scholarly journals Anatomic Structures at Risk during Posterior to Anterior Percutaneous Screw Fixation of Posterior Malleolar Fractures: A Cadaveric Study

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0036
Author(s):  
Kaveh Momenzadeh ◽  
Natalia Czerwonka ◽  
Derek S. Stenquist ◽  
Seth W. O’Donnell ◽  
John Y. Kwon ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Achilles Tendon ◽  
Sural Nerve ◽  
Screw Fixation ◽  
Fracture Site ◽  
Ankle Fractures ◽  
Anatomic Structure ◽  
Starting Point ◽  
The Wire ◽  
Neurovascular Bundles

Category: Ankle; Trauma Introduction/Purpose: Posterior malleolus fractures (PMFs) are typically associated with trimalleolar ankle fractures and have been reported to occur in 10-40% of ankle fractures. The PM may be fixed by direct ORIF or indirect percutaneous reduction. Direct reduction via a posterolateral approach is required for larger fragments, which requires prone or lateral decubitus positioning. Indirect reduction and fixation with anterior to posterior (AP) screws remains the most common method, in which screw threads are not entirely across the fracture site to allow interfragmentary compression.Objective: Determine the risk to anatomic structures utilizing a percutaneous technique for posterior to anterior (PA) screw fixation. It is advantageous as it places all the threads across the fracture site even for small fragments and can be performed in the supine position. Methods: 10 fresh-frozen, morphologically normal cadaver lower leg. Under fluoroscopic guidance, 1.35 mm Kirschner wire was inserted percutaneously from anteromedial to posterolateral. Guidewire was inserted from a starting point just medial to the tibialis anterior tendon and aimed at a point just lateral to the Achilles tendon. Small skin incision was made over the wire posteriorly, displacing the Achilles tendon medially as required. The wire was then over-drilled in posterior to anterior direction and replaced with a 4.0 mm partially threaded cannulated screw directed posterior to anterior. Each specimen was dissected, and adjacent soft tissue and neurovascular structures were identified. The distance from the guidewire to each anatomic structure of interest was measured. Descriptive analysis and the correlation between the mean distances from the guidewire to each structure was calculated using SPSS version 26. Results: The sural nerve was directly transected in 1/10 specimens (10%) and in contact with the wire in a second specimen (10%). There was a significant correlation between the proximity of the guidewire to the apex of Volkmann’s tubercle and its proximity to the sural nerve.(r= 0.705, p = 0.034) The flexor hallucis longus (FHL) muscle belly was perforated by the guidewire 40% of the time but was not tethered or entrapped by the screw. The neurovascular bundles were safely away from the wire in all cases. The lateral 1-2 mm of the Achilles tendon was pierced by the guidewire 20% of the time. Although suboptimal, these injuries may be of little clinical consequence, and the screw passed without tethering the tendon in all cadaveric specimens. Conclusion: Percutaneous PA screw placement is a safe technique which can be improved with several modifications. A mini- open technique is recommended to protect the sural nerve. The surgeon may consider aiming slightly more medial and closer to the Achilles tendon in order to avoid injury to the sural nerve. It is also advisable to use a soft tissue guide when over-drilling the guidewire. There may be potential for tethering of the FHL with use of a washer or large screw head. Risk to the anterior and posterior neurovascular bundles is minimal.

Soft Tissue Structures at Risk With Percutaneous Posterior to Anterior Screw Fixation of the Talar Neck

2018 ◽  
Vol 39 (10) ◽  
pp. 1237-1241
Author(s):  
Lauren E. Roberts ◽  
Martim Pinto ◽  
Jackson R. Staggers ◽  
Alexandre Godoy-Santos ◽  
Ashish Shah ◽  
...  
Keyword(s):  
At Risk ◽  
Soft Tissue ◽  
Sural Nerve ◽  
Injury Rate ◽  
Optimal Placement ◽  
Anatomic Structure ◽  
Shortest Distance ◽  
Fresh Frozen ◽  
Tissue Structures ◽  
Percutaneous Screws

