Outcomes following medial open reduction in infants aged ≤6 months with developmental dysplasia of the hip.

Aim: To evaluate mid-long term radiological outcomes following early medial approach open reduction (MAOR) performed for developmental dysplasia of the hip (DDH) in infants aged ≤6 months old at time of surgery, specifically incidence of clinically significant avascular necrosis (AVN), Severin outcomes and rates of further surgery. Methods: This is a single centre retrospective study of patients treated from 1999 to 2017. Only infants aged ≤6 months old at time of MAOR, and aged at least 6 years old at latest follow-up were included (minimum 5.5 years follow-up). Data was collected from electronic healthcare records and serial radiographs reviewed to assess outcomes. AVN was classified according to Kalamchi and MacEwen, with types 2-4 considered clinically significant. Severin classes I (excellent) and II (good) were considered satisfactory outcomes, and classes III + considered unsatisfactory. Results: MAOR was performed on 48 hips in 44 patients. Mean age at time of surgery was 4 months (SD 1.4, range 2-6), with mean follow-up of 9.8 years (SD 2.7, range 6.2-16.2). Clinically significant AVN developed in 9/48 hips (19 %), all of which were type 2. Only 1/48 hips (2 %) required a subsequent pelvic osteotomy due to residual dysplasia with subluxation at 2 years post MAOR. At final follow-up, 81 % of patients had excellent or good radiological outcomes (Severin I/II). No statistically significant predictors for developing AVN, including age and presence of ossific nucleus, were identified. Conclusion: Early MAOR in infants aged ≤6 months was associated with a very low rate of significant residual dysplasia requiring further surgery, yet was not associated with unacceptable rates or severe forms of AVN. We therefore recommend MAOR is performed early to optimise acetabular remodelling potential and minimise the need for concurrent or subsequent bony procedures.

A case report on ultrasound-guided pericardiocentesis with a right parasternal approach: a novel in-plane lateral-to-medial technique.

INTRODUCTION: Emergency pericardiocentesis is a life-saving procedure that is performed to aspirate fluid from the pericardial space in patients who have severe pericardial effusion that is causing hemodynamic compromise. The current gold standard for pericardial fluid aspiration is ultrasound-guided pericardiocentesis. Echocardiography with a low-frequency transducer has generally been used in pericardiocentesis, but this method lacks real-time visualization of the needle trajectory, leading to complications. Therefore, we describe a case involving an ultrasound-guided pericardiocentesis method using a novel in-plane technique with a lateral-to-medial approach via the right parasternal and a high-frequency probe. The method was performed for an infant with cardiac tamponade. CASE PRESENTATION: We present a case of a 14-month-old male infant who was brought to the emergency room with a history of cough, shortness of breath, and fever following recurrent chest infections. Despite prior treatments, his condition deteriorated, and signs of cardiac tamponade were evident upon examination. Cardiopulmonary point-of-care ultrasound confirmed the presence of a large pericardial effusion with tamponade. Emergency pericardiocentesis was performed using the novel in-plane technique, resulting in successful fluid aspiration and stabilization of the patient's condition. TECHNIQUE DESCRIPTION: The proposed technique involves positioning a high-frequency ultrasound probe over the right parasternal area to obtain real-time visualization of the needle trajectory and surrounding structures, including the sternum, right internal thoracic vessels, pleural sliding end point, pericardial effusion, and myocardium. The needle is inserted laterally to medially at a 45-degree angle, ensuring safe passage between the pleural sliding endpoint and the right internal thoracic vessels while reaching the pericardial effusion. CONCLUSION: The presented technique provides real-time visualization of the needle and surrounding structures, which may potentially help to avoid complications and improve accuracy. The proposed technique may potentially enable access for emergency pericardiocentesis and for loculated pericardial effusion that has formed around the right atrium. Nevertheless, further studies with large patient populations are needed.

Anatomical quantitative evaluation of popliteal artery visualization during medial approach in supine position.

