Bone-graft harvesting from iliac and fibular donor sites: techniques and complications.

The ilium and the fibula are the most common sites for bone-graft harvesting. The different methods for harvesting iliac bone graft include curettage, trapdoor or splitting techniques for cancellous bone, and the subcrestal-window technique for bicortical graft. A tricortical graft from the anterior ilium should be taken at least 3 cm posterior to the anterior superior iliac spine (ASIS). Iliac donor-site complications include pain, neurovascular injury, avulsion fractures of the ASIS, hematoma, infection, herniation of abdominal contents, gait disturbance, cosmetic deformity, violation of the sacroiliac joint, and ureteral injury. The neurovascular structures at risk for injury during iliac bone-graft harvesting include the lateral femoral cutaneous, iliohypogastric, and ilioinguinal nerves anteriorly and the superior cluneal nerves and superior gluteal neurovascular bundle posteriorly. Violation of the sacroiliac joint can be avoided by limiting the harvested area to 4 cm from the posterior superior iliac spine (PSIS) and by not penetrating the inner cortex. The caudal limit for bone harvesting should be the inferior margin of the roughened area anterior to the PSIS on the outer table to keep from injuring the superior gluteal artery. Potential complications of fibular graft harvesting include neurovascular injury, compartment syndrome, extensor hallucis longus weakness, and ankle instability. The neurovascular structures at risk for injury during fibular bone-graft harvesting include the peroneal nerves and their muscular branches in the proximal third of the fibular shaft and the peroneal vessels in the middle third.     

Enlarged perforating branch of peroneal artery and extra crural fascia in close relationship with the tibiofibular syndesmosis

We found an extremely large perforating branch of peroneal artery in an 89-year-old female cadaver’s left ankle. The anterior tibial artery could not reach to supply the ankle and dorsum of the foot. The perforating branch of peroneal artery continued as the dorsalis pedis after giving off an anterior lateral malleolar artery branch. The posterior tibial artery was thinner than usual. On the anterior side of the ankle, there was an extra crural fascia in addition to the regular crural fascia, under the anterior crural muscles. This strong fascia was tightly overlying the perforating branch of peroneal artery and anterior tibiofibular ligament. It is important to know the relationship of these vessels to the surrounding structures. Surgeons must be careful while dissecting this area since the perforating branch of peroneal artery might be anomalously enlarged as well as crossing in front of the tibiofibular syndesmosis in order to prevent vascular injury.This study presented as poster presentation at “22nd Annual Meeting of the American Association of Clinical Anatomists and 4th Joint International Meeting with the British Association of Clinical Anatomists July 20–23, 2005, New York City, NY, USA”.     

Removal of the less invasive stabilization system

The Less Invasive Stabilization System (LISS; Synthes; Paoli, PA) is a newly developed locking plate that has been used for fixation of distal femoral supracondylar and proximal tibial fractures. The early clinical results have been encouraging; however, there is little information available on the removal of these implants. Frequent stripping of the locking screws has been found by our group when removal is attempted. Our approach to this problem is described.     

Extensor hallucis longus innervation: an anatomic study

Thirty legs from skeletally mature embalmed cadavers were dissected to define the most common pattern and the variants of innervation of the extensor hallucis longus muscle and its clinical significance. Twenty-seven muscles had only one innervating branch (90%). Only three muscles had two innervating branches (10%). Twenty-one of the branches entered the muscles from the fibular side (63.6%), six entered the muscles from the tibial side (18.2%), and six entered the muscles from the anterior edge (18.2%). The branches innervating the extensor hallucis longus from the fibular side had a closer relation with the fibular periosteum than those entering the muscle from the tibial side or the anterior edge. The mean length of these branches between their points of origin and entry in the extensor hallucis longus was 5.0 +/- 1.5 cm. The high risk zone for the iatrogenic injury to the muscular branch of the extensor hallucis longus was located between 5.9 +/- 1.7 and 10.9 +/- 1.7 cm inferior to the most distal palpable point of the fibular head. The current study confirmed that the extensor hallucis longus was supplied mostly by one nerve that usually entered the muscle from the fibular side and had a close relation to the fibular periosteum in the dangerous zone.     

Postoperative upper extremity radiographs using the image intensifier: a simple adjunct to the "inverted" C-arm technique

When the C-arm is used as a table in upper extremity surgery, postoperative plain radiographs can be obtained by placing the x-ray cassette directly on the image intensifier. This has many advantages, including more rapid performance than conventional techniques, a high-quality image, and no need for a recovery room radiograph. Additionally, there is no overlying splint material to obscure image detail, and the extremity can be positioned as desired by the operating surgeon.     

Percutaneous skeletal joysticks for closed reduction of femoral shaft fractures during intramedullary nailing.

Closed locked intramedullary nailing remains the most common method for treating femoral shaft fractures. At times a closed reduction of these fractures can be difficult. A percutaneous skeletal joystick represents a simple method that can aid in the reduction maneuver.     

High-risk foot and ankle patients

The surgical treatment of complicated foot and ankle problems requires recognition and appreciation of patient and disease characteristics that may compromise surgical results. Appropriate patient selection is an important factor in obtaining a successful outcome. Modulation and management of these patient characteristics are critical in minimizing complications that are associated with treatment.     

Assessing biomechanics and associated factors in individuals with patellofemoral pain in a clinical setting: A qualitative study based on interviews with expert clinicians

ObjectivesTo explore the perspectives of ten clinicians from different medical disciplines with experience in managing PFP on how to conduct biomechanical assessments in individuals with PFP in a clinical setting.MethodsAn explorative qualitative design was used to explore the perspectives of ten clinicians with at least five years of experience managing patients with patellofemoral pain. A series of semi-structured interviews were done over Zoom video chat. The participants were from six different medical disciplines (physiotherapy, biokinetics, podiatry, sport science, sports medicine, orthopaedic surgery). Data was analysed thematically.ResultsFour main themes emerged from the data. These were: 1) biomechanical contributing factors that clinicians routinely screen for in patients with PFP; 2) relevant functional activities for biomechanical screening in patients with PFP; 3) conducting gait analysis assessments in a clinical setting; and 4) challenges of biomechanical assessment in patients with PFP. The clinicians expressed conflicting opinions on the usefulness of clinical gait analysis. The clinicians questioned the clinical applicability of some of the biomechanical factors identified as important in the evidence.ConclusionsIt is important for clinicians to include the biomechanical assessment of functional activities linked to pain when managing patients with PFP. However, some of the biomechanical factors identified in the evidence are too difficult to observe without 3D movement analysis equipment and should not be considered clinically relevant. Expert clinical opinion is important to provide contextual information when addressing biomechanics in individuals with PFP.