Background: Fractures of the talar neck and body can be fixed with percutaneously placed screws directed from anterior to posterior or posterior to anterior. The latter has been found to be biomechanically and anatomically superior. Percutaneous guidewire and screw placement poses anatomic risks for posterolateral and posteromedial neurovascular and tendinous structures. The objective of this study was to determine the injury rate to local neurovascular and tendinous structures using this technique in a cadaveric model. In addition, we aimed to determine the number of attempts at passing the guidewires required to achieve acceptable placement of 2 parallel screws. Methods: Eleven fresh frozen cadaver limbs were used. Two 2.0-mm guidewires were placed under fluoroscopic guidance, posterior to anterior centered within the talus. The number of attempts required was recorded. A layered dissection was then performed to identify injury to any local anatomic structure. The shortest distance between the closest guidewire and the soft tissue structures was measured. Results: The mean total number of guidewires passed to obtain optimal placement of 2 parallel screws was 2.9 ± 0.7. Direct contact between the guidewire and the sural nerve was seen in 100% of the specimens, with the nerve impaled by the guidewire in 3 of 11 (27.2%) cases. The peroneal tendons were impaled in 1 of 11 (9%) specimens and the Achilles tendon was in contact with the guidewire in 8 of the 11 (72.7%) specimens, and impaled at its most lateral border with the guidewire in 2 specimens (18.2%). Conclusion: The placement of posterior to anterior percutaneous screws for talar neck fixation is technically demanding, and multiple guidewires are needed. Our cadaveric study showed that important tendinous and neurovascular structures were in proximity with the guidewires and that the sural nerve was injured in 100% of the cases. Clinical Relevance: Given the risk of injury to these structures, we recommend a formal posterolateral incision for proper visualization and retraction of the anatomic structures at risk.

Fibular Rod Osteosynthesis in Ankle Fractures With Compromised Soft Tissue

2021 ◽  
pp. 193864002110180
Author(s):  
Ingrid Kvello Stake ◽  
Martin Greger Gregersen ◽  
Marius Molund ◽  
Bengt Östman
Keyword(s):  
Soft Tissue ◽  
Screw Fixation ◽  
Case Series ◽  
Deep Infection ◽  
Ankle Fractures ◽  
Distal Fibula ◽  
Level Of Evidence ◽  
Injury Treatment ◽  
Skin Conditions

Background Complications after plate and screw fixation of ankle fractures are frequently reported in the literature, with a higher rate in patients with advanced age, comorbidities, and poor skin conditions. A reduced complication rate has been reported with intramedullary nailing (IMN) of the fibula; however, the indication has been based on the surgeon’s preferences. We report the results after IMN in patients with compromised soft tissue exclusively. Methods A total of 71 patients with 72 distal fibula fractures were included in this retrospective study. Information about medical history, the ankle injury, treatment, and complications were collected from the medical records. Additionally, the preinjury and 6-week follow-up radiographs were evaluated. Results Postoperative information was available for a minimum of 4.3 years postoperatively or until death. In all, 10 patients had complications related to the nail and required secondary surgery. These included 6 symptomatic hardware issues, 2 construct failures, 1 deep infection, and 1 combined deep infection and construct failure. Conclusions After IMN of the fibula, 14% of the patients required reoperation. Our results support the previous literature suggesting IMN as an acceptable surgical alternative where the risk of complications with plate and screw fixation is considered too high. Compromised soft tissue is one important indication. Level of Evidence: Level IV: Case series without control

Anatomic Structures at Risk During Posterior to Anterior Percutaneous Screw Fixation of Posterior Malleolar Fractures: A Cadaveric Study

2020 ◽  
pp. 193864002094300
Author(s):  
Natalia Czerwonka ◽  
Kaveh Momenzadeh ◽  
Derek S. Stenquist ◽  
Seth O’Donnell ◽  
John Y. Kwon ◽  
...  
Keyword(s):  
At Risk ◽  
Sural Nerve ◽  
Screw Fixation ◽  
Screw Placement ◽  
Percutaneous Technique ◽  
Flexor Hallucis Longus ◽  
Anatomic Structure ◽  
Posterior Malleolus ◽  
Fresh Frozen ◽  
Safe Technique

