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Injury to the medial compartment of the knee is the most common ligament injury to this joint. The medial approach must consider the presence of associated anteromedial instability. Untreated injury of these instabilities can result in failure of the other reconstructed ligaments. As treatment is usually associated with other ligaments, it is relevant that the technique could save grafts and synthetic material. This article aims to describe a technique for the treatment of anteromedial instabilities through semimembranosus tendon tenodesis in a more anterior and distal position, promoting the tensioning of the posteromedial structures., Technique Video Video 1 Reconstruction of a posteromedial structure of a left knee. The patient is in a supine position. The medial approach starts over the medial epicondyle up to 7 cm distal to the joint interline in the medial tibia surface. At this moment, the semitendinosus and gracilis tendons are removed and prepared to serve as a graft for the (MCLs). The direct tibial insertion of the semimembranosus (SM) tendon is individualized and reinserted from the tibia. Anterodistalization of this tendon is carried out, and posterior oblique ligament is tensioned on this anchor with knee flexed at 5°, neutral rotation, and without adduction. Finally, the MCLs are reconstructed and fixed in 30° of flexion using interference screws.

Several approaches have been reported during laparoscopic spleen-preserving distal pancreatectomy (LSPDP), such as medial, lateral, and posterior approaches. This study reports a tail-first approach that is mobilization of the pancreatic gland from tail to neck followed by division. The short-term outcomes are described. Cases which underwent LSPDP from 2014 to 2020 at Qilu Hospital of Shandong University were included. Clinical parameters were collected and analyzed. One hundred five cases were collected, including 54 Kimura, 45 Warshaw, and 6 modified-Warshaw procedures. Seventy-seven patients (73.3%) underwent LSPDP by a tail-first approach (TFA-LSPDP) and 28 (26.7%) by a medial approach (M-LSPDP). Compared with the M-LSPDP, the TFA-LSPDP group had a lower incidence of splenic infraction (9.1 VS 25.0%, P = 0.05) and a higher frequency of Kimura procedure (55.8 VS 39.3%, P = 0.053). TFA-LSPDP is feasible and safe for treatment of benign and low malignant lesions of the distal pancreas, which has a lower incidence of splenic infraction and a higher frequency of splenic vessel preservation compared with the traditional medial approach.

Numerous approaches were described for the management of Pipkin’s type I fracture with no consensus on the “standard of care”. The strategic thinking of the ideal access is through the medial approach. Using Ferguson intermuscular interval, prospective study was done (January 2014–2019) to evaluate radiological and functional outcomes using HHS and Thompson-Epstein criteria. Fracture patterns were subclassified: anterior and posterior-inferior (AI/PI) requiring different reduction positions. Twenty-one patients (mean FU = 24.3 months (range, 12–48)) were divided into 14 (67.7%) AI and seven PI. Excision was performed in five (23.8%) (AI = 3 (14.3%) and PI = 2) and ORIF in 16 (AI = 11 (52.4%) and PI = 5). At the last follow-up, two (9.5%) were graded as excellent, 11 (52.4%) as good, three (14.3%) as fair, and five as poor. Modified Ludloff’s approach provides safe easy direct access to fracture allowing easy excision or direct anatomical reduction, perpendicular compression, and rigid fixation with minimal complications.

Background and objectives: To evaluate the single-injection and triple-injection techniques in infraclavicular blocks with an ultrasound-guided medial approach in terms of block success and the need for supplementary blocks. Methods: This study comprised 139 patients who were scheduled for elective or emergency upper-limb surgery. Patients who received an infraclavicular blocks with a triple-injection technique were included in Group T (n = 68). Patients who received an infraclavicular blocks with a single-injection technique were included in Group S (n = 71). The number of patients who required supplementary blocks or had complete failure, the recovery time of sensory blocks and early and late complications were noted. Results: The block success rate was 84.5% in Group S, and 94.1% in Group T without any need for supplementary nerve blocks. The blocks were supplemented with distal peripheral nerve blocks in 8 patients in Group S and in 3 patients in Group T. Following supplementation, the block success rate was 95.8% in Group S and 98.5% in Group T. These results were not statistically significant. A septum preventing the proper distribution of local anesthetic was clearly visualized in 4 patients. The discomfort rate during the block was significantly higher in Group T (p Conclusion: In ultrasound-guided medial-approach infraclavicular blocks, single-injection and triple-injection techniques did not differ in terms of block success rates. The need for supplementary blocks was higher in single injections than with triple injections. The presence of a fascial layer could be the reason for improper distribution of local anesthetics around the cords.

