In this study, we discuss 68 cases in which peripheral nerve trunks were inadvertently divided by surgeons. Most of these accidents occurred in the course of planned operations. Delay in diagnosis and in effecting repair was common. We list the nerves particularly at risk and the operations in which special care is needed. We recommend steps to secure prompt diagnosis and early treatment.
Advanced 3D imaging and CT-based navigation have emerged as valuable tools to use in total knee arthroplasty (TKA), for both preoperative planning and the intraoperative execution of different philosophies of alignment. Preoperative planning using CT-based 3D imaging enables more accurate prediction of the size of components, enhancing surgical workflow and optimizing the precision of the positioning of components. Surgeons can assess alignment, osteophytes, and arthritic changes better. These scans provide improved insights into the patellofemoral joint and facilitate tibial sizing and the evaluation of implant-bone contact area in cementless TKA. Preoperative CT imaging is also required for the development of patient-specific instrumentation cutting guides, aiming to reduce intraoperative blood loss and improve the surgical technique in complex cases. Intraoperative CT-based navigation and haptic guidance facilitates precise execution of the preoperative plan, aiming for optimal positioning of the components and accurate alignment, as determined by the surgeon’s philosophy. It also helps reduce
Percutaneous stabilisation of tibial fractures by locking plates has become an accepted form of osteosynthesis. A potential disadvantage of this technique is the risk of damage to the neurovascular bundles in the anterior and peroneal compartments. Our aim in this anatomical study was to examine the relationship of the deep peroneal nerve to a percutaneously-inserted Less Invasive Stabilisation System tibial plate in the lower limbs of 18 cadavers. Screws were inserted through stab incisions. The neurovascular bundle was dissected to reveal its relationship to the plate and screws. In all cases, the deep peroneal nerve was in direct contact with the plate between the 11th and the 13th holes. In ten specimens the nerve crossed superficial to the plate, in six it was interposed between the plate and the bone and in the remaining two specimens it coursed at the edge of the plate. Percutaneous insertion of plates with more than ten holes is not recommended because of the risk of injury to the neurovascular structures. When longer plates are required we suggest distal exposure so that the neurovascular bundle may be displayed and protected.
Vascular injuries during total hip arthroplasty
(THA) are rare but when they occur, have serious consequences. These have
traditionally been managed with open exploration and repair, but
more recently there has been a trend towards percutaneous endovascular
management. We performed a systematic review of the literature to assess
if this change in trend has led to an improvement in the overall
reported rates of morbidity and mortality during the last 22 years
in comparison with the reviews of the literature published previously. We found a total of 61 articles describing 138 vascular injuries
in 124 patients. Injuries because of a laceration were the most
prevalent (n = 51, 44%) and the most common presenting feature,
when recorded, was bleeding (n = 41, 53.3%). Delay in diagnosis
was associated with the type of vascular lesion (p <
0.001) and
the clinical presentation (p = 0.002). Open exploration and repair was the most common form of management,
however percutaneous endovascular intervention was used in one third
of the injuries and more constantly during the last 13 years. The main overall reported complications included death (n = 9,
7.3%), amputation (n = 2, 1.6%), and persistent ischaemia (n = 9,
7.3%). When compared with previous reviews there was a similar rate
of mortality but lower rates of amputation and permanent disability,
especially in patients managed by endovascular strategies. Cite this article:
I never considered this to be a significant problem if it is noticed. (back to that later) Aaron Rosenberg's report seems to have agreed, but at the last members meeting of the Knee Society, Boston, September 2009, others had experience that contradicted my view. With their experience, ultimately the results were very substantially compromised. This video and presentation show you how to avoid a bad result, actually obtain a perfect result, if you or your student assistant, resident or fellow, bags the MCL. There are three important points. (1) One needs to recognise the occurrence. (2) The setting is usually varus and so direct end-to-end repair cannot be depended upon. (3) Use of a semitendinosis tenodesis, together with an imperfect, distracted direct repair works perfectly well! (1) Recognition: The setting is usually varus, but I have had one case in which the chief resident, working with the fellow succeeded in getting the MCL in a valgus knee! In this usually tight varus setting the key feature is that at some point in the case, before component placement, one notices that the exposure is all of a sudden better! Now, the guilty resident or just a passive assisting resident/fellow will usually disagree. The extension space is not so obviously lax, but the flexion space is. Secondly, you do not feel an intact ligament in flexion. And, to prove it I have had to do a little more exposure of the superficial MCL to show the tear. There are at least three mechanisms. Most common is a saw cut. Next is possibly injury with the scalpel or cutting cautery during exposure, and last is damage essentially pre-operatively by a very sharp medial osteophyte which has thoroughly abraded the ligament. Laxity in full flexion is not necessarily obvious as the posterior capsular integrity helps hide the instability. Again, the really intact ligament is well felt, and in the situation of laceration, the tibia pulls forward more on the medial side, the medial flexion space opens, and what was usually a tight exposure gets suddenly better. (2) When varus is the setting, I have found it impossible or at least uncomfortable to depend upon direct repair. When the soft tissues are needing to be released or simply undergoing more stress than usual and a lot more than on the lateral side, I see it as unwise to expect or depend upon only a medial repair to hold. (3) The semitendinosis tenodesis has worked essentially perfectly in every one of my cases. These patients have had no post-operative instability and they have had better than average to extremely good ROM. A presumably key point is not to alter the patient's post-operative regimen! And, to avoid some passive alteration of PT, I advise specifically that the surgeon or those in his/her team do not mention the occurrence to the patient, the family or the PT! I put the whole story in the op-note, and weeks later I will specifically tell the patient what the staple in place is all about.
