Introduction. Fixation of posterior malleolar fragments associated with ankle fractures aims to stabilise the syndesmosis and prevent posterior subluxation. Haraguchi described 3 types of posterior malleolar fractures, with type 2 being a medial extension injury, these fractures often involve medial and posterior fragments. We describe the techniques and outcomes for a double window posteromedial approach allowing optimal reduction and stabilisation. Methods. A retrospective review was performed at 2 units, Bristol Royal Infirmary and QE Hospitals Birmingham, between August 2014 and April 2016. Inclusion criteria were all patients having this posteromedial approach for closed ankle fracture fixation. Patients were assessed for complications and postoperative ankle function with the Olerud and Molander scoring system. Results. We identified 9 patients treated over an 18 months with average follow up 9 months (range 4–18 months). All had an ankle dislocation reduced on scene or in ED, with 5 having posterior subluxation of the talus on the original films. None were open injuries. All had fixation of a posteromedial malleolar fragment, with 7 requiring a further direct lateral incision. Olerud and Molander ankle function score averaged at 72 (range 60–85) at short term follow up. Discussion. Approaches to the posteromedial fragments have been previously described in 2 ways. One utilises a window just medial to the Achilles tendon taking the neurovascular bundle medially, while the other approaches between tibialis posterior and FDL taking the neurovascular bundle laterally. Neither delivers complete access to an injury that often has sagittal and coronal splits needing individual reduction and fixation. Our approach over the neurovascular bundle allows 2 safe corridors through a single incision facilitating fragment specific fixation of both the medial and posterior components of the injury. Early results suggest this to be a safe and reliable technique to reduce and stabilise complex posteromedial ankle fractures

Aims

Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis.

Open reduction and internal fixation of tibial plateau fractures is traditionally performed through an anterior, anterolateral or an anteromedial approach and more recently a posteromedial approach. These approaches allow satisfactory access to the majority of fracture patterns with the exception of posterolateral tibial plateau fractures. To improve access to posterolateral tibial plateau fractures, we developed a posterolateral transfibular neck approach that exposes the tibial plateau between the posterior margin of the iliotibial band and the PCL. The approach can be combined with a posteromedial and/or an anteromedial approach to the tibial plateau. Since April 2007, we have used this approach to treat nine posterolateral tibial plateau fractures. All cases were followed up prospectively. Fracture reduction was assessed on radiographs, CT scans and arthroscopicaly. Maintenance of fracture reduction was assessed with radiostereometric analysis. Clinical outcomes were measured using Lysholm and KOOS scores. Anatomic or near anatomic reduction was achieved in all cases. All fractures healed uneventfully and no loss of osteotomy or tibial plateau fracture reduction was identified on postoperative plain X-rays. In the cases monitored with radiostereometric analysis, the fracture fragments displaced less than 2 mm during the course of healing. All osteotomies healed either at the same rate or quicker than the tibial plateau fractures. There were no signs and no symptoms of lateral or posterolateral instability of the knee during or after the healing of the osteotomy. There were no complications related to the surgical approach, including the fibular head osteotomy. All wounds healed uneventfully and there were no symptoms related to the CPN. The patient reported outcomes recorded for this group at six months, using the Lysholm score (mean 71, median 77, range 42–95), compared favourably to the entire cohort of 33 patients treated operatively at our institution for a tibial plateau fracture and followed up prospectively during the same time period (mean 64, median 74, range 20–100). The posterolateral transfibular approach for lateral tibial plateau fractures is an approach that should be considered for a certain specific pattern of fractures of the lateral tibial plateau. Our preliminary results demonstrated no complications through the learning curve of the development of this technique

Purpose: The aim of this prospective controlled study was to assess the natural history of acetabular development in D.D.H. treated under 18 months of age. Method: For this purpose, patients who were treated using a posteromedial approach soft tissue surgical procedure due to unilateral D.D.H., had intraoperative radiographic anatomic reductions, had neither any type of avascular necrosis of the femoral head nor breakage of the Shenton’s line during the follow-up period, had complete follow-up till at least 10 years of age and had normal center-edge angles at the latest follow-up were selected from a prospective series that started in December 1993. Unaffected contrlateral hips were used as controls. Fourteen hips of 14 patients (13 females and 1 male) met the above mentioned strict criteriae and included the study. Acetabular angle of Sharp (AA) was measured to assess the acetabular slope in the frontal plane preoperatively and during follow-up. A paired t-test was used for the statistical analysis of the data and a P value less than 0.05 was considered significant. Conclusion: In anatomically reduced and uncomplicated dysplastic hips which have been treated under 18 months of age, acetabular slope in the frontal plane tends to improve continuosly till at least 10 years of age and reaches to similar angular values as in the unaffected hips at nearly 7 years of age. In such hips, it may not be appropriate to make a final decision on whether the acetabular development is sufficient or not before 7 years of age