Background The treatment of complex 3- and 4-part proximal humeral fractures has been controversial due to numerous postoperative complications. With the further study of medial support and blood supply of humeral head, new techniques and conception are developing. The study aims to illustrate the medial approach of the proximal humeral fracture through cadaver autopsy. Method Upper limbs from 19 cadavers have been dissected to expose the shoulder joint. We selected the coracoid process as the bony reference. Vernier caliper will be used to measure the following data, including distance from coracoid process to circumflex brachial artery, distance between anterior humeral circumflex artery (ACHA) and posterior circumflex brachial artery (PCHA) and their diameters. Assessment included the characteristics of the vascular supply around the humeral head, identification of the structures at risk, quality of exposure of the bony structures, and feasibility of fixation. Results The medial approach is appropriate in 86.84% anatomical patterns. Between the lower part of the shoulder capsule and the insertion of conjoined tendon, the bony surface exposed was limited by the interval between ACHA and PCHA. An interval of 2 to 3 cm (24.29 ± 3.42 mm) was available for medial plate. ACHA (49.35 ± 8.13 mm, 35.14–68.53 mm) and PCHA (49.62 ± 7.82 mm, 37.67–66.76 mm) were about 5 cm away from the coracoid process. Risk structures including ACHA and PCHA originate in common, PCHA originated from the deep brachial artery (DBA), the presence of perforator vessels, musculocutaneous nerve intersects with ACHA, the diameter of PCHA: ACHA Conclusion The medial approach opens a new perspective in the optimal management of complex fractures of proximal humerus. Anatomical research proves that the medial approach is feasible. The interval between ACHA and PCHA is suitable for placement. Anatomical pattern and indication have been discussed, and we hypothesized that ACHA has been destroyed in complex PHFs. With further studies on the anatomy and mechanism of injury, the development of more clinical cases will be an important work of our institution in the future.

Aims: Total knee arthroplasty in patients with fixed valgus deformity is a demanding procedure. The aim of this study was to compare the clinical results of using the lateral approach [LA] versus the medial approach [MA] in the treatment of fixed valgus knee deformities. Methods: This single-center study compared the results of 143 consecutive patients with fixed valgus deformity (mean 21.55° valgus, mean age 68.2 years) undergoing LA Total Knee Arthroplasty [TKA] to 50 patients (mean 16.58° valgus, mean age 67.2 years) undergoing MA TKA. The mean follow-up period was 5.1 years (2–10 years). Data was collected from operative notes, routine postoperative visits, and radiological findings. Apart from a radiological evaluation, patients were clinically assessed both pre- and postoperatively using the Knee Society Score [KSS]. Descriptive statistics together with the Kolmogorov-Smirnov test, the Student’s t-test for independent samples, and the Mann-Whitney U test were used. The level of significance in this study was α = 0.05. Results: In the LA group, the KSS Knee was significantly higher than in the MA group [85.31 vs. 77.42, respectively, p-value < 0.001]. The difference was also in the KSS total but with no statistical significance [155.17 vs. 149.22, p-value 0.087]. The surgery time in the LA group was shorter than in the MA group [81 vs. 91 min, respectively, p-value—0.002]. The complication rate after surgery was higher in the MA group than in the LA group (14% vs. 9%, respectively). Conclusions: The lateral approach is a good alternative to the standard medial parapatellar approach in the treatment of fixed valgus knee deformities. A higher postoperative KSS Knee, shorter surgery time, and similar complication rate make the lateral approach a valuable option for treating patients with osteoarthritis and fixed valgus knee deformity.

Objective: The aim of this retrospective study was to investigate clinical effects of the treatment of intra-articular distal humeral fractures via the combined posterior olecranon osteotomy and anterior approach and the combined lateral Kaplan approach associated with the medial approach. Methods: Between July 2010 and September 2019, 28 cases of intercondylar fractures of the distal humerus (AO/OTA type C) were treated by open reduction and internal fixation (ORIF) via the posterior and anterior approach and combined lateral-medial approach, which were divided into the P-A (n = 13) and L-M (n = 15) groups, respectively. The outcomes in terms of function were assessed using the range of motion (ROM) of the elbow and forearm, humerotrochlear (HT) angle, Visual Analogue Scale (VAS) scores, Mayo Elbow Performance Score (MEPS), and efficacy grade evaluated using the scoring system of Orthopaedic Trauma Association (OTA) at the one-year follow-up. Results: The flexion-extension of elbows and pronation-supination of forearms were respectively 114.1° ± 12.4° and 157.3° ± 9.6° in the P-A group and 117.1° ± 14.5° and 161.3° ± 10.7° in the L-M group. No significant difference was observed between the two groups for the elbow and forearm ROM (p > 0.05). Furthermore, surgery duration, blood loss volume, HT angle, MEPS, VAS scores, OTA rating, and the morbidity of postoperative complications during the one-year follow-up did not differ between groups. Conclusion: The posterior olecranon osteotomy and anterior approach can be used efficiently for exposure of complex distal humeral injuries with similar clinical efficacy and complications in the treatment of intra-articular distal humeral fractures as compared to the lateral-medial approach.

Resumen La movilización del ángulo esplénico del colon es considerada una maniobra compleja y de las más desafiantes en la cirugía colorrectal con vía laparoscópica. A pesar de que existen distintas opciones quirúrgicas para llevarla a cabo, el abordaje de medial a lateral debe ser la técnica de elección. A continuación, se presenta la técnica quirúrgica y la ventajas de este abordaje.

