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Background: Valgus knee deformity poses great challenges in total knee arthroplasty (TKA) and requires precision in balancing of soft tissue and implant component positioning. The surgical approach used for TKA has a determinantal impact on intraoperative soft tissue balancing, postoperative knee function, and complications. We executed a systematic review and meta-analysis of current literature, which included a maximum number of studies with quantitative analysis of all possible outcomes to substantiate the current evidence of the advantage of lateral versus medial approach in TKA for valgus knee deformity. Methodology: We performed a meticulous primary electronic search across PubMed, Emabse, Scopus, and Cochrane Library databases, and looked for the comparative studies that evaluated the medial versus lateral approach in TKA for valgus knees. Statistical analyses were executed with RevMan-5.4.1. Results: On the evaluation of four randomized controlled trials (RCTs), two prospective and five retrospective comparative studies, our analysis revealed a better functional outcome in terms of Knee Society Score [MD 2.24, 95% CI 0.42, 4.05; p = 0.02] with the medial approach. However, comparable results were observed for two approaches with regard to Knee Society Function [MD 0.69, 95% CI − 1.77, 3.15; p = 0.58], knee flexion range of motion (ROM) [MD 3.30, 95% CI − 1.34, 7.95; p = 0.16], overall complications [OR 0.60, 95% CI 0.27,1.34; p = 0.22], wound-related complications, infection, nerve injury, periprosthetic fracture, post-operative valgus, blood loss, duration of surgery, postoperative pain, and patellar tilt for TKA in valgus knee. Conclusion: Evidence from the currently available published data suggests that the lateral approach, compared to the medial approach in TKA for the valgus knee, does not show clear superiority. [ABSTRACT FROM AUTHOR]

Purpose: The medial approach to the popliteal artery has been less commonly used than the posterior approach in surgical repair of traumatic popliteal injury. This study was performed to quantitatively evaluate the visual field of the popliteal artery obtained by staged myotendotomy in the medial approach to the popliteal artery. Methods: Twenty legs of fresh-frozen adult cadavers were dissected using the medial approach to the popliteal artery. In stage 1, the popliteal artery was exposed between the vastus medialis and sartorius muscles without myotendotomy. In stage 2, the medial head of the gastrocnemius muscle was dissected. In stage 3, the tendons of the sartorius and semimembranosus muscles were dissected. In stage 4, the tendons of the gracilis and semitendinosus muscles were dissected to fully expose the popliteal artery. The length of the popliteal artery that could be visualized in each stage was measured. Results: The anatomical length of the popliteal artery from the hiatus of the adductor magnus to the tendinous arch of soleus muscle ranged from 15 to 20 cm (mean, 16.3 cm). On average, 45%, 59%, 72%, and 100% of the popliteal artery were visualized in stage 1, 2, 3, and 4, respectively. Conclusions: The medial approach to the popliteal artery has the advantage of being performed in the supine position, but it requires multiple myotendotomies around the knee. The results of this study may serve as a reference for myotendotomy depending on the site of injury to the popliteal artery. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to validate the feasibility of an endoscopic endonasal combined transoral medial approach for treating lesions in the nasopharynx, parapharyngeal space (PPS), and jugular foramen. Methods: Anatomical and imaging information of six patients who underwent surgery via this approach were reviewed and analyzed. Results: The feasibility and advantages of the endoscopic endonasal combined transoral medial approach, which uses an inside‐to‐outside medial surgical corridor, were identified. Total resection was achieved in 3 cases with benign tumors. Safe resection margins were obtained in 2 cases with recurrent nasopharyngeal carcinoma (NPC). Pathological biopsy of NPC lesion between the Eustachian tube and arterial sheath was achieved. The internal carotid artery (ICA) was accurately located and protected in all cases and no complications occurred. Conclusion: Lesions in the nasopharynx, PPS, and jugular foramen can be directly assessed via this approach. The ICA can be well identified during the surgery. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this meta-analysis of comparative studies was to update the current evidence on functional and radiographic outcomes and complications between medial and lateral approaches for total knee arthroplasty (TKA) for valgus knee deformity. Materials and methods: The PubMed, MEDLINE, Scopus, and the Cochrane Central databases were used to search keywords and a total of ten studies were included. The methodological quality of the included studies was assessed. Data extracted for quantitative analysis included the Knee Society score (KSS), range of motion (ROM), surgical time, hip–knee–ankle angle (HKA), and number and types of complications. Random- and fixed-effect models were used for the meta-analysis of pooled mean differences (MDs) and odds ratios (ORs). The Mantel–Haenszel method was adopted. Results: A total of 1008 patients were identified, of whom 689 and 319 underwent TKA for valgus knee deformity with lateral and medial approach, respectively. The mean age was 70 ± 9.5 and 67.3 ± 9.6 years for the lateral and medial approaches, respectively. The mean follow-up was 37.8 ± 21.9 and 45.9 ± 26.7 months for the lateral and medial approach groups, respectively. Significantly higher functional outcomes were found for the medial approach, as measured by the postoperative KSS (MD = 1.8, 95% CI [0.48, 3.12], P = 0.007) and flexion ROM (MD = 3.12, 95% CI [0.45, 5.79], P = 0.02). However, both of these differences were lower than the minimal clinically important difference. Comparable surgical time and postoperative HKA angle values (MD = 0.22, 95% CI [− 0.30, 0.75], P = 0.40) between the two surgical approaches were found. The incidence of periprosthetic joint infections, fractures, transient peroneal nerve injuries, and deep vein thrombosis was comparable. Conclusion: This meta-analysis of comparative studies showed that when lateral and medial approaches are used for total knee arthroplasty for valgus knee deformity, comparable functional outcomes in terms of the KSS and ROM, surgical time, and postoperative hip–knee–ankle angle values can be expected. Similar rates of periprosthetic joint infection, fracture, and peroneal nerve injury were also found. Level of evidence: I. PROSPERO registration number ID: CRD42023392807. [ABSTRACT FROM AUTHOR]