PURPOSE: The medial approach to the popliteal artery has been less commonly used than the posterior approach in surgical repair of traumatic popliteal injury. This study was performed to quantitatively evaluate the visual field of the popliteal artery obtained by staged myotendotomy in the medial approach to the popliteal artery. METHODS: Twenty legs of fresh-frozen adult cadavers were dissected using the medial approach to the popliteal artery. In stage 1, the popliteal artery was exposed between the vastus medialis and sartorius muscles without myotendotomy. In stage 2, the medial head of the gastrocnemius muscle was dissected. In stage 3, the tendons of the sartorius and semimembranosus muscles were dissected. In stage 4, the tendons of the gracilis and semitendinosus muscles were dissected to fully expose the popliteal artery. The length of the popliteal artery that could be visualized in each stage was measured. RESULTS: The anatomical length of the popliteal artery from the hiatus of the adductor magnus to the tendinous arch of soleus muscle ranged from 15 to 20 cm (mean, 16.3 cm). On average, 45%, 59%, 72%, and 100% of the popliteal artery were visualized in stage 1, 2, 3, and 4, respectively. CONCLUSIONS: The medial approach to the popliteal artery has the advantage of being performed in the supine position, but it requires multiple myotendotomies around the knee. The results of this study may serve as a reference for myotendotomy depending on the site of injury to the popliteal artery.

Endoscopic endonasal combined transoral medial approach to the nasopharynx, parapharyngeal space, and jugular foramen.

OBJECTIVE: This study aimed to validate the feasibility of an endoscopic endonasal combined transoral medial approach for treating lesions in the nasopharynx, parapharyngeal space (PPS), and jugular foramen. METHODS: Anatomical and imaging information of six patients who underwent surgery via this approach were reviewed and analyzed. RESULTS: The feasibility and advantages of the endoscopic endonasal combined transoral medial approach, which uses an inside-to-outside medial surgical corridor, were identified. Total resection was achieved in 3 cases with benign tumors. Safe resection margins were obtained in 2 cases with recurrent nasopharyngeal carcinoma (NPC). Pathological biopsy of NPC lesion between the Eustachian tube and arterial sheath was achieved. The internal carotid artery (ICA) was accurately located and protected in all cases and no complications occurred. CONCLUSION: Lesions in the nasopharynx, PPS, and jugular foramen can be directly assessed via this approach. The ICA can be well identified during the surgery.

Lateral versus medial approach for total knee arthroplasty for valgus knee deformity shows comparable functional outcomes, hip-knee-ankle angle values, and complication rates: a meta-analysis of comparative studies.

INTRODUCTION: The aim of this meta-analysis of comparative studies was to update the current evidence on functional and radiographic outcomes and complications between medial and lateral approaches for total knee arthroplasty (TKA) for valgus knee deformity. MATERIALS AND METHODS: The PubMed, MEDLINE, Scopus, and the Cochrane Central databases were used to search keywords and a total of ten studies were included. The methodological quality of the included studies was assessed. Data extracted for quantitative analysis included the Knee Society score (KSS), range of motion (ROM), surgical time, hip-knee-ankle angle (HKA), and number and types of complications. Random- and fixed-effect models were used for the meta-analysis of pooled mean differences (MDs) and odds ratios (ORs). The Mantel-Haenszel method was adopted. RESULTS: A total of 1008 patients were identified, of whom 689 and 319 underwent TKA for valgus knee deformity with lateral and medial approach, respectively. The mean age was 70 ± 9.5 and 67.3 ± 9.6 years for the lateral and medial approaches, respectively. The mean follow-up was 37.8 ± 21.9 and 45.9 ± 26.7 months for the lateral and medial approach groups, respectively. Significantly higher functional outcomes were found for the medial approach, as measured by the postoperative KSS (MD = 1.8, 95% CI [0.48, 3.12], P = 0.007) and flexion ROM (MD = 3.12, 95% CI [0.45, 5.79], P = 0.02). However, both of these differences were lower than the minimal clinically important difference. Comparable surgical time and postoperative HKA angle values (MD = 0.22, 95% CI [- 0.30, 0.75], P = 0.40) between the two surgical approaches were found. The incidence of periprosthetic joint infections, fractures, transient peroneal nerve injuries, and deep vein thrombosis was comparable. CONCLUSION: This meta-analysis of comparative studies showed that when lateral and medial approaches are used for total knee arthroplasty for valgus knee deformity, comparable functional outcomes in terms of the KSS and ROM, surgical time, and postoperative hip-knee-ankle angle values can be expected. Similar rates of periprosthetic joint infection, fracture, and peroneal nerve injury were also found. LEVEL OF EVIDENCE: I. PROSPERO REGISTRATION NUMBER ID: CRD42023392807.

