Based on our clinical experience and an anatomical study, we examined the conditions under which injury to the popliteal artery, tibial nerve or peroneal nerve and its branches may occur during high tibial osteotomy. In 250 high tibial osteotomies performed in our department, we observed the following intraoperative complications. (1) The popliteal artery was severed in 1 patient and repaired by the same surgical team using a microsurgical technique. (2) A tibial nerve paresis also occurred in 1 patient. (3) In 3 patients, temporary palsy of the anterior tibialis muscle was documented. (4) In 4 other patients, palsy of the extensor hallucis longus occurred. To investigate the causes of these complications in the popliteal artery, tibial nerve and branches of the peroneal nerve, we dissected the neurovascular structures surrounding the area of the osteotomy in 10 cadaveric knees and performed a high tibial osteotomy in another 13 cadaveric knees. We concluded the following. (1) The popliteal artery and tibial nerve are protected, at the level of the osteotomy, behind the popliteus and tibialis posterior muscles. Damage can occur only by placing the Hohman retractor behind the muscles. The insertion of the muscles is very close to the periosteum and can be separated only with a scalpel. (2) The tibialis anterior muscle is innervated by a group of branches arising from the deep branch of the peroneal nerve. In two-thirds of the dissected knees, we found a main branch close to the periosteum, which can be damaged by dividing the muscle improperly or due to improper placement and pressure of the Hohman retractor. This may explain the partially reversible muscle palsy. (3) The extensor hallucis longus is also innervated by 2-3 thin branches, arising from the deep branch of the peroneal nerve, but in 25% of the specimens, only one large branch was found. This branch is placed under tension by manipulating the distal tibia forward. Thus, it may be damaged by the Hohman retractor during distal screw fixation, tensioned by hyperextension or directly injured during midshaft fibular osteotomy.

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IntroductionCarpal tunnel release, one of the most frequently performed operations in the field of orthopedic surgery [6], has traditionally been performed using the classic open technique [18]. Despite the success of this procedure, complications such as painful and deforming scars, tendon and nerve injuries, palmar hematoma, inflammation, reflex sympathetic dystrophy, and delayed return to work have been frequently reported in the literature [5,7,9,11]. Two recently developed, minimally invasive surgical techniques, endoscopic carpal tunnel release (ECTR) and the two small-incision technique, have the advantages of reducing scar size, minimizing postoperative pain, enhancing recovery of grip strength, and accelerating return to work. Despite this, these procedures are not without complications, which include nerve and tendon injuries [12,20], incomplete release of the transverse ligament [13], and accidental release of Guyon's canal [15].While persistent controversy surrounds the use of ECTR, its favorable cosmetic and functional results have contributed to its growing popularity among both orthopedic surgeons and patients [1-4, 8, 14, 17, 19]. Nevertheless, early experience suggests that it is more complex than conventional open methods. Our experience with 76 cases of ECTR using the modified Chow technique has allowed us to identify aspects of this procedure that pose technical difficulties and may contribute to the risk of operative and postoperative complications. Analysis of our experience has provided insight into conditions that improve both the efficiency of this procedure and the likelihood of a good outcome. We believe that application of the modifications proposed in this report, as well as growing surgical experience, will contribute to a reduction in the reported complication rate of this procedure.Abstract In reporting on the preliminary results of our series of 76 patients, this paper aims to identify potentially complicating aspects of endoscopic carpal tunnel release (ECTR) using the two-portal Chow technique, and to recommend solutions, based on our early experience, which enhance the ease and safety of this minimally invasive technique. Of the first 24 patients, 16 cases required conversion to an open procedure. Based on these initial cases, we developed certain modifications of the Chow technique which precluded any need for open conversion in the 60 remaining cases. During a followup interval ranging from 4 to 24 months, there was no recurrence of carpal tunnel symptoms, and the average time to resumption of work activity was 14 days. The complication rate was 5% and included one case of transient hypesthesia, one case of extended hematoma, and one hypersensitive scar. All complications resolved at subsequent follow-up. In our experience, correct positioning of the hand, proper injection of local anesthetic, use of magnifying loupes, and correct use of instruments are essential for a safe and successful procedure.