Safe zone for the approach to the posterior sole (heel): a cadaver study.

BACKGROUND: Surgical approach to the posterior sole or heel is commonly used for various orthopedic procedures. The objective of this cadaver study was to identify the risks to local neurovascular structures using an approach to the posterior sole or heel and to define the safe zone for minimizing the risk of injury. METHODS: Eleven fresh-frozen cadaver limbs were used. A layered dissection was performed from skin to neurovascular structures. Distances of the entire foot length, the lateral plantar nerve from the heel, the calcaneocuboid joint from the heel, the nerve to abductor digiti minimi from the heel, and the lateral plantar nerve from the calcaneocuboid joint; and depth of the lateral plantar nerve from skin of sole in the midline, and angle of the lateral plantar nerve to the midline axis were measured. RESULTS: The mean entire foot length was 2,29.1 (range 215-250) mm. Location of the lateral plantar nerve from the heel in the dissecting midline axis was a mean of 93.5 (range 86-104) mm. Calcaneocuboid joint was located at a mean of 75.7 (range 70-85) mm from heel in the midline axis. The nerve to abductor digiti minimi was located at a mean of 48.1 (range 41-55) mm from the heel. Lateral plantar nerve was located at a mean of 19.4 (range 16-23) mm distal to the calcaneocuboid joint in the midline level. The angle at which the lateral plantar nerve crossed the dissecting midline incision was at a mean of 13.8° (range 9-20°). CONCLUSIONS: Based on these results, we defined the safe zone for the surgical approach to the posterior sole as anterior to the nerve to the abductor digiti minimi in the midline axis and posterior to the calcaneocuboid joint. There were no significant neurovascular structures observed in this zone.

Total talar extrusion without soft tissue attachments.

Total talar extrusion without a soft tissue attachment is an extremely rare injury and is rarely reported. Appropriate treatment remains controversial. We describe the long-term outcomes of two patients who had complete talar extrusion without remaining soft tissue attachment treated with arthrodesis. Both of our patients had complications such as infection and progressive osteolysis. We suggest reimplantation of the extruded talus after thorough debridement as soon as possible as a reasonable option unless the talus is contaminated or missing, because an open wound may arise from inside to outside.

Fractures of the proximal fifth metatarsal: percutaneous bicortical fixation.

BACKGROUND: Displaced intraarticular zone I and displaced zone II fractures of the proximal fifth metatarsal bone are frequently complicated by delayed nonunion due to a vascular watershed. Many complications have been reported with the commonly used intramedullary screw fixation for these fractures. The optimal surgical procedure for these fractures has not been determined. All these observations led us to evaluate the effectiveness of percutaneous bicortical screw fixation for treating these fractures. METHODS: Twenty-three fractures were operatively treated by bicortical screw fixation. All the fractures were evaluated both clinically and radiologically for the healing. All the patients were followed at 2 or 3 week intervals till fracture union. The patients were followed for an average of 22.5 months. RESULTS: Twenty-three fractures healed uneventfully following bicortical fixation, with a mean healing time of 6.3 weeks (range, 4 to 10 weeks). The average American Orthopaedic Foot & Ankle Society (AOFAS) score was 94 (range, 90 to 99). All the patients reported no pain at rest or during athletic activity. We removed the implant in all cases at a mean of 23.2 weeks (range, 18 to 32 weeks). There was no refracture in any of our cases. CONCLUSIONS: The current study shows the effectiveness of bicortical screw fixation for displaced intraarticular zone I fractures and displaced zone II fractures. We recommend it as one of the useful techniques for fixation of displaced zone I and II fractures.

Delayed diagnosed stage 1, 2 distractive flexion injury of the cervical spine.

STUDY DESIGN: Retrospective study. PURPOSE: To examine the clinical and radiologic characteristics of patients with stage 1 and 2 distractive flexion injury according to Allen's classification and who were not diagnosed immediately after injury, and to analyze the outcomes of surgical treatments. OVERVIEW OF LITERATURE: For the diagnosis of stage 1 and 2 distractive flexion injury in the lower cervical spine, attention should be paid when performing radiographs as well as when interpreting the radiographs. METHODS: The study was conducted on 10 patients (group 1) with stage 1 or 2 distractive flexion injury and who were not diagnosed immediately after injury from January 2003 to January 2009. The control group (group 2), 16 distractive flexion injury patients who were diagnosed immediately were selected. The simple radiographs, the degree of soft tissue swelling and the magnetic resonance imaging findings of the two groups were compared, and the clinical and radiologic results were examined. RESULTS: The degree of the prevertebral soft tissue swelling of group 1 was lower in group 1, and it was statistically significant (p = 0.046). The fusion was achieved in all cases (100%) in group 1, however, re-displacement as well as the loss of reduction occurred in one case, despite of delayed fusion and good clinical result. In group 2, bone fusion was achieved in 15 cases of 16 cases (94%). CONCLUSIONS: For the diagnosis of stage 1 and 2 distractive flexion injury in the lower cervical spine, it is desirable to perform computed tomography if diagnosis is not clear. Even if the diagnosis is delayed, stage 1 and 2 distractive flexion injury could be readily reduced by traction, and the treatment outcomes are considered to be comparable to those of the patients diagnosed immediately after injury.

Arthroscopic treatment of localized synovial chondromatosis of the posterior knee joint.

Synovial chondromatosis is an uncommon, benign neoplastic process typically affecting adult men and most commonly involving the knee, hip, and elbow joints. Intra-articular primary synovial chondromatosis in the knee joint may be localized or generalized. The symptoms associated with localized synovial chondromatosis may include diffuse pain, swelling, restricted motion, crepitus with symptoms of locking and giving way, and posteromedial tenderness mimicking medial meniscus tear. Diagnosis is usually established with magnetic resonance imaging (MRI) and confirmed by histological examination. To our knowledge, synovial chondromatosis of the knee joint in the posteromedial corner has not been reported in the literature.