Anatomic Study of Arthroscopic Portal Sites of the Ankle

Foot & Ankle ◽  
1993 ◽  
Vol 14 (3) ◽  
pp. 142-147 ◽  
Author(s):  
Lawrence A. Feiwell ◽  
Carol Frey
Keyword(s):  
At Risk ◽  
Ankle Joint ◽  
Standard Technique ◽  
Joint Capsule ◽  
Anatomic Study ◽  
Fresh Cadaver ◽  
Relative Safety ◽  
Fresh Frozen ◽  
Neurovascular Structures ◽  
Portal Placement

Numerous anatomic structures are at risk when performing ankle arthroscopy through the more commonly utilized portals. The purpose of this paper was to demonstrate the relative safety of each of the arthroscopic portal and Acufex external ankle distractor pin sites by measuring their proximity to the neurovascular structures surrounding the ankle joint. Six fresh cadaver specimens and 12 fresh-frozen, be-low-knee amputations were utilized for this study. An Acufex ankle distractor was applied using the standard technique. Anteromedial, anterolateral, anterocentral, posterolateral, and posteromedial portals were placed using an 11-blade scalpel to make 5-mm longitudinal incisions. The joint capsule was penetrated and a 3-mm arthroscope was placed into the ankle joint. The skin surrounding each of the portals was carefully removed and the proximity of any nerves or vessels was measured with respect to the arthroscope. At least one incidence of contact or penetration of a nerve or vessel was noted for each site. The anterocentral portal was at greatest risk for nerve or vessel damage. The anterolateral, anteromedial, and posterolateral portals were the safest areas for portal placement, with no penetration of neurovascular structures in any case.

scholarly journals Consideration of Medial Anatomical Structures at Risk when Placing Quadricortical Syndesmotic Fixation

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0027
Author(s):  
Philip Kaiser ◽  
Matthew Riedel ◽  
Mohammad Ghorbanhoseini ◽  
Rameez Qudsi ◽  
John Kwon
Keyword(s):  
At Risk ◽  
Ankle Joint ◽  
Distal Tibia ◽  
Lateral Radiograph ◽  
Grid System ◽  
Anterior Portion ◽  
Columnar Zone ◽  
Posterior Malleolus ◽  
Fresh Frozen ◽  
Metal Wires

Category: Trauma Introduction/Purpose: Surgical fixation of ankle fractures with syndesmotic instability using quadricortical fixation through the fibula and tibia is commonly performed to maintain mortise congruency. Quadricortical fixation can be achieved by screws or suture buttons however both involve unprotected drilling and placement of hardware through the medial distal tibia which places anatomic structures at iatrogenic risk. These structures may include the anterior tibialis tendon, the saphenous neurovascular bundle (SNVB) and posteriorly, the posterior tibialis tendon (PTT). This study aims to radiographically map the anatomic course of these structures at risk on a lateral radiograph as would be used intraoperatively during syndesmotic fixation. Methods: Eighteen fresh-frozen cadaveric feet were dissected with preservation of all soft tissue and neurovascular structures over the medial distal tibia. While preserving fascial and tendinous sheath attachments, the SNVB and the PTT were identified and marked with metal wiring. Standardized and calibrated lateral radiographs were obtained to determine the anatomic course of these structures. Lateral radiographs of the distal tibia and fibula were analyzed by a grid system comprised of 1 cm row-increments moving cranially from the ankle joint up to 5 cm and by 3 evenly distributed parallel columnar zones from anterior to posterior (see Figure). The anterior boundary of the columnar zone was placed at the anterior tibial shaft and the posterior boundary was placed at the posterior malleolus of the tibia. The position of respective metal wires placed within the SNVB and the anterior portion of the PTT were charted according to this grid system and results compiled. Results: The SNVB was located in zone 1 or 2 (or anterior to zone 1) in 97.3% of specimens (107/110). The SNVB traversed from proximal-posterior to distal-anterior. For the 16 specimens that crossed a columnar zone, the most common crossover was from zone 2 to zone 1 at 3-4 cm above the ankle joint which occurred in 43.8% (7 of 16) specimens. The PPT was found in zone 3 in all specimens (n=18) with only one specimen demonstrating crossover of a columnar zone into zone 2 at its most distal extent (0-1 cm). The PTT was noted to pass behind (radiographically overlap) with the tibia in 83.3% (15 of 18) of specimens between 1 and 3 cm above the ankle joint. Conclusion: Inappropriate placement of quadricortical syndesmotic fixation may place structures on the medial ankle at risk given blind drilling and hardware placement. The SNVB is at considerable risk along the anterior course of the distal tibial while the PTT is only at risk in zone 3 at the distal extent of the tibia when a true lateral radiograph is obtained. This grid system allows a simple intra-operative check to guide safer placement of quadricortical syndesmotic fixation.