Introduction: Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) is increasingly favored for treating humeral shaft fractures (HSFs). However, conventional MIPPO techniques pose challenges in fixing fractures near fossa olecranon and carry a risk of iatrogenic radial nerve palsy. A novel technique using a medial MIPPO for treating humeral shaft fractures (HSFs) is described. Results of clinical follow-up are presented. Materials and methods: This study is a retrospective case series study. Twenty-one patients (mean age 43.9 ± 17.66 [22‒81] years) with HSFs were treated with the novel MIPPO fixation method. Clinical outcomes including time for radiographic consolidation, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and complications were assessed at the last follow-up. The mean follow-up was 26 ± 17.12 (range 12–67) months. Results: All patients had a bony union at a mean of 15.76 ± 6.74 (range 8–40) weeks based on X-ray with an early and aggressive range of motion. The complication rate was 0. The mean DASH score was3.29 ± 4.09 (range 0–14.17) at the time of the last follow-up. The mean screw density was 0.49 ± 0.1 (range 0.2–0.65). Conclusion: This novel surgical technique for HSFs is a viable alternative to previously described methods with the advantage of being less prone to nerve injury and easy to fix distal extra-articular HSFs. The learning curve is short. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

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Conventional laparoscopic or robotic surgery for right-sided colon cancer often requires intraoperative repositioning and removal of the bowel. Changing positions during robotic surgery can be troublesome and robotic removal of the small intestine carries a risk of unexpected injury because robotic devices have a strong grasping force and no sense of touch. Herein, we introduce a novel mobilization of the medial approach without changing the position for robotic right hemicolectomy. Using this technique, mobilization is performed in counterclockwise succession, allowing all mobilizations and bowel removal to be completed sequentially, without positional change. [ABSTRACT FROM AUTHOR]

We present the case of a 72-year-old man who was referred to our department for treatment of pain on the anteromedial infrapatellar side of the right knee with sensory disturbance that began 2 years earlier. The patient previously underwent right knee arthroscopy at another hospital for a meniscus injury 2 years earlier, which relieved his knee pain, but pain and discomfort near the incision of the medial portal persisted. Given this situation, various physical treatments, such as ice compress, were administered postoperatively. However, the symptom was only partially relieved before discharge. Subsequently, the patient visited two other hospitals and began taking oral pregabalin and duloxetine for treatment of the pain based on a diagnosis of right common peroneal nerve injury. The pain in the same dermatomal distribution was slightly relieved, but a withdrawal reaction was observed. However, the results of an ultrasound at our hospital indicated that the right medial quadriceps femoris tendon showed a hypoechoic area suggesting inflammatory changes. Physical examination of the right knee detected atrophy of the quadriceps femoris muscle, decreased muscle strength (M4), obvious tenderness in the medial side, radiating pain along the anterior tibia, and sensory disturbance (S3+); the results of a drawer test, McMurray test, pivot shift test, and lateral stress test were negative. Based on the afore-mentioned evidence, a diagnosis was made of injury to the infrapatellar branch of the saphenous nerve, after which neurolysis of the nerve in question was carried out. An enlarged incision was made along the original medial approach. Scar hyperplasia was observed after careful separation of the subcutaneous tissue. During neurolysis, branches were found wrapped in the scar; their continuity and integrity were confirmed after relief. The released nerve was placed in a physiological position. The patient's pain was clearly relieved, and numbness disappeared on the first postoperative day. At 1-month follow-up, all symptoms were found to have resolved. [ABSTRACT FROM AUTHOR]