Medial helical versus straight lateral plating of distal femoral fractures-a biomechanical comparative study.

BACKGROUND: Distal femoral fractures are commonly treated with lateral straight plates. However, the lateral approach may not always be desirable, and 180°-helical plates may be an alternative. AIM: To investigate the biomechanical competence of 180°-helical plating versus standard straight lateral plating of unstable fractures at the distal femur. METHODS: Twelve left artificial femora were instrumented with a 15-hole Locking Compression Plate-Distal Femur, using either 180°-helical plates (group 1) or conventional straight lateral plates (group 2). An unstable distal femoral fracture AO/OTA 33-A3.3 was simulated. All specimens were biomechanically tested under quasi-static and progressively increasing combined cyclic axial and torsional loading in internal rotation until failure. FINDINGS: Initial axial stiffness (N/mm) was significantly higher in group 1 (185.6 ± 50.1) compared to group 2 (56.0 ± 14.4), p < 0.001. Group 1 demonstrated significantly higher initial interfragmentary flexion (°) and significantly lower initial varus/valgus deformation (°) under 500 N static axial compression versus group 2 (2.76 ± 1.02 versus 0.87 ± 0.77 and 4.08 ± 1.49 versus 6.60 ± 0.47), p ≤ 0.005. Shear displacement (mm) under 6 Nm static torsion was significantly higher in group 1 versus group 2 in both internal (1.23 ± 0.28 versus 0.40 ± 0.42) and external (1.21 ± 0.40 versus 0.57 ± 0.33) rotation, p ≤ 0.013. Cycles to failure and failure load (N) (clinical/catastrophic) were significantly higher in group 1 (12,484 ± 2116/13,752 ± 1518 and 1748.4 ± 211.6/1875.2 ± 151.8) compared to group 2 (7853 ± 1262/9727 ± 836 and 1285.3 ± 126.2/1472.7 ± 83.6), p ≤ 0.001. INTERPRETATION: Although 180°-helical plating using a pre-contoured standard straight lateral plate was associated with higher shear and flexion movements, it demonstrated improved initial axial stability and resistance against varus/valgus deformation compared to straight lateral plating. Moreover, the helical plates were associated with significantly higher endurance to failure. From a biomechanical perspective, 180°-helical plating may be considered as a valuable alternative to standard straight lateral plating of unstable distal femoral fractures.

Laparoscopic excision of a retroperitoneal pseudocyst using a modified medial approach: A case report.

INTRODUCTION: Retroperitoneal pseudocysts of non-pancreatic origin are rare. Although the laparoscopic approach has been used for their treatment, laparotomy remains the mainstream strategy for these lesions. PRESENTATION OF CASE: We report the case of an asymptomatic 51-year-old male patient who was incidentally diagnosed with a retroperitoneal pseudocyst. Computed tomography showed a 3 × 3 cm cystic lesion in the retroperitoneum, localized between the third part of the duodenum and the inferior vena cava. The patient underwent complete laparoscopic excision using a modified right-sided colonic resection procedure (modified medial approach), and histopathological examination revealed a non-pancreatic retroperitoneal pseudocyst. The patient was discharged without any complications, and no postoperative recurrence was detected. DISCUSSION: Complete excision is of great significance in the treatment of retroperitoneal cysts. There have been few studies on the laparoscopic approach for retroperitoneal pseudocysts. A laparoscopic procedure is less invasive and helps identify the correct tissue planes to ensure complete resection and prevent inadvertent injury to adjacent vital structures. We detached the retroperitoneal lesion from the duodenum and safely removed it without damaging the surrounding organs by a modified medial approach. CONCLUSIONS: Retroperitoneal pseudocysts can be resected laparoscopically by identifying the correct tissue planes and adjacent vital structures.

Medial minimally invasive percutaneous plate osteosynthesis for humeral shaft fractures: a case series and novel technique description.

