Fibular head transfixion wire and its relationship to common peroneal nerve: cadaveric analysis.

Proximal tibio-fibular joint is routinely stabilised during leg lengthening, peri-articular fractures and deformity corrections of tibia. Potential injury to the common peroneal nerve at the level of the fibula head/neck junction during wire insertion is a recognised complication. Previous studies have mapped the course of the common peroneal nerve and its branches at the level of the fibular head, and guidelines are published regarding placement of proximal tibial wires. This study aims to relate the course of the common peroneal nerve to the placement of a lateral insertion fibula head transfixion wire. Standard 1.8-mm Ilizarov 'olive' wires were inserted in the fibula head of 10 un-embalmed cadaveric knees. Wires were inserted percutaneously to the fibula head using surface anatomy landmarks and palpation technique. The course of the common peroneal nerve was then dissected. Distances from wire entry point to the course of the common peroneal nerve were measured post-wire insertion. The mean distance of the common peroneal nerve from the anterior aspect of the broadest point of the fibular head was 24.5 mm (range 14.2-37.7 mm). Common peroneal nerve was seen to cross the neck of fibula at a mean distance of 34.8 mm from the tip of fibula (range 21.5-44.3 mm). Wire placement was found to be on average, 52 % of the maximal AP diameter of the fibula head and 64 % of the distance from tip of fibula to the point of nerve crossing fibula neck. When inserting a fibula head transfixion wire, care must be taken not to place wire entry point too distal or posterior on the fibula head. Observing a safe zone in the anterior half of the proximal 20 mm of the fibula head would avoid injury to the nerve. In cases where palpation of fibula is difficult due to patient habitus, we recommend consideration of the use of fluoroscopic guidance during wire transfixion of the proximal tibio-fibular articulation to avoid wire insertion too distally and subsequent potential nerve injury.

Cadaveric analysis of capsular attachments of the distal femur related to pin and wire placement.

OBJECTIVES: Septic arthritis following intra-capsular penetration of the knee by external fixation devices is a complication of traction/fixation devices inserted in the lower extremity [1,2]. The authors were unable to find reference to or exact measurements of the capsular attachments relating to the distal femur documented in the current literature. This study aimed to demonstrate the capsular attachments and reflections of the distal femur to determine safe placements of wires or traction devices. METHODS: The attachments of the capsule to the distal femur were measured in 10 unembalmed cadaveric knees. Capsular attachments were measured anteriorly at the maximal extension of the supra-patella pouch. Medially and laterally measurements were expressed as percentages related to the maximal AP diameter of the distal femur. RESULTS: Mean distance from the centre of the anterior part of the notch to the superior fold was 79.5mm (Range 48.1-120.7 mm). The medial capsular reflections measured in a plane from the adductor tubercle to the anterior edge of the medial femoral condyle demonstrated the capsular reflection was attached an average of 57% back from the anterior edge (Range 41-74%). Laterally the capsular reflections on a line drawn from the maximal diameter in the sagittal plane were attached an average of 48% from the anterior reference point (Range 33-57%). Measuring the reflections at 45 degrees to the long axis of the femur in the sagittal plane the attachment was an average of 51% from the anterior reference point. CONCLUSIONS: Capsular reflections varied among specimens. Medially the capsule attachment was up to 74% of diameter of distal femur at the level of the adductor tubercle. Therefore, the insertion of distal femoral traction pins or similar should be placed proximal to the adductor tubercle and no further than 25% of the distance to the anterior cortex. Care is also needed to ensure pins do not travel to exit too anteriorly on the lateral side as capsular attachments were found to be up to a distance 48% of the diameter of the femur from anterior reference point. Distal condylar extra-articular fixation with Schanz screws is feasible if orientated in the oblique plane.

Hip dislocation following minor trauma in a patient with neurofibromatosis type 1: a case report and review of the literature.

Neurofibromatosis type 1 (NF-1) is a common autosomal dominant disorder which is known to have associated skeletal manifestations. There are documented cases of hip dislocation in NF-1, although it is a rare occurrence. Previous cases have been associated with intra-articular neurofibromas, acetabular protrusio and femoral deformities such as coxa valga and in one case increased femoral offset.The authors review the literature on pelvic manifestations and report a case of hip dislocation in a 19-year-old woman with neurofibromatosis-one following minor trauma believed to be secondary to markedly increased femoral offset.This case illustrates the effect the NF-1 can have on the anatomy of the proximal femur and one of the complications that can present to the orthopaedic surgeon, without the presence on an intra-articular neurofibroma. In a review of the literature the authors found only two other cases of hip dislocation associated with NF-1 that occurred without the presence of an intra-articular neurofibroma.

Pancreas sparing duodenectomy as an emergency procedure.

BACKGROUND: The operative techniques to close extensive wounds to the duodenum are well described. However, postoperative morbidity is common and includes suture line leak and the formation of fistulae. The aim of this case series is to present pancreas sparing duodenectomy as a safe and viable alternative procedure in the emergency milieu. METHODS: Five patients underwent emergency pancreas sparing duodenal excisions. Re-implantation of the papilla of Vater or the papilla with a surrounding mucosal patch was performed in two patients. In one, the procedure was further supplemented with a duodenocholangiostomy, stapled pyloric exclusion and enterogastrostomy to defunction the pylorus. In another three patients, distal duodenal excisions were done. RESULTS: In four patients, an uneventful recovery was made. One patient died following a myocardial infarction. The surgery lasted meanly 160 minutes with average blood loss of approximately 500 milliliters. The mean hospital stay was 12 days. Enteral nutrition was introduced within the 20 hours after the surgery. Long term follow-up of all surviving patients confirmed a good outcome and normal nutritional status. CONCLUSION: Based on the presented series of patients, we suggest that pancreas-sparing duodenectomy can be considered in selected patients with laceration of the duodenum deemed unsuitable for surgical reconstruction.