Background: Use of the flexor hallucis longus (FHL) tendon is well described for several tendon augmentation procedures. Harvesting the FHL through an open medial approach is commonly done, but is associated with anatomic risks. Recently, several authors have described a minimally invasive (MI) technique to harvest the FHL tendon utilizing a hamstring tendon stripper commonly used in ACL reconstruction. The purpose of this study was to evaluate the safety and effectiveness of harvesting the FHL tendon using this novel minimally invasive retrograde approach. Methods: The FHL tendon was harvested through a transverse plantar incision over the interphalangeal joint of the great toe in 10 fresh-frozen cadaver lower extremities. A lateral-based incision for peroneal tendon repair was made and the FHL was retrieved. Tendon length, complications, and interconnections between the FHL and flexor digitorum longus (FDL) were recorded and classified. The specimens were then dissected by a single surgeon in a standardized fashion, and damage to any surrounding structures was recorded. Results: The average length of the FHL tendon from the distal stump to the first intertendinous connection was 13.3 cm (range 8.8-16 cm, SD 2.3 cm). Eight cadavers demonstrated Plaass type 1 interconnections whereas 2 demonstrated type 3. There was no injury to the medial and lateral plantar arteries and nerves, plantar plate, or FDL tendons. One FHL tendon was amputated at the level of the sustentaculum during graft harvest. No injury of the medial neurovascular structures occurred with retrieval of the FHL tendon through the lateral incision. Conclusions: We found that care must be taken when approaching the sustentaculum with the tendon harvester in order to avoid amputation of the graft against a hard bony endpoint. Additionally, flexion and extension of the lesser toes could aid in successful tendon harvest when tendon interconnections were encountered. Clinical Relevance: Using this MI technique appears to be a safe and effective way to obtain a long FHL tendon graft for tissue augmentation.

Background : Single-incision laparoscopic right colectomy (SILRC) has been reported in 2008, and since that time an increased number of reports appeared in literature. Currently, it remains popular between the centers with achieved experience. Adoption of suprapubic access, instead of umbilical or other access-sites, allows to enhance the final cosmetic outcomes, together with the realization of complete mesocolic excision (CME) and intra-corporeal anastomosis (ICA). Methods : Between January 2016 and August 2018, 20 patients (10 females, 10 males) were submitted to suprapubic single-incision laparoscopic right colectomy (SSILRC) for adenocarcinoma. Mean age was 74 years and mean body mass index was 24 kg/m2. Sixteen patients have already been submitted to open abdominal surgery. Results : Mean total operative time was 233.9 minutes and mean laparoscopic time was 199.4 minutes. Mean time for ICA was 34 minutes. Mean blood loss was 279.5 mL. One additional 5-mm trocar was necessary in 1 patient (5.0%). Mean length scar was 60.5 cm. Mean hospital stay was 7.8 days. A minimal use of pain killers was registered postoperatively. Mean number of lymph nodes retrieved was 24.5. Early complications were one suprapubic abscess and one suprapubic hematoma. No late complications, including suprapubic incisional hernia, were achieved. Conclusion : Since the specimen has to be removed from the abdomen after conventional laparoscopic right colectomy, the suprapubic access can be an option. SSILRC allows to join the surgical procedure, the specimen’s removal and the enhanced cosmetic results through the same access. Other advantages are the CME, the ICA, the reduced postoperative pain, and the decreased incisional hernia’s rate.

The Endoscopic Endonasal Far-Medial approach represents the coronal expansion of the conventional endoscopic endonasal approach to the lower third of the clivus, which allows access to the condylar region and adjacent structures such as the jugular foramen, jugular tubercle, and the craniocervical junction.

In this thesis, we showed that the incidence of (late) DDH increases in regions such as the province of Manitoba (Canada), where there is no screening programme in place, as (selective) ultrasound programmes in other countries have shown to decrease the rate of late presenting DDH. Improved access to health care and well baby clinics in rural areas, including clinical assessment of the hips beyond walking age, can improve diagnosis and overall outcome. It is unclear from our study if the late DDH is due to family predisposition and inbreeding or mechanically induced due to swaddling/restricted hip movements, a regional custom. Screening should also take into consideration risk factors for the province such as first female, breech and presence of clubfoot deformity. The latter is somewhat controversial, and could again be a regional entity, as current screening programmes no longer include clubfoot as a risk factor.(18,19) On the other hand, ultrasound has also its limitations in identifying relevant DDH. Despite abnormal findings on ultrasound suggestive for DDH within the first 6 months of life, many of these abnormalities will improve over time without treatment. Furthermore, abduction treatment of stable well-centered hips in 3 to 4 months old will not alter acetabular development, as 80% will become normal without treatment. Again, this questions the specificity of US as diagnostic tool to identify true hip disease based on Graf Classification alone. The role of Pavlik harness treatment over 6 months of age is questionable but can still be successful in 60% of the cases in moderate dislocation (≤ Graf type III). Prolongation of the Pavlik harness beyond 6 weeks of treatment did not alter the success rate. After failed Pavlik harness, medial approach lead to poor results in 20% of the patients for both radiographic and functional outcomes. The medial approach in patients younger than 6 months showed better results. Thus, the medial approach should probably be reserved to this age group. AVN rate was high, with almost 1/2 showing some changes during growth but eventually only 1/6 developed more severe proximal growth disturbance. The patient's observed outcome was not linked to the type of AVN but the severity of residual dysplasia. Finally, shape varian978-94-6419-087-8ts of AVN hips using SSM can identify early radiographic changes linked to poor outcome. This has the potential to develop as a tool for decision-making process at already a very young age and therefore improving the outcome.

