Lateral para-olecranon approach: surgical guide and anatomical considerations to the anconeus branch: is there a nerve-free zone?

PURPOSE: In the last decades, total elbow arthroplasty, elbow osteosynthesis and revision surgery have been more popularized. The study aimed to assess the course of the anconeus branch of the radial nerve in relation to two variations of the lateral para-olecranon approach, considering iatrogenic nerve injuries. METHODS: The study consisted of 120 upper extremities from 60 Thiel-embalmed human specimens. Two randomized versions of the lateral para-olecranon approach (centrally orientated: P1 and laterally orientated: P2) were performed. The olecranon and the intersection points to the anconeus branch of the radial nerve were determined as anatomical landmarks. The measurements were assessed by two independent observers. Differences were analyzed using the Student's t test; associations were computed with the Pearson correlation (r). An alpha of 0.05 (p) and a confidence interval of 95% were set. RESULTS: The intersection points averaged 12.3 cm (SD 1.8, range 8.2-16.8) for P1 versus 5.5 cm (SD 1.4, range 3.0-9.2) for P2 (p ≤ 0.001). Statistically significantly higher values for male and longer humeral specimens were revealed (all values: p < 0.05). Comparison of left and right sides yielded no difference. Excellent inter-rater agreements were found (ICC = 0.902, range 0.860-0.921). A correlation was evaluated between the humeral length and the distances in both approaches (P1: r = 0.550, p < 0.001, P2: r = 0.669, p < 0.001). CONCLUSION: The data presented here allow preservation of the anconeus branch. The P1 forms a potential advantage by owing a broader safe zone. Using the centrally orientated approach seems to provide adequate nerve protection during surgery for one of the motor branches for extension of the elbow joint and might result in improved postoperative benefits.

Direct anterior versus antero-lateral approach in hip joint hemiarthroplasty.

BACKGROUND: Femoral neck fractures are common injuries in the elderly and represent a major source of morbidity and mortality. Due to the benefits, bipolar hip hemiarthroplasty (BHH) is a popular method to treat. The purpose of this study is to evaluate the functional and radiographic outcomes for BHH comparing the direct anterior approach (DAA) to the anterolateral approach (ALA) to the hip joint. METHODS: We used a prospective, randomized observational study design, where we enrolled 83 patients at a level-I-trauma center presenting with indication for BHH. We followed up the participants at defined intervals over a period of 1 year. The follow-up examinations were carried out at defined time intervals for a period of 1 year. Calculations were performed with Statistical Package for Social Sciences (SPSS) 21.0. RESULTS: Concerning postoperative pain sensation, the anterior group had statistically significantly decreased pain levels at one (p = 0.02), seven (p = 0.04) and 14 days (p = 0.02) following the intervention when compared to the ALA sample. The postoperative modified Barthel-Index showed a statistically significant difference on the first postoperative day at the anterior group. CONCLUSION: Although we compared two minimally invasive approaches, our results shows a statistically significant difference in pain intensity and mobility for the early postoperative period using the direct anterior approach.

Dorsal minimally invasive plate osteosynthesis of the humerus: Feasibility and risk of nervous injury of a modified technique in an anatomical study.

BACKGROUND: The aim of the study was to design a convenient technique for dorsal minimally invasive plate osteosynthesis (MIPO) of extra-articular fractures of both distal thirds of the humeral shaft as well as to characterise the course and proximity of the radial nerve (RN) and the axillary nerve (AN). METHODS: The collective consisted of 20 upper extremities of human adult body donors. A 3.5 mm Locking Compression Plate (LCP), an extra-articular distal humerus plate was inserted through a MIPO approach including two incisions. The primary incision was performed 5 cm in lenght on the dorsal side of the lateral epicondyle. An additional 5 cm incision was conducted distal to the humeral deltoid muscle insertion and the RN was depicted. The longest suitable plate was advanced under nerve protection starting distally and fixed by locking screws. A third incision with a length of 5 cm was made beginning at the distal border of the deltoid muscle, and a muscle split was performed to dissect the AN. The respective plate holes, where the AN and RN were located and the distances between the nerves were examined. RESULTS: The RN was mostly (30%) localised on holes 6 and 7 (starting distally). The AN laid directly on the plate in 65% and on the most proximal plate hole in 12 cases, but was never situated underneath the plate. The distance between the AN and RN was at mean 93.5 mm. CONCLUSIONS: MIPO via a dorsal method proves to be a noteworthy technique and valuable option as indicated by our results. This 5-5-(5) concept may be performed as a two-incision or three-incision technique for extra-articular fractures of both distal thirds of the humerus.