Abstract Background Evidence suggests that tibialis posterior muscle plays an important role in equinovarus foot deformity in patients who had suffered a stroke and it is one of the most frequently injected lower-extremity muscles for the management of spasticity. Our aim was to assess if a needle accurately and safely penetrates the tibialis posterior muscle during the application of dry needling. Methods We conducted a cadaveric descriptive study. Needling insertion of the tibialis posterior was conducted in 11 cryopreserved cadavers with a 70 mm needle. The needle was inserted using two common approaches, at midpoint (posterior/medial approach) and at upper third (anterior approach) of the leg towards the tibialis posterior. The needle was advanced into the tibialis posterior based upon clinician judgement. Cross-sectional anatomical dissections were photographed and analyzed by photometry. Safety was assessed by calculating the distances from the tip and the path of the needle to proximate neurovascular structures. Results Accurate needle penetration of the tibialis posterior muscle was observed in all cadavers with both approaches. In general, distances from the needle to the neurovascular bundles were larger with the posterior/medial approach than with the anterior approach, reaching statistically significance for needle tip to nerve (mean difference: 0.6 cm, 95%CI 0.35 to 0.85 cm) and vascular bundle (mean difference: 0.55 cm, 95%CI 0.3 to 0.8 cm) distances (P

Aim: In laparoscopic colectomy with complete mesocolic excision and D3 lymphadenectomy for right‐sided colon cancer, either an inferior approach (IA) or a medial approach (MA) is selected in our institution based on the surgeon's preference. The present study compared the treatment outcomes between IA and MA. Method: This retrospective, single‐centre study using propensity score matching analysed the short‐ and long‐term outcomes of laparoscopic surgery in patients with right‐sided colon cancer from 2010 to 2019 at Cancer Institute Hospital. Results: After patient selection, 1011 patients remained for the analysis, of which 67% underwent IA surgery and 33% underwent MA surgery. After propensity score matching (1:1), 325 patients in each group were analysed. Regarding the short‐term outcomes, there were no significant differences in the operation time, rate of conversion to open surgery or postoperative complication rate (Clavien–Dindo Grade ≥ III) between the two groups, although the intra‐operative median blood loss was significantly less in the IA group than in the MA group (IA, 13 ml vs. MA, 20 ml, P < 0.0001). Regarding the long‐term outcomes, the relapse‐free survival, liver‐relapse‐free survival, cancer‐specific survival and overall survival were all similar between groups. Conclusion: Both the IA and MA in laparoscopic colectomy with complete mesocolic excision and D3 lymphadenectomy for right‐sided colon cancer are safe and feasible approaches; the IA may have an advantage over the MA in terms of reduced intra‐operative blood loss. Based on their similar oncological outcomes, either the IA or MA can be selected, based on one's preference. [ABSTRACT FROM AUTHOR]

Background: Arthroscopic exploration of ventromedial part of canine coxofemoral joint is limited in conventional dorsal approach. Objectives: We evaluated the efficacy of a medial arthroscopic approach to the coxofemoral joint of dogs by analyzing the joint visible area and performing a safety analysis. Methods: Arthroscopic approaches to the coxofemoral joint were made in five cadavers using a traditional (dorsal) and novel (medial) approach. Three observers scored the visible area of images and videos of the acetabulum and femur. A safety analysis was performed via dissection of the medial hind limb. The distance between neurovascular structures and arthroscopic portals was measured. Results: The acetabulum was more visible in the dorsal than in the medial approach, with mean visualization scores of 16 ± 0.00 and 11.83 ± 1.26, respectively. The medioventral side of the femur was significantly more visible in the medial than in the dorsal approach, with mean visualization scores of 3.9 ± 0.99 and 6.93 ± 0.58, respectively. Safety analysis confirmed the medial portal site was safe, provided that the surgeon has comprehensive knowledge of the joint. The minimum distance from the arthroscopic medial portals to the nearest neurovascular structures was 2.5 mm. Conclusions: A medial arthroscopic approach to the canine coxofemoral joint has potential clinical application. Dorsal and medial approaches differ significantly and have distinct purposes. The medial approach is useful to access the ventromedial joint, making it an eligible diagnostic method for an arthroscopic evaluation of this area. [ABSTRACT FROM AUTHOR]

Background: Outside-in frontal drill out entails drilling the frontal sinus floor in the midline before identifying and dissecting the frontal recesses. It is a more direct approach, especially in revision surgery or cases with challenging anatomy. Objectives: The aim of this study was to highlight the anatomical and surgical concepts for easy and safe outside-in frontal drill out by a preclinical anatomic study on cadaveric heads. In addition, to review our experience with this approach over a 5-year period for challenging frontal sinus pathologies. Methods: The study included 2 sectors; a preclinical study, in which 5 cadaveric heads were dissected and studied to identify and standardize the anatomical landmarks of this approach. This was followed by a clinical case series which included 22 patients with challenging frontal sinus pathologies that were treated with this proposed approach. Results: We concluded from the anatomic study that the nasal spine of the frontal bone (NSFB) and its anatomical orientation in relation to the nasal branch of the anterior ethmoidal artery (NBAEA) is a consistent landmark that enables the surgeon to identify the correct coronal trajectory of drilling to avoid injury of the cribriform and the skull base. The clinical case series included 22 patients that were successfully treated with the proposed approach. No intraoperative nor postoperative complications were reported in this study. Long-term follow-up showed that the frontal neo-ostium was patent in all cases (n = 22). Conclusion: Outside-in frontal drill-out is a safe and easy approach; especially in challenging frontal sinus pathologies; using the NSFB and its anatomical coronal orientation to the NBAEA as a consistent landmark, anterior to the skull base. This approach offers early, safe, and direct bone removal without the need for initial identification and dissection of the frontal recess. [ABSTRACT FROM AUTHOR]

