How to Get to the Distal Posterior Tibial Malleolus? A Cadaveric Anatomic Study Defining the Access Corridors Through 3 Different Approaches.

OBJECTIVE: Our objective is to review the anatomy and exposure of the posterior column and posterior tibial malleolus (the posterior tibial plafond) by defining the access corridors through 3 different approaches-posteromedial, posterolateral, and modified posteromedial. METHODS: Cadaveric dissection with percentage of posterior tibial malleolus exposed, and strain gauge measurements to evaluate traction on the neurovascular bundle. RESULTS: The 3 different approaches are applicable for exposure of different portions of the distal posterior tibial malleolus. Strain gauge measurements reveal the least traction on the flap containing the neurovascular bundle with the modified posteromedial approach (7.0 N) compared with the posteromedial (21.5 N) and posterolateral (16.8 N) approaches. Exposure of the posterior tibial malleolus was greater with the modified posteromedial approach (91%) compared with the other 2 approaches (posteromedial = 64%, posterolateral = 40%). CONCLUSIONS: Depending on the location of the principal fracture fragments, particularly in high energy ankle and pilon fractures, each of the posterior approaches has its indication, with the modified posteromedial approach revealing more of the posterior anatomy than the other 2 approaches. The latter approach places the least traction on the flap containing the neurovascular bundle.

Strategies for surgical approaches in open reduction internal fixation of pilon fractures.

Pilon or tibial plafond fractures usually result from high-energy injuries with rotation and/or axial compression. They occur in an area of relatively poor soft tissue coverage and frequently present a surgical challenge in deciding which incisions will be best for performing open reduction internal fixation. A variety of anterior and posterior approaches have been described based on the ease of fracture reduction and internal fixation with plates. Some of the incisions are fracture specific, that is, planned for a limited approach to the pilon. But in more complex cases, a wider exposure is indicated and thus more extensile approaches, both anterior and posterior, can be valuable. This review article will describe the different surgical approaches, focusing on their indication and technique.

A modified posteromedial approach combined with extensile anterior for the treatment of complex tibial pilon fractures (AO/OTA 43-C).

The anterior approaches that have been described for open reduction internal fixation of multifragmentary pilon fractures are designed to reconstruct the comminuted and impacted anterior articular surface onto a stable posterior column. Thus, reduction of the posterior column, particularly proper length, is critical. There are differing opinions of how best to surgically approach the posterior pilon fracture. There is also no clear indication as to the timing of both anterior and posterior reconstructions. Our objectives were (1) to develop a more midline posterior approach that might provide better visualization of the posterior aspect of the posterior column and juxtametaphyseal/diaphyseal parts of the tibia, first on the cadaver and then with patients, and (2) to use this as part of a combined posterior and anterior approach during the same anesthesia for complex tibial pilon fractures (AO/OTA 43-C) in a preliminary study of 6 patients.

[Lower limb amputation: indication, preoperative workup and complications]. / Amputations du membre inférieur: indications, bitan et complications.

The main causes of lower limb amputations are peripheral artery disease (92% of the cases) and trauma (7%). The selection of the amputation level aims at optimizing the chances of healing and the functionality of the involved limb. Foot preserving amputations offer the best functional outcome but the healing process is frequently slow and difficult. After a below-knee amputation, 60% of the patients are capable of ambulating again, whereas only 20% of the patients undergoing an above-knee amputation ambulate autonomously. Complications after amputations are frequent, can occur a long time after surgery and must be managed by a highly specialized team.

[Metatarsalgia: diagnosis and treatment]. / Métatarsalgies: diagnostic et prise en charge.

Metatarsalgias refer to pain localized in the forefoot and under the metatarsal heads. It is one of the main reasons for specialist consultation. Consequences of a wide array of different diseases, they require a biomechanical and systematic approach to fully understand their cause and presentation in a variety of clinical presentations. Treatment, either conservative or surgical, is based on an accurate knowledge of their etiology and meets specific criteria of classification.

Realignment and extended fusion with use of a medial column screw for midfoot deformities secondary to diabetic neuropathy. Surgical technique.

BACKGROUND: The failure of nonsurgical treatment of patients with midfoot and hindfoot deformity secondary to diabetic Charcot arthropathy may lead to a rocker-bottom foot deformity with recurrent or persistent plantar ulceration. We report our experience with realignment and extended fusion with primary use of a medial column screw for this midfoot deformity. METHODS: From July 2001 through July 2005, we performed reconstructive surgery on fifteen adults with diabetes mellitus who had a severe neuropathic midfoot deformity consisting of a collapsed plantar arch with a rocker-bottom foot deformity. Thirteen had a nonhealing midfoot plantar ulcer. All underwent realignment and arthrodesis with a medial column screw; some required additional fixation techniques depending on the extent of the deformity. Outcome measures included ulcer and surgical wound-healing, radiographic results, complications, and the need for amputation. RESULTS: The mean duration of clinical follow-up was forty-two months. Fourteen patients were able to walk, and there were no recurrent plantar ulcers. Thirteen patients were able to wear custom-made extra-depth, wide-toed shoes with molded inserts. One patient without prior ulceration had development of a deep infection that necessitated an amputation. Four feet had a nonunion, one of which was symptomatic requiring a revision to obtain union. CONCLUSIONS: Surgical reconstruction of a collapsed neuropathic foot deformity is technically demanding, but a successful outcome can result in a plantigrade foot that is free of ulceration and abnormal pressure points and a patient who is able to walk. The procedure described has an acceptable degree of complications although it has a high rate of nonunion.

[What's new in forefoot surgery]. / Chirurgie de l'avant-pied: quoi de neuf?

New implants and instruments have recently emerged in foot surgery. However, an additional and important development is the technique of minimally invasive surgery. As a result of new surgical approaches some common foot deformities can be corrected in a percutaneous manner. The benefits include improved wound healing, less pain, faster recovery, and less need for outpatient care. The main indications for such a technique are hallux valgus, correction of the lesser metatarsals, hallux rigidus, and some diabetic foot deformities.

The extensile approach for the operative treatment of high-energy pilon fractures: surgical technique and soft-tissue healing.

Perhaps the most important advancement in the surgical treatment of high-energy pilon fractures has been the recognition of the need to delay primary surgery. However, at open reduction internal fixation an adequate incision must be made to clearly visualize the articular surface in an attempt to restore intraarticular anatomy. This article illustrates our extensile approach and its effect on soft-tissue healing. The approach allows complete access to the ankle joint to achieve reduction and fixation of the articular surface, as far medially or laterally as is necessary. In addition, it allows for easy placement of plates medially, laterally, or anteriorly. For fractures extending more proximally, plates can be placed subcutaneously from distal to proximal through the open incision.