Mini-open carpal tunnel release: technique, feasibility and clinical outcome compared to the conventional procedure in a long-term follow-up.

We sought to evaluate the findings of our anatomically landmarks based mini-open procedure (MCTR) through a palmar approach and to compare its outcome and practicability to the conventional method (OCTR). The study consisted of 100 matched patients (n = 50 MCTR, n = 50 OCTR) with a minimum follow-up of three years. The outcome was characterized via the Disabilities of Arm, Shoulder and Hand Score (DASH), Symptom Severity Scale (SSS), Functional Status Scale (FSC), and Visual Analogue Scale (VAS). All adverse events were observed. An alpha of 0.05 and a confidence level of 95% were set for statistical analyses. Both techniques showed comparable functional results in a long-term period (mean follow-up MCTR: 60 months and OCTR: 54 months). MCTR versus OCTR at mean: DASH: 4.6/8.3 (p = 0.398), SSS: 1.3/1.2 (p = 0.534), FSC: 1.3/1.2 (p = 0.617), VAS: 0.4/0.7 (p = 0.246). The MCTR convinced through a lower rate of scar sensibility (MCTR: 0% vs. OCTR: 12%, 0/50 vs. 6/50; p = 0.007) and pillar pain, as well as a shortened recovery period and surgical time relative to the OCTR. Low complication rates were observed in both groups, no recurrences had to be documented. The MCTR procedure revealed a similar good clinical outcome as the conventional technique. MCTR is a minimally-invasive, reliable, fast and simple procedure with an obvious benefit regarding scar sensibility.

Definition of a Risk Zone for the Axillary Nerve Based on Superficial Landmarks.

BACKGROUND: The aim of this study was to investigate the axillary nerve's location along superficial anatomical landmarks, and to define a convenient risk zone. METHODS: A total of 123 upper extremities were evaluated. After dissection of the axillary nerve, the vertical distance between the upper border of the anterolateral edge of the acromion and the proximal border of the nerve was measured. Furthermore, the interval between the proximal border and the distal border of the axillary nerve's branches was evaluated. The interval between the distal border of the branches and the most distal part of the lateral humeral epicondyle was measured. The distance between the anterolateral edge of the acromion and the lateral humeral epicondyle was evaluated. Measurements were expressed as proportions with respect to the distance between the acromion and the lateral humeral epicondyle. RESULTS: The distance between the acromion and the proximal border of the axillary nerve's branches was at a height of 10 percent of the distance between the acromion and the lateral humeral epicondyle, starting from the acromion (90 percent when starting from the lateral humeral epicondyle). The interval between the proximal and distal margins of the axillary nerve's branches was between 10 percent and 30 to 35 percent of this interval, starting from the acromion (65 to 70 percent when starting from the lateral humeral epicondyle). CONCLUSIONS: The authors were able to locate the branches of the axillary nerve at an interval between 10 and 35 percent of the distance between the acromion and the lateral humeral epicondyle, starting from the acromion. This makes the proximal third of this distance an easily applicable risk zone during shoulder surgery.

Optimal pin position in supraacetabular external fixation.

