Percutaneous Posterior to Anterior Screw Fixation of the Talar Neck
Category: Trauma Introduction/Purpose: Fractures of the talar neck and body can be fixed with percutaneously placed screws directed from anterior to posterior or posterior to anterior. The latter has been found to be biomechanically and anatomically superior. Percutaneous pin and screw placement pos...
| Main Authors: | , , , , , , , , , |
|---|---|
| Format: | Article |
| Language: | English |
| Published: |
SAGE Publishing
2018-09-01
|
| Series: | Foot & Ankle Orthopaedics |
| Online Access: | https://doi.org/10.1177/2473011418S00204 |
| _version_ | 1829493002821697536 |
|---|---|
| author | Cesar de Cesar Netto MD, PhD Lauren Roberts MD Alexandre Godoy Dos Santos MD, PhD Jackson Staggers BS Sung Lee BS Walter Smith BS Parke Hudson BS Ibukunoluwa Araoye MS Sameer Naranje MD, MRCS Ashish Shah MD |
| author_facet | Cesar de Cesar Netto MD, PhD Lauren Roberts MD Alexandre Godoy Dos Santos MD, PhD Jackson Staggers BS Sung Lee BS Walter Smith BS Parke Hudson BS Ibukunoluwa Araoye MS Sameer Naranje MD, MRCS Ashish Shah MD |
| author_sort | Cesar de Cesar Netto MD, PhD |
| collection | DOAJ |
| description | Category: Trauma Introduction/Purpose: Fractures of the talar neck and body can be fixed with percutaneously placed screws directed from anterior to posterior or posterior to anterior. The latter has been found to be biomechanically and anatomically superior. Percutaneous pin and screw placement poses anatomic risks for posterolateral and posteromedial neurovascular and tendinous structures. The objective of this study was to enumerate the number of trials for proper placement of two parallel screws and to determine the injury rate to neurovascular and tendinous structures. Methods: Eleven fresh frozen cadaver limbs were used. 2.0 mm guide wires from the Stryker (Selzach, Switzerland) 5.0-mm headless cannulated set were percutaneously placed (under fluoroscopic guidance) into the distal posterolateral aspect of the ankle. All surgical procedures were performed by a fellowship-trained foot and ankle surgeon. Malpositioned pins were left intact to allow later assessment of soft tissue injury. The number of guide wires needed to achieve an acceptable positioning of the implant was noted. Acceptable positioning was defined as in line with the talar neck axis in both AP and lateral fluoroscopic views. After a layered dissection from the skin to the tibia, we evaluated neurovascular and tendinous injuries, and measured the shortest distance between the closest guide pin and the soft tissue structures, using a precision digital caliper. Results: The mean number of guide wires needed to achieve acceptable positioning for 2 parallel screws was 2.91 ± 0.70 (range, 2 - 5). The mean distances between the closest guide pin and the soft tissue structures of interest were: Achilles tendon, 0.53 ± 0.94 mm; flexor hallucis longus tendon, 6.62 ± 3.24 mm; peroneal tendons, 7.51 ± 2.92 mm; and posteromedial neurovascular bundle, 11.73 ± 3.48 mm. The sural bundle was injured in all the specimens, with 8/11 (72.7%) in direct contact with the guide pin and 3/11 (17.3%) having been transected. The peroneal tendons were transected in 1/11 (9%) of the specimens. The Achilles tendon was in contact with the guide pin in 6/11 (54.5%) specimens and transected in 2/11 (18.2%) specimens. Conclusion: The placement of posterior to anterior percutaneous screws for talar neck fixation is technically demanding and multiple guide pins are needed. Our cadaveric study showed that important tendinous and neurovascular structures are in close proximity with the guide pins and that the sural bundle was injured in 100% of the cases. We advise performing a formal small posterolateral approach for proper visualization and retraction of structures at risk. Regardless, adequate patient education about the high risk of injury from this procedure is crucial. |
| first_indexed | 2024-12-16T06:25:46Z |
| format | Article |
| id | doaj.art-04522972d57b4d8787e0781445127073 |
| institution | Directory Open Access Journal |
| issn | 2473-0114 |
| language | English |
| last_indexed | 2024-12-16T06:25:46Z |
| publishDate | 2018-09-01 |
| publisher | SAGE Publishing |
| record_format | Article |
| series | Foot & Ankle Orthopaedics |