Category: Hindfoot Introduction/Purpose: Hindfoot arthrodesis is used in patients with flat feet acquired in advanced stages, usually associated with degenerative joint disease. The objective of the study is to evaluate the clinical and radiographic results of hindfoot arthrodesis using the medial approach. Methods: A prospective cohort of 23 consecutive patients who underwent surgical correction between the years 2012 and 2018 through the hindfoot modeling arthrodesis was evaluated. Clinical assessment was performed using the visual analogue pain scale (VAS), AOFAS score for the hindfoot, SF-36 and FFI (Foot Function Index). Radiographic images were also analyzed, as well as satisfaction criteria. Results: In six procedures, calcanecuboid arthrodesis was included, with a small lateral access route. The average pain score decreased by 6.04 points (p Conclusion: Arthrodesis to correct adult acquired valgus flat feet can be performed using the medial approach with good clinical results and low rates of healing complications. However, about 25% of the patients had other complications that led to the need for a surgical approach.

Draf III frontal sinusotomy is one of the most complex surgical procedures on the frontal sinus, designed to limit the risks of restenosis by ensuring unification of the two ostia and resection of the floor of the sinus. This procedure requires a good knowledge of anatomy and sufficient surgical expertise to avoid the risk of CSF leak and to limit the risk of restenosis. The surgeon can use various landmarks, consisting of foramina, bone grooves and arteries located on the anterior part of the cribriform plate to guide the procedure. The purpose of this technical note is to explain the use of these landmarks to ensure safe Draf III frontal sinusotomy via a medial approach.

Background A small proportion of patients suffer from isolated lateral osteoarthritis where the sole lateral unicompartmental knee arthroplasty (UKA) is a possible treatment option. There, both a medial and a lateral surgical approach can be considered. This study should answer the question whether the lateral approach is superior to a modified medial approach in terms of implantation accuracy and subjective outcome. Methods In this retrospective study, 175 patients with lateral UKA were included between 2015 and 2020. In 82 patients, the lateral approach was used, and in 93 patients, the medial approach was used. To assess implantation accuracy, different imaging criteria on postoperative radiographs were analyzed. Postoperative patient-related outcome measurements (PROMs) (OKS, LEFS, and EQ5D) were evaluated. Statistical significance was assumed for P Results The tibial implant relation to the tibial plateau diameter in the lateral approach was significantly larger than in the medial approach (23.6% vs 22.2%; P 15° regarding flexion position of the femoral implant (P = .002) and a higher number of deviations of the slope was found (P = .06) in the lateral approach. The lateral approach showed a significantly higher rate of lateral positioning of the femoral component (P = .007). Post-PROMs showed significant improvement in both approaches. Conclusion The lateral approach is not superior regarding different radiological accuracy criteria. The Hoffa´s fat pad–preserving medial approach showed good results in implantation accuracy and therefore is a good alternative to implant lateral UKA. In addition, significant improvement in PROMs could be demonstrated.

Introduction: Three general approaches to identifying the recurrent laryngeal nerve during thyroid surgery are recognized: lateral, inferior, and superior.1 In the presented video we intro...

Background: Although Multiple studies showed that the median approach is nowadays the most widely accepted approach according to the “no-touch” principle and safety. However, this approach is a demanding procedure with a steep learning curve and has a high rate of conversion to laparotomy. This aim is to explore the feasibility and safety of tunnel approach in laparoscopic radical right hemicolectomy for colon cancer.Methods：From July 2016 to October 2018, a total of 106 consecutive patients with colon cancer who were subjected to the laparoscopic radical right hemicolectomy in the affiliated cancer hospital of zhengzhou university were enrolled. The patients underwent either tunnel approach (TA) (n=56) or traditional medial approach (MA) (n=50) according to the surgical maneuver performed. The patients' baseline demographics and perioperative results were compared between the two groups.Results: The baseline characteristics did not differ between groups. The blood loss was significantly less [20.0(5.0-40.0) vs. 100(50.0-150.0) , p < 0.001] and operation time was significantly shorter [128.4±16.7 vs. 145.6±20.3min, p < 0.001]in the TA group than those in MA group. Time to first flatus and postoperative hospital stay were similar [3.0(2.0-4.0) vs. 3.0(3-4.0)d，p=0.329; 10.4±2.6 vs. 10.7±3.0d，p=0.506] in both groups. The conversion to laparotomy and complication rates were similar between the groups(0 vs. 6.0%, p = 0.203; 14.3% vs. 18.0%, p =0.603,respectively). There was no treatment-related death in both groups.Conclusions: The tunnel approach in laparoscopic radical right hemicolectomy for colon cancer is a technically feasible and safe procedure as a preferable approach at present compared to those of medial approach, meanwhile this method is easier for beginners to master. Hence this tunnel approach right hemicolectomy is worth recommended.