I never considered this to be a significant problem if it is noticed. (back to that later) Aaron Rosenberg's report seems to have agreed, but at the last members' meeting of the Knee Society, Boston, September 2009, others had experience that contradicted my view. With some experience, ultimately the results were very substantially compromised. This video and presentation show you how to avoid a bad result, actually obtain a perfect result, if you or your student assistant, resident or fellow, bags the MCL. There are three important points. (1) One needs to recognise the occurrence. (2) The setting is usually varus and so direct end-to-end repair cannot be depended upon. (3) Use of a semitendinosis tenodesis, together with an imperfect, distracted direct repair works perfectly well!
Recognition: The setting is usually varus, but I have had one case in which the chief resident, working with the fellow succeeded in getting the MCL in a valgus knee! In this usually tight varus setting the key feature is that at some point in the case, before component placement, one notices that the exposure is all of a sudden better! Now, the guilty resident or just a passive assisting resident/fellow will usually disagree. The extension space is not so obviously lax, but the flexion space is. Secondly, you do not feel an intact ligament in flexion. And, to prove it I have had to do a little more exposure of the superficial MCL to show the tear. There are at least three mechanisms. Most common is a saw cut. Next is possibly injury with the scalpel or cutting cautery during exposure, and last is damage essentially pre-op by a very sharp medial osteophyte which has thoroughly abraded the ligament. Laxity in full flexion is not necessarily obvious as the posterior capsular integrity helps hide the instability. Again, the really intact ligament is well felt, and in the situation of laceration, the tibia pulls forward more on the medial side, the medial flexion space opens, and what was usually a tight exposure gets suddenly better. When varus is the setting, I have found it impossible or at least uncomfortable to depend upon direct repair. When the soft tissues are needing to be released or simply undergoing more stress than usual and a lot more than on the lateral side, I see it as unwise to expect or depend upon only a medial repair to hold. The semitendinosis tenodesis has worked essentially perfectly in every one of my cases. These patients have had no post-operative instability and they have had better than average to extremely good ROM. A presumably key point is not to alter the patient's post-operative regimen! And, to avoid some passive alteration of PT, I advise specifically that the surgeon or those in his/her team do not mention the occurrence to the patient, the family or the PT! I put the whole story in the op-note, and weeks later I will specifically tell the patient what the staple in place is all about.
To evaluate the functional outcome of open humerus diaphyseal fractures treated with the Three-stitch technique of antegrade humerus nailing. This is a retrospective study conducted at the Department of Orthopaedics in D. Y. Patil University, School of Medicine, Navi Mumbai, India. The study included 25 patients who were operated on from January 2019 to April 2021 and follow-ups done till May 2022. Inclusion criteria were adult patients with open humerus diaphyseal fractures (Gustilo-Anderson Classification). All patients with closed fractures, skeletally immature patients, and patients with associated head injury were excluded from the study. All patients were operated on with a minimally invasive Three-stitch technique for antegrade humerus nailing. All patients were evaluated based on DASH score. Out of the 25 patients included in the study, all patients showed complete union. The mean age of the patients was 40.4 years (range 23–66 years). The average period for consolidation of fracture was 10.56 weeks (range 8–14 weeks). The DASH score ranged from 0 to 15.8 with an average score of 2.96. Five patients reported complications with three patients of post-operative infection and delayed wound healing and two patients with screw loosening. All complications were resolved with proper wound care and the complete union was noted. None of the patients had an
Several studies have evaluated the risk of peroneal nerve (PN) injuries in all-inside lateral meniscal repair using standard knee magnetic resonance imaging (MRI) with the 30 degrees flexed knee position which is different from the knee position during actual arthroscopic lateral meniscal repair. The point of concern is “Can the risk of PN injury using standard knee MRIs be accurately determined”. To evaluate and compare the risk of PN injury in all-inside lateral meniscal repair in relation to both borders of the popliteus tendon (PT) using MRIs of the two knee positions in the same patients. Using axial MRI studies with standard knee MRIs and figure-of-4 with joint fluid dilatation actual arthroscopic lateral meniscal repair position MRIs, direct lines were drawn simulating a straight all-inside meniscal repair device from the anteromedial and anterolateral portals to the medial and lateral borders of the PT. The distance from the tip of each line to the PN was measured. If a line touched or passed the PN, a potential risk of