INTRODUCTION: Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) is increasingly favored for treating humeral shaft fractures (HSFs). However, conventional MIPPO techniques pose challenges in fixing fractures near fossa olecranon and carry a risk of iatrogenic radial nerve palsy. A novel technique using a medial MIPPO for treating humeral shaft fractures (HSFs) is described. Results of clinical follow-up are presented. MATERIALS AND METHODS: This study is a retrospective case series study. Twenty-one patients (mean age 43.9 ± 17.66 [22‒81] years) with HSFs were treated with the novel MIPPO fixation method. Clinical outcomes including time for radiographic consolidation, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and complications were assessed at the last follow-up. The mean follow-up was 26 ± 17.12 (range 12-67) months. RESULTS: All patients had a bony union at a mean of 15.76 ± 6.74 (range 8-40) weeks based on X-ray with an early and aggressive range of motion. The complication rate was 0. The mean DASH score was3.29 ± 4.09 (range 0-14.17) at the time of the last follow-up. The mean screw density was 0.49 ± 0.1 (range 0.2-0.65). CONCLUSION: This novel surgical technique for HSFs is a viable alternative to previously described methods with the advantage of being less prone to nerve injury and easy to fix distal extra-articular HSFs. The learning curve is short. LEVEL OF EVIDENCE: IV.

A Contemporary Clinico-Anatomical Guide to Craniovertebral Junction Surgery.

Background Surgical treatment of ventral and ventrolateral lesions of the craniocervical junction are among the most challenging neurosurgical pathologies to treat. Three surgical techniques, the far lateral approach (and its variations), the anterolateral approach, and the endoscopic far medial approach can be used to approach and resect lesions in this area. Objective The aim of the study is to examine the surgical anatomy of three skull base approaches to the craniocervical junction and review surgical cases to better understand the indications and possible complications for each of these approaches. Methods Cadaveric dissections with standard microsurgical and endoscopic instruments were performed for each of the three surgical approaches, and key steps and surgically relevant anatomy were documented. Six patients with appropriate pre-, post-, and intraoperative imaging and video documentation are presented and discussed accordingly. Results Based on our institutional experience, all three approaches can be utilized to safely and effectively approach a wide variety of neoplastic and vascular pathology. Unique anatomical characteristics, lesion morphology and size, and tumor biology should all be considered when determining the optimal approach. Conclusion Preoperative assessment of surgical corridors with 3D illustrations helps to define the best surgical corridor. 360 degree knowledge of the anatomy of craniovertebral junction allows safe surgical approach and treatment of ventral and ventrolateral located lesions using one of the three approaches.

Novel mobilization of the medial approach without changing the position for robotic right hemicolectomy.

Conventional laparoscopic or robotic surgery for right-sided colon cancer often requires intraoperative repositioning and removal of the bowel. Changing positions during robotic surgery can be troublesome and robotic removal of the small intestine carries a risk of unexpected injury because robotic devices have a strong grasping force and no sense of touch. Herein, we introduce a novel mobilization of the medial approach without changing the position for robotic right hemicolectomy. Using this technique, mobilization is performed in counterclockwise succession, allowing all mobilizations and bowel removal to be completed sequentially, without positional change.

Case report: A case of injury to the infrapatellar branch of the saphenous nerve caused by medial approach in knee arthroscopy.

We present the case of a 72-year-old man who was referred to our department for treatment of pain on the anteromedial infrapatellar side of the right knee with sensory disturbance that began 2 years earlier. The patient previously underwent right knee arthroscopy at another hospital for a meniscus injury 2 years earlier, which relieved his knee pain, but pain and discomfort near the incision of the medial portal persisted. Given this situation, various physical treatments, such as ice compress, were administered postoperatively. However, the symptom was only partially relieved before discharge. Subsequently, the patient visited two other hospitals and began taking oral pregabalin and duloxetine for treatment of the pain based on a diagnosis of right common peroneal nerve injury. The pain in the same dermatomal distribution was slightly relieved, but a withdrawal reaction was observed. However, the results of an ultrasound at our hospital indicated that the right medial quadriceps femoris tendon showed a hypoechoic area suggesting inflammatory changes. Physical examination of the right knee detected atrophy of the quadriceps femoris muscle, decreased muscle strength (M4), obvious tenderness in the medial side, radiating pain along the anterior tibia, and sensory disturbance (S3+); the results of a drawer test, McMurray test, pivot shift test, and lateral stress test were negative. Based on the aforementioned evidence, a diagnosis was made of injury to the infrapatellar branch of the saphenous nerve, after which neurolysis of the nerve in question was carried out. An enlarged incision was made along the original medial approach. Scar hyperplasia was observed after careful separation of the subcutaneous tissue. During neurolysis, branches were found wrapped in the scar; their continuity and integrity were confirmed after relief. The released nerve was placed in a physiological position. The patient's pain was clearly relieved, and numbness disappeared on the first postoperative day. At 1-month follow-up, all symptoms were found to have resolved.