| spelling | doaj.art-04522972d57b4d8787e07814451270732022-12-21T22:41:01ZengSAGE PublishingFoot & Ankle Orthopaedics2473-01142018-09-01310.1177/2473011418S00204Percutaneous Posterior to Anterior Screw Fixation of the Talar NeckCesar de Cesar Netto MD, PhDLauren Roberts MDAlexandre Godoy Dos Santos MD, PhDJackson Staggers BSSung Lee BSWalter Smith BSParke Hudson BSIbukunoluwa Araoye MSSameer Naranje MD, MRCSAshish Shah MDCategory: Trauma Introduction/Purpose: Fractures of the talar neck and body can be fixed with percutaneously placed screws directed from anterior to posterior or posterior to anterior. The latter has been found to be biomechanically and anatomically superior. Percutaneous pin and screw placement poses anatomic risks for posterolateral and posteromedial neurovascular and tendinous structures. The objective of this study was to enumerate the number of trials for proper placement of two parallel screws and to determine the injury rate to neurovascular and tendinous structures. Methods: Eleven fresh frozen cadaver limbs were used. 2.0 mm guide wires from the Stryker (Selzach, Switzerland) 5.0-mm headless cannulated set were percutaneously placed (under fluoroscopic guidance) into the distal posterolateral aspect of the ankle. All surgical procedures were performed by a fellowship-trained foot and ankle surgeon. Malpositioned pins were left intact to allow later assessment of soft tissue injury. The number of guide wires needed to achieve an acceptable positioning of the implant was noted. Acceptable positioning was defined as in line with the talar neck axis in both AP and lateral fluoroscopic views. After a layered dissection from the skin to the tibia, we evaluated neurovascular and tendinous injuries, and measured the shortest distance between the closest guide pin and the soft tissue structures, using a precision digital caliper. Results: The mean number of guide wires needed to achieve acceptable positioning for 2 parallel screws was 2.91 ± 0.70 (range, 2 - 5). The mean distances between the closest guide pin and the soft tissue structures of interest were: Achilles tendon, 0.53 ± 0.94 mm; flexor hallucis longus tendon, 6.62 ± 3.24 mm; peroneal tendons, 7.51 ± 2.92 mm; and posteromedial neurovascular bundle, 11.73 ± 3.48 mm. The sural bundle was injured in all the specimens, with 8/11 (72.7%) in direct contact with the guide pin and 3/11 (17.3%) having been transected. The peroneal tendons were transected in 1/11 (9%) of the specimens. The Achilles tendon was in contact with the guide pin in 6/11 (54.5%) specimens and transected in 2/11 (18.2%) specimens. Conclusion: The placement of posterior to anterior percutaneous screws for talar neck fixation is technically demanding and multiple guide pins are needed. Our cadaveric study showed that important tendinous and neurovascular structures are in close proximity with the guide pins and that the sural bundle was injured in 100% of the cases. We advise performing a formal small posterolateral approach for proper visualization and retraction of structures at risk. Regardless, adequate patient education about the high risk of injury from this procedure is crucial.https://doi.org/10.1177/2473011418S00204 |
| spellingShingle | Cesar de Cesar Netto MD, PhD Lauren Roberts MD Alexandre Godoy Dos Santos MD, PhD Jackson Staggers BS Sung Lee BS Walter Smith BS Parke Hudson BS Ibukunoluwa Araoye MS Sameer Naranje MD, MRCS Ashish Shah MD Percutaneous Posterior to Anterior Screw Fixation of the Talar Neck Foot & Ankle Orthopaedics |
| title | Percutaneous Posterior to Anterior Screw Fixation of the Talar Neck |
| title_full | Percutaneous Posterior to Anterior Screw Fixation of the Talar Neck |
| title_fullStr | Percutaneous Posterior to Anterior Screw Fixation of the Talar Neck |
| title_full_unstemmed | Percutaneous Posterior to Anterior Screw Fixation of the Talar Neck |
| title_short | Percutaneous Posterior to Anterior Screw Fixation of the Talar Neck |
| title_sort | percutaneous posterior to anterior screw fixation of the talar neck |
| url | https://doi.org/10.1177/2473011418S00204 |
| work_keys_str_mv | AT cesardecesarnettomdphd percutaneousposteriortoanteriorscrewfixationofthetalarneck AT laurenrobertsmd percutaneousposteriortoanteriorscrewfixationofthetalarneck AT alexandregodoydossantosmdphd percutaneousposteriortoanteriorscrewfixationofthetalarneck AT jacksonstaggersbs percutaneousposteriortoanteriorscrewfixationofthetalarneck AT sungleebs percutaneousposteriortoanteriorscrewfixationofthetalarneck AT waltersmithbs percutaneousposteriortoanteriorscrewfixationofthetalarneck AT parkehudsonbs percutaneousposteriortoanteriorscrewfixationofthetalarneck AT ibukunoluwaaraoyems percutaneousposteriortoanteriorscrewfixationofthetalarneck AT sameernaranjemdmrcs percutaneousposteriortoanteriorscrewfixationofthetalarneck AT ashishshahmd percutaneousposteriortoanteriorscrewfixationofthetalarneck |