Nerve and Arterial Supply Pattern of the Popliteus Muscle and Clinical Implications

Introduction. The aim of this study was to investigate the nerve and artery supply and the tibial attachment of the popliteus muscle using anatomical methods. Methods. Forty-four nonembalmed and embalmed extremities were dissected for this study. To measure the attachment area of the popliteus, the most prominent points of the medial epicondyle of the femur and the medial malleolus of the tibia were identified before dissection. A line connecting these two prominent points was used as the reference line, with the most prominent point of the medial epicondyle of the femur as the starting point. This study also investigated the area where the popliteus attaches to the bone and the points where nerves and arteries enter the popliteus muscle when it is divided into three equal parts in the coronal plane. Results. The mean length of the reference line was 34.6 ± 2.1 cm . The origin of the popliteus was found to be at a distance of 16.6% to 35.2% on the tibial bone from the proximal region. The popliteus was innervated by only the tibial nerve in 90% of the cases and by the tibial and the sciatic nerves in the remaining 10% of the cases. The inferior medial genicular artery and the posterior tibial artery supplied blood to the popliteus in 90% and 65% of the cases, respectively. When the popliteus muscle was divided into three equal parts in the coronal plane, the nerve and the artery were found to enter the muscle belly in zones II and III and zones I and II in 92% and 98% of the specimens, respectively. Discussion. The anatomical investigation of the popliteus in this study will help identify patients with clinically relevant syndromes.

A case of fracture talus with medial malleolus treated with headless screws and cancellous cannulated screws using single anteromedial approach

<p>Talar fractures are complex injuries with an array of management options and complications. We present a case of talar fracture with medial malleolus fracture fixed via common anteromedial approach through the fracture site. The incidence of associated malleolar injury has ranged from 19% to 28% in prior studies. The skin condition is often poor and prone to swelling in such cases which makes the management challenging. Along with poor wound healing, joint stiffness, osteonecrosis and osteoarthritis of the ankle are complications affecting the outcome of the patient.</p>

Anatomical reconstruction of the anterior inferior tibiofibular ligament in elite athletes using InternalBrace suture tape

Aims The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes. Methods Data on a consecutive group of elite athletes who underwent isolated reconstruction of the anterior inferior tibiofibular ligament using the InternalBrace were collected prospectively. Our patient group consisted of 19 elite male athletes with a mean age of 24.5 years (17 to 52). Isolated injuries were seen in 12 patients while associated injuries were found in seven patients (fibular fracture, medial malleolus fracture, anterior talofibular ligament rupture, and posterior malleolus fracture). All patients had a minimum follow-up period of 17 months (mean 27 months (17 to 35)). Results All patients returned to their pre-injury level of sports activities. One patient developed a delayed union of the medial malleolus. The mean return to play was 62 days (49 to 84) for isolated injuries, while the patients with concomitant injuries returned to play in a mean of 104 days (56 to 196). The AOFAS score returned to 100 postoperatively in all patients. Knee-to-wall measurements were the same as the contralateral side in 18 patients, while one patient lacked 2 cm compared to the contralateral side. Conclusion This study suggests the use of the InternalBrace in the management of unstable syndesmotic injuries offers an alternative method of stabilization, with good short-term results, including early return to sports in elite athletes. Cite this article: Bone Joint J 2022;104-B(1):68–75.

Access to the talar dome through the medial posterolateral approach: an anatomical study.

Background: The osteochondral grafting has become a popular procedure for treating challenging talar dome lesions. However, the vast majority are treated through medial malleolus osteotomy. The aim of this study was to determine the posteromedial area of the talus that can be reached without malleolar osteotomy through the posteromedial approach. Study Design: Descriptive laboratory study. Evidence Level 4 Methods: Fifteen human cadaveric ankles were dissected in a standard fashion to expose the posteromedial talar dome. Seven approaches were used on the cadaver's left limb (46.7%). We did not observe any significant difference between the evaluated sides (chi-square test, p = 0.715). Results: On average, 2,09 cm2 (range, 1,72-2,69) of the posteromedial talus dome or 15,27 % (range 12-20) of total talus dome can be accessed without osteotomy. Conclusion: If the osteochondral lesion is within the area accessible through PM approach (mean 2 cm2), as seen on magnetic resonance imaging, it is possible that it can be treated without a medial malleolus osteotomy. Keywords: talus; osteochondral lesions; osteotomy; arthrotomy; surgery

Morphological analysis of posterior malleolar fractures with intra-articular impacted fragment in computed tomography scans