Comparison of dorsal and medial arthroscopic approach to canine coxofemoral joint: a cadaveric study.

BACKGROUND: Arthroscopic exploration of ventromedial part of canine coxofemoral joint is limited in conventional dorsal approach. OBJECTIVES: We evaluated the efficacy of a medial arthroscopic approach to the coxofemoral joint of dogs by analyzing the joint visible area and performing a safety analysis. METHODS: Arthroscopic approaches to the coxofemoral joint were made in five cadavers using a traditional (dorsal) and novel (medial) approach. Three observers scored the visible area of images and videos of the acetabulum and femur. A safety analysis was performed via dissection of the medial hind limb. The distance between neurovascular structures and arthroscopic portals was measured. RESULTS: The acetabulum was more visible in the dorsal than in the medial approach, with mean visualization scores of 16 ± 0.00 and 11.83 ± 1.26, respectively. The medioventral side of the femur was significantly more visible in the medial than in the dorsal approach, with mean visualization scores of 3.9 ± 0.99 and 6.93 ± 0.58, respectively. Safety analysis confirmed the medial portal site was safe, provided that the surgeon has comprehensive knowledge of the joint. The minimum distance from the arthroscopic medial portals to the nearest neurovascular structures was 2.5 mm. CONCLUSIONS: A medial arthroscopic approach to the canine coxofemoral joint has potential clinical application. Dorsal and medial approaches differ significantly and have distinct purposes. The medial approach is useful to access the ventromedial joint, making it an eligible diagnostic method for an arthroscopic evaluation of this area.

Inferior versus medial approach in laparoscopic colectomy with complete mesocolic excision and D3 lymphadenectomy for right-sided colon cancer: A propensity-score-matched analysis.

AIM: In laparoscopic colectomy with complete mesocolic excision and D3 lymphadenectomy for right-sided colon cancer, either an inferior approach (IA) or a medial approach (MA) is selected in our institution based on the surgeon's preference. The present study compared the treatment outcomes between IA and MA. METHOD: This retrospective, single-centre study using propensity score matching analysed the short- and long-term outcomes of laparoscopic surgery in patients with right-sided colon cancer from 2010 to 2019 at Cancer Institute Hospital. RESULTS: After patient selection, 1011 patients remained for the analysis, of which 67% underwent IA surgery and 33% underwent MA surgery. After propensity score matching (1:1), 325 patients in each group were analysed. Regarding the short-term outcomes, there were no significant differences in the operation time, rate of conversion to open surgery or postoperative complication rate (Clavien-Dindo Grade ≥ III) between the two groups, although the intra-operative median blood loss was significantly less in the IA group than in the MA group (IA, 13 ml vs. MA, 20 ml, P < 0.0001). Regarding the long-term outcomes, the relapse-free survival, liver-relapse-free survival, cancer-specific survival and overall survival were all similar between groups. CONCLUSION: Both the IA and MA in laparoscopic colectomy with complete mesocolic excision and D3 lymphadenectomy for right-sided colon cancer are safe and feasible approaches; the IA may have an advantage over the MA in terms of reduced intra-operative blood loss. Based on their similar oncological outcomes, either the IA or MA can be selected, based on one's preference.

Homemade pin-hook for surgical treatment of posterior cruciate ligament avulsion fractures.