Endoscopic Endonasal Transclival Approach and Retrosigmoid Approach to the Clival and Petroclival Regions

2009 ◽  
Vol 65 (suppl_6) ◽  
pp. ons42-ons52 ◽  
Author(s):  
Matteo de Notaris ◽  
Luigi Maria Cavallo ◽  
Alberto Prats-Galino ◽  
Isabella Esposito ◽  
Arnau Benet ◽  
...  
Keyword(s):  
Internal Carotid ◽  
Abducens Nerve ◽  
Anatomic Study ◽  
Lateral Extension ◽  
Anatomic Landmarks ◽  
Endoscopic Endonasal ◽  
Fresh Cadaver ◽  
Definition Of ◽  
Surgical Corridor ◽  
Neurovascular Structures

Abstract Objective: The removal of clival lesions, mainly those located intradurally and with a limited lateral extension, may be challenging because of the lack of a surgical corridor that would allow exposure of the entire lesion surface. In this anatomic study, we explored the clival/petroclival area and the cerebellopontine angle via both the endonasal and retrosigmoid endoscopic routes, aiming to describe the respective degree of exposure and visual limitations. Methods: Twelve fresh cadaver heads were positioned to simulate a semisitting position, thus enabling the use of both endonasal and retrosigmoid routes, which were explored using a 4-mm rigid endoscope as the sole visualizing tool. Results: The comparison of the 2 endoscopic surgical views (endonasal and retrosigmoid) allowed us to define 3 subregions over the clival area (cranial, middle, and caudal levels) when explored via the endonasal route. The definition of these subregions was based on the identification of some anatomic landmarks (the internal carotid artery from the lacerum to the intradural segment, the abducens nerve, and the hypoglossal canal) that limit the bone opening via the endonasal route and the natural well-established corridors via the retrosigmoid route. Conclusion: Different endoscopic surgical corridors can be delineated with the endonasal transclival and retrosigmoid approaches to the clival/petroclival area. Some relevant neurovascular structures may limit the extension of the approach and the view via both routes. The combination of the 2 approaches may improve the visualization in this challenging area.

The Hallux Metatarsophalangeal Capsule: An Anatomic Study With Respect to Percutaneous Hallux Valgus Correction

2021 ◽  
pp. 107110072110272
Author(s):  
Kenneth M. Chin ◽  
Nicholas S. Richardson ◽  
John T. Campbell ◽  
Clifford L. Jeng ◽  
Matthew W. Christian ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Hallux Valgus ◽  
Metatarsal Head ◽  
Cadaveric Study ◽  
Anatomic Study ◽  
Orthopedic Surgeons ◽  
Popular Knowledge ◽  
Fresh Frozen ◽  
The Mean ◽  
Anatomic Relationship