Objective: Developmental dysplasia of the hip is one of the most common infantile diseases. Estimating the roles of factors affecting the development of dysplastic hip is essential in determining the treatment outcomes. In this study, we investigated if the cartilaginous acetabular index (CAI), osseous acetabular index, or their difference (delta angle) affect acetabular development in the long- term follow-up. Method: Thirty-five hips of 30 patients are included in the study. The mean age of the patients was 15.71+-6.37 (3-31) months. All patients were treated using a medial approach. The mean follow-up was 149.91+-51.43 (60-262) months. Five hips were excluded due to the development of avascular necrosis. Results: Any statistically significant difference was not found in the evaluation of the correlation between CAI, osseous acetabular index, or delta angle measurements in terms of acetabular development. The acetabular growth in the first year following the reduction was statistically significant (p0.05). Conclusion: CAI, osseous acetabular index, and delta angles do not directly affect acetabular development rate. However, most of the acetabular development occurs during the first year after concentric reduction in children younger than 24 months.

Objectives: The aim of this study was to review and share the results of patients with popliteal artery aneurysms (PAAs) who underwent open surgery in our clinic. Patients and methods: This single-center, retrospective, descriptive study was performed on 32 PAA patients (22 males, 10 females; mean age: 63±14 years; range, 52 to 76 years) surgically treated at our clinic between January 2015 and January 2020. The preoperative data, surgical approach, procedure performed, and graft selection were recorded. Postoperative early mortality and morbidity and one-year patency were evaluated. Results: As a result of bilateral aneurysms in five patients, a total of 37 PAA operations were performed. Ten patients were asymptomatic, and two of these patients had bilateral PAA. Twenty-five (67.6%) limbs were symptomatic, including 14 (37.8%) with acute limb ischemia and two (5.4%) ruptured PAAs. Saphenous grafts were used in 21 (56.7%) patients, polytetrafluoroethylene in 14 (37.8%), and Dacron grafts in two (5.4%) limbs. The median intensive care unit stay was one day (range, 0 to 3 days), and the median hospitalization period was five days (range, 3 to 11 days). Hematoma was observed in two limbs, wound infection in two limbs, and superficial wound infection in two limbs. The primary patency rate was 97.2, 94.4, and 94.44% at 1, 6, and 12 months, respectively. The secondary patency rate was 100% in all follow-ups. Conclusion: Thorough preoperative imaging and meticulous surgical technique are crucial for a better outcome after open repair [Turk J Vasc Surg 2022; 31(2.000): 108-14]

Abstract 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

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. [ABSTRACT FROM AUTHOR]

Objective: To compare the application effect of ultrasound-guided medial and lateral approach continuous fascia iliaca compartment block (FICB) in total hip arthroplasty (THA). Methods: 97 THA patients who were treated in our hospital from June 2019to June 2021 were selected as the research objects. According to the random number table method, the patients were divided into lateral group and medial group, with 48 cases and 49 cases respectively. The perioperative indexes, postoperative block related indexes, pain mediators, stress response indexes and adverse reactions were compared between the two groups. Results: There were no differences between the two groups in the amount of intraoperative bleeding, the sufentanil usage, the time of extubation/operation/hospitalization/first out of bed activity and stay in the resuscitation room (P>0.05). The visual analogue scale (VAS) score at 48h after operation in the medial group was lower than that in the lateral group (P<0.05). There was no significant difference in the time of puncture and drug injection between the two groups (P>0.05). The time of catheter placement in the medial group was shorter than that in the lateral group,the number of cases of catheter re fixation was less than that in the lateral group, and the depth of catheter placement was longer than that in the lateral group (P<0.05). The substance P (SP), prostaglandin E2 (PGE2), neuropeptide Y (NPY) and 5-hydroxytryptamine (5-HT)increased at 24 h after operation in the two groups, but the medial group was lower than the lateral group (P<0.05). Cortisol (Cor),C-reactive protein (CRP) and norepinephrine (NE) increased at 24 h after operation in the two groups, but the medial group was lower than the lateral group (P<0.05). There was no difference in the incidence of adverse reactions between the lateral group and the medial group (P>0.05). Conclusion: The ultrasound-guided medial and lateral approach FICB can provide good analgesic block for THA patients, and promote their postoperative recovery. The medial approach has more advantages in alleviating pain stimulation, stress response and catheter operation. [ABSTRACT FROM AUTHOR]