BACKGROUND: How to treat the posterior cruciate ligament (PCL) tibial insertion small and comminuted avulsion fracture is still challenging. Our study evaluated the clinical and radiological outcomes after ORIF of PCL tibial insertion avulsion fractures through the inverted L-shaped postero-medial approach using a homemade pin-hook. METHODS: Between January 2009 and December 2020, twenty-four patients with isolated PCL tibial insertion bony avulsion were enrolled. There were 16 males and 8 females. The age range was 18-48 (32.5 ± 9.3) years. The time from injury to surgery was 1-10 (4.4 ± 2.8) days. There were 11 cases in the left knee and 13 cases in the right knee. The patients received anticoagulant therapy to prevent thrombosis. Preoperative standard X-ray, computerized tomography (CT) and magnetic resonance imaging (MRI) were performed. According to the Meyers-McKeever classification, there were 8 cases of type II and 16 cases of type III. RESULTS: The operation time was 60-120 (89.6 ± 19.8) min. Postoperative follow-up ranged from 3 to 18 months. The average follow-up was 11.4 ± 4.3 months. In all patients, one or two homemade pin-hooks were used to fix different sizes of fracture segments. X-ray or CT scans taken after surgery revealed fracture union. The fractures healed in 9-16 (11.8 ± 1.7) weeks. At the last follow-up, the patients were able to fully straighten. The ROM (132.6° ± 3.9°), the Tegner-Lysholm score (96.2 ± 2.3) and the IKDC scores (95.5 ± 1.6) were all significantly improved compared with the preoperative values (77.5° ± 13.1°, 46.8 ± 8.9, 36.2 ± 7.9). The posterior drawer test was negative. The gastrocnemius muscle strength did not diminish. No internal fixation migration was observed during the follow-up. No neurovascular bundle- or hardware-related complications were reported. CONCLUSIONS: The inverted L-shaped postero-medial approach with homemade pin-hook fixation for the treatment of PCL avulsion fractures produces acceptable clinical and radiological results. Moreover, the homemade pin-hook made of K-wires is affordable and reduces patient costs. It is a practical application and worth recommending, especially for community hospitals.

Lateral or Medial Parapatellar Surgical Approach to the Valgus Osteoarthritic Knee? A Retrospective Single-Center Study.

Aims: Total knee arthroplasty in patients with fixed valgus deformity is a demanding procedure. The aim of this study was to compare the clinical results of using the lateral approach [LA] versus the medial approach [MA] in the treatment of fixed valgus knee deformities. Methods: This single-center study compared the results of 143 consecutive patients with fixed valgus deformity (mean 21.55° valgus, mean age 68.2 years) undergoing LA Total Knee Arthroplasty [TKA] to 50 patients (mean 16.58° valgus, mean age 67.2 years) undergoing MA TKA. The mean follow-up period was 5.1 years (2−10 years). Data was collected from operative notes, routine postoperative visits, and radiological findings. Apart from a radiological evaluation, patients were clinically assessed both pre- and postoperatively using the Knee Society Score [KSS]. Descriptive statistics together with the Kolmogorov-Smirnov test, the Student's t-test for independent samples, and the Mann-Whitney U test were used. The level of significance in this study was α = 0.05. Results: In the LA group, the KSS Knee was significantly higher than in the MA group [85.31 vs. 77.42, respectively, p-value < 0.001]. The difference was also in the KSS total but with no statistical significance [155.17 vs. 149.22, p-value 0.087]. The surgery time in the LA group was shorter than in the MA group [81 vs. 91 min, respectively, p-value­0.002]. The complication rate after surgery was higher in the MA group than in the LA group (14% vs. 9%, respectively). Conclusions: The lateral approach is a good alternative to the standard medial parapatellar approach in the treatment of fixed valgus knee deformities. A higher postoperative KSS Knee, shorter surgery time, and similar complication rate make the lateral approach a valuable option for treating patients with osteoarthritis and fixed valgus knee deformity.

The posterior/medial dry needling approach of the tibialis posterior muscle is an accurate and safe procedure: a cadaveric study.