Background. There are no established guidelines for fixation of posterior malleolus fractures (PMFs). However, fixation of PMFs appears to be increasing with growing evidence demonstrating benefits for stability, alignment, and early functional outcomes. The purpose of this study was to determine the risk to anatomic structures utilizing a percutaneous technique for posterior to anterior (PA) screw fixation of PMFs. Methods. Percutaneous PA screw placement was carried out on 10 fresh frozen cadaveric ankles followed by dissection to identify soft tissue and neurovascular structures at risk. The distance from the guidewire to each anatomic structure of interest was measured. The correlation between the mean distances from the guidewire to each structure was calculated. Results. The sural nerve was directly transected in 1/10 specimens (10%) and in contact with the wire in a second specimen (10%). There was a significant correlation between the proximity of the guidewire to the apex of Volkmann’s tubercle and its proximity to the sural nerve. The flexor hallucis longus (FHL) muscle belly was perforated by the guidewire 40% of the time but was not tethered or entrapped by the screw. Conclusions. Percutaneous PA screw placement is a safe technique which can be improved with several modifications. A mini-open technique is recommended to protect the sural nerve. There may be potential for tethering of the FHL with use of a washer or large screw head. Risk to the anterior and posterior neurovascular bundles is minimal. Levels of Evidence: Level V

scholarly journals Anatomic Study of Exposed Posterior Malleolus Using the Posterolateral Ankle Approach

2021 ◽  
Vol 5 (1) ◽  
pp. 1-5
Author(s):  
Xin Ma
Keyword(s):  
Achilles Tendon ◽  
Saphenous Vein ◽  
Sural Nerve ◽  
Lateral Malleolus ◽  
Bone Block ◽  
Posterior Portion ◽  
Posterior Malleolus ◽  
Starting Point ◽  
Significant Difference ◽  
Exposed Bone

We compared the effect of the posterolateral ankle approach on the exposed posterior malleolus and vascular nerves in order to reduce the probability of vascular nerve injury during surgical exposure. Five corpses were randomly allocated to incision A and B groups. The tip of the lateral malleolus was used as a starting point, while the lateral line of the Achilles tendon was used as the endpoint to its trisection. Using the two points near the side of the Achilles tendon, we drew two vertical horizontal lines to represent incisions A and B, then measured the horizontal distances between the tip of the lateral malleolus and incision A (a), the tip of the lateral malleolus and incision B (b), and the tip of the lateral malleolus and the midpoint of the sural nerve and small saphenous vein (c). We then exposed the fibula from the posterior portion of the peroneus brevis muscles, dissected the flexor pollicis longus from the posterior edge of the fibula, and used Vernier calipers to measure the maximum length and width of the exposed bone block. There was no statistically significant difference between distances (a) and (c), but there was a significant difference between distances (b) and (c). The length of the exposed posterior malleolus did not differ significantly between incisions A and B, but the width differed significantly. Exposing the posterior malleolus using an approach closer to the lateral Achilles tendon is less likely to injure the sural nerve and small saphenous vein and results in a larger exposed area and easier manipulation. Thus, this could be a better surgical treatment for ankle fractures.

scholarly journals A Comparison of Wound Complications With Surgical Treatment of Achilles Tendon Conditions Using 2 Surgical Approaches

2019 ◽  
Vol 4 (1) ◽  
pp. 247301141881400
Author(s):  
K. J. Hippensteel ◽  
Jeffrey Johnson ◽  
Jeremy McCormick ◽  
Sandra Klein
Keyword(s):  
Soft Tissue ◽  
Achilles Tendon ◽  
Nerve Injury ◽  
Sural Nerve ◽  
Wound Complications ◽  
Soft Tissue Coverage ◽  
Nerve Injuries ◽  
Incision Location ◽  
Deep Wound ◽  
Posterior Midline

