The Effect of Graft Harvest and Skin Incision Angle on Sensory Disturbance in ACL Reconstruction With Semitendinosus-Gracilis Tendon Graft: A Randomized Controlled Trial and Cadaveric Study.

BACKGROUND: Injury to the inferior branch of the saphenous nerve (IBSN) and the subsequent loss of skin sensation after anterior cruciate ligament (ACL) reconstruction are common. The literature suggests that the incision angle may affect the incidence and area of loss of skin sensation. PURPOSE: To determine whether there is a difference in the incidence and area of altered sensory loss on the tibia between vertical (VI) and oblique (OI) incisions for semitendinosus-gracilis tendon graft harvest during ACL reconstruction. The cadaveric component was designed to determine whether there is a "safe zone" for incision by identifying the location and number of branches of the IBSN. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Patients (n = 37) were randomized to receive either VI or OI. Incidence and area of altered skin sensation were documented during at least 1 postoperative visit. In addition, 18 cadaveric knees were dissected. RESULTS: The presence or absence of hypoesthesia did not differ between groups postoperatively. Although no statistical differences between groups were seen in the total area of perceived altered skin sensation at 3 (P = .57), 6 (P = .08), 12 (P = .65), and 24 months (P = .27), data demonstrated a trend toward VI participants having a larger area of hypoesthesia at every time point. Among the 18 cadaveric specimens, 4 variations in the distribution of IBSN were noted: 18 (100%) had 1 branch, 14 (78%) had 2 branches, 6 (33%) had 3 branches, and 1 (6%) had 4 branches. No safe zone for incision could be identified. CONCLUSION: No difference was found between a vertical and an oblique incision with respect to incidence or area of sensory loss. Furthermore, it was not possible to identify a safe zone that would prevent transection of all nerves branches of the IBSN based on the cadaveric component of this study.

Percutaneous treatment of high-risk patients with intra-articular calcaneus fractures: a case series.

INTRODUCTION: Diabetics, smokers, patients with open fractures and drug addicts have shown to be at increased risk of having wound complications with traditional calcaneus fixation. The purpose of the study is to examine if high-risk patients with intra-articular calcaneus fractures can be managed safely using percutaneous reduction and fixation by examining a consecutive series of patients treated by the senior author. METHODS: The treatment group consisted of the senior author's first 17 percutaneously treated calcaneus fractures in high-risk patients. Risk factors included: open fracture, smoking, diabetes and cocaine, alcohol and solvent abuse. Reduction techniques included temporary external fixation, inflatable bone tamps, and arthroscopic assisted reduction manoeuvres. Fixation was accomplished with cannulated 4.5mm screws. Patients were followed up for 3 months minimum to look for wound complications and subsidence. RESULTS: Surgery was performed within 15 days from injury (average 6.7 days). Risk factors included: open fracture 1, smoking 16, diabetes 2, and substance abuse 9. Sanders' classification described: six type 2, nine type 3 and two type 4. Bohlers' angle increased from an average of -1.5° (range -37° to +30) to 25.8° (range 7-36°). There were no wound issues or infections with the calcaneal fixation. Reduction was deemed excellent or good in 14, fair in 2 and poor in 1. Loss of Bohlers' angle of >4° occurred in four cases; in three of these, the patients were non-compliant with weight bearing. CONCLUSION: High-risk patients with intra-articular calcaneus fractures that meet the criteria for surgical management can be managed with percutaneous surgical techniques with low risk of wound complications.

Determining the isometric point of the knee.

Posteromedial and posterolateral reconstructions of the knee are frequently required in the management of knee dislocations. This study compares the accuracy of radiographic reference points to established anatomical landmarks in reproducing the isometric points of the posteromedial corner and posterolateral corner (PLC) of the knee. Posteromedial and posterolateral surgical approaches were made in 20 cadaveric knees. The posteromedial and posterolateral isometric points of each femur were determined using the anatomic landmarks and radiographic reference points in a randomized order. An Isometer was used to measure the displacement, to the nearest millimeter; knees were passed into flexion. A two-tailed t-test was used to analyze the data and statistical significance was set to p < 0.05. For the isometric point of the PLC, the radiographic method resulted in a mean displacement of 1.63 mm as the knee was passed from extension into flexion, while the anatomic method had a mean displacement of 4.84 mm (p < 0.00018). The mean displacement on the posteromedial side using the radiographic method was 2.10 mm as the knee was passed from extension into flexion, while the anatomic method resulted in 3.21 mm of displacement (p = 0.074).

Arthroscopic management of C3 tibial plafond fractures: a technical guide.

Tibial plafond fractures are technically challenging and have the potential for serious complications. Minimizing soft tissue trauma can compromise visualization of articular reduction. There has been recent interest in the use of arthroscopy to improve visualization of plafond fractures while preserving the soft tissue envelope. Here the authors offer some technical points in order to simplify a technically demanding procedure.

Arthroscopic debridement of the talonavicular joint using dorsomedial and dorsolateral portals: a cadaveric study of safety and access.

PURPOSE: The purpose of this study was to examine the safety and access talonavicular arthroscopy provides for the purpose of arthrodesis through dorsomedial and dorsolateral portals in a cadaveric model. METHODS: The talonavicular joints of 8 cadaveric specimens were arthroscopically debrided, by use of a dorsomedial instrumentation portal and a dorsolateral visualization portal. The specimens were dissected with the arthroscopic equipment left in place, the distances from the edge of the instrument to the neurovascular structures were measured, and the specimens were then examined for signs of damage. Finally, the naviculars and tali were removed, and the percentage of debrided subchondral bone was determined by use of ImageJ software (National Institutes of Health, Bethesda, MD). RESULTS: Examination of the talonavicular joint showed mean subchondral debridement of 98.6% of the navicular and 83.2% of the talus. The dorsomedial portal had a median distance of 4.5 mm, 10.5 mm, and 7 mm to the superficial peroneal nerve, the medial terminal branch of the deep peroneal nerve, and the dorsalis pedis, respectively. The dorsolateral portal had a median distance of 1 mm to the lateral branch of the deep peroneal nerve, with the nerve found resting on the arthroscope in 2 specimens. CONCLUSIONS: Arthroscopic debridement of the talonavicular joint is possible. Because of the risk of damage to the lateral terminal branch of the deep peroneal nerve, an alternative to the dorsolateral portal should be considered. CLINICAL RELEVANCE: This study provides evidence that arthroscopic assisted talonavicular arthrodesis is possible but that further research is needed to ensure the safety of the technique.