Background and objectives: To evaluate the single-injection and triple-injection techniques in infraclavicular blocks with an ultrasound-guided medial approach in terms of block success and the need for supplementary blocks. Methods: This study comprised 139 patients who were scheduled for elective or emergency upper-limb surgery. Patients who received an infraclavicular blocks with a triple-injection technique were included in Group T (n = 68). Patients who received an infraclavicular blocks with a single-injection technique were included in Group S (n = 71). The number of patients who required supplementary blocks or had complete failure, the recovery time of sensory blocks and early and late complications were noted. Results: The block success rate was 84.5% in Group S, and 94.1% in Group T without any need for supplementary nerve blocks. The blocks were supplemented with distal peripheral nerve blocks in 8 patients in Group S and in 3 patients in Group T. Following supplementation, the block success rate was 95.8% in Group S and 98.5% in Group T. These results were not statistically significant. A septum preventing the proper distribution of local anesthetic was clearly visualized in 4 patients. The discomfort rate during the block was significantly higher in Group T (p < 0.05). Conclusion: In ultrasound-guided medial-approach infraclavicular blocks, single-injection and triple-injection techniques did not differ in terms of block success rates. The need for supplementary blocks was higher in single injections than with triple injections. The presence of a fascial layer could be the reason for improper distribution of local anesthetics around the cords. Resumo Justificativa e objetivos: Avaliar as técnicas de injeção única e tripla no bloqueio infraclavicular, empregando-se acesso medial guiado por ultrassonografia, comparando-se o sucesso do bloqueio e a necessidade de bloqueios complementares. Método: O estudo incluiu 139 pacientes com indicação de cirurgia de membro superior eletiva ou de emergência. O Grupo T (n = 68 pacientes) recebeu bloqueio infraclavicular com técnica de injeção tripla e o Grupo S (n = 71), bloqueio infraclavicular com injeção única. Registrou-se o número de pacientes que necessitaram bloqueio complementar de nervo ou que apresentaram falha completa do bloqueio, o tempo de recuperação do bloqueio sensorial e as complicações precoces e tardias. Resultados: A taxa de sucesso do bloqueio infraclavicular, sem necessidade de bloqueio complementar de nervo, foi 84,5% e 94,1% para os Grupos S e T, respectivamente. No bloqueio infraclavicular foi necessário bloqueio de nervos periféricos distais em 8 e 3 pacientes dos Grupos S e T, respectivamente. Após a complementação, a taxa de sucesso do bloqueio foi 95,8% e 98,5% para os Grupos S e T, respectivamente. Os resultados não foram estatisticamente significantes. Imagem de septo impedindo a distribuição adequada do anestésico local foi claramente visualizada em quatro pacientes. A taxa de desconforto durante a realização do bloqueio foi estatatisticamente mais alta no Grupo T (p< 0,05). Conclusões: As técnicas de injeção única e tripla em bloqueio infraclavicular guiado por ultrasonografia com acesso medial não diferiram quanto à taxa de sucesso. A necessidade de bloqueio complementar foi maior com a técnica de injeção simples. A ocorrência de invólucro de fascia poderia justificar a distribuição inadequada do anestésico local ao redor dos fascículos do plexo.

Background The coracoid process plays an important role in maintaining the stability of the elbow joint. A fracture of the coronoid process is often treated via surgical approaches, including open reduction and internal fixation, which aim to regain a stable, flexible, and loadable joint. In this study, we compared the anterior, medial, and posterior approaches of internal fixation in the repair of fractures of the coronoid process of the ulna. Methods In this retrospective study, 147 patients with fractures in the coronoid process of the ulna were recruited and classified into the anterior group (n = 73), the medial group (n = 32), and the posterior group (n = 42) according to the surgical approach used for internal fixation. These patients were assessed with respect to incision, operative time, estimated blood loss, fracture healing, and postoperative complications. The Mayo Elbow Performance Score was used to evaluate any form of disability associated with elbow injuries. Multivariate logistic regression analysis was performed to investigate the factors influencing the efficacy of fractures of the coronoid process of the ulna. Results In the medial approach group, the operative time was longer, and perioperative blood loss and postoperative drainage volume were obviously increased compared with the anterior and posterior groups. The anterior group exhibited a better postoperative recovery compared with the medial, and posterior groups. Compared with the anterior group, fracture-healing time in the posterior group was further reduced, whereas elbow joint flexion extension and forearm rotation degree improved. Complications were significantly reduced in the posterior approach group compared with the anterior and medial groups. The factors influencing the efficacy of fractures of the coronoid process of the ulna included the Regan–Morrey classification, perioperative blood loss, and the internal fixation approach. Conclusion In summary, the approach used influences fracture healing or the outcome after osteosynthesis. The posterior internal fixation method produced satisfactory functional outcomes in patients with fractures of the coronoid process of the ulna.

Because of the known tendency for early redislocation following open reduction, we developed surgical methods for shortening the ligamentum teres to improve immediate postoperative stability when performing medial approach open reduction (MAOR) for the management of developmental dysplasia of the hip. Between 2004 and 2014, 32 patients with dysplasia of the hip were managed by MAOR with partial excision and plication of ligamentum teres. The patients were followed up for an average of 6.9 years. At the final follow-up, clinical outcomes achieved were categorized as excellent and good in 39 (39/40; 97.5%) hips. At the latest follow-up, 97.5% (39 hips) were classified as good or excellent on the basis of the Severin classification (Severin grade 1 or 2). In conclusion, this series of MAOR, in which ligamentum teres partial excision and plication was utilized, we found stable reduction in all hips. On the basis of these positive results, we recommend this method for children treated with MAOR. LEVEL OF EVIDENCE Level IV: case series.

The most common conservative approaches to the hip joint are the anterior, the Ganz safe surgical dislocation and the medial approach. The anatomy of these approaches is described in detail in this review. Each approach is also evaluated considering the surgical conservative indications, technique, and complications.