BACKGROUND: This study focuses on (i) the length of the intraosseous part of the supraacetabular pin using the insertion technique from the spina iliaca anterior inferior to the cortical part of the incisura ischiadica major, (ii) the angle of insertion of the supraacetabular pin in the transversal plane and (iii) gender-specific differences of the measured results. METHODS: Images of uninjured pelves from 49 patients (64-line computed tomography scanner) were evaluated, and virtual external fixator pins were positioned using a three-dimensional reconstructions of computed tomography scans. The length of the pins and the insertion angle were investigated. Descriptive statistics were used, and gender-specific differences were calculated. A P-value of <0.05 was considered statistically significant. RESULTS: The results showed significant differences between male and female pelves concerning both pin length and insertion angel. For male pelves, the mean screw length was 82.7 mm (SD 5.1; range 72.9-94.3). For females, this was statistically significantly shorter (P ≤ 0.001), with an average of 74.1 mm (SD 5.0; range 63.1-81.9). In the male subgroup, the insertion angle was a mean of 22.6° (SD 3.4; range 12.4-31.8), and the female pelves had an average angle of 19.7° (SD 4.0; range 11.7-24.5). These values differed statistically significantly (P = 0.0032). CONCLUSION: Based on our measurements, we can confirm that both the length of the Schanz screws and the angle of insertion for the supraacetabular external fixator show a statistically significant difference between males and females.

Patellar Tendon Length is Associated with Lower Extremity Length but Not Gender.

BACKGROUND: The aim of this study was to evaluate the patellar tendon length (PTL) with focus on gender differences and possible correlations with the total leg length (TLL) and the long bones of the lower extremity. MATERIALS AND METHODS: The sample involved 50 paired lower extremities from human adult cadavers. The TLL was measured between the medial malleolus and the apex of the greater trochanter. The femoral length (FL) was evaluated as the interval between the latter and the distal margin of the lateral epicondyle of the femur and the tibial length (TL) from the distal apex of the medial malleolus to the proximal border of the medial condyle of the tibia. The PTL was measured from the apex of the patella to its proximal insertion point at the tibial tuberosity. RESULTS: The PTL was at a mean length of 4.29 ± 0.49 cm (right side) and 4.20 ± 0.55 cm (left side) in females and 4.42 ± 0.53 cm (right) and 4.32 ± 0.55 cm (left) in males. There were no differences regarding gender (p = .412). The left PTL was significantly shorter in both sexes (p = .022). The PTL correlated positively with FL, TL, and TLL in both sexes and sides. CONCLUSION: PTL correlates significantly positively with size without gender differences.

Correlation Analysis of the Anterolateral Ligament Length with the Anterior Cruciate Ligament Length and Patient's Height: An Anatomical Study.

The aim of this study was to evaluate the anatomical characteristics of the anterolateral ligament of the knee (ALL) with the focus on potential gender differences. The ALL length and the length of the lateral collateral ligament (LCL) were taken in extension. The length of the anterior cruciate ligament (ACL) was measured at 120° flexion. We correlated the length of the ALL with the LCL and ACL with respect to potential gender differences. The ALL was significantly (p = 0.044) shorter in females (mean length: 32.8 mm) compared to males (mean length: 35.7 mm). The length of the ALL correlated significantly positively with the lengths of the ACL (p < 0.001) and the LCL (p < 0.001). There was no significant correlation with the total leg length (TLL) (p = 0.888) and body size (p = 0.046). Furthermore, TLL and donor size correlated significantly positively (p < 0.001). The ALL length correlated significantly positively with the ACL and the LCL length. The ALL length did neither correlate with the TLL nor the donor size. This fact may contribute to planning of graft harvesting in the upcoming techniques for ALL reconstruction.

Avoiding radial nerve palsy in proximal radius shaft plating - a cadaver study.

BACKGROUND: Opinions vary concerning the position of forearm rotation during detachment of the supinator in radial nerve palsy Henry's and Thompson's approaches. PURPOSE: To define the optimal forearm position for a safe detachment of the supinator during these approaches and to clarify their close relationship to the posterior interosseous nerve (PIN). METHODS: The study sample comprised 90 upper extremities of 45 human adult cadavers, embalmed using Thiel's method. After detection of the radial nerve in the interval between the brachialis and brachioradialis, its pathway was traced to the Arcade of Frohse (AF). Measurements involved the distance between the AFand the radial border of the distal biceps tendon (DBT) in pronation and supination, the interval between the AF and the radiocapitellar joint space (RCJS) in supination and the radial length (RL). RESULTS: Distances between the DBT and the AF were significantly shorter during pronation (right side: 14.1 ± 3.4mm; left side: 13.5 ± 3.2mm) compared with supination (right side: 20.5 ± 3.6mm; left side: 19.8 ± 3.5mm) for both right and left extremities. The mean interval between the AF and the centre of the RCJS was 25.2 ± 5.9mm for the right side and 24.7 ± 5.6mm for the left side, which correlated positively with the RL. CONCLUSION: These results indicate a safe detachment of the supinator from the radius with the forearm placed in supination during both Henry's and Thompson's approaches.