Background: Minimally invasive surgery for the treatment of hallux valgus deformities has become increasingly popular. Knowledge of the location of the hallux metatarsophalangeal (MTP) proximal capsular origin on the metatarsal neck is essential for surgeons in planning and executing extracapsular corrective osteotomies. A cadaveric study was undertaken to further study this anatomic relationship. Methods: Ten nonpaired fresh-frozen frozen cadaveric specimens were used for this study. Careful dissection was performed, and the capsular origin of the hallux MTP joint was measured from the central portion of the metatarsal head in the medial, lateral, dorsal, plantarmedial, and plantarlateral dimensions. Results: The ten specimens had a mean age of 77 years, with 5 female and 5 male. The mean distances from the central hallux metatarsal head to the MTP capsular origin were 15.2 mm dorsally, 8.4 mm medially, 9.6 mm laterally, 19.3 mm plantarmedially, and 21.0 mm plantarlaterally. Conclusion: The MTP capsular origin at the hallux metatarsal varies at different anatomic positions. Knowledge of this capsular anatomy is critical for orthopedic surgeons when planning and performing minimally invasive distal metatarsal osteotomies for the correction of hallux valgus. Type of Study: Cadaveric Study.

Distal Fibular Length Needed for Ankle Stability

2006 ◽  
Vol 27 (3) ◽  
pp. 185-189 ◽  
Author(s):  
Eiichi Uchiyama ◽  
Daisuke Suzuki ◽  
Hideji Kura ◽  
Toshihiko Yamashita ◽  
Gen Murakami
Keyword(s):  
Ankle Joint ◽  
External Rotation ◽  
Traction Force ◽  
Distal Fibula ◽  
Rotational Angle ◽  
Clear Cut ◽  
Long Term Stability ◽  
Ankle Stability ◽  
Fresh Frozen ◽  
The Stability

Background: The fibula is commonly used for bone grafts. Previous clinical and biomechanical studies have suggested that the length of the residual portion of the distal part of the fibula has an important effect on the long-term stability of the ankle joint. However, we cannot find clear-cut guidelines for the amount of bone that can be harvested safely. Methods: Using six normal fresh-frozen cadaver legs, motions of the tibia, talus and calcaneus were measured. The fibula was cut sequentially 3 cm from the proximal tip of the fibula and distally 10 cm, 6 cm, and 4 cm from the distal tip of the lateral malleolus. The angular motion of each bone was measured while a medial and lateral traction force of 19.6 N was applied to the proximal tibia. Angles of the tibia, talus, and calcaneus were measured. Results: Sequential resection of the fibula increased the inversion angles of the ankle joint. The proximal 3-cm cut increased the inversion angle from 42.1 ± 6.2 degrees to 49.6 ± 3.6 degrees, and the distal 4-cm cut increased the angle from 57.6 ± 6.6 degrees to 67.4 ± 5.9 degrees. The rotational angles were almost constant with sequential resections of the fibula; however, the distal 4-cm cut increased the rotational angle from 11.3 ± 25.1 degrees to 78.7 ± 37.5 degrees. Conclusions: The whole fibula including the head is essential for the stability of the ankle joint complex, and the distal fibula is responsible for stabilizing the ankle mortise during external rotation and inversion. We recommend fixation of the syndesmosis or bracing to prevent ankle joint instability with rotation of the talus in the mortise, especially when the distal fibula is shortened 6 cm or more.

Surgical Exposures

2018 ◽  
pp. 57-70
Author(s):  
Joaquin Sanchez-Sotelo
Keyword(s):  
At Risk ◽  
Rotator Cuff ◽  
Surgical Procedures ◽  
Shoulder Joint ◽  
Shoulder Function ◽  
Front Side ◽  
Shoulder Region ◽  
Neurovascular Structures ◽  
Large Muscle

Adequate exposure is critical for any of the open surgical procedures described in this book. Although exposures may need to be modified, most of the time the same approaches are used for various procedures. Small variations on exposures also exist that are based on surgeons’ preferences. All shoulder exposures are somewhat complicated by three particular issues related to the anatomy of the shoulder region. First, the deltoid is a large muscle that wraps around the front, side, and back of the shoulder. Second, the rotator cuff, so important for shoulder function, oftentimes needs to be divided and repaired. Finally, a number of neurovascular structures are very close to the shoulder joint and at risk for injury.