Fasciae represent a very interesting source of thin, well vascularized soft tissue, which allows gliding of the underlying tendons, especially for coverage of particular anatomical zones, such as the dorsal aspect of the hand and fingers. Some fasciae (such as the fascia temporalis free fiap) have already been used in this way as free fiaps for the coverage of the extremities. The aim of this study was to investigate the blood supply of the posterior brachial fascia (PBF), in order to precise the anatomical bases of a new free fascial fiap. Our study was based on dissections of 18 cadaveric specimens from 10 formalin preserved corpses. Six upper limbs were used to fictively harvest this fiap. The PBF was thin; its surface was broad, easily separable of the overlying subcutaneous and underlying muscular planes in its upper two thirds. It was richly blood supplied by two main pedicles:. the posterior brachial neurocutaneous branch and. the fascial branch of the upper ulnar collateral artery. The well vascularized area was 115mm long and 54mm broad in average. These two pedicles were quite constant (respectively 17 cases and 14 cases out of the 18 specimens) and of sufficient caliber to allow microsurgical anastomoses in good conditions. A rich venous network, satellite of the arteries, was always present. An arterial by-pass between both arterial pedicles could spare venous sutures when both arterial pedicles are present and communicating within the fascial depth (13 cases out of 18). Harvesting the fiap was easy through a posteromedial approach in a patient in supine position. The donor site could always be closed and its scare was well acceptable. The first clinical case is presented in a patient suffering from recurrent tendinous adhesions at the dorsum of the hand after a close trauma with extensive hematoma, after failure of 2 previous tenolyses. After a third tenolysis, the free PBF fiap was performed. The fascia was covered with a free skin graft at day 6. The coverage was nice and the outcome of the tenolysis at 6 month was -15/80 (active motion) and +20/100 (passive motion)

Purpose of the study: One of the most frequent complications of medial meniscal suture is injury to the saphenous nerve or its branches. The purpose of this study was to ascertain the relations of the medial meniscus with the infrapatellar branches of the saphenous nerve. Material and methods: Twenty lower limbs were dissected to study the pathways of the saphenous nerve and its branches in relation to different landmarks of the medial meniscus and palpable bony zones. Sixteen measurements were made on each knee held in extension. Results: The infrapatellar trunk of the saphenous nerve exhibited two terminal branches in all knees dissected. Level of the bifurcation in relation to the joint space varied. Similarly the position of the branches varied greatly in relation to different landmarks. The most frequent configuration was a main trunk situated 8 mm anteriorly to the tubercle of the great adductor and 60 mm from the mid point of the medial border of the patella. The bifurcation into two branches was situated 23 mm above the joint space. The two branches ran obliquely anteriorly and inferiorly forming an angle of 55° on average with a vertical line. The superior branch ran 24 mm behind the anterior meniscal point and 55 mm from the posterior meniscal point; the inferior branch ran 42.6 mm and 38 mm from these two points. Discussion: Injury to the saphenous nerve or its branches is mainly observed for suturing techniques done medially to laterally. Incidence has reached 38% in certain series. This incidence has declined with the increasingly widespread use of arthroscopy, but saphenous injury still occurs for meniscal repairs using a posteromedial approach. The risk is similar for medially to laterally or laterally to medially sutures. Since there is no safety zone, it would be advisable to prefer an «all medially» technique. Conclusion: Measurements made on dissection specimens enabled us to delimit three zones of increasing risk for nerve injury. The zone with the highest risk measures 20 mm wide. Its anterior limit is situated behind the most anterior meniscal point and its posterior limit is situated 28 mm from the posterior meniscal point

