Sihler's staining of the cutaneous nerves of the leg and its implications for sensory reconstruction

Modified Oblique Lobenhoffer (MOL) approach for posterolateral and posteromedial column access in tibial plateau fractures: a detailed cadaveric anatomical study

BACKGROUND

Tibial plateau fractures involving posteromedial (PM) and posterolateral (PL) columns are complex injuries that require an appropriate approach. The management of the PL column in these cases can be controversial, and limitations using deep posteromedial interval approaches have been referenced. In this paper, a modification of the Lobenhoffer approach, designed to optimize the access to the PL column, is described in detail. The aim of this study was to assess the feasibility of this approach in a cadaveric anatomical study.

MATERIALS AND METHODS

In total, five fresh-frozen cadaveric specimens were used for detailed anatomical study surrounding the approach. Relationships with cutaneous and deep neurovascular structures were evaluated. The exposure area of the PL and PM columns using this approach was assessed.

RESULTS

The cadaveric study showed safe and adequate exposure. Oblique skin and fascia incision just medial to the posterior midline was safe to protect the medial sural cutaneous nerve and the small saphenous vein. Elevation of the popliteus and tibialis posterior muscles offered safe protection of the anterior tibial artery and popliteal neurovascular bundle during retractor placement. Adequate full proximal exposure of the PM and PL columns, including the posterolateral lateral (PLL) and posterolateral central (PLC) segments, was obtained in all specimens.

CONCLUSIONS

The Modified Oblique Lobenhoffer (MOL) approach can be a feasible option to access PL and PM columns in tibial plateau fractures.

LEVEL OF EVIDENCE

IV.

"Innervation of the Female Breast and Nipple: A Systematic Review and Meta-Analysis of Anatomical Dissection Studies"

BACKGROUND

Primary cadaveric studies were reviewed to give a contemporary overview of what is known about innervation of the female breast and nipple/nipple-areola complex (NAC).

METHODS

We performed a PRISMA-compliant systematic review and meta-analysis (PROSPERO number CRD42020150250). We searched four electronic databases for studies investigating which nerve branches supply the female breast and nipple/NAC or describing the trajectory and other anatomical features of these nerves. Inclusion criteria for meta-analysis were at least five studies of known sample size and with numerical observed values. Pooled prevalence (PP) estimates of nerve branches supplying the nipple/NAC were calculated using random-effects meta-analyses; the remaining results were structured using qualitative synthesis. Risk of bias within individual studies was assessed with the Anatomical Quality Assurance (AQUA) checklist.

RESULTS

Of 3653 studies identified, 19 were eligible for qualitative synthesis and 7 for meta-analysis. The breast skin is innervated by anterior cutaneous branches (ACBs) and lateral cutaneous branches (LCBs) of the 2nd - 6th and the nipple/NAC primarily by ACBs and LCBs of the 3rd - 5th intercostal nerves. The ACB and LCB of the 4th intercostal nerve supply the largest surface area of the breast skin and nipple/NAC. The LCB of the 4th intercostal nerve is the most consistent contributory nerve to the nipple/NAC (PP 89.0%; 95% CI 0.80-0.94).

CONCLUSIONS

The ACB and LCB of the 4th intercostal nerve are the most important nerves to spare or repair during reconstructive and cosmetic breast surgery. Future studies are required to elicit the course of dominant nerves through the breast tissue.