Background. Open subtalar arthrodesis has been associated with a moderate rate of non-union, as high 16.3%, and high rates of infection and nerve injury. Performing this operation arthroscopically serves to limit the disruption to the soft tissue envelope, improve union rates and reduce infection. Our study describes our outcomes and experience of this operation. Method. Retrospective review of all patients who underwent an arthroscopic subtalar arthrodesis between 2023 and 2008. We excluded patients undergoing concurrent adjacent joint arthrodesis. The primary aim was to report on rates of union. Secondary outcomes included reporting on conversion to open procedure, duration of surgery, infection, and
Recent literature has demonstrated that conventional arthroscopic techniques do not adequately visualise areas of predilection of pathology of the long head of biceps (LHB) tendon and are associated with a 30–50% rate of missed diagnoses. The aim of this study was to evaluate the safety, effectiveness and ease of performing biceps tenoscopy as a novel strategy for reducing the rate of missed diagnoses. Five forequarter amputation cadaver specimens were studied. The pressure in the anterior compartment was measured before and after surgical evaluation. Diagnostic glenohumeral arthroscopy was performed and the biceps tendon was tagged to mark the maximum length visualised by pulling the tendon into the joint. Biceps tenoscopy was performed using 3 different techniques (1. Flexible video-endoscopy, 2. Standard arthroscopy via Neviaser portal. 3. Standard arthroscope via antero-superior portal with retrograde instrumentation). Each was assessed for safety, ease of the procedure and whether the full length of the extra-articular part of the LHB tendon could be visualised. The t-test was used to compare the length of the LHB tendon visualised at standard glenohumeral arthroscopy vs that visualised at biceps tenoscopy. An open dissection was performed after the arthroscopic procedures to evaluate for an
Introduction: Injury to the distal third of the axillary artery is well recognised as a complication of proximal humeral fractures. However the risk of
Controversy remains regarding the optimal treatment for
Controversy remains regarding the optimal treatment for
Controversy remains regarding the optimal treatment for
Objective:. To observe the incidence of intra-operative vascular injuries during anterior cervical decompression and fusion (ACDF). Secondly, management and monitoring of the outcome post vascular injury during ACDF. Methods:. This a prospective study. A review of all spinal patients' records was performed from June 2006 to April 2011. A comprehensive literature review was also utilized. Inclusion criteria – all patients had ACDF post trauma. All non-traumatic cases were excluded. Results:. The study consisted of 55 patients; 15 were females and 40 were males. The age distribution was 23–65 years. Two patients were excluded due to non-traumatic causes. Of the remaining 53 patients, four sustained intra-operative vascular injuries during ACDF surgery. All 4 patients had corpectomies, and one case was an
Introduction and Aims: The Lateral Femoral Cutaneous Nerve is placed at risk of
Intramedullary tibial nailing was performed in ten paired cadavers and the insertion of a medial-to-lateral proximal oblique locking screw was simulated in each specimen. Anatomical dissection was undertaken to determine the relationship of the common peroneal nerve to the cross-screw. The common peroneal nerve was contacted directly in four tibiae and the cross-screw was a mean of 2.6 mm (1.0 to 10.7) away from the nerve in the remaining 16.
Introduction. Soft tissue releases are often required to correct deformity and achieve gap balance in total knee arthroplasty (TKA). However, the process of releasing soft tissues can be subjective and highly variable and is often perceived as an ‘art’ in TKA surgery. Releasing soft tissues also increases the risk of
Aims. We set out to determine if there is a difference in perioperative outcomes between early and delayed surgery in paediatric supracondylar humeral fractures in the absence of vascular compromise through a systematic review and meta-analysis. Materials and Methods. A literature search was performed, with search outputs screened for studies meeting the inclusion criteria. The groups of early surgery (ES) and delayed surgery (DS) were classified by study authors. The primary outcome measure was open reduction requirement. Meta-analysis was performed in the presence of sufficient study homogeneity. Individual study risk of bias was assessed using the Risk of Bias in Non-Randomised Studies – of Interventions (ROBINS-I) criteria, with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria used to evaluate outcomes independently. Results. A total of 12 studies met the inclusion criteria (1735 fractures). Pooled mean time to surgery from injury was and 10.7 hours for ES and 91.8 hours for DS. On meta-analysis there was no significant difference between ES versus DS for the outcome of open reduction requirement. There was also no significant difference for the outcomes: