/OTA 41-B or 41-C) represent a minority of proximal tibia fractures. Numerous surgical approaches have been described, each with unique variations and limitations. The purpose of this study is to quantitatively and qualitatively compare the surface area and structures exposed by four surgical approaches to the posterolateral proximal tibia. METHODS: Four published surgical approaches-direct posterolateral (DPL), transfibular (TF), posteromedial (PM), and anterolateral (AL)-were performed on 10 fresh-frozen cadavers. Once each exposure was obtained, a ruler was placed in the surgical field and calibrated digital images obtained. Overall, 10 bony and soft tissue landmarks were identified and the surgeon's ability to see or touch each landmark was recorded sequentially for each exposure. RESULTS: An average of 3.9 ± 2.7 cm(2) of posterolateral proximal tibial cortex was exposed by the DPL approach with significantly more surface area exposed by the TF, PM, and AL approaches (p < 0.01). The AL and PM approaches revealed a significantly larger area of tibial metaphysis and, when used together, consistently exposed posterior metaphyseal and intra-articular structures. CONCLUSION: A combination of the AL and PM approaches allows comparable surgical exposure to the proximal tibial when compared with two posterolateral approaches. These approaches can be employed together for reduction and fixation of injuries to the posterolateral tibial plateau and allow direct evaluation of the articular surface. Dedicated posterolateral approaches should be reserved for certain clinical situations, including proximal tibiofibular joint fracture or dislocation.