Objective: Our study aimed to determine the short-term outcome of open reduction by medial approach in terms of function, joint reduction, and avascular necrosis. Material & Methods: This was a Descriptive study approved by the institutional review board. We performed open reduction by medial approach in 24 hips in children less than 18 months of age. We followed them for a mean of 32 months ± 10.5 months. The average age of surgery was 9.7 months ± 3.5 months. Results: Out of 24 hips, 22 were successfully reduced and two hips required revision surgery for post-operative redislocation of the hip joint. Avascular necrosis was noted in three hips and functionally classified according to McKay criteria 22 hips showed excellent one hip good, and one hip fair outcome. Conclusion: We concluded that the medial approach is effective and reliable in achieving good short-term outcomes. It is safe and easy with a low rate of complications performed in children less than 18 months of age. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to review and share the results of patients with popliteal artery aneurysms (PAAs) who underwent open surgery in our clinic. Patients and methods: This single-center, retrospective, descriptive study was performed on 32 PAA patients (22 males, 10 females; mean age: 63±14 years; range, 52 to 76 years) surgically treated at our clinic between January 2015 and January 2020. The preoperative data, surgical approach, procedure performed, and graft selection were recorded. Postoperative early mortality and morbidity and one-year patency were evaluated. Results: As a result of bilateral aneurysms in five patients, a total of 37 PAA operations were performed. Ten patients were asymptomatic, and two of these patients had bilateral PAA. Twenty-five (67.6%) limbs were symptomatic, including 14 (37.8%) with acute limb ischemia and two (5.4%) ruptured PAAs. Saphenous grafts were used in 21 (56.7%) patients, polytetrafluoroethylene in 14 (37.8%), and Dacron grafts in two (5.4%) limbs. The median intensive care unit stay was one day (range, 0 to 3 days), and the median hospitalization period was five days (range, 3 to 11 days). Hematoma was observed in two limbs, wound infection in two limbs, and superficial wound infection in two limbs. The primary patency rate was 97.2, 94.4, and 94.44% at 1, 6, and 12 months, respectively. The secondary patency rate was 100% in all follow-ups. Conclusion: Thorough preoperative imaging and meticulous surgical technique are crucial for a better outcome after open repair. [ABSTRACT FROM AUTHOR]

Background: Evidence suggests that tibialis posterior muscle plays an important role in equinovarus foot deformity in patients who had suffered a stroke and it is one of the most frequently injected lower-extremity muscles for the management of spasticity. Our aim was to assess if a needle accurately and safely penetrates the tibialis posterior muscle during the application of dry needling.  METHODS : We conducted a cadaveric descriptive study. Needling insertion of the tibialis posterior was conducted in 11 cryopreserved cadavers with a 70 mm needle. The needle was inserted using two common approaches, at midpoint (posterior/medial approach) and at upper third (anterior approach) of the leg towards the tibialis posterior. The needle was advanced into the tibialis posterior based upon clinician judgement. Cross-sectional anatomical dissections were photographed and analyzed by photometry. Safety was assessed by calculating the distances from the tip and the path of the needle to proximate neurovascular structures.Results: Accurate needle penetration of the tibialis posterior muscle was observed in all cadavers with both approaches. In general, distances from the needle to the neurovascular bundles were larger with the posterior/medial approach than with the anterior approach, reaching statistically significance for needle tip to nerve (mean difference: 0.6 cm, 95%CI 0.35 to 0.85 cm) and vascular bundle (mean difference: 0.55 cm, 95%CI 0.3 to 0.8 cm) distances (P < 0.001) and needle path to vascular bundle distance (difference: 0.25 cm, 95%CI 0.1 to 0.4 cm, P = 0.045). Age and gender did not influence the main results.Conclusions: This cadaveric study suggests that needling of the tibialis posterior muscle can be accurately and safely conducted. Safety seems to be larger with the posterior/medial approach when compared with the anterior approach. [ABSTRACT FROM AUTHOR]

To evaluate mid-long term radiological outcomes following early medial approach open reduction (MAOR) performed for developmental dysplasia of the hip (DDH) in infants aged ≤6 months old at time of surgery, specifically incidence of clinically significant avascular necrosis (AVN), Severin outcomes and rates of further surgery. This is a single centre retrospective study of patients treated from 1999 to 2017. Only infants aged ≤6 months old at time of MAOR, and aged at least 6 years old at latest follow-up were included (minimum 5.5 years follow-up). Data was collected from electronic healthcare records and serial radiographs reviewed to assess outcomes. AVN was classified according to Kalamchi and MacEwen, with types 2–4 considered clinically significant. Severin classes I (excellent) and II (good) were considered satisfactory outcomes, and classes III + considered unsatisfactory. MAOR was performed on 48 hips in 44 patients. Mean age at time of surgery was 4 months (SD 1.4, range 2–6), with mean follow-up of 9.8 years (SD 2.7, range 6.2–16.2). Clinically significant AVN developed in 9/48 hips (19 %), all of which were type 2. Only 1/48 hips (2 %) required a subsequent pelvic osteotomy due to residual dysplasia with subluxation at 2 years post MAOR. At final follow-up, 81 % of patients had excellent or good radiological outcomes (Severin I/II). No statistically significant predictors for developing AVN, including age and presence of ossific nucleus, were identified. Early MAOR in infants aged ≤6 months was associated with a very low rate of significant residual dysplasia requiring further surgery, yet was not associated with unacceptable rates or severe forms of AVN. We therefore recommend MAOR is performed early to optimise acetabular remodelling potential and minimise the need for concurrent or subsequent bony procedures. [ABSTRACT FROM AUTHOR]