Comparison of volar and dorsal plate osteosynthesis for radial shaft fractures: an anatomical pilot study.

BACKGROUND: No publication has yet described the interface between the radius and the plate in various positions. Neither clinical examination nor assessment of fracture radiographs provides information about the anatomy of the radius before injury. PURPOSE: We investigated radius anatomy to analyse dorsal and volar plate-to-bone fit for radial shaft fracture management. METHODS: We examined 20 specimens from human adult cadavers. An 8-hole 3.5-mm titanium locking plate was used at three different positions on the dorsal and the volar side of the bone. The space between the well-positioned plate and the radial shaft was attained for each hole of the plate. RESULTS: The average space between the midshaft radial cortex and the plate holes for all positions was 0.69mm (range: 0.0mmto 2.38mm). The greatest mean distance between the plate and the radial cortex was measured at the volar mid-diaphyseal position of the plate with an average of 1.31mm. CONCLUSION: This incongruence between the radial cortex at the volar diaphysis and the plate should be considered when applying plates to this position of the radius. The results of this cadaver study indicate that radius plate osteosynthesis should preferably be done from the dorsal side.

Scaphoid screw placement under minimal radiation exposure.

BACKGROUND: Percutaneous scaphoid fixation through either a volar or dorsal approach has the advantage of minor soft tissue damage compared with ORIF, and faster fracture union compared with conservative treatment. However, this technique demands highly intraoperative reliance on X-ray control, including increased radiation exposure and all associated side effects. PURPOSE: To test the possibility and efficacy of volar percutaneous scaphoid screw placement under minimalradiation exposure. METHODS: The sample included 20 hands (seven left, 13 right) from human adult cadavers. For this study, the utilised wrists were assumed to have non-displaced scaphoid fractures. Using a percutaneous approach, a 2-mm Kirschner wire (K-wire) was advanced to the distal pole of the scaphoid and placed in a 45° horizontal and vertical angle under monitoring with the C-arm. The K-wire was inserted blindly alongside the estimated length of the scaphoid. Following K-wire insertion, four X-rays were taken to depict K-wire positioning and to assess positioning alongside the axis of the scaphoid and K-wire protrusion. The rating scale comprised 1 (good), 2 (moderate) or 3 (poor). RESULTS: All tested radiographic views were evaluated with a median of 2 points (moderate position) regardingplacement alongside the scaphoid axis. CONCLUSION: Our results indicate that percutaneous scaphoid fixation with the guide wire placed in a 45° horizontal and vertical angle enables primary moderate positioning, which may lead to quicker adjustment to the ideal position and a decrease of radiation exposure.

Description of 'Ponticular Artery' at the atlas: an anatomical case report with potential clinical relevance

The atlas plays an important role as a characteristic connective bony element between the cervical spine and the occiput. Its details and variations are of special interest to neurosurgeons - e.g., in a far lateral transcondylar approach. We investigated 121 atlases and their variations. During our investigations, we periodically found atlases with a complete arcuate foramen (canal for vertebral artery) and an additional foramen in the bony roof of a complete arcuate foramen. Different structures passing through this additional foramen are described in the literature, but no artery. We found a macroscopically clear verified artery in a 67-year-old male cadaver passing through the foramen in the bony roof of a complete arcuate foramen. Such an artery is of clinical importance to neurosurgeons or musculoskeletal surgeons, but unmentioned in literature until now. A potential name for this artery could be 'ponticular artery'. The discovered artery is most likely a branch to the neck muscles. The knowledge of a possible existence of such an artery is necessary to prevent complications during surgical procedures in the region of the upper cervical spine. Furthermore, the special course of this artery could be the reason for atrophy and imbalance of deep cervical muscles and consequently headaches

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