Safe zones and a technical guide for cerclage wiring of the femur: a computed topographic angiogram (CTA) study.

INTRODUCTION: Cerclage wiring for reduction of complex femoral shaft fractures can create iatrogenic vascular injury. OBJECTIVE: To describe the anatomical relation of blood vessels to the femur and develop a technical guide for safe passage of cerclage wire. MATERIALS AND METHODS: CT lower-limb angiographs (CTA) of 80 patients were reviewed and analysed to identify the superficial femoral artery (SFA) and the deep femoral artery (DFA) as well as the relation of those arteries to the femoral cortex. The total length of the femur was measured and divided into eight equal segments (seven levels). At each level, the medial half of the femur was divided into eight sectors labelled A through H and the position of the SFA and DFA was recorded. The shortest distance between the femoral cortex and the SFA and DFA at each level was measured. The data was analysed using STATA version 10.0. RESULTS: The average total femoral length from the tip of greater trochanter to lateral joint line was 402.98 ± 26.16 cm. The average distances from the SFA to the femur (d1) for levels 1 through 7 were 37.20 ± 5.0, 32.09 ± 4.74, 27.13 ± 4.19, 27.71 ± 5.46, 23.71 ± 4.40, 13.63 ± 3.59 and 10.08 ± 3.09 mm, respectively. The average distances between the DFA and the femur (d2) for levels 1 through 3 were 26.70 ± 4.13, 14.76 ± 3.27 and 9.58 ± 3.79 mm, respectively. The position of the SFA is located in sectors B through E at levels 1-3 and in sectors E through H at levels 4-7 and the position of the DFA located in sectors B through F at levels 1-3. CONCLUSION: Cerclage wiring should be started from the posterior intermuscular septum at the linea aspera. The safe area is the proximal half (midshaft) of the femur where the SFA and DFA lie at a safe distance from the femur. Between the midshaft and the distal 1/4, insertion of the passer must be done meticulously with the tip kept close to posteromedial cortex. Below the distal 1/4, the tip of the passer should be kept close to the posterior cortex to avoid injury to the SFA and the sciatic nerve.

Percutaneous cerclage wiring and minimally invasive plate osteosynthesis (MIPO): a percutaneous reduction technique in the treatment of Vancouver type B1 periprosthetic femoral shaft fractures.

BACKGROUND: Periprosthetic femoral fractures (PPFs) associated at or near a well-fixed femoral prostheses (Vancouver type-B1) present a clinical challenge due to the quality of the bone stock and instability of the fracture. OBJECTIVES: The purpose of this study was to present a novel reduction technique and analyze clinical and radiographic outcome in patients with Vancouver type-B1 fractures treated with percutaneous cerclage wiring for fracture reduction and maintenance of reduction with minimally invasive plate osteosynthesis (MIPO) utilizing a locking compression plate (LCP). METHODS: Between March 2007 and December 2008, ten consecutive patients with spiral, oblique or wedge Vancouver type-B1 were treated with closed percutaneous cerclage wiring using a new cerclage passer instrument (Synthes) through small 2-3 cm incisions for reduction and maintenance of reduction. Internal fixation with MIPO was obtained utilizing a long LCP Synthes bridging the fracture. The reduction time, fixation time and operative time were recorded. The rehabilitation protocol consisted of partial weight bearing as tolerated. Clinical and radiographic outcomes included evidence of union, return to pre-injury mobility, and surgical complications were recorded. RESULTS: There were three men and seven women with an average age of 74 years (range 47-84 years) at the time the fracture occured. The average follow-up was 13.2 months. One patient died 2 months after surgery due to cardiovascular problems and was excluded. The average reduction time with percutaneous cerclage wiring was 24.4 min (range 7-45 min). The average fixation time was 79 min (range 53-100 min). The average operative time was 103 min (range 75-140 min). Blood loss was minimal and only two patients needed a blood transfusion. All fractures healed with a mean time to union of 18 weeks (range 16-20 weeks). There was one implant which bent 10° in the post-operative period but went on to heal uneventfully within 16 weeks. There was no evidence of loosening of any implants. Seven patients returned to their previous level of mobility. Two patients required a walker. There were no implant failures, wound complications or infections. CONCLUSIONS: Percutaneous reduction of spiral, oblique or wedge-type B1 PPFs with percutaneous cerclage wiring combined with minimally invasive locking plate osteosynthesis provided satisfactory reduction, adequate stability and healing in nine patients. Our early results suggest that this reduction technique and fixation may be a useful solution for this growing challenge in orthopaedics. The authors caution that this technique must be done carefully to avoid serious complications, e.g., vascular injury.

Posterior approach technique for accessory-suprascapular nerve transfer: a cadaveric study of the anatomical landmarks and number of myelinated axons.

Accessory-suprascapular nerve transfer by the anterior supraclavicular approach technique was suggested to ensure transferrance of the spinal accessory nerve to healthy recipients. However, a double crush lesion of the suprascapular nerve might not be sufficiently demonstrated. In that case, accessory-suprascapular nerve transfer by the posterior approach would probably solve the problem. The aim of this study was to evaluate the anatomical landmarks and histomorphometry of the spinal accessory and suprascapular nerve in the posterior approach. Dissection of fresh cadaveric shoulder in a prone position identified the spinal accessory and suprascapular nerve by the trapezius muscle splitting technique. After that, nerves were taken for histomorphometric evaluation. The spinal accessory nerve was located approximately halfway between the spinous process and conoid tubercle. The average distance from the conoid tubercle to the suprascapular nerve (medial edge of the suprascapular notch) is 3.3 cm. The mean number of myelinated axons of the spinal accessory and suprascapular nerve was 1,603 and 6,004 axons, respectively. The results of this study supported the brachial plexus reconstructive surgeons, who carry out accessory-suprascapular nerve transfer by using the posterior approach technique. This technique is an alternative for patients who have severe crushed injury of the shoulder or suspected double crush lesion of the suprascapular nerve.

Electromyographic comparison of various exercises to improve elbow flexion following intercostal nerve transfer.

We compared the quantitative electromyographic activity of the elbow flexors during four exercises (forced inspiration, forced expiration, trunk flexion and attempted elbow flexion), following intercostal nerve transfer to the musculocutaneous nerve in 32 patients who had sustained root avulsion brachial plexus injuries. Quantitative electromyographic evaluation of the mean and maximum amplitude was repeated three times for each exercise. We found that mean and maximum elbow flexor activity was highest during trunk flexion, followed by attempted elbow flexion, forced inspiration and finally forced expiration. The difference between each group was significant (p < 0.001), with the exception of the difference between trunk flexion and attempted elbow flexion. Consequently, we recommend trunk flexion exercises to aid rehabilitation following intercostal nerve transfer.

Pulmonary and biceps function after intercostal and phrenic nerve transfer for brachial plexus injuries.

This pseudo-randomized study was performed to compare the pulmonary function and biceps recovery after intercostal (19 cases) and phrenic (17 cases) nerve transfer to the musculocutaneous nerve for brachial plexus injury patients with nerve root avulsions. Pulmonary function was assessed pre-operatively and postoperatively by measuring the forced vital capacity, forced expiratory volume in 1 second, vital capacity, and tidal volume. Motor recovery of biceps was serially recorded. Our results revealed that pulmonary function in the phrenic nerve transfer group was still significantly reduced 1 year after surgery. In the intercostal nerve transfer group, pulmonary function was normal after 3 months. Motor recovery of biceps in the intercostal nerve group was significantly earlier than that in phrenic nerve group. We conclude that pulmonary and biceps functions are better after intercostal nerve transfer than after phrenic nerve transfer in the short term at least.