Objective: Ultrasound‐guided stellate ganglion block (usSGB) facilitates improved accuracy of needle position and application of lesser volumes of local anesthetic (LA). Approaches of usSGB, however, have not fully been optimized with respect to efficacy and technical convenience. This pilot study examined the anatomical position and spatial distribution of a small volume of LA injectate dispensed by medial transthyroid usSGB via magnetic resonance imaging (MRI) and assessment of its effect on cervical sympathetic nerves. Methods: Twelve healthy males were tested in a double‐blinded within‐subject design. In a total of 37 usSGB, 3 ml of LA and saline 0.9% solution were injected intramuscularly into the longus colli muscle (LCM) preventing uncontrollable spread of LA within cervical structures. Immediately after injection, distribution of injectate was traced by MRI. Twenty‐four out of the 37 usSGB‐injections with 3 ml ropivacaine 1% (verum) and saline 0.9% (placebo) were compared. Efficacy of usSGB was assessed by the appearance of oculosympathetic paresis and increases in skin temperature. Results: All usSGBs were positioned in the proximity of the LCM muscle belly. Most of the axial injectate was distributed within the transversal plane between the middle section of C5 and the upper section of T1 vertebra. Signs of oculosympathetic paresis and skin temperature increase were found exclusively under verum conditions. Conclusion: This pilot study demonstrated the feasibility of medial transthyroid usSGB using an out‐of‐plane technique and a volume of 3 ml of LA. Further studies are required to establish the relative value and safety of this technique compared to other published approaches. Compared to blind‐techniques, ultrasound‐guided stellate ganglion block (usSGB) facilitates improved accuracy of needle position and application of lesser volumes of local anesthetic (LA). Approaches of usSGB, however, have not fully been optimized with respect to efficacy and technical convenience. This pilot study examined the anatomical position and spatial distribution of a small volume of LA injectate dispensed by medial transthyroid usSGB via magnetic resonance imaging (MRI) and assessment of its effect on cervical sympathetic nerves. Twelve healthy males were tested in a double‐blinded within‐subject design. In a total of 37 usSGB, 3 ml of LA and saline 0.9 % solution were injected intramuscularly into the longus colli muscle (LCM) preventing uncontrollable spread of LA within cervical structures. Immediately after injection, distribution of injectate was traced by MRI. Twenty‐four out of the 37 usSGB‐injections with 3 ml ropivacaine 1 % (verum) and saline 0.9% (placebo) were compared. Efficacy of usSGB was assessed by the appearance of oculo‐sympathetic paresis (Horner's syndrome) and increases in skin temperature. All usSGBs were positioned in the proximity of the LCM muscle belly. Most of the axial injectate was distributed within the transversal plane between the middle section of C5 and the upper section of T1 vertebra. Signs of oculo‐sympathetic paresis and skin temperature increase were found exclusively under verum condition. This pilot study demonstrated the feasibility of medial transthyroid usSGB using an out‐of‐plane technique and a volume of 3 ml of LA. Further studies are required to establish the relative value and safety of this technique compared to other published approaches. [ABSTRACT FROM AUTHOR]

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 < 1.5. In 13.15% anatomical patterns, this risk structure should be taken seriously. 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. [ABSTRACT FROM AUTHOR]

Objective: Developmental dysplasia of the hip is one of the most common infantile diseases. Estimating the roles of factors affecting the development of dysplastic hip is essential in determining the treatment outcomes. In this study, we investigated if the cartilaginous acetabular index (CAI), osseous acetabular index, or their difference (delta angle) affect acetabular development in the long- term follow-up. Method: Thirty-five hips of 30 patients are included in the study. The mean age of the patients was 15.71±6.37 (3-31) months. All patients were treated using a medial approach. The mean follow-up was 149.91±51.43 (60-262) months. Five hips were excluded due to the development of avascular necrosis. Results: Any statistically significant difference was not found in the evaluation of the correlation between CAI, osseous acetabular index, or delta angle measurements in terms of acetabular development. The acetabular growth in the first year following the reduction was statistically significant (p<0.001), while, the acetabular development for the following years were not found to be statistically significant (p>0.05). Conclusion: CAI, osseous acetabular index, and delta angles do not directly affect acetabular development rate. However, most of the acetabular development occurs during the first year after concentric reduction in children younger than 24 months. [ABSTRACT FROM AUTHOR]

Introduction: 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.Material and Methods: 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.Results: 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.Conclusion: 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. [ABSTRACT FROM AUTHOR]

Abstract 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.