Subtalar distraction bone block arthrodesis is a useful technique commonly employed in the management of calcaneal and talar fracture malunion. Traditionally it is performed via a posterolateral or extensile lateral approach, however such approaches have been associated with wound complications, particularly secondary to the added stress caused by the subtalar distraction crucial to this technique. Medial approaches to the subtalar joint have been used in other procedures but have not been reported in subtalar distraction bone block arthrodesis. A novel case and technique illustrating the medial approach for subtalar distraction bone block arthrodesis is discussed. Level of clinical evidence Level 4.

Calcaneal osteotomies are commonly used to correct varus hindfoot alignment in patients with symptomatic cavovarus deformity. Translational, closing wedge, and Malerba-type osteotomies have been implicated in the development of tarsal tunnel syndrome and neurologic injury to branches of the tibial nerve. The authors hypothesized that there would be minimal clinically important injury to the tibial nerve by performing a translational calcaneal osteotomy from a medial approach.All patients undergoing a cavovarus reconstruction by a single surgeon were identified. Patients were included if they underwent a lateralizing calcaneal osteotomy via medial approach. Demographics, operative reports, and clinic notes were reviewed to identify concomitant procedures performed, incidence of postoperative tarsal tunnel syndrome, complications, and preoperative and postoperative nerve examinations. Postoperative radiographs were reviewed for location of the osteotomy relative to the posterior tubercle.Twenty-four patients underwent lateralizing calcaneal osteotomy via a medial approach. Of the osteotomies, 83.3% (20/24) were in the middle third of the calcaneus, with a mean of 11.6-mm translation. No patients developed postoperative tarsal tunnel syndrome or tibial nerve palsy.Lateralizing calcaneal osteotomy performed via a medial approach had a clinically negligible incidence of neurologic injury. Adequate translation was achieved to obtain correction of varus hindfoot deformity. The authors believe that there is less direct and less percussive injury to branches of the tibial nerve when performing the osteotomy from medial to lateral. This technique may represent an operative strategy to minimize risk to the tibial nerve and reduce neurologic deficit following cavovarus reconstruction.Level IV, case series.

© 2017, Yuzuncu Yil Universitesi Tip Fakultesi. All rights reserved.This study has aimed to evaluate the outcomes of open reduction technique by the medial approach performed in the 3-18 months old infants. The patients who underwent an open reduction by the medial approach for typical dysplasia of hip between the years 2007-2011 were screened retrospectively. The study included 28 hips of 19 patients. The correction percentage of acetabular index was calculated by acetabular angle measurements performed prior to operation and at the last control examination. Avascular necrosis (AVN) was classified by the criteria of Kalamchi-MacEwen while radiological and clinical evaluations were performed using Severin and McKay criteria. The mean age at surgery was 12.1 months (3-18 months) while mean follow-up period duration was found 18.6 months (6-48 months). According to Severin radiological criteria, 9 (32.1%) and 9 (32.1%) hips were evaluated as excellent and good, respectively. Whereas, according to the evaluation based on McKay criteria, 22 (78.6%) and 6 (21.4%) hips were found excellent and good, respectively. Avascular necrosis (AVN) of the femoral head was encountered in 3 (10.7%) of the 28 hips. According to the criteria of Kalamchi-MacEwen Classification; 2 and 1 hips revealed Type I and Type 4 avascular necrosis, respectively. We have encountered according to outcomes data of this study that open reduction technique by the medial approach for treatment of developmental dysplasia of the hip (DDH) presented more successful clinical and radiological outcomes in the 3-12 months old infants compared with its application in the 13-18 months old infants.

Arthrodesis of the hindfoot is a common procedure for degenerative joint disease and/or severe deformity. Nonunion is a common complication from this procedure, causing an increased burden to the patient and health care system, often resulting in the need for revision surgery. Recombinant human platelet-derived growth factor (rhPDGF) has been shown to be a safe and effective tool to enhance arthrodesis rates in hindfoot surgery while avoiding the potential morbidity of bone grafting. This article provides a review of the role of rhPDGF in hindfoot fusions, and the surgical technique for performing an rhPDGF enhanced double-arthrodesis through a medial approach.

Background: The purpose of this study is to compare the clinical and radiological outcome of medial versus posterior triceps splitting approach in open reduction internal fixation of displaced supracondylar fracture of humerus in children.Methods: A retrospective review of total 70 children with medial approach (n=30) and posterior triceps splitting approach (n=40) children was made. Time to radiological union, postoperative Bauman’s angle and Lateral humerocapitellar angle was compared for radiological outcome. Cosmetic and functional outcome was assessed and compared using Flynn’s criteria. Results: Radiological parameters like time to union, postoperative Bauman’s angle and Lateral humerocapitellar angle were similar and non-significant between medial and posterior triceps splitting approach. Flynn’s cosmetic outcome was similar between these approach (p=0.198). Loss of ROM was significant in posterior triceps splitting approach (p=0.00). Flynn’s functional outcome was better with medial approach as compared to posterior triceps splitting approach with statistical significance (p=0.00). Conclusions: Medial approach has better functional outcome compared to posterior triceps splitting approach in open reduction internal fixation of displaced supracondylar fracture of humerus in children.Keywords: Children; Humerus; Open reduction; Supracondylar