Open posterior capsular release with an osteotome in total knee arthroplasty does not place important neurovascular structures at risk

2019 ◽  
Vol 27 (7) ◽  
pp. 2120-2123
Author(s):  
Zachariah Pinter ◽  
Rucker Staggers ◽  
Sung Lee ◽  
Shelby Bergstresser ◽  
Ashish Shah ◽  
...  
Keyword(s):  
At Risk ◽  
Total Knee Arthroplasty ◽  
Knee Arthroplasty ◽  
Capsular Release ◽  
Total Knee ◽  
Neurovascular Structures

scholarly journals Safe Zone for Percutaneous Screw Fixation - Talonavicular Fusion

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0043
Author(s):  
Ashish Shah ◽  
Sung Lee ◽  
Sameer Naranje ◽  
Zachariah Pinter ◽  
Robert Stibolt ◽  
...  
Keyword(s):  
Medial Branch ◽  
Screw Insertion ◽  
Anterior Branch ◽  
Bony Landmarks ◽  
Medial Plane ◽  
Extensor Hallucis Longus ◽  
Hindfoot Deformities ◽  
Fresh Frozen ◽  
Optimal Fusion ◽  
Neurovascular Structures

Category: Hindfoot Introduction/Purpose: Talonavicular fusion has been established as a reliable intervention for degenerative, inflammatory, and traumatic joint lesions as well as hindfoot deformities. In order to achieve optimal fusion, various versions of the procedure have been introduced in literature and have remained a topic of contention, with the most common variation involving the insertion of 1 to 3 screws dorsomedially and dorsolaterally. Dorsolateral screw placements commonly cause neurovasculature injury. The purpose of our cadaveric study was first to establish the safety of the dorsolateral percutaneous screw insertion in relation to these dorsal neurovascular structures, and then subsequently to standardize the ideal placement of the dorsolateral screw by comparing two insertion sites based on consistent bony landmarks. Methods: Ten fresh-frozen cadaver legs amputated at the knee were used for this study. Percutaneous cannulated screws were inserted to perform isolated talonavicular arthrodesis. The screws were inserted at 3 consistent sites: “medial screw” at dorsomedial navicular where it intersected at the medial plane of the first cuneiform, “central screw” at the edge of dorsal navicular between medial and intermediate cuneiforms, and “lateral screw” at the edge of dorsal navicular between intermediate and lateral cuneiforms. Superficial and deep dissections were carried out to identify any injured nerves, arteries, and tendons. Results: The mean age at death in our sample of cadavers was 80.1 ± 7.5 years (range 68 to 92) and had the BMI of 21.8 ± 2.4 (range 18.1 to 25.1). There were 5 males (50.0%) and 5 females (50.0%). The medial screw injured the anterior tibialis tendon in 2 cases (20.0%), the central screw injured the extensor hallucis longus tendon in 3 cases (30.0%), and the lateral screw injured the anterior branch of SPN, lateral branch of SPN, and medial branch of DPN once each in a total of 3 cases (30.0%). Conclusion: TN fusion with central screw placement at the interspace between the medial and intermediate cuneiforms protects the neurovasculatures of the foot to a superior extent than lateral screws between the intermediate and lateral cuneiforms.

scholarly journals Two-millimetre diameter operative arthroscopy of the ankle is safe and effective

2020 ◽  
Vol 28 (10) ◽  
pp. 3080-3086 ◽  
Author(s):  
Tobias Stornebrink ◽  
J. Nienke Altink ◽  
Daniel Appelt ◽  
Coen A. Wijdicks ◽  
Sjoerd A. S. Stufkens ◽  
...  
Keyword(s):  
Articular Surface ◽  
Anteromedial Portal ◽  
Human Donor ◽  
Articular Surfaces ◽  
Iatrogenic Damage ◽  
Anterolateral Portal ◽  
Fresh Frozen ◽  
Effective Visualization ◽  
Neurovascular Structures ◽  
Portal Tracts