Introduction: To highlight an alternative method of treatment for femoral fractures associated with vascular injury, allowing both fracture fixation and vascular repair from the same surgical approach.Design: Retrospective case series.Methods: Twelve patients with arterial injury as a consequence of femoral fracture were treated by internal fixation. There were five femoral diaphysis, seven distal femoral including supracondylar and intercondylar fractures. Four patients had injury to the popliteal artery, whereas eight to the superficial femoral artery. Seven patients had a nerve injury. Medial femoral approach was used both for the fixation of the fracture and vascular repair. Fracture fixation was done by plate-screw in all patients, whereas vascular injuries were treated using saphenous vein interposition graft in ten patients and end-to-end repair in two patients. Nerve injuries were not dealt by exploration during the vascular repair.Results: All of the limbs were ultimately survived. Clinical and radiological union was observed in all patients at the last follow-up radiographs. Of the 4 total sciatic nerve palsies, 2 had developed total, one had tibial nerve recovery. One patient had no motor recovery. Of the 3 peroneal nerve palsies, 1 patient had recovery, 2 patients had no motor improvement.Conclusions: A midlateral approach is traditionally used for fractures of femur when plates and screws are used for fixation. In association with vascular injury, this procedure requires two separate incisions. The added soft tissue disruption associated with open reduction and internal fixation by lateral incision can be reduced with the use of single medial approach, which allows bony stabilization under direct visualization of the repaired vessels. [ABSTRACT FROM AUTHOR]

Distal femoral fractures are commonly treated with lateral straight plates. However, the lateral approach may not always be desirable, and 180°-helical plates may be an alternative. To investigate the biomechanical competence of 180°-helical plating versus standard straight lateral plating of unstable fractures at the distal femur. Twelve left artificial femora were instrumented with a 15-hole Locking Compression Plate–Distal Femur, using either 180°-helical plates (group 1) or conventional straight lateral plates (group 2). An unstable distal femoral fracture AO/OTA 33-A3.3 was simulated. All specimens were biomechanically tested under quasi-static and progressively increasing combined cyclic axial and torsional loading in internal rotation until failure. Initial axial stiffness (N/mm) was significantly higher in group 1 (185.6 ± 50.1) compared to group 2 (56.0 ± 14.4), p < 0.001. Group 1 demonstrated significantly higher initial interfragmentary flexion (°) and significantly lower initial varus/valgus deformation (°) under 500 N static axial compression versus group 2 (2.76 ± 1.02 versus 0.87 ± 0.77 and 4.08 ± 1.49 versus 6.60 ± 0.47), p ≤ 0.005. Shear displacement (mm) under 6 Nm static torsion was significantly higher in group 1 versus group 2 in both internal (1.23 ± 0.28 versus 0.40 ± 0.42) and external (1.21 ± 0.40 versus 0.57 ± 0.33) rotation, p ≤ 0.013. Cycles to failure and failure load (N) (clinical/catastrophic) were significantly higher in group 1 (12,484 ± 2116/13,752 ± 1518 and 1748.4 ± 211.6/1875.2 ± 151.8) compared to group 2 (7853 ± 1262/9727 ± 836 and 1285.3 ± 126.2/1472.7 ± 83.6), p ≤ 0.001. Although 180°-helical plating using a pre-contoured standard straight lateral plate was associated with higher shear and flexion movements, it demonstrated improved initial axial stability and resistance against varus/valgus deformation compared to straight lateral plating. Moreover, the helical plates were associated with significantly higher endurance to failure. From a biomechanical perspective, 180°-helical plating may be considered as a valuable alternative to standard straight lateral plating of unstable distal femoral fractures. • 180°- helical plates demonstrate higher shear and flexion movements compared to straight plates. • 180°-helical plates demonstrate improved axial stability and resistance against varus deformation compared to straight plates. • 180°-helical plates demonstrate improved resistance to failure compared to straight plates. • 180°-helical plating may be considered as alternative to straight plating of unstable distal femoral fractures. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of this study was to evaluate the feasibility of the anteromedial minimally invasive plate osteosynthesis (MIPO) approach for distal third humeral shaft fractures and identify neurovascular structures at risk with this approach.Methods: Twenty cadaveric arms were fixed with 12-hole precontoured narrow locking compression plates (LCP) with the anteromedial approach using MIPO technique. The proximal approach was done between the biceps and deltoid muscle directly to the bone. The distal approach involved elevating the brachialis from medial intermuscular septum. The plate was inserted beneath the brachialis tunnel from distal to proximal. Three locking screws were fixed at each end through incisions and the rest of screws were inserted percutaneously. The arms were then dissected to identify damage to or direct contact between the screws and brachial artery (BA), median nerve (MN), musculocutaneous nerve (MCN), and radial nerve (RN). The distances from the screws to structures at risk, humeral length, and length of three distal screws in mediolateral (ML) direction were measured.Results: The average humeral length was 28.97 cm. The average danger zone for the BA and MN were 20.47%-62.66% of the humeral length from the lateral epicondyle, and 20.47%-75.02% for the MCN. The ulnar nerve was not endangered by this approach as it lies posteromedially to the humerus. The danger zone for the RN averaged 27.07%-43.74%, and the most dangerous screw that either penetrated or touched the nerve was at the fifth hole, which lay at 33.14% of the humeral length. The average length of three distal screws in ML direction were 41.4, 25.0 and 22.5 mm.Conclusions: The anteromedial MIPO approach can be performed through the internervous plane beneath the brachialis muscle without exposing any nerves or causing any muscle splitting with a 12-hole plate. Both proximal and distal screw insertion must be done with direct exposure. Insertion of percutaneous screws in the middle part of the plate between the two incisions is not possible. This approach could be an alternative for extra-articular distal third humeral shaft fractures which provides less invasive surgical dissection, allows the use of longer distal screws, and achieves better cosmesis. [ABSTRACT FROM AUTHOR]