Background Intraarticular impacted fragment (IAIF) of posterior malleolar fractures has been reported by a few studies. However its location, morphology, and the correlation of posterior malleolar fractures have not been described in detail. The aim of this study was to describe the morphology of IAIF in posterior malleolar fractures, to analyze the related factors between IAIF and posterior malleolar fragments, and explore the treatment of IAIF. Materials and methods Between January 2013 and December 2018, 108 consecutive patients with unilateral posterior malleolar fractures were managed in our hospital. Basic demographic and computed tomography (CT) data were collected and classified by Lauge–Hansen, OTA/AO, Haraguchi, and Mason classification. Additional radiographic data, including the length and area of posterior malleolar fragment, IAIF, and stable tibial plafond were measured. The location of IAIF was described, and involvement of the fibular notch and medial malleolus was also observed. Statistics were analyzed based on univariate analysis (Chi-square test, t-test, Mann–Whitney U test, Fisher’s test) and Spearman’s correlation test. Results Among the 108 cases of posterior malleolar fractures, 75 (69.4%) were with IAIF and 33 (30.6%) cases were without. There were 74 (68.5%) females and 34 (31.5%) males, and the average age of the patients was 49 years (18–89 years). The average LIFN/(LIFN + LSFN) [length of involving fibular notch/(length of involving fibular + length of stable notch fibular notch)] was 32.9% (11.6–64.9%). The APMF/(APMF + ASTP + AIAIF) [area of posterior malleolar fragment/(area of posterior malleolar fragment + area of IAIF + area of stable tibial plafond)] and AIAIF/APMF (area of IAIF/area of posterior malleolar fragment) were 13.1% (0.8–39.7%) and 52.6% (1.2–235.4%), respectively. Involvement of medial malleolus (fracture line extended to medial malleolus, P = 0.022), involvement of fibular notch (P = 0.021), LIFN/(LIFN + LSFN) (P = 0.037), LMPMF (P = 0.004), and APMF were significantly related to the occurrence of IAIF. Conclusion Our research indicates a high incidence of IAIF in posterior malleolar fractures. All IAIFs were found in posterior malleolar, and the most common location was within the lateral area A. Posterior malleolar fracture lines that extend to medial malleolus or fibular notch herald the incidence of IAIF. LIFN/(LIFN + LSFN), LMPMF and APMF are also associated with the incidence of IAIF. CT scans are useful for posterior malleolar fractures to determine the occurrence of IAIF and make operational plans. Operation approach selection should be based on the morphology of posterior malleolar fragments and the location of IAIF. Level of evidence Level III, retrospective case analysis.

Simultaneous traumatic dislocation of the posterior tibial tendon and long peroneal tendon: a case report

Background Viewing the existing literature, one can find several documents about dislocation of the peroneal tendons. Clinical findings, diagnostics, and therapy are well described. Instead, the list of documents describing dislocations of the posterior tibial tendon is short. We found no case in which a dislocation of both long peroneal tendon and posterior tibial tendon is described. Case presentation We present a case of a 29-year-old male patient who sustained an ankle injury after a fall at a boulder gym. He admitted himself with severe pain, tenderness, and swelling of his left ankle. Dislocation of the posterior tibial tendon and simultaneous dislocation of the long peroneal tendon was diagnosed using x-ray, computed tomography, and magnetic resonance imaging. Transosseous suture repair with periosteal augmentation of the flexor retinaculum was performed at the medial malleolus. At the lateral malleolus, transosseous suture was used to repair the superior retinaculum. The ankle was immobilized following surgery. The patient underwent physical therapy afterwards. The treatment resulted in good recovery, and the patient returned to the same level of performance at rock climbing. Conclusion Our novel finding is that simultaneously sustained dislocations of the posterior tibial tendon and the long peroneal tendon may occur and can be successfully treated as if each injury is treated individually. Level of evidence Level V, case report.

Efficacy of antiglide plate in vertical shear fractures of medial malleolus due to supination adduction injury around ankle: a prospective clinical study

Background: Ankle fractures represent 10% of all fractures with an incidence of around 137/100000 population per year, making these the second most common lower limb fractures after hip fractures. Increasing age, obesity and alcohol abuse are the major causal factors for the fractures around the ankle joint. These are typically low energy injuries with the majority occurring due to simple falls or sport. The aim was to open reduction and internal fixation of these with an antiglide plate.Methods: The present prospective study was carried out at government medical college Amritsar, Punjab in 25 patients of same demographic profile, March 2018 to December 2020 after having the clearance of ethical committee. All the patients after careful assessment of the injury both clinically (pain, swelling, deformity, any blisters) and radiologically (type of fracture, that is, vertical shear fracture of medial malleolus) were internally fixed under spinal anesthesia, with an antiglide plate after reduction of the fracture fragments.Results: The results were assessed accordance with Olerud-Molander ankle score (OMAS). We achieved excellent to good results with an average OMAS score of 80/100 in the present study.Conclusions: The open reduction and internal fixation of vertical shear fractures of medial malleolus with an antiglide plate is an effective way of management of these fractures. It ensures maximum stability and more so safeguards against loss of reduction or the implant failure under axial loading and at the same time ensures the timely union of such fractures without any significant complications.

Physiotherapy Rehabilitation in Operated Case of Patellar Fracture and Medial Malleolus Fracture- A Case Report

Introduction: Road traffic accidents (RTA) are responsible for a considerable amount of global death and morbidity, particularly in developing nations. 'Hidden pandemics,' such as mortality from RTA, often go unnoticed over the world.(1) These days traffic road accidents lead to many fractures included patellar fracture. Patellar fractures account for about 1% of all skeletal fractures and are most common in people between the ages of 20 and 50. 1–3 Men have nearly twice as many cases as women. Clinical Findings: On physical examination respiratory system, cardiovascular system and central nervous system are normal and on local examination of left lower limb demonstrate attitude of limb in hip and knee in extension and foot in external rotation and multiple abrasions are present over the knee and there were abrasion of 10*2cm present over medial aspect of great toe and abrasion of 5*2cm present over the postero-medial aspect of distal 3rd leg, lacerated wound on medial malleolus.In this case patient was on 8 week protocol for physiotherapy management. Discussion: In this case report we are discussing a case of 36 year old male with fracture of patella and medial malleolus managed with tension band wiring and nailing respectively. The primary goal of physiotherapy management was to prevent secondary complications and make the patient independent for which rehabilitation protocol was planned which included isometric exercises, dynamic quadriceps bed mobility exercises and ambulation. Conclusion: Physiotherapy plays an important role in rehabilitation of patient with medial malleolus and patella fracture.