Background: Wound complications are a concern with the open treatment of Achilles tendon conditions. The location of the incision may impact the risk of wound complications because of its relationship to the blood supply to the skin. There is no consensus as to the safest incision location. The purpose of this study was to evaluate and compare the rates of sural nerve injury and wound complications including superficial or deep infections and wound dehiscence between posterior midline and posteromedial surgical incision locations. Methods: 125 patients with Achilles tendon rupture or Achilles tendinopathy were treated with open surgery through a longitudinal posterior midline or posteromedial incision. An L-shaped incision was used in the posteromedial group for cases of insertional repair. Postoperative complications including sural nerve injuries, superficial wound complications, superficial infections, deep wound infections, return to the operating room, and need for soft tissue coverage were recorded and rates were compared between the groups. Results: No significant differences were detected between the posteromedial and posterior incision groups in rates of sural nerve injuries, superficial infection, or deep wound infection. The posterior incision group had significantly fewer wound complications. The wound complications in the posteromedial group primarily occurred when an L-shaped incision was used for insertional repair. No patients in either group required debridement or soft tissue/flap coverage. Conclusion: The posterior incision location had significantly fewer wound complications. The use of an L-shaped incision was likely responsible for the wound complications in this group rather than the location of the incision. The use of a medial incision was not found to decrease the rate of sural nerve injury. Level of Evidence: Level III.

Augmented Repair of Acute Achilles Tendon Ruptures

2000 ◽  
Vol 21 (6) ◽  
pp. 469-474 ◽  
Author(s):  
Richard A. Zell ◽  
Vincent M. Santoro
Keyword(s):  
Soft Tissue ◽  
Achilles Tendon ◽  
Functional Recovery ◽  
Sural Nerve ◽  
Tendon Rupture ◽  
Weight Bearing ◽  
Achilles Tendon Rupture ◽  
Ankle Motion ◽  
Tendon Ruptures ◽  
Early Functional Recovery

Twenty-five patients who had an acute Achilles tendon rupture were managed with an augmented repair using the gastrocnemius-soleus fascia. All patients healed their repair and there were no re-ruptures. There was one infection. Augmented repair allowed early functional recovery as evidenced by full ankle motion by four to eight weeks, full unassisted weight bearing by three weeks, cessation of braces by four weeks, and return to work by one to six weeks post-operatively. Augmentation adds a sufficient amount of collagen to allow early range of motion and weight bearing without re-rupture. Disadvantages included a long incision, soft tissue prominence, one infection, and sural nerve injury.

Iliac Screw Fixation Using Computer-Assisted Computer Tomographic Image Guidance: Technical Note

2011 ◽  
Vol 70 (suppl_1) ◽  
pp. ons16-ons20 ◽  
Author(s):  
John H. Shin ◽  
Daniel J. Hoh ◽  
Iain H. Kalfas
Keyword(s):  
Soft Tissue ◽  
Image Guidance ◽  
Screw Fixation ◽  
Screw Placement ◽  
Computer Screen ◽  
Drill Guide ◽  
Soft Tissue Dissection ◽  
Starting Point ◽  
Tissue Dissection ◽  
Iliac Screw

Abstract BACKGROUND: Iliac screw fixation is a powerful tool used by spine surgeons to achieve fusion across the lumbosacral junction for a number of indications, including deformity, tumor, and pseudarthrosis. Complications associated with screw placement are related to blind trajectory selection and excessive soft tissue dissection. OBJECTIVE: To describe the technique of iliac screw fixation using computed tomographic (CT)-based image guidance. METHODS: Intraoperative registration and verification of anatomic landmarks are performed with the use of a preoperatively acquired CT of the lumbosacral spine. With the navigation probe, the ideal starting point for screw placement is selected while visualizing the intended trajectory and target on a computer screen. Once the starting point is selected and marked with a burr, a drill guide is docked within this point and the navigation probe re-inserted, confirming the trajectory. The probe is then removed and the high-speed drill reinserted within the drill guide. Drilling is performed to a depth measured on the computer screen and a screw is placed. RESULTS: Confirmation of accurate placement of iliac screws can be performed with standard radiographs. CONCLUSION: CT-guided navigation allows for 3-dimensional visualization of the pelvis and minimizes complications associated with soft-tissue dissection and breach of the ilium during screw placement.