Purpose: In esophageal squamous cell carcinoma (ESCC), lymph nodes (LNs) around the subcarina and main bronchi are thought to be highly involved. Therefore, complete dissection of these LNs with preservation of the pulmonary branches of the vagus nerves, which control important pulmonary functions, is recommended. The aim of this retrospective study was to investigate the feasibility of reliable method for lymphadenectomy around the subcarina and main bronchi, named the medial approach, during thoracoscopic esophagectomy in the prone position (TEP). Methods: This was a case-matched control study of patients who underwent TEP for ESCC. The fundamental concept in this method is to first exfoliate the LNs around the subcarina and main bronchi from the pericardium. Developing the operative field contributes to visualizing and preserving the pulmonary branches of the right vagus nerve. Twenty-three patients who underwent the medial approach and 23 patients who underwent the conventional approach were selected by the use of propensity score matching to compare the operative outcomes. Results: The medial approach significantly reduced operative time for procedure (16 ± 3 vs 30 ± 6 min, p < 0.0001) and operative blood loss (123 ± 108 vs 207 ± 162 ml, p = 0.046) comparing with conventional approach. The incidence of postoperative pneumonia was lower in the medial approach group (4%) than in the conventional approach group (15%) (p = 0.069). Conclusions: The medial approach for lymphadenectomy around the subcarina and both main bronchi during TEP is technically safe and feasible in shorting the operative time with possibility to reduce postoperative pneumonia. [ABSTRACT FROM AUTHOR]

Abstract Ankle fractures and fracture dislocations are one of the commonest injuries seen by orthopaedic surgeons. Decisions around the surgical fixation of ankle fractures require an understanding of the bony and ligamentous anatomy of the joint as well as an appreciation of the normal ankle joint biomechanics. The operative treatment of these injuries aims to hold the joint securely in an anatomically reduced position throughout the period of healing, and allow initiation of joint motion as soon as possible. If these treatment goals are met, a good outcome is a reasonable expectation, given the proviso that disruption of any articular surface can result in permanent damage. However the functional outcome of fractures involving a posterior malleolar fragment is often not satisfactory and recent debate has surrounded ankle fracture fixation, with the posterior malleolus in particular being subject to increased scrutiny for its contribution towards long-term ankle stability. With the advent of excellent results from the use of open reduction and rigid internal fixation, the gold standard of treatment for displaced ankle fractures has become surgical fixation. This article explores the evidence behind commonly used surgical approaches to ankle fracture fixation and the rationale behind their use. [ABSTRACT FROM AUTHOR]

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.

Donor site morbidity is the most common limitation of the deep circumflex iliac artery (DCIA) flap, so the purpose of this paper is to describe a new, minimally-invasive, approach to its harvest using virtual surgical planning and CAD/CAM technology to reduce functional and aesthetic morbidity at the donor site. Virtual surgical planning was based on preoperative computed tomographic data. A newly-designed surgical guide made using CAD/CAM technology was used to transfer the virtual surgical plan to the site of operation. This enabled us to raise a bicortical flap from the pelvis with preservation of the anterior superior iliac crest from the medial side with minimal muscular stripping. The guide, designed at slightly less than 90° to the lateral cortex, allowed the cut segment of bone to be raised medially. The new virtual surgical planning guide allowed a medial approach with reduced stripping of muscle and lower morbidity. No complications were encountered during the operation or the healing phase. Patients treated in this way had a shorter recovery period, with minimal complaints about walking or loss of profile of the hip. We conclude that virtual surgical planning can aid a minimally-invasive approach with predictable results. This allows a medial approach to the harvest of DCIA with preservation of important anatomical structures, and a reduction in donor site morbidity. [ABSTRACT FROM AUTHOR]

This study aimed at evaluating the medial approach for open reduction and internal fixation of Gartland type 3 displaced supracondylar fractures of humerus in children. A prospective, single centre study of on displaced supracondylar humerus fractures in 42 children was carried out at our institute. All fractures were managed with open reduction and internal fixation with crossed K-wires via medial approach. The mean follow-up was 12 months and patients were assessed according to Flynn’s criteria. No patients had post-operative ulnar nerve injury. Cubitus varus was not seen in any patient. Superficial pin tract infection occurred in three patients that subsided with anti-septic dressings and antibiotics. No deep infection occurred. 88.09 % patients showed satisfactory results as per Flynn’s criteria. The medial approach provides an excellent view of the supracondylar area. The approach is convenient due to a lower risk for ulnar nerve injury and better acceptability of the medial incisional scar.

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. [ABSTRACT FROM AUTHOR]