The choice of the most suitable surgical approach to the elbow forms the foundation of any successful elbow surgery. The surgical approach is based on the injury or pathology to be addressed and ...therefore specific anatomical details need to be considered. The surgeon must be comfortable with the bony, ligamentous and neurovascular anatomy of the elbow to consider and execute the best approach for each problem. This is an imperative to avoid iatrogenic injury.
This article provides a detailed analysis, valuable technical tips, advantages and disadvantages of the most common approaches to the elbow. The lateral approaches include the Kocher, Kaplan and Extensor Digitorum Communis (EDC) Split approaches, the medial approaches include the Hotchkiss, Flexor carpi ulnaris (FCU) splitting approach, the Taylor and Scham approach. The anterior approach includes the anterior neurovascular interval approach and the posterior approaches include the Olecranon osteotomy, triceps sparing, triceps reflecting approach and finally the Boyd interval approach. The text and illustrations will provide a structured overview for the practicing surgeon.
Abstract
Background
Thumb carpometacarpal joint (CMCJ) osteoarthritis is common and can lead to significant morbidity making it a condition frequently treated by hand surgeons when initial ...conservative measures fail. The surrounding ligamentous structures are complex and important to maintain thumb CMCJ stability.
Objectives
The aim of this study was to review the normal and arthritic anatomy of the thumb CMCJ, focusing on morphology and position of osteophytes and the gap between metacarpal bases, and the effect of these on intermetacarpal ligament integrity. This may be the sole ligament suspending the first metacarpal following trapeziectomy and could determine the need for further stabilization during surgery, avoiding potential future failures.
Methods
Computed tomography (CT) scans of a normal cohort and those with arthritic changes who had undergone trapeziectomy following the scan were identified. The three-dimensional reconstructions were examined for osteophyte position on the saddle and the intermetacarpal distance.
Results
A total of 55 patients, 30 normal and 25 arthritic, were identified and studied. The most common anatomic position for osteophytes was the intermetacarpal ulnar aspect of the trapezium. The intermetacarpal distance increased by an average of 2.1 mm in the presence of the arthritic process.
Conclusions
The findings point to an increase in the intermetacarpal distance, and hence lengthening of the ligament with potential damage, possibly secondary to osteophyte formation and wear. Further prospective research is required to determine whether using preoperative CT scanning to define osteophyte position and measure the intermetacarpal distance would predict probable damage to the ligament, hence providing an indication for stabilization and reconstruction in trapeziectomy surgery.
Level of Evidence
This is a Level III, retrospective cohort study.
Reported is the case of a 68-year-old male presenting with severe wrist and hand stiffness following surgery for a Dupuytren's contracture. Complications of surgery or rehabilitation and complex ...regional pain syndrome were excluded as factors explaining this stiffness. Given the patient's diabetes mellitus and the striking similarity with the typical diabetic stiff hand, it is suggested that diabetes may have contributed to the development of the complication.
The International Emergency Trauma Register (IETR) has facilitated specialist training for more than 1000 members of NHS staff ready to be deployed to crisis zones.2 Inspirational individuals such as ...David Nott have dedicated their surgical skills to high-risk, resource-poor settings such as Syria, as well as helping to train local surgeons in the region.3
Introduction Patients with scaphoid nonunion and wrist pain may have a wide spectrum of potential concomitant pathologies that may be diagnosed and potentially managed arthroscopically. The aim of ...this study is to assess the usefulness of wrist arthroscopy in the assessment and treatment of scaphoid nonunion and any associated injuries.
Materials and Methods We retrospectively reviewed 34 consecutive patients with established scaphoid nonunion between January 2006 and December 2012 who had undergone arthroscopic assessment. The average age of the patients was 40 years (range: 25–64), and all the patients had arthroscopic assessment of the wrist joint before definitive surgery. The patients with associated intra-articular problems, which could be addressed along with the scaphoid open reduction internal fixation (ORIF) and bone grafting (BG), had definite procedure in the same sitting. However, if the patients had major intra-articular pathology that needed change in the management plan, they had staged definitive treatment after discussing with them about the arthroscopic findings.
Results Arthroscopic assessment of the 34 joints showed varying degrees of arthritis affecting radioscaphoid joint (41%) followed by injuries to the triangular fibrocartilage complex (TFCC) (35%), lunotriquetral ligament (LTL) tears (32%), and scapholunate ligament (SLL) injuries (26%). Concomitant procedures performed during the wrist arthroscopy included debridement of synovitis (62%), TFCC debridement (32%), loose body removal (17%), and DRUJ stabilization and TFCC repair (3%). Twenty-nine patients had arthroscopy and definitive procedure in the same sitting, and the remaining had staged or delayed definitive treatment.
Conclusion Our study highlights the usefulness of wrist arthroscopy in assessment and management of the scaphoid nonunion and associated pathologies. Besides in 18% of our patients, the initial management plan changed after arthroscopy.
Level of Evidence This is a Level IV study.
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