Abstract Purpose Technical innovation now offers the possibility of 2-mm diameter operative arthroscopy: an alternative to conventional arthroscopy that no longer uses inner rod-lenses. The purpose of this study was to assess whether all significant structures in the ankle could be visualized and surgically reached during 2-mm diameter operative arthroscopy, without inflicting iatrogenic damage. Methods A novel, 2-mm diameter arthroscopic system was used to perform a protocolled arthroscopic procedure in 10 fresh-frozen, human donor ankles. Standard anteromedial and anterolateral portals were utilized. Visualization and reach with tailored arthroscopic instruments of a protocolled list of articular structures were recorded and documented. A line was etched on the most posterior border of the talar and tibial cartilage that was safely reachable. The specimens were dissected and distances between portal tracts and neurovascular structures were measured. The articular surfaces of talus and tibia were photographed and inspected for iatrogenic damage. The reachable area on the articular surface was calculated and analysed. Results All significant structures were successfully visualized and reached in all specimens. The anteromedial portal was not in contact with neurovascular structures in any specimen. The anterolateral portal collided with a branch of the superficial peroneal nerve in one case but did not cause macroscopically apparent harm. On average, 96% and 85% of the talar and tibial surfaces was reachable respectively, without causing iatrogenic damage. Conclusion 2-mm diameter operative arthroscopy provides safe and effective visualization and surgical reach of the anterior ankle joint. It may hold the potential to make ankle arthroscopy less invasive and more accessible.

scholarly journals Transbrachioradialis Approach to the Radial Tunnel: An Anatomic Study of 5 Potential Compression Sites

Hand ◽  
2018 ◽  
Vol 14 (3) ◽  
pp. 329-332 ◽  
Author(s):  
Jason R. Ummel ◽  
John G. Coury ◽  
Zachary C. Lum ◽  
Marc A. Trzeciak
Keyword(s):  
Single Incision ◽  
Anatomic Study ◽  
Muscle Belly ◽  
Surgical Access ◽  
Distal Edge ◽  
Fresh Frozen ◽  
Utilitarian Approach ◽  
Arcade Of Frohse ◽  
Tunnel Syndrome ◽  
Single Approach

Background: Recent anatomic studies have failed to demonstrate a single utilitarian approach to intraoperative identification and surgical release of all 5 potential sites of posterior interosseous nerve (PIN) compression in the radial tunnel. This study examines if a single incision brachioradialis-splitting approach without the use of additional anatomic windows is capable of adequately exposing the entire length of the radial tunnel, including all 5 sites of PIN compression to allow for adequate release. Methods: Ten fresh frozen cadaver forearms (6 female, 4 male) were dissected utilizing a curvilinear 7 cm incision over the brachioradialis. The muscle belly was split via simple blunt retraction, exposing the radial tunnel. The PIN was identified and mobilized at 5 compression sites: radiocapitellar joint (RCJ), radial recurrent vessels (Leash of Henry), fibrous medioproximal edge of extensor carpe radialis brevis, arcade of Frohse, and distal edge of supinator. Results: The PIN was identified and effectively released in all specimens without difficulty from this single approach. All 5 sites of compression were visible and accessible through the brachioradialis-split approach. Specifically, there was no difficulty in identifying and releasing the PIN at the distal edge of supinator. Conclusions: Radial tunnel syndrome is defined as PIN compression within the radial tunnel spanning from the fibrous RCJ to the distal edge of the supinator. A single brachioradialis-splitting approach is adequate for complete visualization and release of all compression sites of the radial tunnel. Utilizing this technique allows for surgical access and ease as well as minimizing necessity for additional windows or multiple incisions.

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