Fractures in the posterior aspect of the medial malleolus form an important subset of ankle fractures and the indications for fixation include involvement of > 25% of the articular surface or an articular step off by > 2 mm. Several approaches have been described but there has been no recent study on the direct medial approach. Five fresh frozen cadaveric ankles were dissected using the direct medial approach. A longitudinal incision of 10 cm was centered directly over the medial malleolus and deepened straight down to the bone. The periosteum was identified over the distal tibia and careful subperiosteal dissection yielded access to the posterior aspect of the medial malleolus. We investigated the relationship of the neurovascular bundle to the incision by measuring the distance from the center of the medial malleolus to the closest aspect of the bundle. The mean distance from the center of the medial malleolus to the neurovascular bundle was only 2.64 cm (95% CI: 2.06 to 3.22 cm). We found that the neurovascular bundle could be avoided if a periosteal sheath was developed during the dissection and elevated off the posterior aspect of the medial malleolus. The direct medial approach can be performed safely by creating a periosteal sheath through subperiosteal dissection, and the distance of the neurovascular bundle from the incision allows for a good margin of safety during surgery. This approach can be extended proximally and distally and the medial malleolus can be fixed concurrently. Clin. Anat. 31:605-607, 2018. © 2017 Wiley Periodicals, Inc.

Background A trapped temporal horn can be emergently decompressed by inserting a bedside temporal horn external ventricular drain (tEVD). However, no standardized method for this procedure has been described. Objective To identify methods for bedside tEVD insertion, and determine the safest, most accurate, and most easily standardized approach. Methods Volumetric images of 20 patients with trapped temporal horns were analyzed. Three tEVD approaches (perpendicular, lateral, and medial) were defined, along with standardized insertion points and external landmarks for trajectory guidance. Predicted success in penetrating the temporal horn, skin-to-temporal horn entrance distance, temporal horn distance traversed, and trajectory target error and accuracy were evaluated; data were compared with independent sample t tests. Results Nineteen of 20 cases were analyzed; 13 had critical temporal horn entrapment. Penetration was achieved in 100% of perpendicular and 84% (16/19) of lateral and medial approaches (92% [12/13] of critical entrapments). In 19 patients, trajectory error was not significantly different among approaches. The perpendicular approach had significantly more accuracy than the lateral (P = .01) and medial (P = .002) approaches. The lateral approach afforded significantly more traversable distance than the perpendicular approach (P = .009). In cases with critical entrapment, the perpendicular approach had significantly less error (P = .02) and significantly better accuracy (P = .02) than the medial approach. The perpendicular approach trended toward more accuracy than the lateral approach (P = .06). Conclusion The perpendicular approach appears to be the easiest, safest, and most reliable approach tested. We recommend conducting bedside tEVD placement only in patients with a critically dilated temporal horn who are clinically deteriorating at a rate that prohibits other procedures. Abbreviations CSF, cerebrospinal fluidEVD, external ventricular draintEVD, temporal horn external ventricular drainOR, operating room.

Osteochondral lesions of the talus might be a more common cause of pain than previously recognized, especially among those involved in athletic activities. However, the location of an osteochondral lesion on the talar head is much less common than such lesions localized to the dome of the talus and can pose diagnostic difficulties. We present the case of a 14-year-old soccer player who complained of longstanding pain in his left foot. After unsuccessful conservative treatment consisting of rest and bracing, he was ultimately treated with retrograde percutaneous drilling of the talar head performed by a medial approach. This was followed by casting and non-weightbearing for 6 weeks, after which physical therapy was undertaken. He was able to return to full activity and remained asymptomatic during a 5-year observation period. Although rare, osteochondritis dissecans of the talar head should be considered in young athletes with persistent foot pain that is unresponsive to reasonable therapy.

This study evaluated the feasibility, complications and long-term outcomes of using a cannulated drill system combined with intraoperative imaging to place a transcondylar screw for the management of canine humeral intracondylar fissure. Thirteen dogs were enrolled, with one dog undergoing staged bilateral surgery. No intraoperative complications occurred. Five minor (36%) and three major (21%) postoperative complications occurred, giving an overall complication rate of 57%. None of the screws placed penetrated the articular surface. The mean duration of surgery was 28 min (SD ±3.5) for dogs that developed a major complication versus 46 min (SD ±18.1) for those that did not (p=0.015). The duration of preoperative lameness was significantly shorter for cases which suffered a major complication (2 days; SD ±2.8) than those that did not (34 days; SD ±31.7, p=0.008). None of the variables assessed were significantly associated with minor complications. Median time from surgery to last follow-up was 5.8 years (range 3.5-8.5 years). Median Liverpool Osteoarthritis in Dogs questionnaire score at the final point of follow-up was 16 (range 7-27). A significant number of patients were found to require analgesia at long-term follow-up.

Surgical access to the subtalar joint is required in a plethora of pathologic conditions of the hindfoot. The conventional lateral approach can give excellent access to subtalar joint; however, in hindfoot valgus deformities, there can be unacceptable risks of wound problems and incomplete deformity corrections. The medial approach offers good access to the subtalar joint with an increasing evidence base for its use, especially with double fusions in pes planus deformities. The authors review the current evidence in the use of the medial approach for the subtalar joint.