Aim: This study was carried out in order to clarify the causes that are mainly responsible for the necessity of reoperation after the initial correction of the deformity in congenital talipes equinovarus. The cases, which had been treated surgically with the same method and recurred later, were studied retrospectively in order to be ascertained epidemiological data related to the disease, to be isolated operative findings related to its pathology and to be estimated the surgical results based on clinical and radiological criteria. Material-Methods: During the 15-year-period from 1990 to 2004, 123 infants (196 feet) with congenital talipes equinovarus have been treated operatively. There were 88 males and 35 females. Seventy three patients (59.3%) had the deformity bilaterally, 20 patients in right foot and 30 in left. Family history was positive in 5 infants. Other congenital anomalies coexisted in 12 infants (9.7%). Preoperative application of successive plasters was started into the first week for 93 infants (75.6%) and its duration was 3 months for 83.7% of cases. All the patients have been operated on with posteromedial approach, extensive ligament division and generous release of soft tissues during the first year of age. Two thirds of cases (67.4%) were treated surgically into the first 6 months of age. Results: Anatomical variations were revealed during the operation in 14 feet (7.1% of the cases). The clinical results as well as the radiological signs into the first 6 postoperative months were satisfactory, but a reoperation was necessary in 21 feet (in 14 infants) for correction of part of the initial deformity into the following 2–5 years. The clinical criteria were related to the manner of standing and walking, the range of motion of the foot joints and block test. The radiological criteria were related to anteroposterior and lateral talocalcaneal angles and the angle between the longitudinal axis of the talus and that of the first metatarsal in the anteroposterior view as well as the position of the calcaneus in the lateral view. The causes that led to recurrence were related to imperfect correction with the plasters, to incomplete release of soft tissues during the initial operation and to some likely predisposing congenital and environmental factors. Conclusions: The prevention of recurrence of the initial deformity, in the operative correction of congenital talipes equinovarus, is mainly related to the attentive pre-operative application of plasters, the careful lege artis surgical technique and the early diagnosis and treatment of the predisposing factors

Purpose: We report our expeience with the medial and posteromedial approach to the humerus for plate fixation of fractures of the distal two-thirds of the humerus. Material: Fifteen patients (eleven men and four women) were treated for fractures (n=13) or nonunion (n=2) situated below the proximal third of the humerus without radial nerve involvement. Methods: Eight patients were installed in the supine position for median approach between the humerus bundle and the median nerve anteriorly and the ulnar nerve posteriorly. The posteriomedian approach, with the ulnar nerve posteriorly and the brachial triceps anteriorly, was used for seven other patients installed in the prone position. The fixation plate applied to the medial aspect allowed at least six corticals on either side of the fracture line. The patients were immobilised for 45 days. Passive rehabilitation exercises involved the elbow and the shoulder without external rotation. Clinical and x-ray follow-up data were available for all patients. Results: One patient was lost to follow-up two months after surgery: at this time the x-ray had demonstrated bone healing. Function could not be assessed as the fracture had occurred on the same side as the hemiplegia also caused by the initial trauma. For the fourteen other patients, mean follow-up was 12 months (range 6 – 36). Three patients operated via the median approach presented paraesthesia in the median nerve territory which was regressive in two. There were no neurological complications in the posteromedian approach group. Function was good for elbow and shoulder except for two patients. Bone healing was achieved in all cases. Discussion: These approaches allowed avoiding dissection of the radial nerve and provided a more aesthetic scar. Several difficulties were encountered with the median approach and reduction was difficult to control. In such cases it is advisable to widen the exposure to avoid stretching the median nerve. These approaches are contraindicated if radial nerve injury is identified preoperatively. Conclusion: Osteosynthesis of the humerus via a median approach avoids the need for radial nerve dissection. Reduction appears to be easier via the posteromedian approach with less risk than with the median approach

Aims

To investigate health-related quality of life (HRQoL) of older adults (aged ≥ 60 years) after tibial plateau fracture (TPF) compared to preinjury and population matched values, and what aspects of treatment were most important to patients.

The April 2015 Trauma Roundup³⁶⁰ looks at: Negative presure wound therapy in open tibial fractures; Priority-driven approach to pelvic injuries; Early surgery essential in hip fracture management; Sheer fractures to the posteromedial plateau; Fasciotomy closure under the spotlight; Why do patients die from hip fracture?; Acetabular fractures down the line; Biomechanics of femoral neck fractures reviewed