BACKGROUND: Evidence suggests that tibialis posterior muscle plays an important role in equinovarus foot deformity in patients who had suffered a stroke and it is one of the most frequently injected lower-extremity muscles for the management of spasticity. Our aim was to assess if a needle accurately and safely penetrates the tibialis posterior muscle during the application of dry needling.  METHODS : We conducted a cadaveric descriptive study. Needling insertion of the tibialis posterior was conducted in 11 cryopreserved cadavers with a 70 mm needle. The needle was inserted using two common approaches, at midpoint (posterior/medial approach) and at upper third (anterior approach) of the leg towards the tibialis posterior. The needle was advanced into the tibialis posterior based upon clinician judgement. Cross-sectional anatomical dissections were photographed and analyzed by photometry. Safety was assessed by calculating the distances from the tip and the path of the needle to proximate neurovascular structures. RESULTS: Accurate needle penetration of the tibialis posterior muscle was observed in all cadavers with both approaches. In general, distances from the needle to the neurovascular bundles were larger with the posterior/medial approach than with the anterior approach, reaching statistically significance for needle tip to nerve (mean difference: 0.6 cm, 95%CI 0.35 to 0.85 cm) and vascular bundle (mean difference: 0.55 cm, 95%CI 0.3 to 0.8 cm) distances (P < 0.001) and needle path to vascular bundle distance (difference: 0.25 cm, 95%CI 0.1 to 0.4 cm, P = 0.045). Age and gender did not influence the main results. CONCLUSIONS: This cadaveric study suggests that needling of the tibialis posterior muscle can be accurately and safely conducted. Safety seems to be larger with the posterior/medial approach when compared with the anterior approach.

Nasal Spine of the Frontal Bone: A Consistent Landmark for Safe Outside-In Frontal Drill-Out.

BACKGROUND: Outside-in frontal drill out entails drilling the frontal sinus floor in the midline before identifying and dissecting the frontal recesses. It is a more direct approach, especially in revision surgery or cases with challenging anatomy. OBJECTIVES: The aim of this study was to highlight the anatomical and surgical concepts for easy and safe outside-in frontal drill out by a preclinical anatomic study on cadaveric heads. In addition, to review our experience with this approach over a 5-year period for challenging frontal sinus pathologies. METHODS: The study included 2 sectors; a preclinical study, in which 5 cadaveric heads were dissected and studied to identify and standardize the anatomical landmarks of this approach. This was followed by a clinical case series which included 22 patients with challenging frontal sinus pathologies that were treated with this proposed approach. RESULTS: We concluded from the anatomic study that the nasal spine of the frontal bone (NSFB) and its anatomical orientation in relation to the nasal branch of the anterior ethmoidal artery (NBAEA) is a consistent landmark that enables the surgeon to identify the correct coronal trajectory of drilling to avoid injury of the cribriform and the skull base. The clinical case series included 22 patients that were successfully treated with the proposed approach. No intraoperative nor postoperative complications were reported in this study. Long-term follow-up showed that the frontal neo-ostium was patent in all cases (n = 22). CONCLUSION: Outside-in frontal drill-out is a safe and easy approach; especially in challenging frontal sinus pathologies; using the NSFB and its anatomical coronal orientation to the NBAEA as a consistent landmark, anterior to the skull base. This approach offers early, safe, and direct bone removal without the need for initial identification and dissection of the frontal recess.

Dislocation fracture of the femoral head in adult.

The smaller the head fragment, the more likely it is located at the bottom and in front of the femoral head, which then determines the most suitable approach. A CT scan is essential after reduction and before resumption of weight-bearing to verify the size and congruence of the fragments and whether there are foreign bodies and/or a fracture of the posterior wall. Classifications should include the size of the fragment and whether or not there is an associated fracture of the acetabulum or femoral neck (historical 'Pipkin', modernised 'Chiron'). In an emergency, the dislocation should be rectified, without completing the fracture (sciatic nerve palsy should be diagnosed before reduction). A hip prosthesis may be indicated (age or associated cervical fracture). Delayed orthopaedic treatment is sufficient if congruence is good. A displaced fragment can be resected (foreign bodies and » head), reduced and osteosynthesised (⅓ and ½ head), and a posterior wall fracture reduced and osteosynthesised. Small fragments can be resected under arthroscopy. The approach is medial (Luddloff, Ferguson, Chiron) to remove or osteosynthesise ⅓ or » fragments; posterior for ½ head or a fractured posterior wall. The results remain quite good in case of resection or an adequately reduced fragment. Long-term osteoarthritis is common (32%) but well tolerated with a low rate of prosthetisation. Avascular necrosis remains a possible complication (8.2%). Sciatic nerve palsy (4% of fracture dislocations) is more common for dislocations associated with posterior wall fractures.