Aims Open reduction is required following failed conservative treatment of developmental dysplasia of the hip (DDH). The Ludloff medial approach is commonly used, but poor results have been reported, with rates of the development of avascular necrosis (AVN) varying between 8% and 54%. This retrospective cohort study evaluates the long-term radiographic and clinical outcome of dislocated hips treated using this approach. Patients and Methods Children with a dislocated hip, younger than one year of age at the time of surgery, who were treated using a medial approach were eligible for the study. Radiographs were evaluated for the degree of dislocation and the presence of an ossific nucleus preoperatively, and for the degree of AVN and residual dysplasia at one and five years and at a mean of 12.7 years (4.6 to 20.8) postoperatively. Radiographic outcome was assessed using the Severin classification, after five years of age. Further surgical procedures were recorded. Functional outcome was assessed using the Pediatric Outcomes Data Collection Instrument (PODCI) or the Hip Disability and Osteoarthritis Outcome Score (HOOS), depending on the patient’s age. Results A total of 52 children (58 hips) were included. At the latest follow-up, 11 hips (19%) showed signs of AVN. Further surgery was undertaken in 13 hips (22%). A total of 13 hips had a poor radiological outcome with Severin type III or higher. Of these, the age at the time of surgery was significantly higher (p Conclusion This retrospective long-term follow-up study shows that one in five children with DDH who undergo open reduction using a medial surgical approach has poor clinical and/or radiological outcome. The poor outcome is not related to the presence of AVN (19%), but due to residual dysplasia. Cite this article: Bone Joint J 2018;100-B:822–7.

The valgus knee is a challenging knee for total knee arthroplasty. The deformity is less common than varus and requires more releasing to correct the deformity. The medial approach is the more common one because it is familiar to the surgeon; however, the lateral approach affords excellent visualization. The ligament imbalance can be approached both with tightening and releasing techniques, but releasing is once again more familiar to the operating surgeon.

Acetabular dysplasia is a common cause of osteoarthritis. The Bernese periacetabular osteotomy (PAO) as described by Ganz is a powerful tool that enables correction of inadequate femoral head coverage due to acetabular dysplasia. In addition to decreasing pressure forces on hip cartilage by increasing contact surface area, it can decrease joint reactive forces through medialization of the hip joint. Also, the osteotomy allows for correction of acetabular version. Since its inception in the mid-1980s, multiple modifications have been described. In this chapter, we will highlight a modification that utilizes a groin incision to perform the ischial and pubic cuts.

The medial approach to the subtalar joint allows good visualization of the articular surfaces. Compared with the lateral approach, advantages are found particularly in flatfoot correction, in which the single-incision technique can be used for corrective fusions of rigid flatfoot deformity. Union rates are comparable with the traditional lateral approach; however, wound healing problems occur less frequently. Avascular necrosis of the talus is a rare but serious complication, although frequency seems to be independent of the approach chosen. Clinical studies showed no increased morbidity when comparing the medial to the lateral approach.

The decision to treat a femoral head fracture conservatively or surgically is the subject of ongoing debate. Several surgical approaches have been proposed for the open reduction and internal fixation of femoral head fractures. To our knowledge, fixation through a minimally invasive medial approach has not been described until now. The novel medial hip approach passes between the adductor muscle bellies posteriorly and their aponeuroses anteriorly. It provides direct access to the fracture site and allows for fixation by compression, without needing to dislocate the hip or detach the muscles. Any loose bodies in the joint that cannot be fixed can also be removed during the procedure. These features make the medial hip approach a clinically-relevant treatment option for the surgical management of femoral head fractures.

The article analyzed the methods of suprapancretic lymph node dissection in laparoscopic gastrectomy which were developed and applied in Japan. The authors described the details of operation technique. There were noted the advantages of medial approach for suprapancreatic lymph node dissection.

Background Bilateral dual transversus abdominis plane (BD-TAP) injections were devised to cover the T7–8 and L1 dermatomes, which are usually spared with classical and mid-axillary TAP injections. The purpose of this study was to delineate the vertical and lateral extent of injectate spread following a lateral to medial approach for TAP injections in embalmed cadavers. Methods Ultrasound-guided subcostal and lateral TAP injections were performed on nine embalmed cadavers using 30 ml of 0.5% methylcellulose (20 ml for subcostal and 10 ml for lateral injections) with a 12-cm Tuohy needle in the first six cadavers (nine hemi-abdomens). Vertical extent and the medial to lateral extent of the dye spread were recorded after dissections of the abdominal wall. In a pilot of three cadavers not receiving TAP injections, anatomical impediments to proximal injectate spread were explored separately. Results The vertical spread of injectate was T7–L1 (n = 2/9), T8–L1 (n = 5/9) and T9–L1 (n = 2/9). None of the TAP injections extended beyond the mid-axillary line. No anatomical impediments for the flow of injectate to the T7 or T8 intercostal nerves were found at the level of the interdigitations of the transversus abdominis muscle and diaphragm. Conclusion A lateral to medial approach for TAP injection resulted in spread of the injectate ranging from T7/8–L1 dermatomes in the majority of the hemi-abdomens. Subcostal and lateral TAP injections do not cover the lateral cutaneous branches of the segmental nerves.