Use of the AO Wire Passer to Aid Placement of Obstetrical Saw Wire for Osteotomy

1994 ◽  
Vol 07 (04) ◽  
pp. 180-182
Author(s):  
N. Gofton ◽  
Joanne Cockshutt
Keyword(s):  
Soft Tissue ◽  
Close Contact ◽  
Soft Tissue Trauma ◽  
Wire Saw ◽  
Tissue Dissection ◽  
The Wire ◽  
Tissue Trauma

The AO wire passer can be used as an effective guide for passage of obstetrical saw wire for osteotomy. Use of the wire saw and passer reduces soft tissue trauma by minimizing tissue dissection, and promoting positioning of the saw in close contact with the bone.

scholarly journals Fixation stability and implant-associated complications in periacetabular osteotomy: a comparison of screw and K-wire fixation

2021 ◽  
Author(s):  
Vincent Justus Leopold ◽  
Juana Conrad ◽  
Robert Karl Zahn ◽  
Christian Hipfl ◽  
Carsten Perka ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Screw Fixation ◽  
Periacetabular Osteotomy ◽  
Implant Migration ◽  
Major Complications ◽  
Significant Difference ◽  
Duration Of Surgery ◽  
Wire Fixation ◽  
Fixation Stability ◽  
Screw Group

Abstract Aims The aim of this study was to compare the fixation stability and complications in patients undergoing periacetabular osteotomy (PAO) with either K-wire or screw fixation. Patients and methods We performed a retrospective study to analyze a consecutive series of patients who underwent PAO with either screw or K-wire fixation. Patients who were treated for acetabular retroversion or had previous surgery on the ipsilateral hip joint were excluded. 172 patients (191 hips: 99 K-wire/92 screw fixation) were included. The mean age at the time of PAO was 29.3 years (16–48) in the K-wire group and 27.3 (15–45) in the screw group and 83.9% were female. Clinical parameters including duration of surgery, minor complications (soft tissue irritation and implant migration) and major complications (implant failure and non-union) were evaluated. Radiological parameters including LCE, TA and FHEI were measured preoperatively, postoperatively and at 3-months follow-up. Results Duration of surgery was significantly reduced in the K-wire group with 88.2 min (53–202) compared to the screw group with 119.7 min (50–261) (p < 0.001). Soft tissue irritation occurred significantly more often in the K-wire group (72/99) than in the screw group (36/92) (p < 0.001). No group showed significantly more implant migration than the other. No major complications were observed in either group. Postoperative LCE, TA and FHEI were improved significantly in both groups for all parameters (p = < 0.0001). There was no significant difference for initial or final correction for the respective parameters between the two groups. Furthermore, no significant difference in loss of correction was observed between the two groups for the respective parameters. Conclusion K-wire fixation is a viable and safe option for fragment fixation in PAO with similar stability and complication rates as screw fixation. An advantage of the method is the significantly reduced operative time. A disadvantage is the significantly higher rate of implant-associated soft tissue irritation, necessitating implant removal. Level of evidence III, retrospective trial.

Fifth Metatarsal Jones Fractures in the Athlete

2017 ◽  
Vol 39 (2) ◽  
pp. 250-258 ◽  
Author(s):  
David A. Porter
Keyword(s):  
Screw Fixation ◽  
Nonoperative Treatment ◽  
Fracture Site ◽  
Medullary Canal ◽  
Return To Sports ◽  
Stress Reactions ◽  
Current Standard ◽  
Level Of Evidence ◽  
Metatarsal Fractures ◽  
Intramedullary Screw

Fifth metatarsal fractures, otherwise known as “Jones” fractures, occur commonly in athletes and nonathletes alike. While recent occurrence in the popular elite athlete has increased public knowledge and interest in the fracture, this injury is common at all levels of sport. This review will focus on all three types of Jones fractures. The current standard for treatment is operative intervention with intramedullary screw fixation. Athletes typically report an acute episode of lateral foot pain, described as an ache. Radiographic imaging with multiple views of the weightbearing injured foot are needed to confirm diagnosis. If these images are inconclusive, further magnetic resonance imaging (MRI) or computed tomography (CT) is used. Nonoperative treatment is not commonly used as the sole treatment, except when following reinjury of a stable screw fixation. While screw selection is still controversial, operative treatment with intramedullary screw fixation is the standard approach. Technical tips on screw displacement are provided for Torg (types I, II, III) fractures, cavovarus foot fractures, recurrent fractures, revision surgery, occult fractures/high-grade stress reactions, and Jones’ variants. Excellent clinical outcomes can be expected in 80% to 100% of patients when using the intramedullary screw fixation to “fit and fill” the medullary canal with threads across the fracture site. Most studies show the timing for return to sports with optimal healing to be seven to twelve weeks after fixation. Level of Evidence: Level V, expert opinion.

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